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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 19
| Issue : 3 | Page : 60-67 |
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Supracondylar Fracture of Humerus
TR Easwar1, Manesh Stephen2
1 Palakkad District Cooperative Hospital and Research Centre, Palakkad, Kerala, India
2 Department of Orthopaedic Surgery, TD Medical College, Alappuzha, Kerala, India
| Date of Submission | 29-Mar-2022 |
| Date of Acceptance | 04-Apr-2022 |
| Date of Web Publication | 25-May-2022 |
Correspondence Address:
Manesh Stephen
Palakkad District Cooperative Hospital and Research Centre, Palakkad, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2667-3665.346023
Introduction: Supracondylar Fracture of Humerus is one of the most common fractures in children. Good results can be obtained in the majority of typical fracture patterns with proper and prompt care. In India, the delay in presentation is a key factor in treatment decision making. This could be due to poor awareness, prior treatment with native bone setters or other care providers. Materials and Methods: Typical Extension type Supracondylar Fracture of Humerus is reviewed here in this article with appropriate current evidence of care. Literature review of the delayed presenting ones and their results were also listed and discussed. Conclusion: It has been proven that good results can be obtained in cases with delay in presentation. This is especially important in the Indian scenario where some delay in presentation can be expected. Emergency reduction and fixation is not necessary unless there is a neurovascular compromise, Fixation patterns for the Gartland Type I to Type III are discussed. The Type IV pattern of fracture with inherent instability of reduction has to be watched for and appropriately stabilised. Radiological landmarks of Bauman's angle, Anterior Humeral Line, which determine whether reduction is satisfactory are discussed in the article.
Keywords: Supracondylar Fracture, Humerus, Children
How to cite this article:
Easwar T R, Stephen M. Supracondylar Fracture of Humerus. J Orthop Assoc South Indian States 2022;19, Suppl S1:60-7 |
| Introduction | |  |
Supracondylar fracture of the humerus is the most common fracture around the elbow in children.[1]
Although undisplaced fractures have good results with immobilization for 3–4 weeks,[7] it has been noted that unsatisfactory reduction of displaced fractures and pin fixation are the two most common reasons for nerve injuries and malunion.[3] In addition, malunion of the distal humerus has limited capacity to remodel.[4],[5] Even sagittal plane malunion is thought to permanently change and restrict the elbow motion.[6]
It is very important, therefore, to manage these fractures appropriately without delay. We examine the basic concepts and principles in care of typical supracondylar fracture of humerus in children.
| Note | | |
In this chapter, we dealt with only typical fracture patterns and its care. Atypical fracture patterns, vascular injury, and its treatment will be dealt with in dedicated chapters elsewhere.
| Epidemiology | | |
Demographics
Supracondylar fracture is the most common fracture around the elbow in children. This is usually seen in children <7 years of age. It is the most common cause of elbow surgery in children.[8]
Incidence
The incidence of the fracture is reported to be 58%.[10] It is the most common fracture around the elbow in children.[10] The mean age of incidence is 5–6 years, and in some studies, the incidence is more in boys than girls. Left side is more commonly reported than right,[9],[10] with up to 65% incidence on the nondominant side.[11]
Even though in an urban setting the child is expected to report to a hospital early, a study in rural India[11] showed that 95 (36.12%) patients reported 1 week after injury after initial care with local quacks or bonesetters, and three had gangrene of the forearm up to elbow caused by tight bandaging. Totally, 60.08% of patients reported 48 h after injury, and 74.68% had initial care with a traditional bonesetter.
| Pathophysiology and Anatomy | | |
Mechanism of injury
In rural India, a fall onto an outstretched hand was the predominant mechanism of injury, followed by a fall from the rooftop or stairs and fall when playing.[11] Fall onto an outstretched hand with the elbow extended is the most common type of injury, resulting in the extension type of fracture (98%), whereas a fall onto a flexed elbow is much less common, resulting in the flexion type fracture.[11] Flexion type has been reported to be more common in older children.[12]
Extension type
In a typical extension-type supracondylar fracture the elbow is locked in hyperextension [Figure 1] and the olecranon is inside the fossa acting as a fulcrum. The anterior capsule of the elbow stretched. The stress is therefore concentrated on the thin supracondylar bone as the child falls. When the weight of the fall is borne by the hyperextended elbow, this fulcrum is overloaded and yields at the supracondylar area, causing the fracture. As it fractures, the anterior periosteum is ruptured and the distal fragment hyperextends, rotates, and causes displacement posteriorly. Posterior periosteal continuity is generally preserved.
The distal fragment displaces either posteromedially (in 75% of cases) or posterolaterally. In posteromedially displaced fractures, the medial periosteum remains intact and the lateral periosteum remains intact in posterolaterally displaced fractures. Posteromedial displacement generally stabilizes better in pronation and posterolaterally displaced fracture stabilizes better in supination as the intact periosteal hinge is stretched. Not all Gartland Type III fractures are stable in pronation. An additional point to note is that the Gartland Type IV fractures [Table 1] would not be stable in extension or flexion, as the periosteum anteriorly and posteriorly is disrupted.
Associated with this displacement of distal fragment posteromedially/posterolaterally, the proximal fragment will move distally and anteriorly.
This movement may impale and/or stretch the anterior neurovascular structures on the sharp edge of the proximal fragment. There will also be an injury to the anterior soft tissue, brachialis muscle.
Flexion type
In flexion-type supracondylar fracture, by contrast, the injury is as a result of a fall on the point of the elbow with the elbow flexed. Therefore, the distal fragment is pushed anteriorly and the posterior periosteum ruptures first.
| Anatomy | | |
Fracture anatomy
Bone
The supracondylar region in children is weak and thin and hence prone to fracture. Olecranon fossa and coronoid fossa border this posteriorly and anteriorly, respectively. The supracondylar ridges form the medial and lateral pillars, which end into the respective condyles and epicondyles. Trochlea has a 4° valgus tilt in males and 8° valgus in females (called carrying angle). The trochlea is in 3°–8° of external rotation, which results in an external rotation of the arm when it is flexed to 90°.[13]
Soft-tissue structures
The bone in the supracondylar area gives rise to muscles which are responsible for the displacement of the fracture fragments and rotation. In addition, the neurovascular structures lie very close to the bone. Brachial artery is anteromedial, superficial to the brachialis muscle.
The median, radial, and ulnar nerves are in close relation with the supracondylar region.[13] All these neurovascular structures are at risk during the fracture and fragment displacement.
| Clinical Presentation and Examination | | |
Presentation
The child typically has swelling, elbow pain, and restricted movements after a fall. There may be an ecchymotic area over the anterior aspect of the elbow, and if the displacement is severe, there may be even tenting or puckering of the skin in the cubital fossa [Figure 2].[16]
Other fractures
As a rule, the entire upper extremity should be examined thoroughly to rule out other fractures, such as forearm fractures. The presence of forearm fractures along with supracondylar fractures increases the risk of compartment syndrome.[14]
Neurological injury
A thorough neurovascular assessment of the extremity is very important as a neurological injury is present in up to 11.3% of cases.[15] The risk of neurological injury is greatest for the anterior interosseous nerve, followed by the median, radial, and ulnar nerves. The risk of ulnar nerve injury is highest in flexion-type supracondylar fractures [Table 2]. | Table 2: Clinical tests for neurological injury in supracondylar fracture
Click here to view |
Vascular injury
It is very important to do a thorough assessment of perfusion of the limb. Vascular injury association has been reported to be about 20%.[14] Skaggs has classified the vascular status as follows for clinical reporting:[12]
- Present pulses with a warm hand
- Pulseless with a warm hand
- Pulseless with a cold hand.
Besides the clinical assessment of the radial and ulnar artery pulse, a handheld Doppler is a useful tool at the emergency room for the assessment of swollen limbs where pulsation is not readily felt. A formal Doppler ultrasonography can be done if there is suspicion. The clinical perfusion of hand perfusion is a reliable indicator as there are collaterals that originate above the elbow and perfuse the hand even when there is an arterial spasm or injury. Clinical indicators of perfusion to watch for are normal capillary refill, skin temperature, and pink digits. The child with a vascular injury can have severe forearm pain, loss of motor power, pain with passive stretch of the finger, and paresthesia. A documented vascular injury and poor perfusion is a surgical emergency.
Radiology
Supracondylar fracture in children needs only plain radiographs to identify and classify the fracture. To interpret the X-ray findings of pediatric elbow, the surgeon must have sound knowledge of the normal ossification pattern of the distal humerus and proximal radius and ulna and its variants [Table 3]. The general rule is to compare the X-ray to the opposite side for confirmation. [Table 3] gives the general time frame of the appearance of secondary ossification centers around the elbow.
| Radiographs | | |
Recommended views
Standard radiographs for supracondylar fractures include AP of distal humerus, lateral view of the elbow with the forearm in neutral rotation, and Jones view or shoot-through view of the elbow [Figure 3]a and [Figure 3]b. When in doubt, internal and external rotation views of the elbow are taken. It is difficult to position the child for X-ray in view of the pain and apprehension of the child and parents. We find it easy to position for X-ray, with the child sitting on a stool and the elbow resting on the cassette [Figure 4]a and [Figure 4]b. | Figure 3: (a) AP and lateral X-ray of the elbow. (b) Shoot-through or Jones view
Click here to view |
 | Figure 4: (a) AP of the distal humerus. (b) Lateral elbow X-ray and Jones or shoot-through view
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| Radiographic Measures | | |
Indicators of occult fractures
Fat pad sign
There are three areas where fat pads overlie structures around the elbow. One is in the coronoid fossa anteriorly, the second is in the olecranon fossa posteriorly, and the third fat pad overlies the supinator muscle. Classical fat pad sign of the elbow [Figure 5] is the elevation of anterior/coronoid and posterior fat pad overlying the capsule in lateral view. This occurs due to distention of the capsule because of edema and is seen in supracondylar fractures and early infection. Posterior fat pad elevation is more specific for SC fracture as compared to the anterior fat pad. The sign occurs only when the capsule is intact. The supinator fat pad is elevated in fractures of the radial head.
| Indicators of Displacement | | |
Anterior humeral line
The line drawn along the anterior border of the distal humerus shaft passes through the middle third of the ossification center of the capitellum.[18] If the line passes through the anterior third of the ossification center it indicates posterior angulation and posterior angulation if it passes through the posterior third [Figure 6].
Coronoid line
A line drawn along the anterior border of the coronoid just touches the ossification center of the capitellum anteriorly [Figure 7].
| Indicators of Carrying Angle | | |
The humeral–ulnar angle
It is the angle formed by the intersection of lines drawn along the long axis of the shaft of the humerus and the long axis of the ulna in AP view. It is the most accurate measure of the clinical carrying angle [Figure 8].
Baumann's angle
The ossification center of the lateral condyle in AP view is oblique and extends to the lateral crista of the trochlea. This oblique physeal line forms an angle with the long axis of the shaft of humerus and is called Baumann's angle. This angle is not an accurate measure of carrying angle and also varies with cephalad or caudal rotation or angulation by more than 20°. It also changes with the rotation of the distal fragment. It has to be compared to the normal opposite side, and a difference of more than 5° is significant. According to Mauricio Silva,[20] the Baumann's angle of the humerus is a simple, repeatable, and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the pediatric population with an excellent interobserver reliability. The mean Baumann's angle was found to be 72° standard deviation: 4°, and 95% of normal elbows had a Baumann's angle of 64°–81°[19] [Figure 9].
| Radiographic Patterns | | |
The patterns are based on the modified Gartland classification:
Type 1 fracture is an undisplaced fracture, with bony tenderness over the supracondylar area and positive posterior and/or anterior fat pad sign [Figure 10]a. | Figure 10: (a) Type I – Anterior and posterior fat pad sign. (b) Type II –nsupracondylar fracture with hyperextension – Note anterior humeral line relationship loss
Click here to view |
Type 2 is a hinged fracture, intact posterior cortex but no rotation. The anterior humeral line does not pass through the capitellum and coronoid line is displaced [Figure 10]b.
Type 3 is displaced fracture, 3A is posterior medial displacement, and 3B is posterior lateral displacement. There may be associated comminution [Figure 11]a, [Figure 11]b and [Figure 12]a, [Figure 12]b.[2] | Figure 11: (a) Type III – Posterior medial displacement. (b) Type III – Posterior lateral displacement
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 | Figure 12: (a) Medial physeal compression/injury. (b) Posterolateral comminution
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| Classifications | | |
Gartland classification
The Gartland classification [Table 1] is the most commonly used to describe extension-type supracondylar fractures. This is based on the extent of radiographic displacement of fragments.
Decision-making on Type II fractures continued to be difficult and their behavior was difficult to predict with Gartland classification. Wilkins[15] modified the Gartland classification by dividing Type II fractures into subtypes A and B [Table 4] to help with treatment decision-making in Type II fractures. The subtypes help predict the behavior and stability of the Type II fractures after reduction and direct decision-making of whether to proceed with conservative or operative treatment in a particular Type II fracture.
Leitch et al.[21] further added a Type IV fracture to the Gartland classification. These fractures are unstable in both flexion and extension because of complete tear of a periosteal hinge (traumatic or because of forceful flexion during reduction maneuvers).
| Approach to Treatment | | |
Management of supracondylar fracture of humerus (extension type) is according to the modified Gartland classification [Table 5].[14]
Type I fractures
The Type 1 fractures can be managed with 3–4 weeks of long-arm cast immobilization with the elbow flexed to 90° and forearm in neutral rotation.[15]
Type II fractures
Management of Type II fracture is controversial with varied opinions on the management of IIA and IIB types. Type IIA can be managed with closed reduction and immobilization. They require close observation to note a loss of reduction and appropriate care if it occurs. Type IIB is better managed with closed reduction and pinning.
Type III fractures
These are best managed with closed reduction and pinning. After successful closed reduction, pins can be used in various configurations [Figure 13]. | Figure 13: Pin configurations: (a) Three lateral K-wires, (b) two lateral and one medial K-wires, and (c) three lateral (using olecranon fossa for cortical purchase) and one medial K-wires in comminution
Click here to view |
These are kept for a period of 3–4 weeks with periodic radiographs to check for loss of reduction. After 3–4 weeks, K-wires can be removed and the child can be managed in a sling with elbow range of motion exercises.[4]
Type IV fractures
In these fractures, instability is present in flexion and extension. Therefore, an attempt to rotate the arm for a fluoroscopic lateral view will result in displacement. It is, therefore, desirable to rotate the C-Arm Unit. Leitch et al.[21] recommend that pins may be placed in a distal fragment before reduction is attempted.
| Special Cases | | |
Delayed presenters
In some unavoidable situations, especially in the Indian context,[11] supracondylar fractures present late (6–21 h) to the surgeon. In such situations, the limb is usually quite swollen and tense. Many times, there would have been a previous visit to a native bonesetter and oil massage at that center.
Even though it was a traditional practice to treat supracondylar fracture as emergency even at night, citing swelling increase, difficulty with closed reduction, pin infection, vascular injury, or compartment syndrome, this practice is now questioned by studies. Although open reduction may be required to achieve a reduction in such cases, Gupta et al.[22] studied the effects of delayed presentations and concluded that delay (12 h) in operative treatment in the absence of significant soft-tissue or vascular injury did not increase the rate of open reduction or compromise perioperative risks. This also corroborates with the results of other authors like Mehlman et al. Of the 69 Type III fractures reported by Gupta et al., in their series with a delay of 12 h, only 6% of fractures required open reduction.
Most authors conclude that in the absence of vascular injury, it is safe to immobilize the elbow in long-arm plaster at about 20°–40° of flexion and keep the child under close observation for neurological or vascular injury. Children can be observed through the night and operated in the morning in the absence of neurovascular deficits.[15] In very young and children with cognitive disabilities, it is very important to have a high degree of suspicion for compartment syndrome.
Open reduction
Failure to achieve closed reduction is the most common indication for open reduction. Even late presenters without significant soft-tissue or vascular injury deserve a trial of closed reduction. Open reduction is done most commonly via the lateral or anterior approach.
Anterior approach allows visualization of vital structures and also allows us to deal with soft-tissue obstructing reduction at the fracture site.
Lateral approach is also a well-recognized approach to reduce and pin these fractures.
| Complications | | |
The complications of supracondylar fractures can be at the time of presentation, during treatment, or after healing. These will be elaborated in a separate section.
At presentation
- Neurological injury to median, anterior interosseous, radial, and ulnar nerves
- Injury to vascular structure, brachial artery
- Compartment syndrome in delayed presenters.
During treatment
- Iatrogenic vascular or nerve injury
- Pin tract infection
- Loss of reduction and malunion
- Compartment syndrome.
After healing/neglected cases
- Cubitus varus due to malunion
- Sequelae of nerve of vascular injury
- Volkmann ischemic contracture after compartment syndrome.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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