Paediatric Supracondylar Humeral Fractures

Definition

  • Fracture through the distal humerus just proximally to the growth plate

Aetiology

  • Most commonly fall on outstretched hand with extended elbow-
  • Extension injury with posterior fragment displacement most common ~98% of all injuries
  • Rarely flexion injuries can occur with anterior fragment displacement ~2% of all injuries

Epidemiology

  • Most common fracture of the elbow in kids accounting for approximately (3%) of all paediatric fractures
  • Peak incidence age 5-7 years old

Anatomy

Ossification CentreOssification (Years Old)Fusion (Years Old)
C- Capitellum0 – 110 – 15
R- Radial head2 – 612 – 16
I- Internal (Medial) Epicondyle2 – 813 – 17
T- Trochlea5 – 1110 – 18
O- Olecranon6 – 1113 – 16
E- External (Lateral) Epicondyle8 – 1312 – 16
Order of ossification of the elbow bones- Occurs by commonly by the acronym CRITOE
On average girls will develop ossification and fusion of these sites prior to boys by about 1-2 years.

Pathology

  • 95 % are hyperextension type with olecranon as the fulcrum
  • rotation leads to instability & tilting

Classification

Gartland Classification

  • Lateral radiograph is used to determine the staging for this classification.
TypeDescription
1ANon or minimal displaced
1BNon displaced with medial impaction
2ADisplaced with angulation however posterior cortex intact.
2BDisplaced with angulation however posterior cortex intact. Some degree of rotatation or translation of fracture present.
3Complete displacement ( usually posteromedial)
Modified Gartland Classification of Supracondylar Fractures
  • Further classification should include other features (extension/flexion) and any neurological/vascular involvement

Type II Supracondylar Fracture Type II Supracondylar Fracture

History

  • Pain and swelling of affected elbow
  • Decreased use/function
  • Fall on to outstretched hand with straight elbow

Examination

  • Presents with painful swollen elbow
  • Neurological assessment
    • AIN most commonly affected nerve in extension injury (AIN>median>radial>ulnar)
    • Ulna most commonly injured in flexion injury
  • Vascular status
    • Distal Pulses
    • Peripheral perfusion (eg CRT)
    • Often categorised as normal, pulseless with pink hand (pulseless but CRT retained) or pulseless with white hand (dysvascular)
    • Emergency surgery is indicated for pink pulseless hand and dysvascular presentations
  • Examination can be difficult due to age of patient and pain/fear. Comprehensive examination and documentation of neurovascular status should however always be performed.

Investigations

  • X-Ray
    • best investigation to assess for fracture
    • AP/Lateral images
    • if no fracture visible, the presence of a posterior fat pad on XR can indicate the presence of an underlying fracture
    • anterior humeral line
      • measured from lateral humeral XR
      • anterior humeral line is a marker drawn down the anterior humerus, should intersect with the middle third of the capitellum ossification site (may be in the anterior third in kids under 4)

Differential Diagnosis

  • Lateral condyle fracture
    • second most common paediatric fracture (12-20% of all paediatric fractures)
    • highly associated with missed diagnosis causing long term issues with non union/mal union

Treatment

  • Type 1A
    • above elbow cast for 3 weeks
  • Type 1B
    • above elbow cast for 3 weeks
    • if significant varus exists manipulate & if manipulated pin it
  • Type 2A
    • Debate exists to whether casting or percutaneous pinning is most appropriate
    • Percutaneous pinning growing favour of treatment however casting may still be viable
  • Type 2B
    • Closed reduction and percutaneous pinning
  • Type 3
    • Closed reduction & percutaneous pinning is the standard
    • Open reduction is rarely required

Surgical Technique

  • Considerations
    • Capitellum should not be posterior to the anterior line of the humerus
    • Closed reduction & percutaneous pinning is the standard
    • Open reduction is rarely required
    • Medial versus lateral incision
    • S shaped anterior incision if vascular repair is required
    • Medial displaced – pronate
    • Laterally displaced – supinate
  • Technique
    • GA
    • Traction to  disengage the proximal fragment from the brachioradialis
    • Then fix the translation in the coronal plane
    • Correct rotational deformity
    • Follow this with bringing the olecranon back over, like reducing an elbow dislocation
    • Bring the arm out in extension & pronate or supinate
    • Now pin lateral & then extend elbow for medial – 0.062 pins
    • Assess an adequate Reduction:
      • Anterior humeral line bicects the capitellum
      • Bowman angle within 5° of the contralateral side
      • diameter of the fracture ends are equal
    • If pulseless – reduce, then reassess pulse if viable pin the arm, if not viable pin the arm & follow with vascular repair
  • Late cubitus varus is treated with an osteotomy

Complications

  • Chance of ipsilateral distal radius fracture
    • supracondylar fractures with associated diaphyseal fractures are at an increased risk of compartment syndrome
  • Neurovascular compromise
    • Traumatic
      • AIN>median>radial>ulnar
    • Iatrogenic
      • Often ulna nerve injury
    • Most recover within 2-3 months
  • Cubitus Varus
    • most common complication as result of fracture
    • potential complication regardless of casting or pinning
    • painless complication however may be linked with increased risk of elbow instability later in life
    • for children with substantial residual cubitus varus, lateral osteotomy should be considered
  • Pin Site Infections
    • ~1-2% of pinning operations

Prognosis

  • With correct diagnosis and appropriate treatment good outcomes are expected with minimal long term issues or complications
  • Delays in identifying and treating neurovascular compromise however can cause long term issues for the patient, therefore thorough examination and early involvement of orthopaedics is required

T Condylar Fracture

  • Adolescent type fracture & treat with fixing the articular surface first

References

  • Abzug, Joshua M. MD; Herman, Martin J. MD Management of Supracondylar Humerus Fractures in Children: Current Concepts, Journal of the American Academy of Orthopaedic Surgeons: February 2012 – Volume 20 – Issue 2 – p 69-77 doi: 10.5435/JAAOS-20-02-069
  • American Academy of Orthopaedic Surgeons EvidenceBased Clinical Practice Guideline for the Treatment of Pediatric Supracondylar Humerus Fractures
  • Kumar V, Singh A. Fracture Supracondylar Humerus: A Review. J Clin Diagn Res. 2016;10(12):RE01-RE06. doi:10.7860/JCDR/2016/21647.8942
  • Author Contribution
  • Miyazaki CS, Maranho DA, Agnollitto PM, Nogueira-Barbosa MH. STUDY OF SECONDARY OSSIFICATION CENTERS OF THE ELBOW IN THE BRAZILIAN POPULATION. Acta Ortop Bras. 2017;25(6):279-282. doi:10.1590/1413-785220172506170954
  • Tejwani, Nirmal MD; Phillips, Donna MD; Goldstein, Rachel Y. MD, MPH Management of Lateral Humeral Condylar Fracture in Children, American Academy of Orthopaedic Surgeon: June 2011 – Volume 19 – Issue 6 – p 350-358

Author Contribution

Updated by Dylan Ellis 2021

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