SC - Fracture ZMH

Pediatric Supracondylar
Humerus Fractures
Capt Zaw Myo Han

1
Introduction
Most common elbow fracture in

children
Most commonly occurs in 5-7 yrs
Common mechanism is from a low

energy fall
2
 Fractures of the distal humerus in children are most
often supracondylar (70%) or involve a single
condyle.
 Radiographic assessment - difficult for non-
orthopaedists, because of the complexity and
variability of the physeal anatomy and development
 A thorough physical examination is essential,
because neurovascular injuries can occur before and
after reduction
3
CRITOE
 Capitellum (2years)
 Radius(4years)
 Internal (or medial)
epicondyle(6years)
 Trochlea(8 years)
 Olecranon(10 years)
 External (or lateral)
epicondyle(12 years)
Mechanism of injury
 Posterior angulation or displacement (95

per cent of all cases) hyperextension
injury, due to a fall on the outstretched
hand.
 The humerus breaks just above the
condyles. The distal fragment is pushed
backwards and (because the forearm is
usually in pronation) twisted inwards.
 Anterior displacement is rare; due to
direct violence with the joint in flexion.
5
Extension Type
• Common ,97.7%
• Monkeybars, trampolines, cartwheels, etc
• In extension type fracture line runs
upwards and backwards
Flexion type
• Uncommon,2.3%
• In flexion type it runs downwards and
backwards
6
Extension Type Fr
When forced into hyperextension, the olecranon can act as a fulcrum through
which an extension force can propagate a fracture across the medial and
lateral columns
Flexion Supraconylar Fr
A posteriorly applied force with the elbow in flexion creates a flexion-

type supracondylar humeral fracture (arrow).
Clinical features
 PHYSICAL EXAM
• Pain
• Refusal/inability to move the
elbow
• Deformity proportional to
displacement
• Swelling & bruising
• Skin integrity
•Tenting/compromise
• Open fractures
9
10
11
 Brachialis sign:
• Antecubital ecchymosis
• Skin puckering
• Subcutaneous bone
fragment (soft-tissue
interposition)
• Indicator of:
• Significant injury and
swelling
• Potential failure of closed
reduction
12
 NEUROVASCULAR EXAM
• Neurologic exam can be

challening in injured child but
important to document pre-
manipulation exam
• Pulseless hand may still be

perfused because of excellent
collateral circulation in
pediatric elbow Rockwood
and Green
13
 VASCULAR INJURY
• Occurs in 0.5-5%
• Vascular status
• Assess pulse
(palpation or doppler)
• Assess perfusion
• Capillary refill (<2s)
• Warmth of fingers
• Color of skin
14
Three Categories Of Vascular Status
1. Hand well perfused ( warm and red ) , radial pulse present
2. Hand well perfused ( warm and red ) , radial pulse absent
3.Hand poorly perfused ( cool and blue) , radial pulse absent

15
 NEUROLOGIC EXAM
• Median nerve: sensation pulp of index
finger
• Anterior interosseus nerve: flexion IP
thumb and DIP index
• Radial nerve: sensation dorsum of thumb
• Posterior interosseus nerve: extension IP
thumb
• Don't be fooled by intrinsics (extension
finger IPs)
• Ulnar nerves: finger abduction/adduction
BEDSIDE TEST (many options):
Thumbs up (PIN) - Cross Fingers (Ulnar N) -
AOK (AIN)
16
 RISK FACTOR:
• Median Nerve /AIN
Injuries:
posterolateral
displacement
• Radial Nerve
Injuries:
posteromedial
displacement
• Ulnar Nerve Injuries:
flexion types
17
 Radiographs may be misleading because
 (1) the fragment consists mainly of
cartilage;
 (2) in an immature child the fragment
seems smaller than it actually is; and
 (3) the displacement, although it is
pronounced, may not seem appreciable.
18
X-ray positioning The correct method of taking a lateral
view is with the upper extremity directed anteriorly rather
than externally rotated.
19
IMAGING
• XR usually sufficient
• AP + LAT of elbow
• Ipsilateral forearm/wrist
• Look for posterior fat pad
sign in non displaced
fractures (arrow)
• Advanced imaging rarely
indicated (intra-articular
variant)
20
21
GARTLAND CLASSIFICATION
• Fracture Type: Characteristic
Type 1: Nondisplaced
Type 2:
• Angulation
• Posterior hinge intact
Type 3:
• Complete displacement
• Loss of posterior hinge
22
Baumann’s angle
23
Elbow Fractures
Radiograph Anatomy/Landmarks
 Baumann’s angle is formed by a

line perpendicular to the axis of
the humerus, and a line that goes
through the physis of the
capitellum
 There is a wide range of normal
for this value
 Can vary with rotation of the
radiograph
 In this case, the medial impaction
and varus position reduces
Bauman’s angle
Elbow Fractures
Radiograph Anatomy/Landmarks
 The capitellum is
angulated anteriorly about
30 degrees.
 The appearance of the
distal humerus is similar to
a hockey stick.
30
Type 1
Non-displaced
 Note the nondisplaced fracture

(Red Arrow)
 Note the posterior fat pad

(Yellow Arrows)
-Skaggs. The posterior fat pad sign in association with occult fracture of
the elbow in children. J Bone Joint Surg Am. 1999;81:1429.
-Bohrer. The fat pad sign following elbow trauma. Its usefulness and
reliability in suspecting “invisible” fractures. Clin Radiol. 1970;21:90.
Type 2
Angulated/displaced fracture with
intact posterior cortex
Type 3
Complete displacement, with no contact
between fragments
29
30
31
32
 Depending on the type of fracture,
there are four basic types of
treatment:
 (1) side-arm skin traction,
 (2) overhead skeletal traction,
 (3) CRPP, and
 (4) ORIF.
33
Supracondylar Humerus Fractures Treatment
 Type 1 Fractures
 immobilization for approximately 3 weeks,
at 90 degrees of flexion
 Ifthere is significant swelling, do not flex
to 90 degrees until the swelling subsides
 Recheck after 5-7 days ( displacement)
Type 2A
 swelling is usually not severe

 The risk of vascular injury is low.
 Ifthe posterior cortices are in
continuity, the fracture can be
reduced under general anaesthesia
35
step-wise manoeuvre
 (1) traction for 2–3 minutes in the length of the arm with counter-
traction above the elbow;
 (2) correction of any sideways tilt or shift and rotation (in
comparison with the other arm);
 (3) gradual flexion of the elbow to 120 degrees, and pronation of
the forearm, while maintaining traction and exerting finger
pressure behind the distal fragment to correct posterior tilt.
 Then feel the pulse
36
37
Four point check for good reduction
1 the AHL intersects the capitellum
2 Baumann's angle is greater than

10 degrees
3 Medial column is intact
4 lateral column is intact
38
TYPES II B AND III
 associated with severe swelling,

 difficult to reduce
 often unstable;
 there is a considerable risk of neurovascular injury or
circulatory compromise due to swelling.
 The fracture should be reduced under general
anaesthesia as soon as possible, and then held with
percutaneous crossed K-wires;
39
40
Anterior displaced fracture
 less than 5 per cent

 However, ‘posterior’ fractures are sometimes
inadvertently converted to ‘anterior’ ones by excessive
traction and manipulation.
 The fracture is reduced by pulling on the forearm with
the elbow semi-flexed, applying thumb pressure over
the front of the distal fragment and then extending the
elbow fully.
 Crossed percutaneous pins are used if unstable.
41
Percutaneous pin configurations
 include
 two crossed pins,
 two lateral pins (three lateral pins can be used if the
fracture is considered unstable with only two lateral
pins),
 two lateral “divergent” pins and
 two pins laterally and one medially.
42
Fixation of supracondylar humeral fractures can be done
with (A) two crossed pins or (B) two lateral pins.
A B
43
ORIF is indicated
1. for open fractures,

2. irreducible fractures,
3. vascular injuries,
4. nerve or vessel entrapment, and
5. unacceptable closed reduction.
44
 If ORIF is done,
 it should be performed emergently (<8

hours) or urgently (≤24 hours) or
 after the swelling has decreased, but not

later than 5 days after injury because the
possibility of myositis ossificans apparently
increases
45
46
 Indications for Vascular
Exploration
 Persistent non perfused hand
after adequate CRPP
 Loss of pulse after fracture
reduction
 Perfused pulseless associated
with median nerve injury
management
 Controversial
 To explore or not to explore?
 Anterior approach preferred
47
48
Complications
Early Late
 Nerve Injury  Malunion
 Brachial Artery Injury  Elbow stiffness
 Compartment  Myositis ossifican
Syndrome
49
50
THANK YOU
51

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Pediatric Supracondylar

Capt Zaw Myo Han

Most common elbow fracture in

Most commonly occurs in 5-7 yrs

Common mechanism is from a low

 Posterior angulation or displacement (95

A posteriorly applied force with the elbow in flexion creates a flexion-

• Neurologic exam can be

• Pulseless hand may still be

1. Hand well perfused ( warm and red ) , radial pulse present

2. Hand well perfused ( warm and red ) , radial pulse absent

3.Hand poorly perfused ( cool and blue) , radial pulse absent

 Baumann’s angle is formed by a

 Note the non- displaced fracture

 Note the posterior fat pad

 swelling is usually not severe

1 the AHL intersects the capitellum

2 Baumann's angle is greater than

3 Medial column is intact

4 lateral column is intact

 associated with severe swelling,

 less than 5 per cent

1. for open fractures,

 it should be performed emergently (<8

 after the swelling has decreased, but not

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