Etiology

Most common < 10 years, peak age 5-8 y.o.


80% of all pediatric distal humerus fractures


2:1 males


Classification


Extension type: Extension type accounts for 90-98% of all supracondylar fx’s

Gartland Classification


I: nondisplaced

IIA: displaced, posterior cortex intact; rotationally stable

intact posterior cortex acts like a hinge


IIB: displaced, posterior cortex intact; rotationally unstable

III: completely displaced, no cortical contact

most often a medial periosteal sleeve intact when medially displaced and visa versa


Closed Reduction


Reduction Maneuver


Traction: disengages the proximal fragment from the brachialis ms


Coronal plane correction: medial or lateral translation


Axial plane correction: correction of internal rotation deformity


Distal fragment reduced: push with thumb on olecranon


Elbow flexion >100°


Pronation: tightens medial periosteal sleeve

Notes:


Closed reduction is NOT attempted in type III fx’s


Reduction under flouro control is recommended


In the laterally intact periosteal sleeve, supinate to lock it in

Assessing adequacy of reduction:


Jones view: hyperflexionn shoot through elbow; distal humerus resting on c-arm for coronal reduction assessment…difficult to interpret due to imposition of the proximal forearm


Baumann’s Angle: comparison to uninjured side, difference >5degrees is unacceptable


Anterior Humeral Line

Other Methods: restoration of olecranon fossa anatomy, humero-ulnar angle, crescent sign (overlapping of the ossification centers of the lateral epicondyle and olecranon on a lateral view is unacceptable)

Definitive Treatment


Type I Fracture

Immobilization: long arm cast in 90° elbow flexion, neutral forearm


Repeat radiographs @ 1 week: checking fracture hasn’t drifted into varus


3 weeks: protected ROM, elbow exercises


Notes:


Conservative treatment guided by lack of displacement, rarity of NV comprismise


May or may not admit overnight for assessment of NV status, compartments

Type II Fracture

Hyperflexion required to maintain reduction


Immobilization: long arm cast, long arm cast split, or long posterior splint with lateral struts


Observe overnight for NV and compartment assessment


3 weeks: protected ROM, elbow exercises


CRPP: significant swelling, inadequate circulation with elbow flexion, rotationally unstable injury

Notes:


Millis et al CORR 1984 showed that 120degrees of flexion needed to maintain closed reduction of type II supracondylar fractures


Casting these injuries as means of definitive treatment carries risk of compartment syndrome, as swelling is not allowed in the cast…this is especially true with the greater amount of flexion used to maintain the reduction

Type III fracture:

higher energy injury


Increased swelling and soft tissue injury


Difficult reduction, therefor: "Splint it where it lies" f/b CRPP


More complications: Admit for NV and compartment assessment


CRPP Technique

Sterile draped C-arm operating surface


Lateral pin first


0.062mm small child


5/64inch older child

Starting point: lateral condyle immediately lateral to olecranon fossa


Across capitellum and distal humeral physis


Engage medial humeral cortex


2 lateral pins may achieve stability


Notes:


Maintain ~120 flx full pronation / use Jones view of elbow / may externally rotate through the shoulder to avoid moving C-arm / fracture site


First pin: don’t attempt perfect center of lat cond; want to leave room for 2nd lateral pin

Medial pin:


*80-90° elbow flexion: Less elbow flexion for medial pin as more flexion will bring ulnar nerve volar into Kwire’s path, and lateral pin is providing some stability. Utilize c-arm before firing to assure you are not in the ulnar groove

*Starting point: Different angle taken with medial pin will make it more transverse than lateral pin


*Mini-incision over medial epicondyle


*Spread with hemostat assuring ulnar nerve position

Post Operative Care

Leave pins protruding


Re-assess vascular status before drape removal


Splint: 60-90° elbow flexion with neutral forearm


Admit overnight for NV checks


Pin removal in 3-4 weeks: PT usually not required


Open Reduction


Indications:

Irreducible by closed methods


Vascular comprimise


Open fractures


Notes:


Wilkins Ortho Clin 1990 talked about brachialis entrapment in fracture site consistently requires open reduction


Vascular: poor color after closed reduction; kids vascular exam comments on pink warm digits as an actual palpable pulse not necessarily as important

Open Approach

Transverse Antecubital Incision


Enlarge Incision:


Medial side: proximal


Lateral side: distal

Notes:


Posterolateral displacement with NV comprimise: anteromedial approach


Consider: area of NV injury and periosteal disruption

Complications:


Neurologic Injury

5-19% of supracondylar farctures


Type III supracondylar fractures:

Median nerve 52% (especially posteromedial displacement)


Radial nerve: 28%


Most are neuropraxic injuries


Motor Recovery: 7-12 weeks


Sensory: ~6 months

Notes:


Nerve injury can also occur s/p CRPP Royce et al JPO 1991: 143 supracondylars treated CRPP 4 nerve palsies were found, ALL from medial pin. They also found an iatrogenic nerve injury rate of 2-3% after CRPP. This is why Pediatrics Ortho attendings often prefer 2 lateral pins before going medial.

Wound / Nerve Exploration Indications

Culp et al JBJS 1990 nerve injury in supracondylar fx’s: 5 months after injury with NO clinical or EMG evidence of return


Open fracture over disrupted nerve


Neurologic impairment after closed reduction

Arterial Injury


*5-12%

Shaw et al JOT 1990: immediate CRPP restored pulse in 13/17 pulseless supracondylar fractures. Their study also found that arteriography preoperatively would not have contributed to the management of these injuries as thos still lacking a pulse after CRPP were opened and explored acutely and found to have brachial artery disruption at the fracture site.





Angular Deformity_

Distal Humeral Physis: 20% of longitudinal growth


Remodeling: plane of motion only


NO coronal remodeling


NO axial remodeling

Cubitus Varus: Cosmetic in the short term

Recent studies show that in the long term, varus may lead to posterolateral rotary instability of the elbow


Caused by malreduction


11% due to medial distal physeal disruption


Osteotomy: cosmetic procedure


Delay until 1 year post injury to await possibility of medial growth arrest being responsible for deformity; if so lateral epiphysiodesis would accompany osteotomy

Osteotomy Options:

Lateral closing wedge osteotomy


Dome rotational osteotomy


Step-cut lateral closing wedge osteotomy


Compartment Syndrome


*1% incidence: Ottolengi et al European study with 830 supracondylars

Volkman’s Contracture

Be aggressive


Compartment syndrome may be masked by median nerve disruption


Fasciotomy:

Clinical signs


Pressure >30 mm Hg OR within 30 mm Hg of DBP


Flexion-type Supracondylar

1-10% of all supracondylar


Gartland Classification


Reduction Maneuver: elbow extension

Varus force addresses anterolateral displacement


Treatment: CRPP

Casting in elbow extension difficult for patient to deal with


Gartland Classification: nondisplaced / intact anterior cortex / complete displacement usually ant lat

Across to lateral column


Cross lateral pin above olecranon fossa


Engage lateral humeral cortex