distal fractures of the humerus........ Flashcards
at what age does supracondylar fractures peak ? and why ?
at 7 years of age due maximum ligament laxity
supracondylar fracture of the humerus is called the pulseless hand?
pulseless hand
fracture displacement -injuring the radial and median nerve and brachial artery and injury to the surrounding tissue
extension injury - anterior interosseous nerve injured and child unable to do the ok sign
flexion type - ulnar nerve injury
physical should perform careful neuromuscular examination on supracondylar fractures
if increased demand for analgesia = COMPARTMENT SYNDROME
CAPILLARY REFILL should be less than 2 sec
pallor
cold hand
and edema signs for pulseless hand
suggestive vascular injury - antecubital ecchymosis
what are the fracture types ?
supracondylar fractures
single column (condyle) fractures - lateral condyle more common
bicolumn fractures
coronal shear fractures
distal intercondylar fractures are the most common fracture patter
pathoanatomy of distal humeral fractures ?
elbow position affects fracture type
elbow flexed < 90°
axial load leads to transcolumnar fracture
elbow flexed > 90°
may lead to intercondylar fracture
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supracondylar fractures - IN CHILDREN
extension type
flexion type is rare occurs when falling directly on a flexed elbow
what causes an extension type supracondylar fracture ?
falling on outstretched hand
what branch is the anterior interosseous nerve from ? injury to the anterior interousus nerve causes what problems ?
branch of the median nerve
weakness of flexor digitorium profundus muscle of the index finger - the lateral part
flexor pollicis longus muscles
causing the patient not to do the ok sign with his or her hand
what are the classification for supracondylar fractures ? and their treatment
gartland classification for
extension type
type 1 - non displaced fracture line
cast immobilisation for 3-4 weeks
COLLAR AND CUFF BANDAGE
type 2 - angulated but with an intact posterior cortex
treated with closed reduction and percutaneous pinning
type 3 - completely displaced
treated with closed reduction and percutaneous pinning
flexion type -
crpp and
type 3 high incidence for compartment syndrome
what are the closed reduction techniques in supracondylar humeral fractures ?
the child is laid down
the arm is extended to approximately 10° short of full extension. With an assistant supporting the proximal humerus
axial traction on the forearm and wrist should be maintained for at least 5-10 minutes.
goal of this maneuver is to align the fragments by disengaging the humeral shaft from the anterior muscles and skin
The “pucker sign”, if present, will also be visibly reduced.
If reduction cannot be achieved and there is no clear bone contact, the pierced brachialis muscle might be entrapped. A milking maneuver over the muscles (biceps and brachialis muscle), starting in the middle of the humerus and continuing distally, can be done in an attempt to release the muscle
Correction of medial/lateral translation and varus/valgus deformity should be done if visible on x-ray.
Angulation and translation are corrected by direct manipulation, using a thumb and index finger on the epicondyles. The correction is verified using an image intensifier.
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Reduction of extension angulation
maintain the correction of rotational, varus/valgus, and/or translational displacement,
the elbow is flexed with the hand in supination.
For this maneuver, the thumb is placed on the olecranon and pushes it anteriorly while the rest of the hand fixes the humerus.
The fracture is reduced only if the elbow can be flexed more than 120°. If the elbow cannot be flexed more than 120°, it is a sign that the distal fragment still remains posterior, that the complete length has not been regained, or there is muscle entrapment.(the maneuver has to be repeated)
the forearm should be rotated so that it is fully pronated when the arm reaches full flexion. The pronation helps to tilt the distal fragment out of any varus position and also assists in stabilizing the fracture
The elbow is maintained in full flexion and the reduction is verified
The integrity of the posterior periosteum should be preserved, because it helps to reduce and stabilize the fracture as a tension band.
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OR USE Dunlop’s traction
what is the reduction technique in flexion type supracondylar humeral fractures ?
account for less than 5% of all supracondylar fractures.
anterior periosteum is mostly intact
the arm is extended to approximately 10° short of full extension.Gentle longitudinal traction is applied for 4-5 minutes.
A good reduction should be attempted through direct manual manipulation of the distal fragment, which is anteriorly displaced.
Then the length and alignment are verified using image intensification.
Once the fracture has been reduced, the elbow can be flexed to 90°, while maintaining the thumb pressure over the distal fragment.
The alignment must be checked under image intensification in a lateral view.
If lateral and rotational alignments are perfect, internal fixation by K-wires is recommended. K-wire fixation in this type of fracture can be difficult as these fractures are often oblique.
diagnosis of supracondylar fractures?
ap view
and lateral elbow view
look at fat pad for occult fracture - such as the sail sign (joint effusion)
(2)
normal to have an anterior fat pad but no posteriori fat pad at all - there is an occult fracture
in lateral view the anterior humeral line - should intersect the middle third of the capitulum
(3)
complication of supracondylar fracture ?
there is vascular compromise in up to 20 percent due to the upper part of the fracture segment displaced anteriorly and causes brachial artery injury - radial pulse absent
for the extension type
injury most commonly anterior interosseous neuropraxia (branch of median nerve)
radial nerve neuropraxia (wrist and finger extension)
for the flexion type
the distal fragment may cause ulnar neuropraxia
fracture minion - causes cubitus valgus
volkman ischmic contracture - occurs due to compression of the brachial artery when the cast is applied in hyeprflexion of more than 90 degrees
is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful.acute ischaemia and necrosis of the muscle fibres of the flexor group of muscles of the forearm, especially the flexor digitorum profundus and flexor pollicis longus. The muscles become fibrotic and shortened.
compartment syndrome - if dysvacularity for more than6 hours -Volar compartment fasciotomy
the ulnar nerve neuroparexia causes what ?
muscular branch of ulnar nerve :
flexor capri ulnaris - flexes the wrist
flexor digitorium profundus - the medial part
deep branch
hypothenar muscles for flexing and abducting
adductor pollicus
cutaneous - dorsal and palmar side of the ulnar half
what are the classification of fracture types ?
AO classification
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distal single column fractures = Milch classification
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distal bicolumnar fractures
classified using Jupiter classification
5 major articular fragments have been identified:
capitellum/lateral trochlea lateral epicondyle posterolateral epicondyle posterior trochlea medial trochlea/epicondyle
what is the AO classification ?
type a - Extraarticular (supracondylar fracture),80% are extension type; epicondyle
type b - intraarticular-Single column
type c -Intraarticular-Both columns fractured
what is milch classification ?
Milch Type I Lateral trochlear ridge intact
Milch Type II Fracture through lateral trochlear ridge
