Supracondylar Fracture Flashcards
Epidemiology of Supracondylar fractures
Common in children with a peak incidence at 5-7 years
Very rare in adults
Mechanism of injury
FOOSH with elbow in extension
Rarely by landing directly onto a flexed elbow
Common associated injury with supracondylar humeral fractures
Damage to surrounding neurovascular structures
Clinical features
Recent fall or direct trauma
Sudden-onset severe pain + reluctance to move affected arm
Examination findings
Gross deformity
Swelling
Limited range of elbow movement (mainly due to pain)
Ecchymosis of anterior cubital fossa
Other examinations to be done
Neurovascular examination + joint above and below.
What nerves should be examined?
Median nerve
Anterior interosseus nerve
Radial nerve
Ulnar nerve
What vascular examinations should be done?
Check the hand for features of vascular compromise
Are hands cold?
Pallor?
Delayed capillary refill time?
Absent pulses?
Urgent orthopaedic review is required for all supracondylar fractures
Dx
Distal humeral fracture
Olecranon fracture
(Important to exclude because management will vary)
Soft tissue injury
Subluxation of radial head
Investigations
AP and lateral plain film radiographs.
CT imaging can be useful for comminuted fractures or where intra-articular extension is suspected.
X-ray findings
Posterior fat pad sign (lateral view)
Displacement of the anterior humeral line
What classification system is used in supracondylar fractures?
Gartland classification
Explain Gartland classification
1 - Undisplaced
2 - Displaced with intact posterior cortex
3 - Displaced in two or three planes
4 - Displaced with complete periosteal disruption (can only be diagnosed intra-operatively)
Management can be either conservative or surgical.
What decides which to use?
Type 1 is usually trialled with conservative management.
Also type 2 with minimally displaced fracture can be tried for conservative management.
Explain conservative management.
Above elbow cast in 90 degrees flexion with analgesia
Indications for surgical management.
Neurovascular compromise (needs immediate closed reduction)
Type II, Type III, Type IV nearly always require closed reduction.
Open fracture
Explain surgical management.
Neurovascular compromise, Type II, III and IV requires closed reduction with percutaneous K-wire fixation
Open fracture should be fixed by open reduction with percutaneous pinning
If closed reduction fails -> Do open reduction
Ongoing vascular compromise not fixed by reduction warrants vascular exploration by vascular surgeon
When can K-wire be removed?
3-4 weeks after in clinic.
Complications
Nerve palsies
Malunion
Volkmann’s contracture
Nerve palsies in supracondylar fractures
Neuropraxia rate is around 10% but rarely result in permanent damage
Anterior interosseous nerve (from median nerve) is most commonly damaged.
Ulnar nerve is also quite common (especially during insertion of medial K-wire)
Features of anterior interosseus nerve damage
Weakness in the muscle innervated by the AIN including the flexor digitorum profundus muscle to the index (and sometimes the middle) finger, the flexor pollicis longus muscle to the thumb and the pronator quadratus of the distal forearm.
There are no sensory fibres from AIN
Malunion in supracondylar fractures
More common in fractures managed suboptimally.
Cubitus varus deformity might develop (gunstock)
Volkmann’s contracture in supracondylar fracture.
Due to vascular compromise (brachial artery) leading to ischaemia and subsequent necrosis of flexor muscle of the forearm.
They will then fibrose and form a contracture
This leads to wrist and hand held in permanent flexion as a claw-like deformity.
