Supracondylar Fx Part I pptx - د.رائد

Supracondylar Fractures

of the Humerus
Inter-active
Part I

• Basic concepts

• Management of the fractures
• The prevention and management of the Complications will be covered in Part II.
In this first part we are going to cover:

The incidence peaks at

I. Incidence
At what age do supracondylar fractures
most commonly occur ?
Why?
3 years
7 years.
10 years

That is the age when children reach
their maximum ligamentous laxity.

When a child falls on their extended upper extremity,

which ones are most likely to sustain
supracondylar fractures?
Those who have cubitus recurvatum.

When a child falls on their extended upper extremity,

which ones are most likely to sustain
distal radius fractures?

distal radius fractures?
Those who lack full elbow extension.

Mechanism of Injury

What other factor contributes
to the development of
fractures in the supracondylar area?
The supracondylar area consists
of weak metaphyseal bone.

Very thin

cortical
structure

II. Mechanism of Injury

What is the mechanism of injury

for extension type supracondylar fractures ?

As the

extended extremity
attempts to break
the fall,
the olecranon
is forced
deep into its fossa.

This causes

the humerus to fail
in the weak metaphyseal
supracondylar area.

Into what two major types are supracondylar
fractures commonly sub-classified?
The extension type is
the
most common type.

What

type ?
Exten
sion
III. Classification

What is this less common type?

Flex
ion

How are the extension type supracondylar

humeral fractures further classified?
*
*Gartland,JJ:.
Surg Gynecol Obstet 109:145,1959.
What does his classification represent ?

How are the extension type supracondylar

humeral fractures further classified?
His types represent
no more than the
three stages
of displacement.
What are the
three stages
of displacement?

Type I

No displacement
Type II
Incomplete
displacement
Type III
Complete
displacement

Why all this

emphasis
on the classification?
It dictates
the
method of
treatment.
*
*Abraham E, Powers T, Witt P, Ray RD
Clin Orthop 171:309, 1982.

Let us examine the treatment

based upon the

Gartland Types.
IV. Extension type supracondylar fractures

What are the criteria for Type I Fractures ?

What are the criteria for Type I Fractures ?
Absence of
a crescent sign

If there was no definite fracture

seen on the injury films,
what confirms the presence
of a suspected Type I fracture?
Injury film
3 wks post fracture

fat pads displaced

Type I suspected

Periosteal new bone
The original suspicions of
a fracture are now confirmed.

How are the Type I

fractures usually treated?

Originally felt

to be undisplaced
The major pitfall is
a failure to recognize
the true nature
of the fracture pattern.

What are the two major displacement deformities occurring in Type I injuries ?
1. Medial greenstick collapse
2. Hyperextension of the condyles

This can accentuate the varus.

A more careful evaluation
of our original “undisplaced” fracture
reveals both deformities were present
on the original x-rays.

Medial greenstick collapse

Distal hyperextension
The crescent sign
indicates a varus alignment.

All of this combines to form a

very
unappealing
clinical appearance

How can one avoid this complication?

Is this
acceptable?
Is there varus?
Is the
crescent sign real?
The anterior
humeral line
barely passes
through the
capitellum.

The surgeon needs to perform both
careful x-ray and clinical assessments.
Or is it the result of
a poorly
taken x-ray?

The clinical examination involves

This allows the surgeon to determine that
the carrying angle has been maintained.

carefully coaxing the elbow into extension.

However, displacement in the
saggital plane may be difficult
to determine clinically.

What are the
criteria for
Type II fractures ?
Usually some
cortical
integrity
remains.
This integrity must
be sufficient
to prevent rotation
of the distal
fragment.

How must Type II fractures

be managed?
Treatment
1. Manipulate to obtain a reduction
then
2. Stabilize the reduction

Treatment

150
What must be accomplished with
the manipulative process?
First

This is usually accomplished

by first forcing the forearm
into pronation.
The deformities in both planes
need to be corrected.
Some manipulative correction
may need to be accomplished
in the coronal plane as well.

150

One usually meets resistance,

at the point where the shaft condylar malalignment limits flexion.
First

Then

The deformities in both planes

need to be corrected.

This usually re-establishes the saggital

alignment (shaft-condylar angle) of the distal fragment.
To obtain a complete reduction in the
saggital plane, one must
To obtain a complete reductionin the
saggital plane one must

400

How does one determine

if this fracture can be
immobilized with a cast
alone?
Following this hyper flexion, the elbow is then extended
and examined to be sure the carrying angle
has been corrected as well.

Full

The reduction has been maintained

at 1200 of flexion
and 900 of external rotation.

Determine if it is

400
.

If the reduction is stable

at 1200 of flexion,
and there is no evidence
of
vascular compromise,
how can these fractures
be best immobilized
post reduction?

Stabilization with a

may not be adequate !!

The elbow must be flexed to 120 0

Injury film

Reduced at 1200

Reduction lost

at 900

WARNING

Flexing to > 1200 may increase the risk
of vascular problems.
*
*Millis MB, Singer IJ, Hall JE.
Clin Orthop 188:90–97,1984.
to maintain the reduction .

Thus these fractures need to be immobilized

with a figure

8
cast.

Always incorporate

the sling into
the cast.

Mommy,

this sling
is
bothering me!

That’s

much
better !
But,
loss of
elbow
flexion
may
result in
a loss of
reduction.

With Type II fractures, if
there is any concern about
vascular compromise
or fracture stability
due to the severe swelling,
then secure the fragments
with percutaneous pins,
so that the extremity can be
immobilized at 90 degrees.

In fact, a recent study has demonstrated

that asymptomatic pressures of > 30mm Hg. may
occur in the deep volar forearm compartment,
even when
the elbow is flexed to just above 90 degrees.
*
*Battaglia TC, Armstrong DG, Schwend RM.
Journal of Pediatric Orthopedics 22:431,2002.
For this reason, some surgeons advocate
stabilizing all Type II fractures with pins.

What are the criteria for

fractures?

How are Type III extension supracondylar

fractures sub-classified?

Yes

Posteromedial vs. Posterolateral
• Nerve, Vessel Injured
• Surgical Approach
• Rate of Complications
In what aspects is there a difference?
What type has a greater
potential for complications?

The rate of complications is greater with the posterolateral fractures.

Posterolateral Pattern

Higher Risk of:

1.Vascular injuries

What’s the major concern with the posterolateral pattern ??

What’s the major concern with posterolateral pattern ??

Posterolateral Pattern

Higher Risk of:

2.Irreducibility

What is the major concern

with the posteromedial fractures ?

The radial nerve
is more vulnerable
to injury.

Treatment

How are Type III fractures
best treated?

Simple

1. Obtain the reduction
then
2. Maintain the reduction

Do these fractures have to be reduced

in the middle of the night?
No, as long as there is no evidence of
any vascular compromise.
Several studies have demonstrated that
a delay of 6-8 hours in reducing these fractures,
does not increase the incidence of
complications or unsatisfactory results.
*
* Leet AI, Frisancho J, Ebramzadeh E.
Journal of Pediatric Orthopedics. 22:203,2002.
Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH..
Journal of Bone & Joint Surgery.83A:323,2001.

It consists of four steps:
Reduction of the fracture
What does the manipulative
process entail ?

With the elbow in extension, align the distal fragment

to the proximal fragment in the coronal plane.

1. Correct coronal plane alignment

2. Re-establish Length

Traction

Counter-Traction
This usually requires
an assistant.

3.Correct Angulation

and
Posterior Displacement

Apply longitudinal traction

with the elbow semi- flexed,
while applying posterior
pressure on the proximal fragment.

Then, slowly flex the elbow to bring

the distal fragment into alignment.

4. Temporary stabilization and assessment

to lock the distal
fragment to the
proximal fragment.
Once the fragments are reduced,

hyper-flex the elbow

with
hyper-pronation

Then, confirm the reduction

in full external rotation
on the monitor.

Warning!!

If unable to obtain
full flexion
STOP!!
There may be
interposed tissue
between the fragments!!

Now-- how do we

maintain the
reduction?

Using a cast alone for post-reduction,

produces the poorest results
when compared with other methods.
*Pirone AM, Graham HK, Krajbich JI. J Bone Joint Surg 70A:641,1988.
Kurer MH, Regan MW. Clinical Orthopaedics & Related Research. 256:205,1990.
*

How much
flexion is needed
to prevent rotation
of the distal fragment?

This immobilization

device is no
longer commercially
available.

Full flexion

is required
to prevent
rotation of
the distal
fragment.

Percutaneous
pin
fixation
If a cast is inadequate,
then what is the standard for maintaining the reduction?

• Advantages ?

• Most stable construct
• Post-operative, one is able to fully extend elbow to visualize coronal alignment
• Disadvantages ?
• Ulnar nerve injury
Medial-lateral
pins
In what manner may the pins be used?

How can the danger of ulnar nerve

injury be minimized?
By
making an incision
directly over the
medial epicondyle,

to locate the

medial epicondyle
by direct vision.

Then, insert the medial pin by direct vision

into the center of the medial epicondyle.

while the ulnar nerve
is
retracted posteriorly.

The pin is inserted,

Advantages ?

Easy to apply
Almost no risk of nerve injury

Disadvantages

Poor rotational stability
Pins must be parallel
or divergent

Two lateral

pins

Pins crossing at the
fracture lack stability
*Cheng J, Lam T, Shen W.
J Orthop Trauma 9:511,1995.
*
What are the principles of lateral pin fixation?

Loss of rotation of distal fragment

These three pins with

no separation allowed rotation.

But, since the coronal alignment has been maintained,

in addition to the shaft condylar angle,

this rotational malalignment

is usually of
no clinical significance.

Advantages ?
Almost as strong as medial-lateral pins

Disadvantages?

The larger patients may still have rotational instability,
requiring supplementation with a medial pin.
*Zionts LE, McKellop HA, Hathaway R.
J Bone Joint Surg [Am];76:253,1994.
How can the rotational stability with lateral pin be enhanced?
By separating the pins

and adding a third pin.

Is there a way to put X pins

without producing this scar?

Lateral Antegrade pin

Following pin fixation,

how are these fractures managed ?
For three weeks

What is this physical finding ??

The “Pucker Sign” which may indicate irreducibility.

How may the proximal spike be

dis-impaled

By performing the “milking ” maneuver.

The “milking ” maneuver

The distal humeral spike

is impaled through
the brachialis muscle.

With the milking maneuver

*Archibeck,MJ et. al.:
Jour Pedi Orthop 17:298,1997.
*

The brachialis is milked distally

past the impaled fragment.

In those irreducible fractures, what dictates the preferred surgical approach?
Anteromedial incision
Anterolateral Incision

The ability to visualize

the interposed vital structures is essential.
Post-Lat Fracture:

Post-Medial Fracture

Medial humeral
spike

Lateral humeral

spike

What about the posterior approach?

This fracture

was irreducible
by closed
manipulation.
Injury film

The posterior

triceps
splitting
approach
Advantages:
Easy approach
Direct
visualization
of fracture site
Disadvantages:
Injures virgin
tissue
Unable to
visualize
anterior A. & N.

*Compliments of Jamie Maclean(Pearth ,Scotland)

What is the primary purpose of an open reduction?

• The goals are to
• remove the interposed structures which
• facilitates a closed reduction and
• a percutaneous pinning.

What is one of the main tissues

preventing an anatomical reduction?

The periosteum
tears proximally,
and remains as
big wad
attached distally.

Post-reduction

Gap persists

6 weeks
3 months
Gap has remodeled
X-ray evidence of this periosteal interposition
often is demonstrated as a gap in many fractures
Gap with interposed
periosteum
Mind the Gap!

While the periosteum tears proximally,

This flap of periosteum

can serve as a guide to
locating and reducing
the distal fragment.

it remains attached distally as a large flap.

What about late-appearing fractures ?

2 wks. post

closed reduction
What now?
Repeat
closed reduction?
Open reduction?

Periosteal
new bone

Wait. Remodeling can change things.

He had only slight valgus alignment with full elbow motion

What are the risks
of doing a late open reduction ?

Myositis Ossificans

*
*Lal, G.M. Bhan,S.:
Int.Ortho.15:89,1991.
The dilemma when one of these
fractures presents late is:
1.Do a delayed open reduction
and risk loss of motion from myositis.
or
2.Wait and do a corrective osteotomy
when the patient has recovered
full motion.

In addition to evaluating the neurovascular

function, what else needs to be done ?
Always check for ipsilateral fractures.

Do the patients with ipsilateral

fractures have more of a risk
for compartment syndromes?
The answer is not clear!
In three series, there was
no increase in vascular complications.
*
*Harrington P, Sharif I, Fogarty EE, Dowling FE, Moore DP.:
Archives of Orthopaedic & Trauma Surgery. 120:205, 2000.
Roposch,A et.al.: Jour Pediatr Orthop 21:307,2001.
Siemers,F et.al.: Zentralblatt fur Chirugie 127:212,2002.

The answer is not clear!
In two other series
compartment syndromes developed.
*
Because ipsilateral fractures
are usually the result of trauma
of greater magnitude,
they need to be followed closely.
Both fractures need
to be stabilized surgically
to eliminate the need for
constrictive cast.
*Blakemore,LC et.al.: Clin. Orthop and RR 376:32,2000.
Ring,D et.al.: Jour Pediatr Orthop 21:456,2001.
Do the patients with ipsilateral
fractures have more of a risk
for compartment syndromes?

Ipsilateral shaft fractures

Yes. One has to establish a lever arm first.

1
2
1
2
In what order do they need
to be stabilized?

Distal radius
Are they treated differently ?

What type of supracondylar fracture

does this patient have?

Flex

ion

How do the flexion patterns present?

Type I:
Criteria?
They are undisplaced. Therefore no reduction is needed.
Type II:
Criteria?
There is enough intrinsic stability to be treated with a cast alone.
Type III:
Criteria
They have no intrinsic stability, thus they need surgical stabilization.

They present

in the same manner as the extension types.

Type I Flexion Injury

What are the limits of acceptability ?
No good data
Greater than 20 0 of an increase of the shaft-condylar angle
probably should be corrected.

550

Tendency toward

valgus alignment
Increase in the shaft
condylar angle
Because, if the flexion of the condyle is not aggressively
corrected, the elbow may lose extension.

Type II Flexion Injury

What is the

management?
The treatment entails a closed reduction
+
a long arm extension cast.

This classical Type III pattern

is obviously a flexion injury.
With these one needs to be
prepared to do an open reduction !!

8 y.o.

Is this a simple extension
type supracondylar fracture ??

It also has

anterolatateral
displacement !!

The distal fragment is

not flexed,
but also it is not extended to any degree.

This also is a Type III Flexion Pattern.

What is different
about this fracture?
But, if not recognized as such, it may be a problem.
This fracture was irreducible,
and required an open reduction !!!

There are some clues to these occult flexion injuries.

1. The distal fragment is not extended,
however,it may not be flexed to any degree.

It may be

rotated!!

2. The distal fragment is in valgus.

3. The medial spike of the proximal fragment is usually posterior.

4. There may be clinical signs of ulnar nerve dysfunction.

Why are these fractures irreducible ?

The location of the proximal medial spike is critical.

The medial spike

is pressing against
the ulnar nerve.
It is also posterior to the
intermuscular septum.

What is the operative approach ?

It involves an anteromedial incision.

Ulnar Nerve
Anterior N.V. Bundle

Medial
spike

One needs to be able to see the:

So what’s the message here?
If critically evaluated
flexion SC fractures
may be more common.
Be prepared to
perform open reduction
on Type III flexion injuries.