Supracondylar fractures of

Humerus in children

Supracondylar fracturesMost common -80% of elbow injury in childrenAge 3-12 yrsWeakest part of humerus in childrenCompound 1%VIC -- 0.5%

TYPES

Extension type 95%Flexion type

EXTENSION TYPEGartland’s classificationType I non-displacedType II minimally -dis placed Type III completely dis- placed

Type 1 – Ant humeral line intersect capitulum/ normal Baumann’s angle

Type11 –Ant humeral line willnot/ Baumann’angle may show varus

Type111 –Total displacement

Baumann’s angle

Humerocapitularangle

Mechanism

CLINICAL FEATURESSwellingPuckering of skin

NERVE INJURYMedian nerve/ Ant interosseous nerveRadial nerveUlnar nerveUsually neuropraxia

RADIOLOGYFracture displacementBauman’s angle in true AP viewMedial cortical impaction

Treatment

Splint in LA slab x 3wks

Type1

TYPE11

Look for medial impactionLateral 2pins enough

Thickness of pin

1.6 mm for younger children 1.8–2.0 mm for older children

Pin configuration [lateral]

Parallel pins Crossed pins

Medial pin transcapitularInstability – 3rd pin

Newton’s study

AO recommendation

TYPE 111CMR LA POP if fail K-wire fixation In August 1995, an audit into the outcome following the treatment of Gartland’s type III supracondylar fractures was conducted

52.5% chance of re-operation 50% chance of developing cubitus varus deformity

CMR and closed pinning

TYPE 111•Manipulative reduction•Under GA•Step wise correction

Type 111– 1 lateral pin + 1medial pin

Crossed Pin Vs parallel lateral pins in Type 111

medial pin post to ant -- lateral ant to post

angulated superiorly approximately 40 deg

engage the opposite cortex

Instability test – add k-wire on lateral side

Ziont’s study

AO recommendation

Medial pin -- ulnar nerve injury

Extension of elbow 60 deg flexion after lateral pin Palpate nerve in groove Small incision over pin entry blunt dissection Using drill sleeve.

VASCULAR INJURYBrachial artery injury / vascular insufficiencyAssess by color, warmth, capillary refillAngiogram ? NONeed emergency reduction and pinning

Pulse is absent 12-15% but vascular repair is needed only in1-2% [Rockwood and Green]

No pulse after reduction in 15mts Pink warm hand –observation Cold pale hand Intraoperative ANGIOGRAPHY

Exploration of artery and vascular repair

Open reduction

Vascular repairCompound injuryUnreducable situation –posterolateral displacement interposition of soft tissueApproach controversial

COMPLICATIONSCompartment syndromeMyositis ossificansAvascular necrosis of trochlea

Angular deformities – CUBITUS VARUS

CUBITUS VARUS

AETIOLOGYMalunion on s.c.fx coronal angulation aggravated by malrotation and hyper extension --- static deformity

Growth disturbance 20% of growth

[5yr old 1 yr growth is 2mm]

Avascular necrosis of trochlea rare cause

CMR &LA POP Cubitus varus --50% of cases.CMR and closed pinning -- 6.6%

GUNSTOCK DEFORMITYVarus tiltInternal rotationhyperextension

ProblemsCosmetic problemRisk of fracturePosterior shoulder instabilityTardy ulnar palsyMay have throwing problems

Clinical

Evident only in full extension and supination

Three bony point relationship Olecranon- med epicondyle distance get reduced Triceps shift medially Narrow ulnar tunnel

Internal rotation of shoulder more than opposite side.

Remodeling

Cubitus varus -- little potential for correctionHyper extension may remodelAttenborough-- 'once a varus always a varus'.

OSTEOTOMYThese are broadly divided into four groups:

1.Medial open wedge, 2.Lateral closing wedge with rotatory correction,3.Lateral closing wedge without rotatory correction,4.Dome ,Pentalateral or Oblique or Step-cut osteotomy.

TIMING OSTEOTOMYThe true extent of varus can be assessed with the elbow fully extended and forearm supinated

Corrective osteotomy after elbow regained full extension

PREOP PLANNING

FixationScrewsTB WiringPlate and screwsThe necessity of correction of internal rotation deformity in cubitus varus is controversial

ComplicationsLoss of correctionLateral bony prominence – cosmetic problemStiffnessRecurrence of deformityNerve injury

Thank You