Supracondylar fracture

Definition:
A supracondylar fracture of the humerus is a
fracture which occurs in the distal third of the bone. The
fracture line lies just proximal to the bone masses of the
trochlea and capitulum and often runs through the
apices of the coronoid and olecranon fossae.
 The fracture line is generally transverse.
 It is one of the most common and important fracture of
childhood.
 It is seldom seen in adults.
 It should always be regarded as potentially dangerous
because of the risk of the injury to the brachial artery

Types:
Two types are described depending upon the
displacement of the distal fragment
1. Extension type - commonly seen
In this the distal fragment is
extended (tilted backwards) in
relation to the proximal fragment.
2. Flexion type – Rare
The distal fragment is flexed (tilted forwards) in
relation to the proximal fragment.
Mechanism of Injury
a. Extension type: fall b. Flexion type: fall on the
on an out stretched hand with point of the fully flexed elbow
hyperextension at the elbow due to direct violence
Position of limb
a. Hyperextension of elbow –
posterior displacement
b. Usually pronation of forearm –
a. pushed. backward
c. Dorsiflexion of hand –

Displacements:
a. Extension type: Posterior, medial/ lateral and rotation.
b. Flexion type: Anterior, medial/ lateral and rotation.
Radiological point/ component for extension type SC #
a. Posterior displacement of distal fragment: indicated by
i. Loss of tear drop sign
ii. Coronoid line
iii. Fat pad sign
iv. Anterior humeral line
b. Coronal tilting of the distal fragment: usually varus
i. Crescent sign
ii. Baumann’s angle
c. Horizontal rotation of the distal fragment: indicated by
Classification i. Fish tail sign
Based on Gartland classification
Type I Undisplaced.
Type II Displaced with intact posterior cortex.
Type III Displaced with no cortical contact
Classification (apley)
Type I is an undisplaced fracture.
Type II is an angulated fracture with the posterior cortex
still in continuity.
IIA – a less severe injury with the distal fragment
merely angulated.
IIB – a severe injury; the fragment is both angulated
and malrotated.

Wilkins modification of the Gartland system.

Type I: Undisplaced fracture.
Type II a: Greenstick fracture with anterior angulation (posterior tilting of
the distal fragment);
Type II b: Greenstick fracture with anterior angulation and rotation; (fish tail
appearance)
Clinical feature
A. Presenting complaints:
A history of fall followed by pain and swelling, inability
to move the affected elbow
B. On examination:
a. Early (before significant swelling has occurred)
i. S – shaped deformity due to posteriorly displaced
fracture
ii. Since the fracture is above the condyles, the three
bony-points relationship i s maintained, as in a
normal elbow.
b. Late (gross swelling) makes it difficult to appreciate these
signs.
i. Brachial artery injury must be carefully looked
for in all cases.
ii. Radial and ulnar pulses may be absent with or
without signs of ischaemia
iii. Look for nerve injury to - the median nerve
(pointing-index) or
the radial nerve (wrist-drop).

No vascular complication,
(1) pure posterior displacement
(2) lateral or medial displacement of 50% or less, and
(3) angulation of less than 15°
May be accepted as remodelling is generally rapid
and effective.
(4) Rotation
(5) valgus or varus or
(6) loss of bony contact
Require correction

X – Ray – The fracture is seen most clearly in the lateral view

A. If undisplaced fracture –
Fat pad sign should raise suspicions:
There is a triangular lucency in
front of the distal humerus, due
to the fat pad being pushed
forwards by a haematoma.

B. If displaced fracture
AP view –
1. Baumann’s angle: measure the degree of medial angulation before and
after reduction
2. Cubitus varus/valgus :Long axis of humerus and transverse axis of
elbow is normally 90 degree

Baumann’s angle
 AP x-rays are sometimes difficult to make out, 80
especially if the elbow is held flexed after reduction of the
supracondylar fracture.
 Measurement of Baumann’s angle is helpful.
 This is the angle between the longitudinal axis of the
humeral shaft and a line through the coronal axis of the
capitellar physis, A B
 Normally this angle is less than 80 degrees. (A)
 If the distal fragment is tilted in varus, the increased
Lateral view –
1. Teardrop sign
Shadow above the capitulum
Anterior dense line – posterior margin of the coronoid fossa
Posterior dense line – anterior margin of olecranon fossa
Inferior portion – ossification centre of capitulum
It is disrupted.

2. Anterior humeral line

A line along the anterior border of the distal
humeral shaft passes through the middle
third of capitulum
If passes through anterior 1/3 rd – posterior
displacement of the distal fragment

3. Shaft condyler angle – 30 degree

angulation between the long axis of
humerus and long axis of lateral epicondyle
is 40 degree

4. Coronoid line

5. Fish tail sign

Rotation of the distal fragment the anterior
border of proximal fragment looks like a
sharp spike
6. Crescent sign

Treatment
A. Conservative
 a. Undisplaced –
Fractures or even suspicion of fracture require
immobilisation in an above-elbow plaster slab, with
the elbow in 90 degrees flexion
b. Displaced –
i. the child should be admitted to a hospital
because serious complications can occur within
the first 48 hours
ii. Closed reduction under G/A and Immobilization
by plaster – in Type II A
iii. If slipped then closed reduction and
percutenious pinning
B. Continuous traction
 If presenting late with excessive swelling or bad
wounds around the elbow.
i. Skeletal traction (Smith's traction) a K-wire
passed through the olecranon
ii. Skin traction (Dunlop's traction) below-elbow
skin traction.
C. Operative treatment
 Evacuation of haematoma ORIF with 2 crossed K
wires
i. A fracture which simply cannot be reduced
closed such as in type II B , III
ii. In an open fracture
iii. A fracture associated with vascular damage

Complication:
A. Immediate
B. Early
a. Vascular injury - brachial artery injury leads to
Volkmans ischemia
b. Nerve injury -
C. Late
 Indication of traction
1. If after closed reduction
elbow can not maintained
100 degree flexion
2. Hugely comminuted # in
supracondylar area
3. Massive swelling of elbow
with totally displaced #

Type I –
 The elbow is immobilized at 90 degrees and neutral
rotation in a splint or cast and the arm is supported by a
sling.
 It is essential to obtain an x-ray 5–7 days later to check
that there has been no displacement.
 The splint is retained for 3 weeks and supervised
movement is then allowed.
.
The capitulum normally angles forward about 30 degrees; if the capitulum is in
a straight line with the humerus on the lateral x-ray, it will still remodel

TYPE II A: POSTERIORLY ANGULATED FRACTURE – MILD

swelling is usually not severe and the risk of vascular injury is low.
Closed reduction under G/A following step-wise manoeuvre:

(1) Traction for (2) Correction (3) Gradual flexion of the (4) Feel
2–3 min in the of any elbow to 120 degrees, & the pulse
length of the sideways tilt pronation of the forearm, and check
arm. with or shift & while maintaining traction & the
counter - rotation (in exerting finger pressure capillary
traction above comparison behind the distal fragment to return
 If the distal circulation is suspect, immediately relax the
amount of elbow flexion until it improves.
 X-rays are taken to confirm reduction, checking carefully to
see that there is no varus or valgus angulation and no rotational
deformity.
 Following reduction, the arm is held in a collar and cuff;
 The circulation should be checked repeatedly during the first
24 hours.
  An x-ray is obtained after 3– 5 days to confirm that the
fracture has not slipped.
 The splint is retained for 3 weeks, after which movements are
begun.

TYPES II B AND III: ANGULATED AND MALROTATED

OR POSTERIORLY DISPLACED

Nature of the fracture line and its importance

• In extension type, it is directed obliquely upwards and backwards.
• In flexion type, it is directed obliquely downwards and forwards.
The nature of the fracture line is of importance in the treatment of
supracondylar fracture.
• An extension type of supracondylar fracture is stable in flexion and
hence after reduction, it is immobilized in flexion. It is unstable in
extended position of the elbow.
• A flexion type of supracondylar fracture is stable in extension and
hence after reduction, it is immobilized in extension. It is unstable in
flexed position of the elbow.

The Role of Triceps and Brachialis Muscle

These muscles play a role in maintaining the reduction of this
fracture.
 The triceps muscle acts as an internal splint
and helps in maintaining the reduction in
extension type of supracondylar fracture when
the elbow is immobilized in flexion.
 The brachialis muscle acts as an internal
splint and helps in maintaining the reduction in
flexion type of supracondylar fracture when the
elbow is immobilized in extension.

.
 Discuss the management of supracondylar fracture of 6
years old boy
Introduction:
 A supracondylar fracture of the humerus is a fracture
which occurs in the distal third of the bone.
 It is one of the most common and important fracture of
childhood.
 It should always be regarded as potentially dangerous
because of the risk of the injury to the brachial artery
The management of supracondylar fracture includes:
Semisterile technique – Lobst
1. History taking et all
2. Clinical examination 1. No infection
2. Immobilization of 60 – 80
3. Investigation deg flexion
4. Definitive treatment 3. Chek X ray after 1 week
4. K-wire removal 3-4 week
a) From History we get Mechanism of injury
a. Fall on outstretched hand in extended elbow – Extension type
(98%)
b. Fall on the point of elbow with joint in flexion – Flexion type
b) Clinical feature
a. Complain of
i. Pain and swelling of elbow joint (usually left)
ii. Deformity
iii. Loss of movement of elbow
b. On examination
i. Look
White pulse less hand

FasciotomyVascular repair if neededEmergency OR+ pinning

- Attitude of upper limb

- Gross deformity (usually S deformity)
- Dimpling of the skin
ii. Feel
1.

- Severe tenderness
- In immediate case, less swelling disruption of
isoscalic triangle can be felt
- Vascular assessment
With radial pulse
Capillary return check
Passive extension of finger (painful/painless–
for compartment syndrome)
- Assessment of neurological condition
2.

In extension type – AIN of median N, Median N,

Radial N,
In flexion type – Ulnar nerve
Motor function – Loss or intac
iii. Move –
- As it is a very painful condition active and passive
3.

movement of elbow is not done without

anaesthesia
- Wrist and finger movement
c) Investigation
a. X ray – elbow joint
i. AP view – Baumann’s angle
Fat pad sign
Fish tail sign
Crescent sign
 ii. Lateral view – Tear drop sign
Anterior humeral line
To asses - Degree of comminution
Intraarticular extension
Displacement
Rotation
Tilting
iii. Oblique view – To exclude minimally displaced fracture
b. Routine examination for G/A – CBC, ESR, Urine R/E, CXR,
BT/CT

d) Treatment
a. Conservative – Cast or traction (Side arm skin / Overhead
skeletal)
b. Operative – CRIF / ORIF with K wire
It depends on the classification of extension type of
supracodyler fracture that is
Gartland classification
Type I Undisplaced.
Type II Displaced with intact
posterior cortex.
Type III Complete displacement

Wilkins divided Type II into

Type II A – Distlal fragment is merely angulated
Type II B – Angulation and rotation of distal
fragment
Definitive treatment:
Type I
 The elbow is immobilized at 90 degrees flexion with
forearm neutral in a splint or cast and the arm is
supported by a sling for 3 – 4 weeks
 Check x-ray at 3/5/7/14/21 days to see position, any
displacement
 After 3 weeks supervised movement is then allowed.
Type II A – Closed reduction and immobilization by cast
Type II B – Closed reduction + Percutenious pinning + cast
Type III – Closed reduction + percutenious pinning or ORIF

Indication of open reduction

1. If closed reduction fails 2 time 5. Floating elbow
2. Open fracture 6. Nerve palsy
3. Non vascular limb 7. Compartment syndrome
4. Skin puckering

Complication:
Fracture related Per operative
1. Immediate – at the time of # Common even with ideal
management (4.2%)
a. Brachial artery injury 1. Pin migration
b. Radial nerve commonly 2. Pin tract infection
Medial N. occasionally 3. Septic arthritis
2. Early – within 2-3 days 4. Loss of reduction
a. VIC 5. Cubitus varus deformity
 3. Late – week to month
a. Stiffness
b. Heterotrophic ossification
c. Deformity
Conclusion: