Pediatric fractures hold special attention owing to the fact that bones in this age group have an enormous growth as well as remodeling ability. Long term functional outcome and radiological appearance of a fracture treated in pediatric age group may be quite different from the immediate post-management status. Neurovascular complications associated with this fracture make it an orthopaedic emergency thus, understanding of this fracture is extremely important.

Supracondylar fracture of the humerus is one of the most talked about and often encountered injury (only after clavicle and both bone forearm fracture) in pediatric age group with a male predominance accounting for 16% of all pediatric fractures and 60% of all pediatric elbow fractures, classically occurring as a result of fall on an outstretched hand [1-3]. Immediate complications associated with it are limb threatening (by virtue of involving neurovascular structures) whereas late complications are a serious concern to functional status of the patient. Due to the above reasons they require a strict vigilance and a proper management protocol. In pediatric age group the more common age of presentation is 5-7 years (90% cases). Extension type injury is more common than flexion type [4]. It is frequently found in the non-dominant extremity. The flexion type is common in elderly children [5]. Certain studies have reported up to 30% incidence of open fractures in this subset of patient [6].Reduction of a Supra-Condylar Fracture of Right Humerus Essay.

Pertinent Anatomy

Bone – In children, the supracondylar region consists of a weak, thin bone located in the distal humerus. This area is bordered posteriorly by olecranon fossa, anteriorly by coronoid fossa and on both sides by respective supracondylar ridges. The medial and lateral supracondylar ridges end into respective condyles and epicondyles. The trochlea is normally tilted 4° valgus in males and 8° valgus in females (carrying angle). The trochlea is also 3-8° externally rotated, resulting in external rotation of the arm when is flexed to 90° [2,7].

Soft tissue structures – Both supracondylar ridges, condyles and epicondyles give rise to attachment of various muscles which are responsible for the displacement and rotation of distal fragment. Neurovascular structures lie in proximity to supracondylar region. Brachial artery which commonly gets involved in supracondylar fracture of humerus lies along the antero-medial aspect of distal humerus just superficial to the brachialis muscle. Major neurological structures of the upper limb (median, radial and ulnar nerves) are also in close relation with supracondylar region [2].

Pathoanatomy

The ossification process of distal humerus occurs at different ages. The first to appear is capitulum at 1 year of age. The radial head and medial epicondyle begins to ossify at 4-5 years of age, followed by trochlea and olecranon epiphysis at 8-9 years of age. The lateral condyle is generally the last to appear at approximately 10 years of age. The supracondylar area undergoes remodeling between 6 to 7 years of age and is typically thinner with a more slender cortex, predisposing this area to fracture. Reduction of a Supra-Condylar Fracture of Right Humerus Essay. As elbow forced into extension, the olecranon serves as a fulcrum and focuses the stress on the distal humerus causing fracture [8].

Approach To a Case

History – In a case where there is a classical history of fall on an out stretched hand followed by pain and swelling over the elbow with loss of function of upper limb, onset of pain holds special consideration. It is of utmost importance to ascertain whether the pain is due to fracture or because of muscle ischemia which has a late onset (hours after the injury).

Clinical examination – Initial gross assessment should be aimed to rule out any associated systemic trauma and neurovascular involvement. The clinical presentation is that of a painful swollen elbow that the patient is hesitant to move, when a patient history includes a high energy trauma or a significant fall. Urgent orthopaedic review in Emergency Department is indicated in the following circumstances: when there is absence of radial pulse, ischaemia of hand (pale and cool extremities); severe swelling in forearm and or elbow, skin puckering or anterior bruising, open injury and neurological injury [9].

Both radial and ulnar pulses must be palpated at the wrist of injured extremity. In case of pulselessness, other signs of perfusion must be checked viz., color (the hand should be pink), temperature, capillary refill and oxygen saturation on pulse oximeter. Ultrasound with Doppler flow should be performed in children with evidence of vascular injury (e.g., decreased or absent radial pulse) [8].

If a neurological involvement is noted, it warrants a careful evaluation and documentation such as when it first became apparent, the degree of involvement and possible progression/ regression of symptoms. Reduction of a Supra-Condylar Fracture of Right Humerus Essay.

The median nerve along with the brachial artery crosses the elbow joint. Anterior Interosseous Nerve Branch (AION) of the median nerve is most prone to get involved in postero-lateral displacement of the distal fracture fragment [10].

AION syndrome in children and adolescents most of the time present with proximal forearm pain followed by weakness in the hand without any sensory deficit. A weak “OK sign” (e.g., more of a pincer grasp than an OK sign) can be elicited on physical examination. The radial nerve runs between the brachialis and brachioradialis muscles before crossing the elbow and penetrating the supinator muscle. Radial nerve impingement most commonly occurs when the distal fracture fragment is displaced postero-medially. This occurs because the proximal fracture fragment is displaced laterally. The ulnar nerve is prone to injury following flexion type of supracondylar fractures as the nerve crosses the elbow posterior to the medial epicondyle. If a neurological/vascular involvement appears following manipulation or splint placement, one must consider immediate re-manipulation. Neuropraxias are not uncommon and generally resolve with restoration of normal alignment and lengths.

A puckered, dimple and/or ecchymosis of the skin just anterior to the distal humerus may be suggestive of a difficult reduction probably due to the fact that the proximal, anteriorly directed fragment has penetrated the brachialis muscle and possibly the subcutaneous layer as well [8].

Radiographic Assessment- The standard radiographic study of the injured limb should include an Antero-Posterior (AP) and a lateral view of the elbow and any other sites of deformity, pain, or tenderness. Because of the association of supracondylar fractures with forearm fractures, the clinician should also obtain AP and lateral radiographic views of the forearm [11]. Radiographs should be obtained only after appropriate analgesia and splintage of the extremity so as to avoid any neurovascular injury or its exacerbation by the fractured fragments. Reduction of a Supra-Condylar Fracture of Right Humerus Essay. Idea of splintage is to provisionally stabilize the limb and it should be done in a position of comfort (approximately 20°–30° of flexion) [12]. Splinting in displaced or unstable fractures with elbow in full extension or hyper-flexion is contraindicated because it stretches the neurovascular bundle over the fracture site or they may get impinged between fractured fragments [13].

The carrying angle (the varus or valgus attitude of the distal humerus and elbow) is evaluated on AP view by looking at Baumann’s angle. Radiographs of the contralateral elbow should be used for comparison, if needed, as the Baumann’s angle varies among all individuals [14].

On the lateral view, the following radiological parameters are looked for: (a) Anterior humeral line; (b) Coronoid line; (c) Fish tail sign; (d) Fat pad sign; (Anterior and Posterior) [5,15].

A positive fat pad sign (sail sign) is suggestive of occult fracture when no radiological fracture line is obvious.

Treatment of Fractures of Supracondylar Humerus

Undisplaced (Gartland Type I) or minimally displaced fractures in children can potentially be treated with an above-elbow splint in 90° of flexion for 3 weeks [9]. Circumferential casting and extremes of flexion should be initially avoided to prevent compartment syndrome and vascular compromise [15,18-20]. While it is often easiest to visualize displacement or angulation on the lateral radiograph, but varus mal-alignment/ impaction is best depicted by Baumann’s angle on the AP radiograph. In case of varus at the fracture site of more than 10° (compared to the contralateral upper limb), closed reduction and percutaneous pinning should be strongly considered. In principle, larger diameter pins provide better stability and are more effective at maintaining fracture reduction and alignment. In a randomized trial by Ponce et al., in a study population of 50 children managed by per cutaneous pinning [20], they concluded that those immobilized initially in a posterior splint and sling returned to normal activity sooner than those immobilized in a collar and cuff sling (median two versus seven days, p≤0.01), but there is no difference between the two groups in daily pain scores or in resumption of normal activity or mobility at two weeks.

Gartland Type II fractures require close reduction [21]. Further, these may become stable after closed reduction and casting at 90° of flexion [Table/Fig-1a,​,b]b] but if more than 90° of flexion is needed to maintain reduction, then in order to minimize risks of complications associated with the increased elbow flexion, stabilization of the fracture with percutaneous pinning should be performed [Table/Fig-2a,​,b].b]. In the largest reported series by Skaggs et al., in management of Type II fractures [22], they reported an extremely low rates of complication after closed reduction and percutaneous pinning; secondary operations were also uncommon (0.5%).Reduction of a Supra-Condylar Fracture of Right Humerus Essay. This series demonstrated a high probability of satisfactory outcome after operative treatment of Type II fractures compared to previous studies of children treated by closed reduction without pinning [22].

[Table/Fig-1a]:

Pre-operative images showing gartland Type-II fracture.

[Table/Fig-1b]:

Post-Reduction images in lateral and shoot through view.

[Table/Fig-2a]:

Pre-operative images showing gartland Type-II fracture.

[Table/Fig-2b]:

Post-operative images in lateral and AP view showing fixtion by percutaneous K –wires after close reduction.

Reduction manoeuvres for supracondylar humerus fractures: With the patient preferably under General Anaesthesia (GA) and with fluoroscopy assistance-before pounding on to anatomic reduction freeing the proximal fragment from soft-tissue entrapment is essential. First step is to apply traction in line with the humerus, with the elbow in slight flexion. Traction in full extension has to be avoided as this may cause tethering of neurovascular structures over the proximal fragment. If there is suspicion that the proximal fragment has pierced through the brachialis muscle (clinically elicited by S sign), then a persistent, gradual traction is given in slightly flexed elbow for a full minute which often gives a palpable feeling of freeing of the proximal fragment. Alternatively, the same may be achieved by proximal to distal “milking” manoeuvre over the brachialis [23].

For the reduction maneuver, it should begin with hyper-flexing the elbow while simultaneously pushing in an anterior direction on the olecranon. While keeping the elbow in hyper-flexed state fluoroscopic assessment is done with an AP image, though difficult to interpret due to overlapping of proximal ulna and radius over the fracture site. However, Jone’s view allows assessment of the continuity of the medial and lateral columns and Baumann’s angle.

Rotation of distal fragment if present can be addressed by repeating the reduction with two additional maneuvers. Reduction of a Supra-Condylar Fracture of Right Humerus Essay. If the distal fragment is internally rotated (most common), to press selectively harder on the medial side during the reduction, and pronate the forearm during the reduction as well, the opposite applies for an externally rotated distal fragment. If normal range Baumann’s angle is not achieved, to repeat the reduction while stressing the arm in valgus.

Reduction maneuvers should not be attempted if the vascular status doesn’t improve after gross reduction and stabilisation in a splint. Taking decision as per appropriate use criteria [24-26] is wise in such circumstances. Cases of an open fracture, significant swelling over the elbow, vascular deficit, unstable reduction (Gartland III and IV) pose certain limitations in reduction maneuvers for supracondylar humerus fractures. In these cases one must go for open reduction as attempting close reduction may further worsen the situation.

Gartland Type III fractures are particularly prone to neurovascular compromise. The closed reduction and percutaneous pinning is the preferred treatment for displaced fractures. Fractures with displacement treated by closed reduction and casting have a higher incidence of residual deformity as compared to those managed with close/open reduction and pinning, complication rates [27-30] or the quality of the reduction [31]. However, considering it as an orthopaedic urgency, optimal management of a displaced fracture should be done by close/open reduction and percutaneous pinning preferably within 24 hours. Sadiq et al., in a review of 20 cases of grade III supracondylar fractures who were managed conservatively with straight-arm lateral traction with arm in 90° abduction and full supination showed no complication in any patient with uneventful recovery [32]. They concluded straight-arm lateral traction as a safe and effective maneuver for treating these fractures.

In a study by de Gheldere A and Bellan D, on 74 patients with Gartland Type II and III fracture managed by closed reduction and immobilization with a collar sling fixed to a cast around the wrist in order to keep forearm in pronation, they found no statistically significant difference in the final outcomes as measured by Baumann’s angle (except in posterolateral displacements) but humerocapitellar angles show statistically significant difference in Type III group [33]. The purpose of the study is to give a more precise limitation of this technique. This study suggests that Gartland Type II and pure posterior or posteromedial displaced Gartland type III fractures can be treated by closed reduction and immobilization with success, whereas Type III fractures with posterolateral displacements should preferably be fixed.

Effect of supination versus pronation in the non-operative treatment of pediatric supracondylar humerus fractures was studied prospectively by Seyed Ali MN et al., in which they concluded that considering late complication of malunion, no obvious difference was observed between the two positions of forearm after closed reduction and casting [34].Reduction of a Supra-Condylar Fracture of Right Humerus Essay.  However, as cubitus varus and valgus were reported in both the groups with unstable Type III fractures, so it is advisable to prevent this complication by operative fixation.

Complications of Supracondylar Fracture of The Humerus