Table Of Contents
Supracondylar Fractures
Elbow fracture account for 10% of childhood fractures. Supracondylar fractures are the most common paediatric elbow injury and will form the bulk of the discussion below. Elbow fractures have a high incidence of neurovascular complication at the distal humerus since the elbow acts as a very narrow tube that allows vessel (brachial, radial and ulnar) to pass through the forearm. Operative treatment should be considered for elbow fracture, especially in our setting due to the high risk of complications.
Classification of elbow fractures
| Fracture | Description |
|---|---|
| Supracondylar (40%) | Fracture above the elbow. Fall ont an outstreched hand with the arm extended. Typical in children aged 5 – 7 years. Classified based on severity according to Gartland classification. |
| Condylar | Fracture through the medial or lateral condyle. Second most common elbow fracture. Typically involve the lateral condyle and affect the joint and physises. Risk of avascular necrosis due to distruption of blood supply. Commonly treated operatively. |
| Epicondylar | Fracture of the epicondyle. Occurs in school-aged boys. Usually invovles the medial epicondyle and does not typically require operative intervention |
Gartland Classification of Supracondylar fractures
| Classification | Description |
|---|---|
| Type I | Non-displaced. Treated with cast immobilization for 2 – 3 weeks. |
| Type II | Displaced with posterior cortext intact. Treated with closed reduction and percutaneous pinning (CRPP) |
| Type III | Complete displacement in 2 or 3 planes or rotational instability. Treated with CRPP or open reduction and percutaneous pinning (ORPP) |
| Type IV | Complete periosteal disruption with instability in flexion and extension. Treated with CRPP or ORPP |
- Patient History (supracondylar fracture)
- Child that fell with hyperextended arm
- 5 – 7 years
- Increased ligamentous laxity
- Signs and symptoms
- Pain at elbow
- Swelling
- Guarding
- Irritability
- Abnormal neurovascular exam
- Physical exam
- Should focus on detecting neurovascular complications
- Check distal pulses (radial and ulnar arteries to ensure brachial artery is intact)
- Watch for swelling (compartment syndrome)
- Check for numbness of the hand (radial, ulnar nn.)
- Investigation
- X-Ray of the elbow: Best initial test
- A line drawn along the anterior border of the distal humerus (anterior humeral line) should intersect the long axis of the capitellum in the middle third (1/3)
- In the setting of a painful elbow following a fall, if this line does not intersect the capitellum, then a supracondylar fracture should be suspected.
- Arteriogram: Emergency arteriogram if there are absent pulses
- X-Ray of the elbow: Best initial test
- Treatment of a supracondylar fracture with vascular compromise
- Arteriogram followed by ORPP/CRPP and Casting
- Treatment of a supracondylar fracture without vascular compromise
- Type I: casting for 2 – 3 weeks
- Type II: CRPP
- Type III and IV: ORPP/CRPP
- Treatment of a supracondylar fracture with features of compartment syndrome
- Emergent fasciotomy in addition to ORPP/CRPP and Casting
- Complications of supracondylar fracture of the humerus
- Vascular injury e.g. brachial artery
- Nerve injury e.g. ulnar injury
- Compartment syndrome: tightness, tender to palpation, discoloration, and pain on passive movement due to loss of circulation (or reperfusion)
- Permanent disability
- Volkmann’s contracture
