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Supracondylar Fracture of the Humerus

Supracondylar fracture of the humerus
Objectives
  1. Describe a useful classification system for supracondylar fractures of the humerus
  2. Describe useful radiographic parameters for assessing quality of reduction of supracondylar fractures
  3. Describe necessary components of the physical exam of a child with a displaced supracondylar fracture
  4. Describe the reduction maneuver for a supracondylar fracture
  5. Discuss methods of fixation for supracondylar fractures
  6. Describe strategies to avoid complications for supracondylar fractures
  7. Discuss indications for open reduction
  8. Describe patterns of neurovascular injuries with supracondylar fractures
  9. Describe the functional problems, if any, associated with cubitus varus

Discussion
There is no shortage of information available on supracondylar fractures, Wilkins includes 325 references following his text chapter on the subject in 1996. The task is to distill this information. Gartland's 1959 classification has continued to be widely used, with Type I being nondisplaced, Type II hinged, and Type III displaced. Sometimes Type III fractures are subdivided into posterolateral or posteromedial fractures. Type I fractures obviously are easy to treat, sometimes they are hard to recognize on initial radiographs, a recent paper underscored the value of the posterior fatpad in detection. Type II fractures can be recognized on the lateral view by a posterior tilt of the distal fragment (lack of normal anterior tilt), without displacement on the AP view. Type III fractures provide no challenge in diagnosis, are most often complicated. Postermedial fractures are most likely to injure the radial nerve; posterolateral with brachial artery and/ or median nerve; the distal spike of the proximal humeral fragment being the culprit. The need of a good preoperative neurovascular assessment is obvious, recognizing that it is not always easy. The anterior interosseous nerve, supplying the flexor pollicis longus, and the FDP to the index finger seems to be most sensitive to injury; often undiscovered as there is no sensory distribution of this nerve. Reduction is accomplished by first correcting medial or lateral displacement, then flexing and reducing the posterior angulation. It is important to ensure that rotation of the distal fragment matches the proximal, this is best done on the lateral view. Most authors use Bauman's angle to gauge the reduction on the AP view, some believe it is too subjective. Percutaneous pinning is now used for all closed reductions of Type III fractures and some Type II. Crossed pins of adequate diameter (usually 5/ 64") provide the most secure fixation; better if the pins do not cross at the fracture site. The lateral pin is placed first. Two lateral pins may be used; this voids the possibility of iatrogenic ulnar nerve injury, but the lateral pins are less stable. There are continuing reports of iatrogenic ulnar nerve (usually) neuropraxia from medial pin placement. The ulnar nerve can lie over the medial epicondyle in flexion, or even anterior in some patients. For this reason, an increasing number of experienced surgeons use a small incision for the medial pin to ensure the ulnar nerve is protected. Type II injuries can be maintained in 120 degrees of flexion without pinning. A recent study on Doppler response of the radial artery to elbow flexion found that was point where the pulse became impaired, so there is some justification for pinning Type II as the elbow can then be extended to a safe position. With percutaneous pinnings, the rate of Volmann's ischemia of the forearm is virtually eliminated. Indications for open reduction include 1) an irreducible fracture, vascular compromise, or 2) an open fracture, in which case neurovascular injuries may be more severe. Olecranon traction is still a very acceptable option for the very swollen or comminuted fracture. Vascular compromise following reduction is another obvious indication, the vessel has been found in the fracture itself following reduction.

Other than neurovascular problems, the main complication of supracondylar fractures is cubitus varus, resulting from faulty reduction or loss of reduction. For many years, we have been taught that this was only a cosmetic problem, but recent studies have documented late onset ulnar nerve dysfunction, average onset about 15 years postfracture.

References
  1. Abe M, Ishizu T, Shirai H, Okamoto M, Onomura T. Tardy ulnar nerve palsy caused by cubitus varus deformity. Journal of Hand Surgery -American Volume 1995; 20( 1): 5-9.
  2. Archibeck MJ, Scott SM, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. Journal of Pediatric Orthopedics 1997; 17( 3): 298-302.
  3. Badhe NP, Howard PW. Olecranon screw traction for displaced supracondylar fractures of the humerus in children. Injury 1998; 29( 6): 457-60.
  4. Barrett IR, Bellemore MC, Kwon YM. Cosmetic results of supracondylar osteotomy for correction of cubitus varus. Journal of Pediatric Orthopedics 1998; 18( 4): 445-7.
  5. Devnani AS. Lateral closing wedge supracondylar osteotomy of humerus for post-traumatic cubitus varus in children. Injury 1997; 28( 9-10): 643-7.
  6. Fleuriau-Chateau P, McIntyre W, Letts M. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Canadian Journal of Surgery 1998; 41( 2): 112-8.
  7. Gennari JM, Merrot T, Piclet B, Bergoin M. Anterior approach versus posterior approach to surgical treatment of children's supracondylar fractures: comparative study of thirty cases in each series. Journal of Pediatric Orthopaedics. Part B 1998; 7( 4): 307-13.
  8. Gugenheim JJ, Jr. The Ilizarov fixator for pediatric and adolescent supracondylar fracture variants. Journal of Pediatric Orthopedics 2000; 20( 2): 177-82.
  9. Joist A, Joosten U, Wetterkamp D, Neuber M, Probst A, Rieger H. Anterior interosseous nerve compression after supracondylar fracture of the humerus: a metaanalysis. Journal of Neurosurgery 1999; 90( 6): 1053-6.
  10. Lyons JP, Ashley E, Hoffer MM. Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children's elbows [see comments]. Journal of Pediatric Orthopedics 1998; 18( 1): 43-5.
  11. Lyons ST, Quinn M, Stanitski CL. Neurovascular injuries in type III humeral supracondylar fractures in children. Clinical Orthopaedics & Related Research 2000( 376): 62-7.
  12. Mapes RC, Hennrikus WL. The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children. Journal of Pediatric Orthopedics 1998; 18( 4): 441-4.
  13. Mohammad S, Rymaszewski LA, Runciman J. The Baumann angle in supracondylar fractures of the distal humerus in children. Journal of Pediatric Orthopedics 1999; 19( 1): 65-9.
  14. Mostafavi HR, Spero C. Crossed pin fixation of displaced supracondylar humerus fractures in children. Clinical Orthopaedics & Related Research 2000( 376): 56-61.
  15. Okamoto M, Abe M, Shirai H, Ueda N. Morphology and dynamics of the ulnar nerve in the cubital tunnel. Observation by ultrasonography. Journal of Hand Surgery -British Volume 2000; 25( 1): 85-9.
  16. Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Ortho Surg 1997; 5: 19-26.
  17. Rasool MN, Naidoo KS. Supracondylar fractures: posterolateral type with brachialis muscle penetration and neurovascular injury. Journal of Pediatric Orthopedics 1999; 19( 4): 518-22.
  18. Ristic S, Strauch RJ, Rosenwasser MP. The assessment and treatment of nerve dysfunction after trauma around the elbow. Clinical Orthopaedics & Related Research 2000( 370): 138-53.
  19. Sabharwal S, Tredwell SJ, Beauchamp RD, Mackenzie WG, Jakubec DM, Cairns R, et al. Management of pulseless pink hand in pediatric supracondylar fractures of humerus [see comments]. Journal of Pediatric Orthopedics 1997; 17( 3): 303-10.
  20. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. Journal of Bone & Joint Surgery -American Volume 1999; 81( 10): 1429-33.
  21. Takahara M, Sasaki I, Kimura T, Kato H, Minami A, Ogino T. Second fracture of the distal humerus after varus malunion of a supracondylar fracture in children. Journal of Bone & Joint Surgery -British Volume 1998; 80( 5): 791-7.
  22. Taniguchi Y, Matsuzaki K, Tamaki T. Iatrogenic ulnar nerve injury after percutaneous cross-pinning of supracondylar fracture in a child. Journal of Shoulder & Elbow Surgery 2000; 9( 2): 160-2.
  23. The RM, Severijnen RS. Neurological complications in children with supracondylar fractures of the humerus. European Journal of Surgery 1999; 165( 3): 180-2.
  24. Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. Journal of Pediatric Orthopedics 1995; 15( 4): 435-9.
  25. Wilkins KE. Supracondylar fractures of the distal humerus. In: Rockwood CA, Jr., Wilkins KE, Beatty JH, editors. Fractures in children. Philadelphia: Lippincott-Raven; 1996. p. 669-752.
  26. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. Journal of Bone & Joint Surgery -American Volume 1994; 76( 2): 253-6.

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