Supracondylar Fracture of Humerus

Aka: Supracondylar Fracture of Humerus, Humeral Supracondylar Fracture, Supracondylar Fracture at Elbow

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II. Epidemiology

  1. Most common elbow Fractures in Children
  2. Age of onset ranges between 2 and 12 years of age (peaks between 5 and 8 years of age)
  3. Gender: Twice as common in boys

III. Definitions

  1. Supracondylar Fracture of Humerus
    1. Distal Humerus Fracture above the epicondyles and above the physis

IV. Pathophysiology

  1. Supracondylar region of the Humerus is the weakest part of the elbow (Humerus flattens, and widens)
  2. Mechanisms
    1. Fall on an outstretched hand with extended elbow (most common)
    2. Direct blow to Posterior Elbow (uncommon)

V. Exam

  1. Vascular
    1. Capillary Refill
    2. Radial pulse and ulnar pulse
      1. Pulse may be absent despite warm, pink hand due to collateral circulation
      2. Absent pulse is an indication for emergent surgical intervention
  2. Skin
    1. Open Skin Wound overlying Fracture (open Fracture)
    2. Skin Tenting
    3. Skin puckering
      1. Seen with local subcutaneous Hemorrhage (e.g. brachialis Muscle penetrated by bone shard)
  3. Palpation
    1. Humeral Condyle tenderness
    2. Decreased elbow range of motion
  4. Neurologic
    1. Median Nerve function
      1. Anterior interosseous branch injury is most common
      2. Test with patient opposing thumb and index finger tips ("make OK sign")
    2. Ulnar Nerve function
    3. Radial Nerve function
  5. Compartment Syndrome
    1. Pain, Pallor, Paresthesias, Pulselessness and Poikilothermia (5 P's)
    2. Distal finger passive range of motion is painful

VI. Imaging

  1. See Elbow XRay
  2. Obtain a true lateral Elbow XRay
    1. Elevated anterior fat pad ("Sail Sign") or visible posterior fat pad suggest Fracture
    2. Normal lateral xray will demonstrate an hour glass appearance to the distal Humerus
  3. Posterior fat pad sign
    1. Always abnormal
    2. May be only finding in a Type 1 supracondylar Fracture
  4. Anterior humeral line
    1. Line drawn down the anterior Humerus should normally pass through middle third of capitellum
    2. Displaced in Type 2 and Type 3 Fractures
  5. Radiocapitellar line
    1. Line drawn down the mid proximal radius should bisect the capitellum
  6. Cortical Disruption
    1. See grading below (based on anterior and posterior cortical disruption)
  7. Extension Fracture (most common)
    1. Distal fragment displaced posteriorly

VII. Grading

  1. Type 1: Non-displaced or minimally displaced
  2. Type 2: Distal anterior fragment displaced and intact posterior cortex
  3. Type 3: Displaced and no contact between Fracture fragments (both anterior cortex and posterior cortex disrupted)

VIII. Management

  1. Orthopedic referral in all cases
    1. Emergent surgical intervention for neurovascular deficit
    2. Urgent surgical reduction by orthopedic surgery
  2. Type 1 Fracture
    1. Splint initially
      1. Long Arm Splint or Double Sugar-Tong Splint with elbow in 80-90 degrees flexion
    2. Cast
      1. Longarm cast with Forearm in neutral rotation and elbow at 90 degrees
      2. Cast for 3 weeks followed by XRay to demonstrate supracondylar callus
      3. Active range of motion starts after three weeks of Casting
  3. Type 2 Fracture
    1. Splint as above
      1. Gentle flexion to 30-40 degrees is sufficient to avoid manipulating into a neurovascular injury
    2. Urgent orthopedic referral to determine whether Casting will be sufficient
      1. Open reduction and internal fixation in some cases
  4. Type 3 Fracture
    1. Splint as above for stability in gentle flexion (30-40 degrees) and emergent Consultation
    2. Open reduction and internal fixation in all cases

IX. Complications: Type 3 Fracture

  1. Malunion or poor healing
    1. Secondary to severe displacement, incomplete reduction, or significant Soft Tissue Injury
    2. Gun stock deformity
      1. Elbow varus angulation and loss of full elbow extension
  2. Compartment Syndrome
  3. Nerve injury (transient Neuropraxia typically resolves in weeks after injury)
    1. Volkmann's Ischemia with contracture
      1. Due to local swelling and compounded by tight Splinting or cast
        1. Avoid excessive compression when applying splint
      2. Results in a combined median and Ulnar Neuropathy
        1. Flexion at the wrist and elbow, pronated Forearm, extended MCP joints
        2. Claw Hand and loss of grip strength at the index finger
    2. Median Nerve injury
    3. Radial Nerve injury
    4. Anterior interosseus nerve injury
      1. Motor function only: Thumb and index finger flexion
  4. Vascular injury
    1. Brachial artery injury (rare)

X. References

  1. Eiff (2012) Fracture Management for Primary Care, Saunders, Philadelphia, p. 265-6
  2. Wolfe and Santillanes (2021) Crit Dec Emerg Med 35(10): 12-3

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