Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Supracondylar Elbow Fracture

Basics
Description
  • Occurs at the metaphyseal diaphyseal junction of the distal humerus
    • The fracture goes through the olecranon fossa of the distal humerus, which is a weak area.
  • The mechanism (hyperextension) usually causes elbow dislocation in adults, supracondylar humerus fractures in children, and fractures through the growth plate of the distal humerus in toddlers.
  • Classification:
    • By mechanism of injury:
      • Hyperextension type (95% of fractures)
      • Flexion type
    • The Gartland classification system is the most commonly used (1).
      • Type I: Nondisplaced
      • Type II: Displaced, but with an intact cortex; hinge or greenstick
      • Type III: Completely displaced, with no continuity between fragments; at highest risk for complications
  • Synonym: Distal humerus fracture
Epidemiology
  • These fractures affect the distal humerus of children at a rate of 308 per 100,000, and 56% of those elbow fractures are supracondylar.
  • Mean age of patients at time of injury is ~8 years .
  • Distribution between genders is approximately even .
  • This fracture is rare in adults, with rates of distal humerus fractures at 5.7 cases per 100,000.
Risk Factors
Fall on an outstretched arm
Etiology
  • A fall on an outstretched hand with the elbow hyperextended
  • A fall onto a flexed elbow (extremely rare)
Associated Conditions
  • Ipsilateral distal forearm fractures
  • Ipsilateral midshaft humeral fractures
  • Nerve and artery damage
Diagnosis
Signs and Symptoms
  • Pain, swelling, and possibly instability occur after an acute traumatic event.
  • After a few hours, typically ecchymosis occurs in the antecubital region.
  • Nerve injuries are common with this fracture, signaled by lack of full active ROM.
  • Arterial injuries also are possible and produce loss of pulse, color, temperature, and later, movement.
Physical Exam
  • Swelling and tenderness are common.
  • With type III fractures, an S-shaped deformity at the elbow is common and may be mistaken for a dislocation.
  • Perform a thorough neurovascular examination of the involved extremity because a substantial risk of injury exists.
  • Document full active flexion and extension of all digits at both MCP and IP joints.
  • Substantial pain on passive stretch of the fingers may signal compartment syndrome.
  • Check pulse, color, and temperature to assess vascular status.
Tests
Imaging
  • AP and lateral radiographs usually are sufficient for diagnosing the injury.
  • For nondisplaced fractures, a posterior fat pad sign may be the only radiographic finding.
  • When ordering a radiograph of a suspected supracondylar fracture, specify the distal humerus as the part to be examined rather than the elbow because the patient may not be able to straighten the elbow fully.
Differential Diagnosis
  • Elbow dislocation
  • Bicondylar humeral fracture
  • Growth plate fracture (in toddlers)
Treatment
Initial Stabilization

Initial treatment should involve immobilization of the injured elbow in 20-30° of flexion to prevent additional displacement or neurovascular damage until an orthopaedic surgeon can evaluate the patient.
General Measures
  • Type I injuries: Immobilization
  • Type II injuries: Closed reduction and immobilization or operative intervention
  • Type III injuries: Operative intervention
  • Immobilization should be at <90° of flexion because flexion of >90° leads to increased compartment pressures and risk of compartment syndrome .
Special Therapy
Physical Therapy
  • Physical therapy for children has not been shown to improve results .
  • Physical therapy is useful in adult fractures.
    • Timing depends on healing and strength of internal fixation.
    • ROM is emphasized, followed by strength.
Medication
Acetaminophen or acetaminophen with codeine for pain control
Surgery
  • For type II fractures angulated >5-10° and for type III fractures, closed reduction should be attempted with the patient under adequate analgesia or anesthesia.
    • If anatomic reduction cannot be achieved by closed reduction, open reduction should be performed.
    • Fractures without vascular injury may be splinted and pinned on a delayed basis.
    • A delay of <24 hours does not seem to alter outcomes .
  • An unstable fracture should be stabilized with percutaneous pin fixation.
    • 2 lateral PINS and crossed medial and lateral PINS give mechanical stability.
    • Use of only lateral PINS prevents possible injury to the ulnar nerve .
    • Flexion injuries are treated with reduction and pinning.
    • After surgery, the elbow is immobilized at 90° of flexion for 3-4 weeks.
    • The PINS are removed at 6 weeks.
  • Compartment syndrome:
    • May be prevented by timely recognition of arterial injury
    • If ischemia time exceeds ~6 hours, fasciotomy of the forearm probably should be included in the treatment.

Follow-up
Prognosis
  • Prognosis is excellent with anatomic reduction.
  • If malunion occurs, additional surgery may be needed to correct the deformity.
Complications
  • Nerve injuries: The median nerve is the most commonly injured, followed by the radial nerve.
  • It may take several months to regain normal function (11).
  • Arterial injuries: The brachial artery is the most commonly injured.
  • Compartment syndrome may result in Volkmann ischemic contracture.
  • Varus deformity of the elbow
  • Elbow stiffness: Uncommon with anatomic reduction
  • AVN of the trochlea, leading to a fishtail deformity
Patient Monitoring
  • Patients require radiographs and examinations at 1-2 weeks and ~6 weeks after fracture to ensure maintenance of the reduction during fracture healing.
  • A small risk of malreduction exists.
  • Patients should be seen after bone healing to document good alignment and ROM.

Miscellaneous
Codes
ICD9-CM
  • 812.41 Closed supracondylar fracture
  • 812.51 Open supracondylar fracture
Patient Teaching

Adult patients and parents of injured children should be informed about the signs of ischemia and compartment syndrome (increasing pain, loss of finger motion, cold fingers, and loss of color) because compartment syndrome may (rarely) occur in the 1st few days after reduction secondary to tight dressings or intimal injury to the vessels.
Activity
To prevent refracture, rough play should be prohibited for a month after pin removal.
FAQ
Q: Which supracondylar fractures should be treated with surgery?
A: Type II fractures with an unsatisfactory reduction require reduction and pinning. Type III fractures require reduction and percutaneous pinning.

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