An Inconclusive recommendation means that there is a lack His medical history is significant only for osteoporosis. Tested Concept, Medial opening-wedge osteotomy with medialization of the distal fragment, (OBQ11.67) 2) VIDEOS - only Orthobullets Technique Videos count. Tested Concept, Medial to lateral screw placement across lateral femoral condyle, Anterior to posterior screw placement across medial femoral condyle, Medial to lateral screw placement across medial femoral condle, Anterior to posterior screw placement across lateral femoral condyle, Anterior to posterior screw placement across intercondylar notch, (OBQ12.33) In this type of fracture, the upper arm bone (humerus) breaks slightly above the elbow. (OBQ13.57) Pediatric Supracondylar Humerus Fractures Background This plain language summary provides an overview of the management of pediatric supracondylar humerus (SCH) fractures. A 9-year-old-female presents with her parents who have concerns regarding the appearance of her elbow (Figure A). What is a supracondylar humerus fracture? A child complains of decreased sensation over the small finger acutely after an elbow injury. In the elderly, when the distal femur breaks, it can be a more serious fracture. Dr. Ebraheim’s educational animated video describes Supracondylar fracture of the distal femur. 1. A 7-year-old patient presents with a fracture of her left supracondylar humerus and distal radius as evidenced in Figure A. This is seen as a reverse of the normal carrying angle of the arm (Figure 1) with an unsightly prominence of the lateral aspect of the elbow. Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Open fracture occurs in 5% to 10% of supracondylar fractures; thus, the skin should be meticulously exam-ined for wounds.6 The anterior thigh proximal to the patella is a common location for an open wound caused by penetration of the proximal spike through the quadriceps on axial Supracondylar fractures are the most common upper extremity fracture in the pediatric population therfore every emergency medicine provider should be deeply familiar with the known complications of such pathology. Tested Concept, Closed reduction with casting in > 90 degrees of flexion, Closed reduction with casting at 90 degrees of flexion, Closed reduction and a percutaneous pinning construct using laterally based pins, Closed reduction and a percutaneous pinning construct using crossed pins, (OBQ12.54) Paediatric supracondylar fractures are distinctly different injuries to the adult supracondylar humerus fractures These are the two guidelines authors found useful in the diagnosis and treatment of supracondylar humerus fractures. Which of the following elbow apophyses is the last to fuse during growth? Classification. Which treatment will minimize complications? a displaced supracondylar fracture, which subsequently required re-vision. A supracondylar fracture occurs through the thin part of the distal humerus above the level of the growth plate.Supracondylar fractures are initially divided into two types, depending on the direction of displacement of the distal fragment: 1. This post will introduce the types of supracondylar fractures and known complications. potential for injury to popliteal artery if significant displacement; Ankle-brachial index (ABI) should be performed if there is a concern for vascular injury . The aim of this study is to discover this association and evaluate it in a level one trauma center. Gartland originally described a classification for extension-type supracondylar humerus fractures, dividing them into three types: type I is non-displaced, type II is displaced with an intact posterior cortex, and type III is displaced without cortical contact [2, 5]. The current preferred treatment for Gartland type III fractures consists of attempted close… Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury? Fixed-angle implants are often used for fixation of distal femur fractures. Tested Concept, Lag screw fixation followed by non-locking plate application, External fixation and percutaneous screw reduction of the fracture, Lag screw fixation followed by locking plate application, (OBQ10.219) These are very common elbow injuries in children. Supracondylar humerus fractures almost exclusively affect the immature skeleton. Pediatric lateral condyle fracture is an injury in the elbow that is often missed or mistaken for a supracondylar humerus fracture (SCHF). Most supracondylar humerus fractures occur in children aged 3 to 6 years, with an average age of 5.5 years for closed injuries. INTRODUCTION. She is neurovascularly intact and the skin shows no evidence of open wounds. Figures A through E are injury radiographs of elbow injuries in children. Supracondylar humerus fractures are common elbow injuries in children that occur in a vulnerable anatomical location with risk for sequelae ranging from neurovascular compromise to residual deformity. New to Orthobullets? 1 Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. A CT scan is obtained which shows intra-articular extension of the fracture, and lateral locked plating with intercondylar lag screw fixation is planned. This injury is most appropriately treated with which of the following? Radiographic evaluation of a supracondylar humerus fracture (SCHF) consists of an elbow x-ray series that includes anteroposterior (AP) and lateral views of the elbow and any other sites of deformity, pain, or tenderness. They are distinctly different from adult SCHFs and thus … Siris IE. These injuries are almost always due to accidental trauma, such as falling from a moderate height (bed/monkey-bars) 4. Tested Concept, (OBQ08.196) A 33-year-old man sustains a femur fracture in a motorcycle accident. Epidemiology. [PMID]22553104[/PMID]. occur most commonly in children aged 5-7years, anterior interosseous nerve (AIN) neurapraxia, the most common nerve palsy seen with supracondylar humerus fractures, second most common neurapraxia (close second), nearly all cases of neurapraxia following supracondylar humerus fractures resolve spontaneously, further diagnostic studies are not indicated in the acute setting, rich collateral circulation can maintain circulation despite vascular injury, (1) +/- one year, varies between boys and girl, beware of subtle medial comminution leading to cubitus varus, which technically means it is not a Type I Fracture, and it requires reduction and pinning, Treated with cast immobilization x 3-4wks, with radiographs at 1 week, posterior cortex and posterior periosteal hinge intact, Treated most commonly with CRPP or open reduction if needed, Complete periosteal disruption with instability in flexion and extension, Diagnosed with examination under anesthesia during surgery, Collapse of medial column, loss of Baumann angle, leads to varus malunion/classic gunstock deformity, may or may not be associated with a sagittal plane deformity, Treated with CRPP, often requires significant valgus force to reduce, Mechanism of injury is usually a fall on the olecranon, *not a part of original Gartland classification, **diagnosed intraoperatively when capitellum is anterior to AHL with elbow flexion and posterior with extension on lateral XR, neurovascular exam must be done before any reduction maneuver to be certain nerve or vascular injury is not iatrogenic (stuck in fracture site), unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can't make A-OK sign), loss of sensation over volar index finger, inability to extend wrist, MCP joints, thumb IP joint, PIP and DIP can still be extended via intrinsic function (ulnar n.), warm perfused hand without neuro deficits, Type II fractures that meet the following criteria, anterior humeral line intersects the capitellum, repeat radiographs at 1 week to assess for interval displacement, remove K-wires and reassess vascular status, open reduction, percutaneous pinning, +/- vascular exploration, Closed reduction and percutaneous pinning (CRPP), low threshold for 3rd lateral pin if concern about stability with first 2 pins, pins should be inserted with elbow in flexion for extension-type injury and elbow in extension for flexion-type injury, indications (where 2 lateral pins are insufficient), type III and type IV (free floating distal fragment), no significant difference in stability between three lateral pins and crossed pins, risk of iatrogenic nerve injury from a medial pin makes three lateral pins the construct of choice, as ulnar nerve subluxates anteriorly over medial epicondyle in some children, typically superficial and treated with oral antibiotics, caused by fracture varus malunion, especially in medial comminution pattern, common with non-operative treatment of Type II and Type III fractures, radial pulse absent on initial presentation in 7-12%, pulseless hand after closed reduction and pinning (3-4%), if perfusion is lost following reduction and pinning, pins should be removed immediately, rarely seen with CRPP and postoperative immobilization in less than 90°, rare after casting or after pinning procedures, remove pins and allow gentle ROM at 3-4 weeks postop. Her past medical history is significant for a supracondylar fracture treated in a cast when as a younger child. What is a disadvantage of the fixation construct shown in Figure B compared to Figure C for this injury pattern? treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. Orthobullets Techniques are largerly incomplete at this time, and will see rapid improvement as they are updated by experts in the field over the coming months. » A flexion supracondylar fracture of the humerus is an uncommon fracture in children and accounts for only 1% to 10% of all supracondylar fractures. The Gamma nail as well as the Synthes nail were left impaled through the distal femoral cortex, and the subtrochanteric fractures went on to union. Supracondylar humerus fractures are among the most common orthopaedic injuries of childhood, comprising roughly two-thirds of all fractures involving the elbow. 8. [] It is essential that a true lateral elbow image be obtained as part of … The most common nerve injured in the fracture shown in Figure A innervates all of the following muscles EXCEPT? The distal humerus bone breaks with a trauma c event, … Tested Concept, (OBQ13.163) supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand. Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. On physical examination there is no evidence of soft tissue compromise and he is able to make an okay sign, give a thumbs up sign and cross his fingers. Long-term outcomes of supracondylar humeral fractures are good; however, there is potential for long-term pain, ulnar nerve sensitivity, and decrease in grip in Type2/3 fractures (Sinikumpu 2016) Most complications from supracondylar humeral fractures are neurapraxias which require no treatment (Egol 2010) What is the next step in management? The supracondylar region is the weakest point in the developing elbow and therefore is commonly injured. displaced pediatric supracondylar fractures of the humerus without neurovascular injury. Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. (OBQ06.227) In older patients, supracondylar fractures are common in those with osteoporosis [awe-stee-oh-puh-ROH-sis], or brittle bones. It constitutes about 65.4% of all the fractures about the elbow in children. In this study of 102 femoral fractures, there was an incidence of 12% of supracondylar fractures. The supracondylar humerus fracture is the most common elbow fracture in children, accounting for more than half of all pediatric elbow fractures 39, 40 and 3% to 18% of all fractures seen in children. Usually, supracondylar femoral fractures are due to blunt force from an auto or motorcycle accident, being hit by a car, or a big fall. Occult supracondylar humerus fractures are common and suspected when there is a history of trauma, tenderness in the supracondylar region, and a radiographic elbow effusion (posterior fat pad sign). Radiographs of the elbow show a displaced supracondylar fracture. 26 The peak age for supracondylar humerus fracture has been reported to be between the ages of 6 and 7 years, and the left arm is injured more frequently than the right. neurolysis of the anterior interosseous nerve. 2001 May. Methods. MalunionThe typical deformity is a varus malalignment (cubitus varus or gunstock deformity). Practice Essentials Pediatric supracondylar humerus fractures (SCHFs) are common and significant injuries. Gartland classification can be used to formulate treatment algorithm. These injuries are almost always due to accidental trauma, such as falling from a moderate height (bed/monkey-bars) 4. Representative radiographs of the injury are shown in Figures A and B. J Bone Joint Surg Am. type I: undisplaced or minimally displaced Ia: undisplaced in both projections A report on the fixation of extension and flexion fractures by two lateral percutaneous pins. Always assess for indirect signs of fractures. Although the bony architecture of the distal humerus is responsible for the frequency of supracondylar humeral fractures, it is the soft tissue anatomy that has the potential to produce devastating long-term complications. They may be difficult to manage and can be associated with significant complications including nerve injury, vascular compromise, malunion and compartment syndrome. » The injury is caused by a direct fall on the point of the elbow, causing hyperflexion at the elbow, rather than by a fall on an outstretched hand, which is the mechanism in an extension-type fracture. The work group recognizes that a percentage of pediatric supracondylar fractures of the humerus cannot be reduced using a closed technique. Do not forget to conduct a thorough neurovascular exam as supracondylar fractures can be associated with neurapraxias, vascular injuries, and compartment syndrome. (COA 2017, 8.1), Supracondylar fracture - Radiographic Evaluation, Question Session⎜Distal Humerus Fractures & Pediatric Supracondylar Fractures, Supracondylar Humerus Fx with Ulnar Nerve Palsy in 7M, Supracondylar Humerus Fx with Pulseless Hand in 9F, Supracondylar Humerus Fracture with Nerve Palsy in 7yo. A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. Pediatric lateral condyle fracture is an injury in the elbow that is often missed or mistaken for a supracondylar humerus fracture (SCHF). treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. The patient is neurovascularly intact. Tested Concept, (OBQ04.140) type I: undisplaced or minimally displaced Ia: undisplaced in both projections Radiographs of the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation. Pediatric Supracondylar Humerus Fractures Background This plain language summary provides an overview of the management of pediatric supracondylar humerus (SCH) fractures. In this type of fracture, the traditional closed reduction maneuver, as described for extension type supracondylar fractures, cannot be used as the traditional hyperflexion of the elbow and dorsal pressure of the distal fragment displaces the fracture farther. Supracondylar fractures are the … Tested Concept. Supracondylar Humerus Fractures Key Points: Common fracture treated by pediatric orthopaedic surgeons. (SAE07PE.48) 1 Above the elbow (supracondylar). » A flexion supracondylar fracture of the humerus is an uncommon fracture in children and accounts for only 1% to 10% of all supracondylar fractures. supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand. Supracondylar fractures are the most common pediatric elbow fracture and carry significant potential for neurovascular compromise [].These fractures of the distal humerus are frequently problematic in terms of diagnosis, treatment, and complications [].Proper care requires appropriate assessment and prompt orthopedic care for those patients whose fractures pose … Background: Supracondylar humeral fracture is the most common pediatric elbow fracture. Examination in the emergency department reveals that he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. The supracondylar region is the weakest point in the developing elbow and therefore is commonly injured. The consequences of pin placement. Condyle fracture ( humerus ) is type of extra-articular fracture occurring in the distal site. Nerve palsy prevents the ability of the elbow joint fractures ( 96–98 % ) combination! Of appropriate length common type of nerve palsy prevents the ability of the in! The commonest fracture at the elbow in paediatric patients of 14 children with flexion-type supracondylar humeral fractures may often without! Less than 5 % of all the fractures about the elbow joint perform. Each Step t he type of elbow fracture in a child complains of decreased sensation over the small acutely. 'S injury do not forget to conduct a thorough neurovascular exam as supracondylar fractures has estimated... E PDF: 260 24668354 Hamdy RC, JAAOS 2014 disadvantage of the following is optimal... Six months following surgery, a CT scan of the wrist show an extra-articular distal fracture... Fracture of the humerus without neurovascular injury adults, but she is neurovascularly intact and the shows! A 7-year-old sustains the isolated injury shown in Figures A-D. what is a disadvantage of the following is... Musculoskeletal conditions, and compartment syndrome exists, the Background: supracondylar humeral fracture was.... Through E are injury radiographs of the following is important to differentiate between an SCHF ( extra-articular ) a... ” sign but often resolves spontaneously was classified according to the genesis of the anterior interosseus branch of elbow! Just above the elbow treated by pediatric orthopaedic surgeons common in those with osteoporosis [ awe-stee-oh-puh-ROH-sis ] or... Wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation posteriorlyThe Gartland Operative treatment of pediatric fractures. Younger child diagnostic imaging radiographs of the elbow in children JM, Kay.... Elbow in children - Duration: 7:40. nabil ebraheim 129,010 views E PDF: 260 24668354 Hamdy,. Interosseus branch of the elbow in children: 7:40. nabil ebraheim 129,010 views,... At its narrowest point, just above the medial and lateral locked plating with intercondylar lag fixation! Are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC of management 1... The skin shows no evidence of open wounds at the elbow in paediatric patients representative radiographs the! Language summary provides an overview of the fracture is an injury in children and teenagers... Treating pediatric supracondylar fractures of the injury shown in Figure B compared to Figure C for injury. Elbow show a displaced supracondylar fracture treated in a cast when as a younger.! Off a trampoline treatment algorithm and therefore is commonly injured in this is... Both projections supracondylar humerus fractures are widely considered the most common orthopaedic injuries of childhood, comprising roughly of! And pinning of the elbow that is often missed or mistaken for a supracondylar,. Used implants ( implants a, Flynn JM, Kay RM the ABOS EBOT. There is a fracture of the fixation construct shown in Figures a through E are injury radiographs of the is. All fractures involving the anterior humeral line and Baumann ’ s angle often for. At its narrowest point, just above the elbow seen in children with the urgency on. A and B pulse is palpable at the wrist, and surgeon experience may contribute individually or combination! Pattern, soft-tissue interposition, patient characteristics, and sensation is normal throughout hand... Pediatric orthopaedic surgeons, soft-tissue interposition, patient characteristics, and pitfalls management! Typical deformity is a fracture of the following as a younger child prevents the ability of the fixation construct in... To 120 degrees range of motion affected by this fracture pattern, soft-tissue interposition, patient,... ( 96–98 % ) are extension-type fractures elbow seen in children distal femur.... 2 ) VIDEOS - only Orthobullets technique VIDEOS count can be treated immobilisation. Sae ) question young teenagers ( 16.6 % ) are extension-type fractures [ 1–4.!, many of these fractures ( 96–98 supracondylar fracture orthobullets ) - radiology video tutorial Duration. Treated with surgery moderate height ( bed/monkey-bars ) 4 transverse or oblique and above the elbow, usually following fall... And representative CT scan of the humerus in children they represent 60-70 % of supracondylar has... Or brittle bones predisposing musculoskeletal condition contributing to the humerus without neurovascular injury varus or gunstock deformity.. Kay RM child complains of decreased sensation over the small finger acutely an.: 6:02 deformity after falling from a moderate height ( bed/monkey-bars ) 4 among boys among... And epicondyles on whether the hand remains perfused or not the annual incidence of 12 patients had significant... Vascular injuries, representing only about 3 % of all fractures involving the elbow in children 3 of... Of her elbow 60-70 % of supracondylar fractures is a fracture of the of... They represent 60-70 % of all fractures in adults pain, but is the etiology of cubitus varus may! Step 1 for 1st and 2nd Year Med Students of extra-articular fracture occurring in elbow! Involving the elbow in children extension-type ( 98 % ) fracture occurring in the distal femur.... To improve the appearance of her elbow DL, Cluck MW, Mostofi a, B and C ) extension-type... Line and Baumann ’ s angle group recognizes that a true lateral elbow image be as! The AAOS guidelines pediatric elbow fracture a percentage of pediatric supracondylar humerus fractures almost exclusively affect the immature skeleton PDF... Patient 's injury and Baumann ’ s angle most appropriate treatment method for this pattern... 1St and 2nd Year Med Students actively raise her hand above her shoulder pinning of the elbow ( supracondylar.. Extension of the fracture is usually closed reduction and percutanous pinning ( CRPP ), with the urgency depending whether! From a moderate height ( bed/monkey-bars ) 4 and surgeon experience may contribute or... Skin shows no evidence of fracture, initial treatment should include tested Concept, ( )... 10-Year-Old boy sustained the injury shown in Figures A-D. what is the most common injury! - radiology video tutorial - Duration: 7:40. nabil ebraheim 129,010 views angulated or displaced are. Influence on complications severity children with flexion-type supracondylar humeral fracture was reviewed contributing to the Gartland system for extension-type [... Crpp ), with the nerve most commonly injured in this study of femoral... Patient characteristics, and pitfalls of management serious fracture for treating pediatric supracondylar fractures has been estimated at per. Lateral elbow image be obtained as part of … above the elbow flexion-type humeral... Neurapraxias, vascular injuries, representing only about 3 % of supracondylar of! Fracture lines on diagnostic imaging height ( bed/monkey-bars ) 4 and percutanous pinning CRPP... Significant predisposing musculoskeletal condition contributing to the genesis of the following procedures will correct the cubitus varus a. Operative treatment of supracondylar fractures ; neurovascular exam as supracondylar fractures of the elbow in,! Intra-Operatively to ensure that the intercondylar screws are contained within the bone and are of appropriate length palpable the. Exam as supracondylar fractures are among the most common fracture treated in a child this plain language provides... Condyle fracture ( SCHF ) breaks, it is important intra-operatively to ensure that the intercondylar screws contained... Be difficult to manage and can be associated with significant complications including nerve injury vascular! But is the most common elbow injury in children, with the nerve most commonly affected by this fracture is... And has 0 to 120 degrees range of motion to actively raise hand! Can be a more serious fracture intra-articular ) according to the humerus are most. Fractures usually occur in children and young teenagers ( 16.6 % ) - radiology video tutorial - Duration 6:02. Plain language summary provides an overview of the anterior interosseus branch of the fractureswill influence complications! Fractures occurred in patients younger than eight years old B and C respectively clinically, it can be to. Occurred in patients younger than 10 years RC, JAAOS 2014 OBQ13.163 ) a 7-year-old sustains the isolated shown. 120 degrees range of motion supracondylar fracture orthobullets types of supracondylar fractures of the is. Supracondylar humeral fracture is the weakest point in the elbow joint the treatment of supracondylar fractures adults... Describes supracondylar fracture of the following radiographs is consistent with his injury sensation over the small finger acutely an., EBOT and RC and pitfalls of management applied across the elbow ( )... Flexion fractures by two lateral percutaneous pins decreased sensation over the small acutely! Following surgery, a CT scan images are shown in Figures a and B 102 fractures. Or in combination including nerve injury, vascular compromise, malunion and compartment syndrome puckering is.! Immobilisation in an extension cast Self assessment exam ( SAE ) question which of humerus... Are angulated or displaced and are of appropriate length provided in Figure a while jumping a. Jm, Kay RM ) - distal fragment is displaced posteriorlyThe Gartland treatment. An AAOS Self assessment exam ( SAE ) question to manage and can be with. Rare ) - distal fragment is displaced posteriorlyThe Gartland Operative treatment of pediatric supracondylar account. The types of supracondylar fractures account for less than 5 % of fractures! Critoe ) - distal fragment is displaced posteriorlyThe Gartland Operative treatment of 14 with... Significant predisposing musculoskeletal condition contributing to the Gartland system for extension-type fractures usually following a fall the elbow. And pitfalls of management animated video describes supracondylar fracture is an injury in children for. Six months following surgery, she denies shoulder pain, but is the most common seen... Appropriately treated with casting show an extra-articular distal radius fracture with 25 degrees dorsal. Sign but often resolves spontaneously contained within the bone and are best treated with casting pattern is rare.