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Supracondylar Humerus Fractures

Supracondylar Humerus Fractures. Fractures of the distal humerus just above the epicondyles Typically remains extra articular 55 % to 75% of all elbow fractures P eak incidence  5 to 8 years, after which dislocations become more frequent

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Supracondylar Humerus Fractures

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  1. Supracondylar Humerus Fractures • Fractures of the distal humerus just above the epicondyles • Typically remains extra articular • 55% to 75% of all elbow fractures • Peak incidence  5 to 8 years, after which dislocations become more frequent • The left, or nondominant side, is most frequently injured

  2. Supracondylar Fractures • In 5 – 8 year olds, bone remodeling causes a decreased anteroposterior diameter in the supracondylar region, making this area susceptible to injury • Ligamentous laxity in this age range  increased likelihood of hyperextension injury • The anterior capsule is thickened and stronger than the posterior capsule. • In extension: the fibers of the anterior capsule are taut, serving as a fulcrum by which the olecranon becomes firmly engaged in the olecranon fossa • With extreme force: hyperextension may cause the olecranon process to impinge on the superior olecranon fossa and supracondylar region • The periosteal hinge remains intact on the side of the displacement

  3. Mechanism of Injury • Extension type • Hyperextension occurs during fall onto an outstretched hand with or without varus/valgus force • Hand is pronated  posteromedial displacement *More common *Possible radial nerve injury • Hand is supinated  posterolateral displacement *Possible median nerve and vascular compromise • Flexion type: Caused by direct trauma or a fall onto a flexed elbow

  4. Typical presentation: swollen, tender elbow with painful range of motion • S-shaped angulation at the elbow: a complete (Type III) fracture results in two points of angulation to give it an S shape. • Pucker sign • Dimpling of the skin anteriorly secondary to penetration of the proximal fragment into the brachialis muscle • Means reduction of the fracture may be difficult with simple manipulation • Evaluate integrity of the median, radial, and ulnar nerves plus their terminal branches • Can be occult on radiographs with only a positive fat pad sign

  5. Lateral radiograph with positive fat pad sign in a patient with a nondisplaced fracture of the radial head Anterior lucency (arrow)  elevated anterior fat Posterior lucency (arrowhead)  elevated posterior fat pad

  6. Supracondylar Fractures Gartland Classification  based on the degree of displacement EXTENSION TYPE (98%) FLEXION TYPE (2%)

  7. Gartland - Extension Type type I (undisplaced), II (displaced with an intact posterior cortex), and III (displaced with no cortical contact)

  8. Treatment EXTENSION TYPE

  9. Treatment FLEXION TYPE

  10. Immobilization in a long arm cast (or posterior splint for swelling) with the elbow flexed to 90 degrees and the forearm in neutral for 2 to 3 weeks postoperatively, at which time the cast may be discontinued and the pins removed • The patient should then be maintained in a sling with range-of-motion exercises and restricted activity for an additional 4 to 6 weeks

  11. Special Characteristics of Pediatric Bones

  12. Anatomy • Less dense and more porous o More vascular channels o More water and cellular content, less mineral content o Higher collagen to bone ratio • Periosteum o Stronger, thicker and more fibrous o Loosely attached and easily elevated with trauma (especially diaphysis) o More firmly attached in metaphyseal-epiphyseal region  helps stabilize the growth plate allowing more active bone growth o Thickens and is continuous with physis at perichondreal ring (ring of Lacroix) Additional resistance to shear force

  13. Anatomy • Physis (Growth plate)  unique cartilaginous structure o Thickness depends on age o Weaker than bone in torsion, shear and bending  predisposes children to injury o Facilitates remodelling o Can possibly cause deformity • Ligaments  functionally stronger than bone in children o More injuries result in fractures rather than sprains

  14. Anatomy • Blood supply o In growing bone  rich metaphyseal circulation with fine capillary loops ending at the physis

  15. Biomechanics • More elastic and weaker  Injury at lower energy trauma (compression, torsion, bending forces)

  16. Physiology • More rapid bone healing / metabolism o Increased blood flow o Increased cellular activity o More active periosteum • High remodeling potential especially near the growth plate

  17. Elbow X Ray (AP)

  18. Elbow X Ray (Oblique)

  19. Elbow X Ray (Lateral)

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