Supracondylar Fracture

Question 1

Epidemiology of Supracondylar fractures

Answer 1

Common in children with a peak incidence at 5-7 years

Very rare in adults

Question 2

Mechanism of injury

Answer 2

FOOSH with elbow in extension

Rarely by landing directly onto a flexed elbow

Question 3

Common associated injury with supracondylar humeral fractures

Answer 3

Damage to surrounding neurovascular structures

Question 4

Clinical features

Answer 4

Recent fall or direct trauma

Sudden-onset severe pain + reluctance to move affected arm

Question 5

Examination findings

Answer 5

Gross deformity

Swelling

Limited range of elbow movement (mainly due to pain)

Ecchymosis of anterior cubital fossa

Question 6

Other examinations to be done

Answer 6

Neurovascular examination + joint above and below.

Question 7

What nerves should be examined?

Answer 7

Median nerve

Anterior interosseus nerve

Radial nerve

Ulnar nerve

Question 8

What vascular examinations should be done?

Answer 8

Check the hand for features of vascular compromise

Are hands cold?

Pallor?

Delayed capillary refill time?

Absent pulses?

Urgent orthopaedic review is required for all supracondylar fractures

Question 9

Dx

Answer 9

Distal humeral fracture

Olecranon fracture

(Important to exclude because management will vary)

Soft tissue injury

Subluxation of radial head

Question 10

Investigations

Answer 10

AP and lateral plain film radiographs.

CT imaging can be useful for comminuted fractures or where intra-articular extension is suspected.

Question 11

X-ray findings

Answer 11

Posterior fat pad sign (lateral view)

Displacement of the anterior humeral line

Question 12

What classification system is used in supracondylar fractures?

Answer 12

Gartland classification

Question 13

Explain Gartland classification

Answer 13

1 - Undisplaced

2 - Displaced with intact posterior cortex

3 - Displaced in two or three planes

4 - Displaced with complete periosteal disruption (can only be diagnosed intra-operatively)

Question 14

Management can be either conservative or surgical.

What decides which to use?

Answer 14

Type 1 is usually trialled with conservative management.

Also type 2 with minimally displaced fracture can be tried for conservative management.

Question 15

Explain conservative management.

Answer 15

Above elbow cast in 90 degrees flexion with analgesia

Question 16

Indications for surgical management.

Answer 16

Neurovascular compromise (needs immediate closed reduction)

Type II, Type III, Type IV nearly always require closed reduction.

Open fracture

Question 17

Explain surgical management.

Answer 17

Neurovascular compromise, Type II, III and IV requires closed reduction with percutaneous K-wire fixation

Open fracture should be fixed by open reduction with percutaneous pinning

If closed reduction fails -> Do open reduction

Ongoing vascular compromise not fixed by reduction warrants vascular exploration by vascular surgeon

Question 18

When can K-wire be removed?

Answer 18

3-4 weeks after in clinic.

Question 19

Complications

Answer 19

Nerve palsies

Malunion

Volkmann’s contracture

Question 20

Nerve palsies in supracondylar fractures

Answer 20

Neuropraxia rate is around 10% but rarely result in permanent damage

Anterior interosseous nerve (from median nerve) is most commonly damaged.

Ulnar nerve is also quite common (especially during insertion of medial K-wire)

Question 21

Features of anterior interosseus nerve damage

Answer 21

Weakness in the muscle innervated by the AIN including the flexor digitorum profundus muscle to the index (and sometimes the middle) finger, the flexor pollicis longus muscle to the thumb and the pronator quadratus of the distal forearm.

There are no sensory fibres from AIN

Question 22

Malunion in supracondylar fractures

Answer 22

More common in fractures managed suboptimally.

Cubitus varus deformity might develop (gunstock)

Question 23

Volkmann’s contracture in supracondylar fracture.

Answer 23

Due to vascular compromise (brachial artery) leading to ischaemia and subsequent necrosis of flexor muscle of the forearm.

They will then fibrose and form a contracture

This leads to wrist and hand held in permanent flexion as a claw-like deformity.