Supracondylar Fracture Flashcards
Which patient group are supracondylar fractures common in?
Supracondylar humeral fractures are a common paediatric elbow injury, but are almost never seen in adults.
The peak age of incidence is 5-7 years.
Briefly describe the pathophysiology of supracondylar fractures
The most common mechanism of injury is falling on an outstretched hand (FOOSH) with the elbow in extension (a small percentage occur from landing directly onto a flexed elbow).
How do supracondylar fractures present clinically?
Patients typically present following a recent fall or direct trauma, resulting in sudden-onset severe pain and reluctance to move the affected arm.
How do supracondylar fractures present on examination?
On examination, there may be signs of gross deformity, swelling, limited range of elbow movement (secondary to pain) and ecchymosis of the anterior cubital fossa. Ensure to look closely for evidence of an open injury.
Which nerves need to be examined following a supracondylar fracture?
It is essential to carefully examine the median nerve, the anterior interosseous nerve (the deep motor branch of the median nerve), the radial nerve, and the ulnar nerve.
What are the features of vascular compromise?
Check the hand for features of vascular compromise, such as a cool temperature, pallor, delayed capillary refill time or absent pulses.
What investigations should be ordered for supracondylar fracture?
The mainstay of investigation for suspected supracondylar fractures is via plain film radiographs in both antero-posterior (AP) and lateral views of the elbow.
CT imaging may be useful for comminuted fractures or where intra-articular extension is suspected, which aides with surgical planning.
What are the signs of plain film radiograph for a supracondylar fracture?
Subtle signs on plain film radiograph for a supracondylar fracture include:
- Posterior fat pad sign (lucency visible on the lateral view)
- Displacement of the anterior humeral line (in children >5yrs, this should intersect the middle third of the capitellum)
What is shown in the X-ray?
Plain film radiograph of a supracondylar fracture in lateral view.
Briefly describe the Gartland Classification System
The Gartland classification system of supracondylar fractures is a system commonly used in clinical practice, also aiding in management planning:
- Type I- undisplaced
- Type II- displaced with an intact posterior cortex
- Type III- displaced in two or three planes
- Type IV- displaced with complete periosteal disruption
Briefly describe the conservative management of a supracondylar fracture
Patients with supracondylar fractures with associated neurovascular compromise on presentation need immediate closed reduction. In children, this will invariably require this to be performed in theatre; the reduction is then secured with K-wire fixation (which can be removed in clinic after 3-4 weeks).
Conservative management can be trialled with type I fractures or minimally displaced Type II fractures, which can be managed in an above elbow cast in 90 degrees flexion.
Briefly describe the surgical management of supracondylar fractures
Type II, Type III and Type IV supracondylar fractures will nearly always require a closed reduction and percutaneous K-wire fixation.
Open fractures warrant open reduction with percutaneous pinning. Any cases which fail closed reduction will also require open intervention.
Any ongoing vascular compromise, despite adequate reduction, may need discussion with vascular surgeons for potential vascular exploration.
What is shown in the X-ray?
Post-operative radiograph, 3 weeks following K-wire fixation for a supracondylar fracture.
What are the complications of a supracondylar fracture?
- Nerve palsies
- Malunion
- Volkmann’s contracture
Briefly describe the risk of nerve palsies following supracondylar fractures
Nerve palsies are common with supracondylar fractures, with neuropraxia rates around 10%; however, this rarely results in permanent damage.
The anterior interosseous nerve is most commonly affected by the initial injury, however ulnar nerve palsy is the most common post-operative complication. The ulnar nerve is at risk during insertion of the medial K-wire
What deformity can be common following malunion of a supracondylar fracture?
In some cases, patients may even develop a cubitus varus deformity (often termed “gunstock deformity”), whereby the extended forearm deviates towards the midline.
Briefly describe Volkmann’s contracture
A Volkmann’s contracture can occur following vascular compromise with a supracondylar fracture. Ischaemia and subsequent necrosis of the flexor muscles of the forearm, eventually begins to fibrose and form a contracture; this results in the wrist and hand to be held in permanent flexion, as a claw-like deformity.
