Supracondylar Fractures

Cite this article as:
Lisa Dunlop. Supracondylar Fractures, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20215

Malcolm is 9 years old. He jumped off the swing at the play park but tripped and fell onto his outstretched hands. His left arm took the brunt and had severe pain and swelling in his left elbow after the injury. He attends the local Emergency Department and is informed that he has a supracondylar fracture of his humerus.

Epidemiology

Supracondylar fractures are very common in children and account for about 60% of all paediatric elbow fractures.  The fracture occurs just above the elbow at the area of the distal humerus that is relatively narrow and weak in the immature skeleton.  It is the most common fracture seen in children below the age of 7 and the second commonest up the age of 16. 95% result from a fall onto an outstretched hand with the elbow in full extension.

 

Presentation – History

A child will usually present to the emergency department with a very painful elbow that they refuse to move. They will complain of swelling and likely some bruising to the area. Due to high incidence of neurovascular compromise with this fracture, the child may also complain of loss of sensory or motor function in the affected hand.

 

Presentation – Examination

Examination can be difficult, especially when assessing the neurological status. Ensure adequate pain relief and a comforting environment whilst assessing the child.

Signs such as gross swelling, anterior bruising, skin puckering and deformity at the elbow indicate significant disruption of the joint.

This type of fracture has a particularly high complication rate. It is essential, as with all fractures, that the neurovascular status is thoroughly assessed and documented. 

Finally, as with all injuries it is imperative that we thoroughly examine the joint below and above and assess for any other injuries on the child. The most common injury associated with supracondylar fracture is the distal radius.

 

Investigations

Of course, we need an x-ray. The views required are an AP and true lateral of the elbow. 

The majority (97-99%) of these fractures are extension type injuries. If there is displacement (25% have minimal or no displacement), it most likely to be posterior due to the extension mechanism. Only (1-3 %) are flexion type injuries or are caused by posterior blow to the arm resulting in anterior displacement.

To detect more subtle fractures, it is useful to have a strategy for assessing less obvious displacement.  This can be achieved using the anterior humeral line (AHL). On a true lateral X-ray, a line drawn along the anterior surface of the humerus will intersect the middle third of the capitellum in most children >4 years old.  In younger children the AHL may lie in the anterior third of the capitellum.

Case courtesy of Dr Benoudina Samir, Radiopaedia.org. From the case rID: 41167

 

The X-ray will also show abnormal fat pads unless the joint capsule is disrupted.

 

Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org. From the case rID: 45115

 

Make sure you look at the bigger picture. X-ray any other body parts where you suspect a fracture.

 

The Gartland classification

We can classify these fractures according to degree of displacement: The Gartland Classification (see the image below):

  • Type 1: minimal or no displacement of the fracture. There is a normal anterior humeral line on the x-ray. Often only abnormality are abnormal fat pads.
  • Type 2: with posterior displacement the posterior cortex remains intact and with anterior displacement the anterior cortex remains intact.
  • Type 3: completely displaced with complete cortical disruption.2
  • Type 4: The periosteum is completely torn and is the most unstable type of fracture (can only be diagnosed intraoperatively).

 

Treatment: Immediate in the ED

Prior to any examination or investigation adequate analgesia is required.

Keep the child nil by mouth as they may need urgent surgery.

Immobilise the elbow to 30-40 degrees in a long arm back slab to reduce pain, risk of compartment syndrome, neurovascular injury and loss of skin integrity (this can be done pre- or post-imaging depending on amount of pain). It is important to closely monitor for any signs of these complications.

 

Treatment: Following imaging

Ongoing treatment depends on the degree of displacement.

Not displaced (Gartland type 1)

  • Conservative management with either collar and cuff or long arm (above elbow) cast at 80-90° for 3 weeks (see areas of controversy below for more on this).
  • Follow up in fracture clinic.

Displaced (Gartland type 2 – 4)

Above elbow cast at 30-40°  to reduce chance of neurovascular injury and manage pain.

These require surgery on the day of injury but not overnight unless neurovascular or skin compromise:3

  • No radial pulse
  • Signs of reduced perfusion to the hands
  • Skin viability threatened
  • Evidence of nerve injury

Many trusts will have local guidance from the orthopaedic team about specifics of management, referral and follow-up, so refer to your departmental policy.

If the fracture is open: manage the wound conservatively and administer antibiotics appropriately.

As with all paediatric situations: consider NAI if the injury appears more significant than the history would suggest, especially if under 2 years old.

 

Operative management

The British Society for Children’s Orthopaedic Surgery recommend bicortical wire fixation when operative management is required. This is with closed manipulation under anaesthesia. Open reduction increases risk of infection and stiffness.

If the limb is perfused but no radial pulse present it is not recommended that the brachial artery is explored. However, if the limb is ischaemic prior to theatre; the orthopaedic team must alert a vascular team expert in small vessel repair as exploration of the artery may be required if fracture reduction fails to re-perfuse the limb.

Most nerve injury caused by the fracture or by the operative management is a transient neuropraxia and can be managed expectantly.

 

Areas of controversy

Traditionally displaced supracondylar fractures were reduced as an emergency, whether or not there was neurovascular injury. It has been shown that there are increased iatrogenic complications if the surgery is done overnight and so is recommended that only injuries with compartment syndrome, neurovascular injury or loss of skin integrity are operated on overnight.

Gartland type 1 fractures should be managed conservatively with immobilisation. This could be by plaster or collar and cuff, with some centres preferring the collar and cuff method. A randomised controlled trial by Oakley et al 2009 compared the use of above elbow plaster immobilisation to collar and cuff without plaster (n=50, 27 with plaster and 23 with collar and cuff). The outcomes assessed were pain, resumption of the child’s normal activities and parent satisfaction. None of the patients had fracture displacement or neurovascular compromise at the 2 week check, all had a degree of impairment of motion and there were similar levels of immobilisation device issues between the groups. The table below describes the primary outcomes of the study.


Potential complications

Vascular injury:

  • The brachial artery lies anterior to the humeral cortex at the supracondylar region and therefore the fracture can impinge on the brachial artery causing significant vascular compromise.

Nerve injury:

  • 11% will have associated nerve injury, most commonly the anterior interosseous nerve – check the child can make the “OK” sign (flexion of thumb IPJ and index finger DIPJ).
  • The less common flexion injuries can result in ulnar nerve damage – check finger abduction and sensation to the ulnar border of the little finger.
  • The median nerve is at risk of injury though is structurally stronger and less likely to be injured than the brachial artery. Apparent nerve injury is usually transient.
  • For a reminder of how to assess peripheral nerve function have a look at our elbow examination post.

Compartment syndrome:

  • Bleeding from an injured vessel and swelling in the region can induce a compartment syndrome and cause further neurovascular and muscular injury.
  • The median nerve and radial artery can be compressed in the forearm’s anterior compartment.
  • Remember: loss of radial pulse is a late sign of compartment syndrome!

Volkmanns Ischaemic contracture:

  • Prolonged reduction in blood supply to the muscles results in necrosis and later fibrous replacement of the muscle tissue. This can be due to delayed reperfusion of an ischaemic limb and/or compartment syndrome. The results in an irreversible flexion of the fingers and wrist and pronation of the wrist, which is disabling.

Malunion:

  • Good reduction position is required to reduce risk of deformity.

Myositis ossificans

Bone growth in the muscle can occur in this type of fracture.

 

Things not to miss!

  • Take a good look at the X-ray: are the fat pads normal? Is the anterior humeral line normal?
  • Carefully check and DOCUMENT neurovascular status. Make sure this is closely monitored
  • The anterior humeral line may not be reliable in very young children as the capitellum may only be partially ossified, but normal. If in doubt: seek expert help.

 

 

Case resolution

Malcolm was found to have a weak radial pulse and was taken straight to theatre from the ED. He had an external manipulation and wire placement and an uncomplicated recovery. He had an X-ray in 5 days and noted to have satisfactory position. The wires and plaster were removed in 3 weeks and he was back on the swing 5 days later…

 

Selected references

Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.

British Orthopaedic Association Standards for Trauma (BOAST), British Society for Children’s Orthopaedic Surgery (2014) BOAST 11: SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN. Accessed 19/03/2019 <https://www.boa.ac.uk/resources/boasts/boast-11-pdf.html>

St. Clair BJ & Schreiber VM. Supracondylar Humerus Fractures. Operative Techniques in Orthopaedics. 2019 29:11–16. doi.org/10.1053/j.oto.2018.12.003

Saeed W, Waseem M. Elbow Fractures Overview. 2019 Jan 20. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from PubMed PMID: 28723005.

Herman MJ, Boardman MJ, Hoover JR & Chafetz RS. Relationship of the anterior humeral line to the capitellar ossific nucleus: Variability with age. Journal of Bone and Joint Surgery. 2009; 91(9):2188–2193

Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone page 193-5

American Academy of Orhopaedic Surgeons, 2014. Appropriate use criteria for the management of pediatric supracondylar humerus fractures. Accessed 19/03/2019 <>

Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev. 2018 Oct 1;3(10):526-540. doi: 10.1302/2058-5241.3.170049. eCollection 2018 Oct. PubMed PMID: 30662761; PubMed Central PMCID: PMC6335593.

Oakley E, Barnett P, Babl FE. Backslab versus non-backslab for immobilization of undisplaced supracondylar fractures: a randomized trial. Pediatr Emerg Care. 2009 Jul;25(7):452-6. doi: 10.1097/PEC.0b013e3181ab7898. PubMed PMID: 19564806

Davies FCW, Bruce CE and Taylor-Robinson K.  Emergency are of minor trauma in children.  2011. London: Hodder & Stoughton

Hill CE and Cooke S. Common Paediatric Elbow Injuries. The Open Orthopaedics Journal. 2017; 11: 1380–1393

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About Lisa Dunlop

AvatarI am an Emergency Medicine trainee in the West of Scotland having recently made the move up back form London. I have an interest in major trauma and toxicology. Outside of work I am a keen cyclist, runner and collector of all things plants.

Avatar
Author: Lisa Dunlop I am an Emergency Medicine trainee in the West of Scotland having recently made the move up back form London. I have an interest in major trauma and toxicology. Outside of work I am a keen cyclist, runner and collector of all things plants.

One Response to "Supracondylar Fractures"

  1. Avatar
    Tanbir Nadim 12 months ago .Reply

    Hi Lisa Dunlop,
    This supracondylar fracture post is really super. The way you described everything is really easy to understand. I really love this blog. I hope you will be doing well in trauma and toxicology as well.

    Thanks.

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