Supracondylar fractures of Humerus in children
Supracondylar fractures of
Humerus in children
Supracondylar fracturesMost common -80% of elbow injury in childrenAge 3-12 yrsWeakest part of humerus in childrenCompound 1%VIC -- 0.5%
TYPES
Extension type 95%Flexion type
EXTENSION TYPEGartland’s classificationType I non-displacedType II minimally -dis placed Type III completely dis- placed
Type 1 – Ant humeral line intersect capitulum/ normal Baumann’s angle
Type11 –Ant humeral line willnot/ Baumann’angle may show varus
Type111 –Total displacement
Baumann’s angle
Humerocapitularangle
Mechanism
CLINICAL FEATURESSwellingPuckering of skin
NERVE INJURYMedian nerve/ Ant interosseous nerveRadial nerveUlnar nerveUsually neuropraxia
RADIOLOGYFracture displacementBauman’s angle in true AP viewMedial cortical impaction
Treatment
Splint in LA slab x 3wks
Type1
TYPE11
Look for medial impactionLateral 2pins enough
Thickness of pin
1.6 mm for younger children 1.8–2.0 mm for older children
Pin configuration [lateral]
Parallel pins Crossed pins
Medial pin transcapitularInstability – 3rd pin
Newton’s study
AO recommendation
TYPE 111CMR LA POP if fail K-wire fixation In August 1995, an audit into the outcome following the treatment of Gartland’s type III supracondylar fractures was conducted
52.5% chance of re-operation 50% chance of developing cubitus varus deformity
CMR and closed pinning
TYPE 111•Manipulative reduction•Under GA•Step wise correction
Type 111– 1 lateral pin + 1medial pin
Crossed Pin Vs parallel lateral pins in Type 111
medial pin post to ant -- lateral ant to post
angulated superiorly approximately 40 deg
engage the opposite cortex
Instability test – add k-wire on lateral side
Ziont’s study
AO recommendation
Medial pin -- ulnar nerve injury
Extension of elbow 60 deg flexion after lateral pin Palpate nerve in groove Small incision over pin entry blunt dissection Using drill sleeve.
VASCULAR INJURYBrachial artery injury / vascular insufficiencyAssess by color, warmth, capillary refillAngiogram ? NONeed emergency reduction and pinning
Pulse is absent 12-15% but vascular repair is needed only in1-2% [Rockwood and Green]
No pulse after reduction in 15mts Pink warm hand –observation Cold pale hand Intraoperative ANGIOGRAPHY
Exploration of artery and vascular repair
Open reduction
Vascular repairCompound injuryUnreducable situation –posterolateral displacement interposition of soft tissueApproach controversial
COMPLICATIONSCompartment syndromeMyositis ossificansAvascular necrosis of trochlea
Angular deformities – CUBITUS VARUS
CUBITUS VARUS
AETIOLOGYMalunion on s.c.fx coronal angulation aggravated by malrotation and hyper extension --- static deformity
Growth disturbance 20% of growth
[5yr old 1 yr growth is 2mm]
Avascular necrosis of trochlea rare cause
CMR &LA POP Cubitus varus --50% of cases.CMR and closed pinning -- 6.6%
GUNSTOCK DEFORMITYVarus tiltInternal rotationhyperextension
ProblemsCosmetic problemRisk of fracturePosterior shoulder instabilityTardy ulnar palsyMay have throwing problems
Clinical
Evident only in full extension and supination
Three bony point relationship Olecranon- med epicondyle distance get reduced Triceps shift medially Narrow ulnar tunnel
Internal rotation of shoulder more than opposite side.
Remodeling
Cubitus varus -- little potential for correctionHyper extension may remodelAttenborough-- 'once a varus always a varus'.
OSTEOTOMYThese are broadly divided into four groups:
1.Medial open wedge, 2.Lateral closing wedge with rotatory correction,3.Lateral closing wedge without rotatory correction,4.Dome ,Pentalateral or Oblique or Step-cut osteotomy.
TIMING OSTEOTOMYThe true extent of varus can be assessed with the elbow fully extended and forearm supinated
Corrective osteotomy after elbow regained full extension
PREOP PLANNING
FixationScrewsTB WiringPlate and screwsThe necessity of correction of internal rotation deformity in cubitus varus is controversial
ComplicationsLoss of correctionLateral bony prominence – cosmetic problemStiffnessRecurrence of deformityNerve injury
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