Supracondylar humerus and pink pulseless extremity

Supracondylar Humerus Fractures In Children And Pink

pulseless extremity

Dr. Chandrashekhar Sonawane

Elbow Fractures in Children

• Very common injury (approximately 65% of pediatric trauma)

Supracondylar Humerus Fractures

• Approximately 60 % of Elbow Trauma

Hospital Statistics 2012 2013 Total

Paediatrc Fractures- 12 6 18

Fractures around Elbow 7 4 11

Supracondylar Humerus 4 3 7

Conservative 1 2 3

Operative 3 1 4

Elbow Fractures in Children:Physical Examination

• Swelling

• Pain

• Difficulty in movement at elbow

Elbow Fractures in Children:Physical Examination

• Neuro-motor exam • Thumb extension– EPL (radial – PIN

branch)• Thumb flexion – FPL (median – AIN

branch)• Cross fingers - Adductors (ulnar)

Elbow Fractures in Children:Physical Examination

• signs of compartment syndrome.

• Thorough documentation of all findings is important. A simple record of “neurovascular status is intact” is unacceptable.

• Rule out associated trauma –

distal forearm fractures seen in 5 %(common )

midshaft humerus fractures(rare)

Nerve injuries – 7 to 16 %

- posterolateral displacement associated with median and anterior interosseous nerve dysfunction

Physical Examination

Physical Examination

- posteromedial displacement associated

with radial nerve injury

- ulnar nerve injury more often associated

with flexion type injuries

Physical Examination

• Vascular injuries – permanent vascular compromise of extremity occurs in less that 1%

• Entrapment of brachial artery in fracture site may compromise circulation of extremity with reduction- constant vascular evaluation necessary

Elbow Fractures in Children:Radiographs

• AP and Lateral

• Oblique views may be necessary for evaluation, especially for the evaluation of suspected lateral condyle fractures.

Elbow Fractures in Children:Radiograph Anatomy/Landmarks

• Bauman’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum.

Elbow Fractures in Children:Radiograph Anatomy/Landmarks

• Anterior Humeral Line:

Elbow Fractures in Children:Radiograph Anatomy/Landmarks

• Humerocapitellar angle

30

Elbow Fractures in Children:Radiograph Anatomy/Landmarks

• Radiocapitellar line –

• Immobilize injured elbow with splint

Supracondylar Humerus Fractures:Classification

• Gartland (1959)• Type 1 non-displaced

• Type 2 Angulated/displaced fracture with intact posterior cortex

• Type 3 Complete displacement, with no contact between fragments

Type 1: Non-displaced

• Note the non- displaced fracture (Red Arrow)

• Note the posterior fat pad (Yellow Arrows)

Supracondylar Humerus Fractures:Treatment

• Type 1 Fractures:• In most cases, these can be treated with

immobilization for approximately 3 weeks, at 90 degrees of flexion. If there is significant swelling, do not flex to 90 degrees until the swelling subsides.

Type 2: Angulated/displaced fracture with intact posterior cortex

Supracondylar Humerus Fractures:Treatment

• Type 2 Fractures: Posterior Angulation

• If minimal (anterior humeral line hits part of capitellum) -immobilization for 3 weeks.

• Anterior humeral line misses capitellum – reduction necessary.

• If varus/valgus malalignment exists, most authors recommend reduction.

Type 3: Complete displacement, with no contact between fragments

Supracondylar Humerus Fractures:Treatment

• Type 3 Fractures:

• a high risk of neurologic and/or vascular compromise,

• Current treatment protocols use percutaneous pin fixation in almost all cases.

• In rare cases, open reduction may be necessary, especially in cases of vascular disruption.

Treatment• Type III – closed reduction with percutaneous

pinning- to close reduce:

1) traction to disengage proximal fragment 2) translation of the distal fragment to proper

medial-lateral orientation, 3) internal rotation deformity corrected, 4) distal fragment is pushed forward with thumb

while flexing the patients elbow to 120 degrees and pronating the wrist to tighten the periosteal hinge

Adequacy of Reduction

• Baumann’s angle

• Relationship of the capitellum to the anterior humeral line

• Restoration of the anatomy of the olecranon fossa

Treatment

• Evaluate with AP and lateral radiograph

• Deviation of >5 degrees relative to Baumann’s angle in non-injured elbow represents inadequate reduction

Supracondylar Humerus Fractures: Indications for Open Reduction

• Inadequate reduction with closed methods

• Vascular injury

• Open fractures

Supracondylar Humerus Fractures: Associated Injuries

• Vascular injuries are rare, but pulses should always be assessed before and after reduction

• In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of the excellent collateral circulation about the elbow

Supracondylar Humerus Fractures: Associated Injuries

• Type 3 supracondylar fracture, with absent ulnar and radial pulses, but fingers with capillary refill less than 2 seconds.

• The pink, pulseless extremity

Brachialis Sign- Proximal Fragment Buttonholed through Brachialis

What to do?

a persistent pulseless, but well-perfused hand postreduction

Changing trends

In olden days - No reduction in pink pulseless

extremity

Traction - 1) Traction in extension

2) Dunlop traction

In Recent Years – Two schools of thought have evolved

1) surgical exploration

2) watchful expectancy

‘In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evaluation and vascular exploration and repair in selected cases’.

White L, Mehlman CT, Crawford AH. J Pediatr Orthop. 2010 Jun;30(4):328-35. doi: 10.1097/BPO.0b013e3181da0452

‘the management of a persistent pink pulseless hand remains a 'watchful expectancy’.

Ramesh P , Avdhani A , Shetty AP , Dheenadhayalan J , Rajsekaran S

J Pediatr Orthop B. 2011 May;20(3):124-8. doi: 10.1097/BPB.0b013e328342733e

‘Surgical exploration should be recommended only if there is either severe pain in the forearm

persisting for more than 12 h after the injury or if there are signs of a deteriorating neurological

function’.Ramesh P , Avdhani A , Shetty AP , Dheenadhayalan J , Rajsekaran S

J Pediatr Orthop B. 2011 May;20(3):124-8. doi: 10.1097/BPB.0b013e328342733e

•Colour-flow duplex monitoring,

• Magnetic resonance angiography and

•Waveform of pulseoximeter

• Good waveform on pulse oximeter

• Poor waveform on pulse oximeter.

‘The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations’.

Soh RC, Tawng DK, Mahadev A.

Clin Orthop Surg. 2013 Mar;5(1):74-81. doi: 10.4055/cios.2013.5.1.74. Epub 2013 Feb 20

Conclusion• Supracondylar fractures form large chunk of

total paediatric fractures.• Fracure classification and Neuro-vascular

assesment is crucial in deciding

management.• There is growing trend towards watchful

expectancy in pink pulseless extremity.

Thank you