Fracture Supracondylar

Pemberton DJ, Evans PD, Grant A, Mckibbin B, Fractures of the Distal Femur in the Elderly Treated with a Carbon-Fiber Supracondylar Plate, Injury-International, Journal of the Care of the Injured, 25(5), 317-321, 1994. 

Elbow joints in children are susceptible to supracondylar fractures and straightening the elbow into an AP view may cause permanent damage to the joint. A lateral elbow projection must be imaged and assessed prior to moving the joint. The child is sat (younger children can sit on the carers knee) with the affected side against a table. The arm is carefully raised and placed on the table and the table height is adjusted until the shoulder, elbow and wrist lie at the same level (Fig. 2.20). 

In cases of suspected supracondylar fracture careful handling of the joint is required. An older child may be less distressed if the lateral elbow is imaged in the same position as shown above for an erect lateral projection of the humerus. 

Fractures in the region of the elbow can be particularly difficult to diagnose and delineate accurately. Ultrasound has been shown to be a useful adjunct to plain radiography, particularly if clinical suspicion is high and radiographs are indeterminate (Davidson et al. 1994 Markowitz et al. 1992 Vocke-Hell and Schmid 2001). With supracondylar fractures of the humerus, ultrasound may demonstrate the fracture line in association with a joint effusion and elevation of the fat pads (Figs. 4.5,4.6). 

Fig. 4.6. Lateral radiograph of the elbow confirms the diagnosis of a supracondylar fracture...

Approximately 65%-75% of fractures in children occur in the upper limh, principally due to their tendency to fall on an outstretched hand. Most fractures occur at the distal radius with less than 10% of them occurring at the elbow. Of the elbow injuries, the vast majority are at the distal end of the humerus with the supracondylar fracture being the commonest, followed by lateral condyle fractures. 

An estimation of the distribution of fracture patterns about the elbow is supracondylar (70%), lateral condyle (15%), medial epicondyle (10%), olecranon (5%), radial neck (1%), medial condyle (1%), capitel-lum (1%), T condylar (<1 %). 

Supracondylar humeral fractures are the commonest fractures in children under the age of 7. Complications are common, with rates of nerve injury reported between 6% and 16% (Lyons et al. 2000), and a high... 

Flexion type fractures, with anterior displacement of the distal fragment, account for less than 1% of supracondylar fractures (Blount 1977). These types of fractures are usually caused by a direct blow to the posterior aspect of the flexed elbow and are often very unstable. 

It is important to distinguish between flexion and extension fractures, since flexion injuries almost always require surgical stabilisation and often open reduction (Fig. 18.5). The rest of the limb should be examined since ipsilateral forearm fractures have been reported in 3%-13% of supracondylar fractures (Roposch et al. 2002). 

Fig. 18.5. Flexion supracondylar fracture. Anterior displacement of the distal fragment...

Fig. 18.6. Gartland type 1 extension supracondylar fracture (undisplaced)...

Fig. 18.7. a Gartland type II supracondylar fracture. Note intact posterior periosteal hinge, b Flexion of elbow leads to reduction of fracture... 

Lateral condylar fractures are the second most common elbow injury after supracondylar fractures in children. They are estimated to form between 10%-20% of paediatric elbow injuries, and have a typical age range from 5-10 years old. 

Fig. 18.8. a Lateral radiograph of type III extension supracondylar fracture with posterolateral displacement of the distal fragment, b Internal fixation with crossed K-wires... 

Fig. 18.9. Malunion of grade Ilb supracondylar fracture, resulting in varus deformity (cubitus varus). Although of little functional significance, such gunstock deformities are often cosmetically unacceptable...

Foster DE, Sullivan JA, Gross RH (1985) Lateral humeral condylar fractures in children. J Pediatr Orthop 5 16-22 Gartland JJ (1959) Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 109 145-154... 

Karlsson J, Thorstien T, Thorleifsson R, Arnason H (1986) Entrapment of the median nerve and brachial artery after supracondylar fractures of the humerus in children. Arch Orthop Trauma Surg 104 389-391... 

Kilfoyle RM (1965) Fractures of the medial condyle and epi-condyle of the elbow in children. Clin Orthop 41 43-47 Lee SS, Mahar AT, Miesen D, Newton PO (2002) Displaced pediatric supracondylar humerus fractures biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 22 440-443... 

Leet AI, Young C, Hoffer MM (2002) Medial condyle fractures of the humerus in children. J Pediatr Orthop 22 2-7 Lyons JP, Edwin A, Hoffer MM (1998) Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children s elbows. J Pediatr Orthop 18 43-45 Lyons ST, Quinn M, Stanitski CL (2000) Neurovascular injuries in type III humeral supracondylar fractures in children. Clin Orthop 376 62-67... 

Mclauchan GJ, Walker CRC, Cowan B, Robb JE, Prescott RJ (1999) Extension of the elbow and supracondylar fractures in children. J Bone Joint Surg Br 81 402-405 Metaizeau JP, Lascombes P, Lemelle JL, Finlayson D, Prevot J (1993) Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop 13 355-360... 

Milch H (1964) Fractures and fracture dislocations of humeral condyles. J Trauma 4 592-607 Mirsky EC, Karas EH, Weiner LS (1997) Lateral condyle fractures in children evaluation of classification and treatment. J Orthop Trauma 11 117-120 Mostafavi HR, Spero C (2000) Crossed pin fixation of displaced supracondylar humerus fractures in children. Clin Orthop 376 56-61... 

O Hara LJ, Barlow JW, Clarke NM (2000) Displaced supracondylar fractures of the humerus in children. Audit changes practice. J Bone Joint Surg Br 82 204-210 Prathapkumar KR, Garg NK, Bruce CE (2006) Elastic stable intramedullary nail fixation for severely displaced fractures of the neck of the radius in children. J Bone Joint Surg Br 88 358-361... 

Rogers LF, Malave S Jr, White H, Tachdjian MO (1978) Plastic bowing, torus and greenstick supracondylar fractures of the humerus radiographic clues to obscure fractures of the elbow in children. Radiology 128 145-150 Roposch A, Reis M, Molina M, Davids J, Stanley E, Wilkins K, Chambers HG (2002) Supracondylar fractures of the humerus associated with ipsilateral forearm fractures in children a report of forty-seven cases. J Pediatr Orthop 21 307-312... 

Williamson DM, Coates CJ, Miller RK, Cole WG (1992) Normal characteristics of the Baumann angle, an aid in assessment of supracondylar fractures. J Pediatr Orthop... 

The most common lesion treated in the authors center is femoral artery thrombosis complicating catheterization, especially for balloon angioplasty of the aortic arch or aortic valve. These procedures require the insertion of a large balloon, which is currently mounted on large shafts. Initially a local low-dose approach from the opposite groin was preferred, but now systemic therapy is frequently used if there are no contraindications. Local low-dose thrombolysis is used for thrombosis of Blalock-Taussig shunts, dialysis fistula, pulmonary artery thrombosis, iliofemoral thrombophlebitis, aortic thrombosis in neonates, and brachial artery occlusion after supracondylar fracture. 

Al-Shawi AK, Smith SP, Anderson GH (2002) The use of a carbon fibre plate for peripros-thetic supracondylar femoral fractures. J Arthroplasty 17 320-324... 

Karakurt L, Ozdemir H, Yilmaz E et al (2005) Morphology and dynamics of the ulnar nerve in the cubital tunnel after percutaneous cross-pinning of supracondylar fractures in children s elbows an ultrasonographic study. J Pediatr Orthop B 14 189-193... 

Brown J, Eustace S (1997) Neonatal transphyseal supracondylar fracture detected by ultrasound. Pediatr Emerg Care 13 410-412... 

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