Supracondylar Fracture Of The Humerus In Children - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes supracondylar fractures of the humerus.

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Supracondylar fracture of the humerus occurs in children between the ages of 4 - 10 years. The injury is caused by a fall onto an outstretched hand. The majority of the fractures are extension type fractures. Type III is a displaced fracture and it carries a high incidence of neurovascular deficit and compartment syndrome. Compartment syndrome may not develop right away, it may take hours to develop. The physician should not confuse compartment syndrome with the arterial injury. You can have arterial injury and compartment syndrome or compartment syndrome without arterial injury, and in this case you will need fasciotomy to release the compartment syndrome. The anterior interosseous nerve is involved in the extension type injury. The patient cannot do the O.K. sign. If you have an extension type injury and you find that the patient has an ulnar nerve palsy after surgery, then it is probably not due to the extension type injury, but rather is due to the medial pin that may have affected the ulnar nerve. In the flexion type injury, the ulnar nerve injury is more common.
CLASSIFICATION
GARTLAND CLASSIFICATION SYSTEM
- TYPE I Nondisplaced
- TYPE II Angulated with an intact posterior cortex
- TYPE III Displaced
TREATMENT
Type I - Immobilize.
Type II & Type III - Closed reduction and percutaneous pinning. If you cannot get the alignment correct, then do open reduction.
You will place two or three lateral pins. If a medial pin is needed, be careful of the position of the ulnar nerve. Use open incision to introduce the medial pin. Have the elbow in extension, not in flexion, when you place the medial pin because this will relax the ulnar nerve. When you use the pins, do diversion pins. The cross pins configuration, medial and lateral pins, gives the maximum rotatory stability. The crossing should be approximately 2 cm proximal to the fracture. Normally we use two diversion lateral pins and adding a third pin will increase the stiffness in case of medial comminution. Avoid malposition of the fragments because it can lead to malunion and cubitus varus. Very rarely you may have to do corrective osteotomy for the cubitus varus (it is only a cosmetic problem, not a functional problem).
If you have a pulseless, pink hand or a pulseless, white hand, then there is decreased perfusion. You will need to do emergency closed reduction and pinning. If closed reduction cannot be done, then you will do open reduction and pinning. After this, if the hand is pink and warm, then you observe. Observe for capillary refill, for temperature, and for color with the elbow in some flexion, but not in hyperflexion. If after the closed reduction and pinning the hand continues to be white and cold, you will do exploration of the artery. A pulseless, white hand from the beginning and you reduced and pinned the fracture, but the hand continues to be white, then you need to explore and repair the artery. You will repair the artery through an anterior approach and you will do fasciotomy after that. Initially, if the circulation was good, but after reduction and fixation you have a pulseless, white hand, then you need to unreduce the fracture fixation. When you have a nerve injury, observe the patient, do not explore the nerve! The recovery will start in about 6 - 12 weeks and the majority are completed in 4 - 5 months. Do not explore the nerve in closed fractures! What if the patient had an ulnar nerve palsy after surgery and the patient did not have that before surgery? Then remove the medial pin and observe.

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