Supra condylar fractures in children. Still a challenge?
Manuel Cassiano Neves
The supracondylar fracture is the most common fracture around the elbow in
children with a peak between 3 and 6 years of age and accounts for 22% of the
fractures in children at age 2 to 4.
It results from a a direct fall on the outstretched hand in the majority of the cases
(fracture in extension) or from a fall over the elbow (flexion fracture – 5%), that
sometimes is difficult to recognize due to its rarity. Because of the close
iteraction between the humerus and neuro-vascular structures around the
elbow, several complications can be associated. It is fundamental to look for the
associated injuries that constitute a challenge: the most common nerve palsy
seen with supracondylar humerus fractures is the neuropraxia of the anterior
interosseous nerve neuropraxia (branch of median n.) followed by the radial and
ulnar nerve palsy. The vascular injury can be present in 1% of the cases and calls
for close monitoring.
The clinical exam will show an elbow with oedema with a typical deformity with
swelling, bruising and limited active elbow motion in the presence of a displaced
fracture. On the physical exam it is fundamental to exam the neurovascular
structures and look for the inability to flex the interphalangeal joint of his thumb
and the distal interphalangeal joint of his index finger (can't make A-OK sign) or
inability to extend the wrist or digits due to radial nerve injuryVascular insufficiency at the initial stage can be present in 5 -17% defined as
cold, pale, and pulseless hand. A warm, pink, pulseless hand does not qualify as
vascular insufficiency, since the rich collateral circulation can maintain
circulation despite vascular injury.
Radiographs will help in the final diagnosis: on the lateral view the anterior
humeral line should intersect the middle third of the capitellum, In a case of a SC
fracture in extension the capitellum moves posteriorly to this reference line in
the extension type.
On the AP view a Baumann's angle is created by drawing a line parallel to the
longitudinal axis of the humeral shaft and a line along the lateral condylar physis
Normal is 70-75 degrees, but best judge is a comparison of the contralateral side
deviation of more than 5 degrees indicates coronal plane deformity and should
not be accepted.
Giving the displacement of the fragments fractures are classified according to
Gartland: Type I no displacement, Type II displaced but posterior cortex intact
and Type III full displacement.
Recently the AAOS come up with guidelines regarding the treatment of SC
fractures in children: the recommendation goes for a plaster with the elbow in
flexion (below 90º) for the Type I and close reduction and pin fixation for the
Types II and III. There is still some debate between the configuration of the
construct with no clear indication between the lateral entry pins versus the cross
pin configuration. However it seems that the lateral entry is safer with less
neurological complications and with the same stability when compared with
cross-pins.
The challenge is the treatment of the fractures with complications: nearly all
cases of neurapraxia following supracondylar humerus fractures resolve
spontaneously, and therefore, further diagnostic studies are not indicated in the
acute setting. For the fractures associated with vascular injury emergency
reduction is indicated and this solve the absence of pulse in the most of the cases.
In the presence of a no-pulse with hand is mandatory the vascular exploration