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Supracondylar Fractures of The Humerus in Children.3
Supracondylar Fractures of The Humerus in Children.3
Abstract
The treatment of type II and type III supracondylar fractures of the humerus in medial displacement of the distal
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children with closed reduction and percutaneous pinning has dramatically low- humerus; a lateral periosteal hinge
ered the rate of complications from this injury. The incidence rates of malunion is intact with lateral displacement.
(cubitus varus) and compartment syndrome have both decreased. Nerve injury
accompanying this type of fracture (prevalence, 5% to 19%) is usually a neura-
praxia, which should be managed conservatively. Vascular insufficiency at pre- Physical Examination
sentation (prevalence, 5% to 17%) should be managed initially by rapid closed
reduction and pinning without arteriography. Persistent vascular insufficiency The initial evaluation of the child
necessitates exploration and vascular reconstruction. with an elbow injury must include
J Am Acad Orthop Surg 1997;5:19-26 an overall assessment to rule out
associated trauma. Fractures of the
midshaft of the ipsilateral humerus
are uncommon, but distal forearm
Supracondylar fracture of the sion or flexion injuries. The exten- fractures are common; both injuries
humerus is a common elbow injury sion type is the most common, may be overlooked if attention is
in children. Two thirds of all hospi- accounting for 90% to 98% of cases. focused solely on the elbow.
talizations for elbow injuries in chil- It is caused by a fall on an out- The elbow with a supracondylar
dren are for supracondylar frac- stretched hand with the elbow fracture is characterized by swell-
tures,1 but the incidence of supra- hyperextended.6 The characteristic ing and deformity. With type III
condylar fractures has yet to be docu- displacement of the distal humeral fractures, an S-shaped deformity of
mented. In his review of 8,672 pedi- fragment in extension-type injuries the elbow develops due to angula-
atric fractures, Landin2 found that has been reported to be posterome- tion and translation of the fracture
supracondylar fractures accounted dial in 90% of cases and posterolat- fragments. A thorough neurovas-
for only 3.3%. Supracondylar frac- eral in 10%.7 In our study,8 49% of cular examination of the involved
tures are most common in children the supracondylar fractures were
aged less than 10 years, with a peak displaced posterolaterally. The
incidence between ages 5 and 8 flexion-type fracture, which is
years.3 These fractures often require caused by falling on a flexed Dr. Otsuka is Assistant Professor of
surgery and historically are associat- elbow, is a rare occurrence. Orthopaedic Surgery, University of California,
ed with significant morbidity due to There have been numerous San Francisco (UCSF), and Chief, Pediatric
Orthopaedic Service, UCSF Medical Center.
malunion, neurovascular complica- attempts in the literature to classify
Dr. Kasser is Associate Professor of
tions, and compartment syndrome.4,5 supracondylar fractures. Gartland’s Orthopaedic Surgery, Harvard Medical School,
As a result, controversy still exists as classification9 is simple and widely and Orthopaedic Surgeon-in-Chief, Depart-
to what constitutes optimal manage- used. In that system, type I frac- ment of Orthopaedic Surgery, Children’s
ment of this type of fracture and its tures are nondisplaced. Type II Hospital, Boston.
complications. fractures are displaced with a vari-
Reprint requests: Dr. Kasser, Department of
able amount of angulation, but the
Orthopaedic Surgery, Children’s Hospital, 300
posterior cortex of the humerus is Longwood Avenue, Boston, MA 02115.
Classification intact. Type III fractures are com-
pletely displaced with no cortical Copyright 1997 by the American Academy of
Supracondylar fractures of the contact. A medial periosteal hinge Orthopaedic Surgeons.
humerus are categorized as exten- is intact in type III fractures with
A B C
Fig. 1 A, Type I supracondylar humeral fracture. Solid arrow defines the fracture line. The anterior humeral line partially transects the
capitellum, and there is a posterior fat-pad sign (open arrow). B, Type II supracondylar fracture with an intact posterior cortex (arrow).
C, Type III supracondylar fracture with a totally displaced distal humeral fragment.
the difficulty of identifying the degree of soft-tissue swelling, but required to maintain reduction.
capitellar growth plate. An alter- this usually is not necessary. A radio- After reduction and immobiliza-
native to Baumann’s angle, the graph should be taken 1 week after tion, patients should be observed in
medial epicondylar epiphyseal injury to be sure that displacement the hospital overnight for swelling
angle, has recently been described has not occurred, which usually is and circulatory changes. Casting
as a means of evaluating supra- evidenced by an increase in varus should be maintained for 3 weeks,
condylar fractures.11 This angle is angulation. After 3 weeks of immo- after which protected active range-
created by the intersection of a line bilization, protected active range-of- of-motion exercises can be begun.
drawn down the humeral axis and motion elbow exercises may be Maintenance of hyperflexion in a
a line drawn along the medial epi- started. Usually, no further treat- circular cast carries a high risk of
condylar epiphyseal plate. ment or observation is necessary for compartment syndrome. Therefore,
Both Baumann’s angle and the these nondisplaced fractures. we believe these fractures should be
medial epicondylar epiphyseal pinned percutaneously if there is
angle are also useful in determin- Type II Fractures significant swelling, if there is inad-
ing the adequacy of reduction of Type II fractures are angulated equate circulation when the elbow
supracondylar fractures. In prac- but not translated, because the pos- is flexed, or if the fracture might
tice, we use three criteria to deter- terior cortex remains intact. Reduc- become unstable. Potentially unsta-
mine the adequacy of reduction: tion can be achieved by flexion of ble type II fractures are those with a
(1) Baumann’s angle, (2) the rela- the elbow and pronation of the possible fracture of the posterior
tionship of the capitellum to the forearm with the patient under cortex, especially when rotational
anterior humeral line, and (3) anesthesia. Rang described the use deformity is present. Two lateral
restoration of the anatomy of the of a figure-of-eight cast for immo- pins, rather than crossed pins, may
olecranon fossa. In radiographic bilization in hyperflexion and be used to decrease the risk of ulnar
evaluation of type I fractures treat- pronation without encircling the nerve injury by the medial pin (Fig.
ed in a cast, we have found that the elbow in plaster. 1 Millis et al 12 3). The use of two lateral pins is less
best films are obtained by using a showed that flexion of the elbow secure than the use of two crossed
fiberglass cast and ordering an AP by more than 120 degrees was pins.13 If two lateral pins are used,
view of the distal humerus rather
than an AP view of the elbow.
Treatment
Type I Fractures
Type I fractures are nondisplaced
and are not associated with neu-
rovascular injury. These fractures
can be treated with immobilization
in a splint or circular cast with the
elbow flexed to 90 degrees and the
forearm in neutral position. A B
Children may be admitted to the Fig. 3 Anteroposterior (A) and lateral (B) views of a supracondylar humeral fracture
hospital for observation and eleva- pinned with two lateral percutaneous Kirschner wires placed parallel to each other.
tion of the arm, depending on the
they should be placed either parallel ing this fracture. Patients should be
to each other or crossing well above observed in the hospital after this
the fracture line. If swelling of the injury to monitor neurovascular sta-
elbow does not allow reduction, tus.
traction can be used until swelling
has decreased enough that reduc- Closed Reduction
tion can be attempted. In general, Accurate reduction of the frac-
traction is not required. ture is important in the prevention
of cubitus varus deformity. Under
Type III Fractures fluoroscopic control, traction is first
Type III fractures are the result of applied to disengage the proximal
more severe injuries and are associ- fragment from the brachialis mus-
ated with greater soft-tissue damage cle. The distal fragment must then
and swelling, difficult reduction, be translated into proper medial-to-
compartment syndromes, and neu- lateral orientation relative to the
rovascular injuries. These fractures shaft. The internal rotation deformi-
are completely displaced with most ty is then corrected. Next, with the
of the periosteum torn, and there is examiner’s thumb over the olecra-
significant risk of injury to the non, the distal fragment is pushed
brachialis muscle and neurovascu- forward while flexing the patient’s
lar bundle. Residual deformity is elbow to 120 degrees and pronating
Fig. 5 After traction and centralization,
also a potential problem. The inci- the wrist to tighten the periosteal the distal fragment is reduced by direct
dence of cubitus varus (Fig. 4) has hinge (Fig. 5). In the posterolateral pressure over the olecranon as the elbow is
been reported to be as high as 58%.7 fracture, the wrist is supinated to flexed.
Closed reduction and cast immobi- tighten the lateral periosteal hinge.
lization should not be used in treat- The reduction is then checked on
AP and lateral views with the use of
fluoroscopy. The fracture is gener- down the ulna) is a more accurate
ally stable in external rotation, means of assessing the adequacy of
which allows a lateral view of the reduction. Because the position of
elbow to be obtained by externally the reduced distal humerus is usu-
rotating the shoulder while holding ally evaluated with the elbow
the elbow in hyperflexion. flexed, we have not found this
The adequacy of reduction in view to be particularly helpful.
the coronal plane can be assessed Lagrange and Rigault15 and Conn
with Jones views of the distal and Wade16 described the “crescent
humerus with the hyperflexed sign” (overlapping of the ossifica-
elbow in slight internal and exter- tion centers of the lateral condyle
nal rotation. These views can be and the olecranon) on the lateral
difficult to evaluate, however, view as an indicator of inadequate
because of imposition of the proxi- reduction, but we have found that
mal radius and ulna. As described Baumann’s angle, the relationship
previously, Baumann’s angle and of the capitellum to the anterior
the medial epicondylar epiphyseal humeral line, and restoration of the
angle are useful ways to assess normal anatomy of the olecranon
reduction. A deviation of more fossa are the best indicators of an
than 5 degrees relative to the acceptable reduction.
Baumann’s angle measured in the
noninjured extremity represents an Percutaneous Pinning
inadequate reduction.1 Webb and After anatomic reduction, percu-
Fig. 4 Child with cubitus varus deformity
of the elbow after a supracondylar humeral
Sherman14 report that the humero- taneous pinning of the elbow can
fracture. ulnar angle (the angle between the be performed with use of the ster-
midhumeral line and a line drawn ilely draped screen of the fluo-
roscopy (C-arm) unit as the operat- the distal humeral physis. The posi- Traction
ing surface. The distal fracture tion of the wire should be checked Traction has lost popularity as
fragment is usually stable in 120 fluoroscopically on AP and lateral percutaneous pinning of supra-
degrees of flexion in pronation, and views. For the lateral view, the arm condylar fractures has gained
the arm can be moved from neutral can be externally rotated at the broad acceptance. However, trac-
to external rotation so that imaging shoulder while flexion and prona- tion is a treatment option for the
of the elbow can be done in differ- tion of the elbow is maintained. severely swollen arm, the irre-
ent planes without moving the C The medial wire is placed with ducible or comminuted fracture,
arm. Slight internal and external the arm in 80 to 90 degrees of flex- and the fracture that cannot be
rotation of the arm will allow the ion; additional elbow flexion may pinned because of an associated
medial and lateral columns of the cause the ulnar nerve to subluxate skin disorder or a life-threatening
distal humerus to be visualized. volarward into the path of the condition. Traction necessitates
For comminuted fractures or frac- Kirschner wire. Because the lateral constant supervision and adjust-
tures that are unstable, crossed pin- wire provides sufficient stability, ment to prevent varus deformity.
ning with one lateral and one hyperflexion is no longer necessary. Our primary indication for trac-
medial pin is advised (Fig. 6). Two A medial incision is then made over tion is supracondylar comminution
lateral pins may be satisfactory if a the medial epicondyle. A hemostat (Fig. 7). Dunlop’s skin traction17 or
stable reduction has been achieved. is used to separate tissues down to modifications involving skeletal
Percutaneous pinning is per- the medial epicondyle to ensure traction have been described. A
formed with the maximally flexed that the ulnar nerve is not injured. variation of skeletal traction
and pronated arm resting on the An AO tissue protector can be used involves insertion of the Ormandy
sterile C-arm screen. The lateral to protect soft tissues. The position screw 18 or the Palmer winged
side is approached first. A smooth of the Kirschner wire should be screw19 into the ulna. Traction can
Kirschner wire is inserted through checked with the C arm before be applied overhead or in a side-
the lateral condyle, crossing just lat- insertion to ensure that it is piercing arm manner. We find that over-
eral to the olecranon fossa and the medial epicondyle and not the head traction with use of an olecra-
engaging the medial humeral cor- ulnar groove. The wire is then driv- non screw is the easiest to manage.
tex. A 0.062-mm wire is appropri- en up the medial column so that it Traction can be used with a short
ate for a small child aged less than 4 crosses the lateral wire proximal to arm cast if there is also a forearm
years; a 5/64-inch wire is appropri- the olecranon fossa. The medial fracture. Once swelling has re-
ate for an older child. The wire is wire is usually more transverse solved, the elbow can be placed in
passed through the capitellum and than the lateral wire. plaster, remanipulated, or pinned
The reduction and wire place- percutaneously.
ment should then be checked again Pirone et al 20 compared three
with the C arm. The wires are bent methods for treatment of supra-
and generally left protruding from condylar fractures: closed reduc-
the skin for easy removal in 3 tion with casting, skeletal traction,
weeks. Before the drapes are and closed reduction with percuta-
removed, the vascular status of the neous pin fixation. They found
arm should be checked. The elbow that the results for patients treated
is splinted in 60 to 90 degrees of with skeletal traction were equal to
flexion with the forearm in neutral those for patients treated with
rotation. A bivalve cast or splint is closed reduction with percuta-
applied, and the patient is admit- neous pinning.
ted for observation overnight.
The Kirschner wires are re- Indications for Open Reduction
moved without anesthesia in the The indications for open reduc-
office 3 to 4 weeks postoperatively tion of supracondylar fractures
Fig. 6 Supracondylar humeral fracture after healing of the fracture. include (1) a fracture that is irre-
that has been pinned with lateral and Physical therapy is generally not ducible by closed methods, (2) vas-
medial Kirschner wires. Note that the
medial wire enters through the medial epi-
required, as the child will regain cular compromise necessitating
condyle above the ulnar groove. full use of the elbow over the ensu- exploration and repair of the
ing 3 weeks. brachial artery, and (3) an open
found that the rate of iatrogenic tracture is necessary. It should be recurrent deformity. Corrective
nerve injury after percutaneous recognized that the pain and signs osteotomy provided permanent
pinning was 2% to 3%. Nerve of compartment syndrome may be correction of the deformity in the
palsies without transection of the absent if the median nerve has been absence of growth arrest. A correc-
nerve should be treated conserva- injured, resulting in an anesthetic tive osteotomy for cubitus varus
tively; resolution will generally hand. 30 Mubarak and Carroll 31 deformity should be delayed until
occur within 6 months. have recommended that forearm at least 1 year after injury to evalu-
fasciotomy be performed if there ate the possible presence of medial
Arterial Injuries are clinical signs of compartment growth arrest.
The prevalence of vascular syndrome or if intracompartmental Cubitus valgus deformity does
insufficiency accompanying supra- pressure measurements are greater not occur as commonly as cubitus
condylar fractures has been report- than 30 mm Hg. varus and is not as well document-
ed to range from 5% to 12%. 28,29 ed in the literature. This deformity
Shaw et al29 recommend immediate Deformity causes functional loss of extension
closed reduction and Kirschner- Angular deformities of the distal and the development of a tardy
wire stabilization of fractures ac- humerus are common after supra- ulnar nerve paralysis.
companied by vascular insufficien- condylar fractures. The remodel-
cy. This treatment protocol result- ing potential of the distal humerus Stiffness and Myositis Ossificans
ed in restoration of pulse in 13 of is limited because the distal physis Loss of motion in the anatomi-
their 17 patients (12% of 143 type contributes only 20% of the growth cally reduced supracondylar frac-
III fractures). Arterial exploration of the humerus. Although remod- ture is uncommon. Significant loss
was performed in 3 patients who eling of posterior angulation can of flexion can occur after fractures
had an intact pulse preoperatively occur, angular deformities in the with posterior angulation of the
but no pulse after reduction; in coronal plane will not remodel, distal fragment. In a review of
each case, there was a discrete arte- resulting in a cubitus varus or cubi- supracondylar fractures in chil-
rial lesion at the level of the frac- tus valgus deformity. dren, Henrikson 3 reported that
ture. Shaw et al concluded that Cubitus varus deformity is pri- fewer than 5% were ultimately
preoperative arteriography would marily a cosmetic, rather than a associated with flexion or extension
not have contributed to the man- functional, disability. The deformi- loss exceeding 5 degrees as com-
agement of these injuries with ty is most apparent with full exten- pared with the noninjured side.
strong clinical signs suggestive of sion of the elbow. The primary in- Although extensive manipulation
vascular compromise. Their indi- dication for surgical correction is and physical therapy have been
cations for arterial exploration also cosmetic. The techniques for noted to incite myositis ossificans,
were (1) the absence of a palpable corrective osteotomy include lateral this complication is extremely rare.
pulse after reduction with any sug- closing-wedge osteotomy, dome
gestion of decreased capillary refill, rotational osteotomy, and step-cut
increased compartment pressure, lateral closing-wedge osteotomy. 1 Summary
or pallor, and (2) the total absence However, these osteotomies are
on Doppler imaging of a pulse in a associated with a significant com- Although supracondylar fractures
nonischemic extremity. They also plication rate. Labelle et al32 report- of the humerus are common in
asserted that delaying treatment of ed a loss of correction and/or nerve children, management of the injury
a pulseless extremity to obtain an injuries in 33% of their patients. and treatment of complications are
arteriogram before reduction and In a 1994 study, Voss et al 33 still controversial. Expedient man-
pinning is not warranted. found that the cubitus varus defor- agement of the fracture with reduc-
A dreaded complication of vas- mity was generally the result of tion and stabilization markedly
cular compromise or injury is malreduction, but disruption of decreases the incidence of neuro-
Volkmann’s ischemic contracture. medial growth was the cause in vascular complications. Anatomic
Ottolenghi 28 reported that this 11% of their patients with progres- reduction and Kirschner-wire fixa-
complication occurred in fewer sive deformity. If medial growth tion with special attention given to
than 1% of his 830 patients with arrest was present, these authors soft tissues and careful monitoring
supracondylar fractures. An suggested that a lateral epiphysi- of neurovascular function are key
aggressive surgical approach to odesis should accompany the to management of this injury in
prevent Volkmann’s ischemic con- osteotomy to reduce the risk of children.
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