Supracondylar Fracture

Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. This fracture often requires immediate orthopedic consultation secondary to the displacement of the fracture and the frequency of concomitant neurovascular injury.

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Overview

Definition

A supracondylar fracture affects the distal humerus, just above the elbow, and is seen frequently in the pediatric population.

Epidemiology

  • 15% of all pediatric fractures
  • Most common pediatric elbow fracture (60%)
  • Peak incidence 2–7 years old
  • Nondominant arm most often fractured
  • Male predominant

Etiology

  • Falls:
    • Fallen onto an outstretched hand in 70% of cases
    • < 3 years old: fall from < 1 m (< 3 ft)
      • Changing table
      • Bed
      • Parent’s lap
    • > 3 years old: fall from > 1 m (> 3 ft)
      • Playground structures
  • Direct blows to elbow in older patients.

Pathophysiology

The distal humerus’s supracondylar area in children is made of thin, structurally weak developing bone, making it a common fracture site. 

  • Extension fractures (95%):
    • Fallen onto an outstretched hand
    • Posterior displacement of the elbow
  • Flexion fractures (5%):
    • Anterior force placed on flexed elbow (usually direct trauma)
    • Elbow displaced anteriorly
  • 5%–10% of supracondylar fractures are associated with damage to neurovascular structures:
    • Brachial artery: 
      • Superior to brachial muscle
      • Injury risk during fracture and reduction, especially with posterolateral displacement
    • Median nerve:
      • Runs with brachial artery 
      • Injury risk with a posterolateral displacement of the fracture
      • Anterior interosseous nerve (AIN nerve): branch of median nerve most commonly injured nerve 
    • Radial nerve: injured with the same frequency as median nerve
    • Ulnar nerve: much less common, may be injured with flexion type fractures

Classification

Gartland classification is based on the degree of displacement:

  • Gartland type 1: minimally displaced or occult fracture
  • Gartland type 2: displaced fracture with intact posterior cortex
  • Gartland type 3: completely displaced fracture with cortical disruption, subtypes based on the direction of displacement
  • Gartland type 4: multidirectional instability with circumferential periosteal disruption; diagnosis made during exam under anesthesia/intraoperatively
Gartland classification

Gartland classification of supracondylar fractures:
The Gartland classification system of supracondylar elbow fractures is based on the degree of displacement of the fractures. Gartland type I is a minimally displaced fracture. Gartland type II features more displacement, but the posterior cortex remains intact. Gartland type III is a completely displaced fracture.

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Clinical Presentation and Diagnosis

Supracondylar fractures are the most common type of elbow fracture found in children. These fractures often require emergent treatment secondary to associated neurovascular injuries.

Signs and symptoms

  • Patients usually present after fallen onto an outstretched hand or direct trauma.
    • Fallen onto an outstretched hand leads to extension-type injury (97%–99%).
    • Fall onto the posterior elbow can lead to flexion-type injury.
  • Localized pain to the supracondylar area with decreased range of motion
  • Often have associated swelling, ecchymosis, and obvious deformity of elbow
  • Ecchymosis and skin puckering of the anterior aspect of elbow (“brachialis sign”) can indicate neurovascular injury and compartment syndrome.

Neurovascular examination

Repetitively evaluate motor and sensory nerve function and assess for vascular insufficiency.

  • Neurological exam: 
    • Median nerve: Assess for abduction of thumb or flexion of distal phalanx of thumb.
    • Anterior interosseous nerve (AIN): Assess for flexion of distal phalanx of thumb.
    • Radial nerve neuropraxia: Assess for extension of wrist and extension of thumb interphalangeal joint.
    • Ulnar nerve: Assess first dorsal interosseous muscle.
  • Vascular exam:
    • Evaluate for discoloration, warmth of limb, and capillary refill.
    • Evaluate both radial and ulnar arteries.
    • Doppler may be helpful
    • Cold, pale, pulseless hand requires immediate surgical evaluation and fracture reduction.
    • May need vascular exploration
    • Approximately 10%–20% of displaced supracondylar fractures present with alterations in vascular status. Fracture reduction can be used to restores perfusion.

Radiographs

  • General considerations:
    • Adequate analgesia and immobilization should be done before imaging to prevent further displacement and damage. 
    • 2 + views (anteroposterior and lateral) should be obtained: true lateral is essential.
    • Imaging of unaffected side may be done to differentiate between ossification centers and true fractures in pediatric patients.
  • Findings on abnormal radiographs:
    • Visible posterior fat pad (a sign of elbow effusion)
    • Wide (sail sign) anterior fat pad
    • Anterior humeral line passes through the anterior 3rd of capitellum or fails to intersect with it because of posterior displacement of the distal humerus.

Potential complications

  • Acute:
    • Vascular compromise
    • Compartment syndrome
      • Edema of soft tissue around fracture resulting in excessive pressure within a closed muscle compartment 
      • Results in ischemia of muscle and nerve tissue
  • Long term:
    • Development of Volkmann’s ischemic contracture
    • Permanent neurological injury
    • Loss of range of motion of elbow
    • Cubitus varus (gunstock deformity)

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Management

Treatment of supracondylar fractures is based on the amount of displacement of the fracture.

  • Initial management: 
    • Immobilization of elbow in long-arm splint at 30°–40°
    • Control pain.
    • Avoid further neurovascular injury and decrease risk of compartment syndrome.
    • Repeated evaluation and monitoring of neurovascular status essential (before and after application of initial splint)
  • Further management based on grade:
    • Gartland type I: generally managed with long-arm splint or cast < 90° of flexion
    • Gartland type II: majority treated with closed reduction and surgical pinning
    • Gartland type III and IV:
      • Closed reduction and surgical pinning
      • Type IV injuries are only diagnosed under anesthesia.

Clinical Relevance

Additional important pediatric skeletal injuries:

  • Buckle or Torus fracture: fracture affecting growing metaphyseal bone secondary to compression load, where bone buckles or compresses. This fracture is generally considered a stable fracture. Treated by immobilization and has a good prognosis.
  • Greenstick fracture: partial-thickness fracture, which involves complete break of cortex and periosteum on only 1 side of the bone. The condition is termed “greenstick” because the fracture resembles the break in a live “green” twig, where 1 side of the stick remains intact. High risk for refracture and should be completely immobilized. Rarely requires reduction, but should be managed cautiously to prevent malunion or angulation deformities. This fracture often should be referred for orthopedic follow-up.
  • Apophyseal avulsion fracture: apophysis is a secondary ossification center found in nonweight-bearing segments of bones and is the site of ligament or tendon insertion. Acute apophyseal avulsion fracture occurs when a portion of apophysis is pulled off by ligament, usually secondary to explosive movements and eccentric muscular contractions. This condition is primarily treated conservatively, with rest and pain control, but may require surgical repair if a fragment of avulsed bone is large with significant displacement. 

References

  1. Holt JB, Glass NA, Shah AS. (2018). Understanding the Epidemiology of Pediatric Supracondylar Humeral Fractures in the United States: Identifying Opportunities for Intervention. J Pediatr Orthop. https://pubmed.ncbi.nlm.nih.gov/29462120/ 
  2. Lins RE, Simovitch RW, Waters PM. (1999). Pediatric elbow trauma. Orthop Clin North Am. https://pubmed.ncbi.nlm.nih.gov/9882730/ 
  3. Farnsworth CL, Silva PD, Mubarak SJ. (1998). Etiology of supracondylar humerus fractures. J Pediatr Orthop. https://pubmed.ncbi.nlm.nih.gov/9449099/ 
  4. Shrader MW. (2008). Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. https://pubmed.ncbi.nlm.nih.gov/18374807/ 

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