Supracondylar Humerus Fractures

Key Points:

• Common fracture treated by pediatric orthopaedic surgeons.
• Radiographic evaluation includes assessment of the anterior humeral line and Baumann’s angle.
• Gartland classification can be used to formulate treatment algorithm.
• Awareness of signs that indicate a more severe fracture and appropriate timing of intervention are important factors to consider to minimize the risk of complications.
• Closed reduction and percutaneous pinning is the mainstay of operative treatment.

Description:

• Common elbow fracture in young children.
• Anatomy of the distal humerus includes medial and lateral columns.  There is an intervening thin area of bone connecting the olecranon fossa and coronoid fossa, which is the location of most supracondylar humerus fractures. 
• Gartland classification (modified)
  • Type 1 – nondisplaced.
  • Type 2 – angulation present but a posterior bony hinge remains intact.
  • Type 3 – complete displacement with no bony hinge.  Periosteum is usually intact.
  • Type 4 – a controversial category describing a fracture that is unstable in flexion and extension, implying a lack of intact periosteum.  
• Occult supracondylar humerus fractures are common and suspected when there is a history of trauma, tenderness in the supracondylar region, and a radiographic elbow effusion (posterior fat pad sign).

Epidemiology:

• Young children, ages 3 years to 7 years most common.
• Slightly more common in boys. 
• Most are closed injuries.
• Neurovascular compromise upon presentation in less than 10%

Clinical Findings:

• Elbow pain, tenderness, swelling, decreased range of motion are standard findings
• Look for antecubital ecchymosis, skin puckering, forearm swelling to indicate a more severe injury
• A detailed neurologic examination is performed in all patients to include both motor and sensory function
• The perfusion status of the extremity should be noted.  Important findings include warmth, capillary refill, and the presence or absence of a radial pulse by palpation and/or Doppler ultrasound. 

Imaging Studies:

• Elbow imaging includes AP and lateral radiographs of the elbow.  An oblique image of the elbow can also be obtained.
• AP and lateral radiographs of the forearm are obtained to rule out associated fractures of the forearm (floating elbow).
• It is not recommended that additional studies (arteriogram) be obtained for evaluation of a pulseless supracondylar humerus fracture as this may unnecessarily delay treatment.
• Things to look for on imaging studies: 
  • AP radiograph – Baumann’s angle, assess medial comminution
  • Lateral radiograph – anterior humeral line, posterior fat pad sign 

Treatment:

• In general, the Gartland Classification can be used for a basic treatment algorithm.
• Type 1 –Place in a long arm cast, elbow flex ≤ 90 degrees
• Type 2 – There are differing opinions on the treatment of Type 2 supracondylar humerus fractures.  Treatment may consist of placement of a long arm cast with close follow-up or closed reduction and percutaneous pinning.  With either treatment method, critical analysis of Baumann’s angle and the anterior humeral line are important.
• Type 3 – Treatment consists of closed reduction and percutaneous pinning.  Timing of intervention is a key point.  In the presence of vascular compromise or compartment syndrome, emergent intervention is essential.
• Duration of immobilization is approximately 3 to 4 weeks.  The need for range of motion exercises or formal physical therapy is controversial.

Complications:

• Compartment syndrome – Minimize risk with immediate intervention for Type 3 injuries associated with vascular compromise.  Significant swelling, wide displacement, antecubital ecchymosis, ipsilateral fractures, and neurologic deficit are relative indications for early intervention.  Patients with any of the above risk factors should be observed carefully.  Pay close attention to the 3 A’s in pediatric patients (anxiety, agitation, analgesic requirement) as potential signs of impending compartment syndrome.  Immobilize in relative extension (≤ 70 degrees for displaced fractures) to reduce compartment pressures.
• Loss of fixation – Minimize risk by having adequate spread of pins at fracture site, test construct for stability prior to leaving the operating room.  Loss of fixation is usually related to an intraoperative technical error.
• Neurologic injury – Usually a neuropraxia that will resolve.  Recognize the importance of complete median nerve injury as a possible indicator of brachial artery injury and as a risk factor for compartment syndrome.  Some surgeons use lateral-only pins to avoid iatrogenic ulnar nerve injury.  If medial pin fixation is necessary, care should be taken to avoid injury to the ulnar nerve.
• Stiffness – Inform families that there may be a mild difference in postoperative range of motion compared to the contralateral side.  
• Malunion – Restore a normal carrying angle to minimize the risk of cubitus varus. Maintenance of an acceptable anterior humeral line intersecting the capitellum will restore the arc of motion. 

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References:

1. Abzug, Joshua M.; Herman, Martin J.  Management of Supracondylar Humerus Fractures in Children: Current Concepts.  Journal of the American Academy of Orthopaedic Surgeons. 20(2):69-77, February 2012
2. Babal JC, Mehlmann CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010; 30 (3): 253-263.
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10. Skaggs DL, Sankar WN, Albrektson J, Vaishnav S, Choi PD, Kay RM.  How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children? J Pediatr Orthop. 2008; 28 (2):139-141.
11. Tripuraneni KR, Bosch PP, Schwend RM, Yaste JJ. Prospective, surgeon randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children. J Pediatr Orthop B 2009;18(2):93-98
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