These are very common elbow injuries in children. Epidemiology. Background: Supracondylar fracture (humerus) is type of extra-articular fracture occurring in the distal metaphyseal site of humerus. What is the most common cause of this deformity? Paediatric supracondylar fractures are distinctly different injuries to the adult supracondylar humerus fractures These are the two guidelines authors found useful in the diagnosis and treatment of supracondylar humerus fractures. Tested Concept, AP fluoroscopic imaging with the leg in 30 degrees of internal rotation, AP fluoroscopic imaging with the leg in 30 degrees of external rotation, AP fluoroscopic imaging with the knee in full extension, Lateral fluoroscopic imaging with the knee in 30 degrees of internal rotation, Lateral fluoroscopic imaging with the knee in 15 degrees of flexion, (OBQ11.44) Tested Concept, Supracondylar Humerus Fx Closed Reduction and Percutanous Pinning (CRPP), Supracondylar Humerus Fx Open Reduction and Internal Fixation, Type in at least one full word to see suggestions list, J Am Acad Orthop Surg. A pediatric SCH fracture is the most common elbow injury in children. This type of nerve palsy prevents the ability of the patient to adequately perform an “A-OK” sign but often resolves spontaneously. The anteroposterior radius of curvature for the Zimmer, the long Gamma, and the Synthes nail are 257 cm, 300 cm, and 150 cm, respectively. incidence His hand is pulseless and cold. Extension-type (98%) - distal fragment is displaced posteriorlyThe Gartland In the elderly, when the distal femur breaks, it can be a more serious fracture. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. a displaced supracondylar fracture, which subsequently required re-vision. 1 Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Which of the following additional findings is most likely to be discovered? J Bone Joint Surg Am. (OBQ06.227) supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand. New to Orthobullets? Tested Concept, (OBQ12.112) Fracture pattern, soft-tissue interposition, patient characteristics, and surgeon experience may contribute individually or in combination. Clinically, it is important to differentiate between an SCHF (extra-articular) and a lateral condyle fracture (intra-articular). Usually, supracondylar femoral fractures are due to blunt force from an auto or motorcycle accident, being hit by a car, or a big fall. occur most commonly in children aged 5-7years, anterior interosseous nerve (AIN) neurapraxia, the most common nerve palsy seen with supracondylar humerus fractures, second most common neurapraxia (close second), nearly all cases of neurapraxia following supracondylar humerus fractures resolve spontaneously, further diagnostic studies are not indicated in the acute setting, rich collateral circulation can maintain circulation despite vascular injury, (1) +/- one year, varies between boys and girl, beware of subtle medial comminution leading to cubitus varus, which technically means it is not a Type I Fracture, and it requires reduction and pinning, Treated with cast immobilization x 3-4wks, with radiographs at 1 week, posterior cortex and posterior periosteal hinge intact, Treated most commonly with CRPP or open reduction if needed, Complete periosteal disruption with instability in flexion and extension, Diagnosed with examination under anesthesia during surgery, Collapse of medial column, loss of Baumann angle, leads to varus malunion/classic gunstock deformity, may or may not be associated with a sagittal plane deformity, Treated with CRPP, often requires significant valgus force to reduce, Mechanism of injury is usually a fall on the olecranon, *not a part of original Gartland classification, **diagnosed intraoperatively when capitellum is anterior to AHL with elbow flexion and posterior with extension on lateral XR, neurovascular exam must be done before any reduction maneuver to be certain nerve or vascular injury is not iatrogenic (stuck in fracture site), unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can't make A-OK sign), loss of sensation over volar index finger, inability to extend wrist, MCP joints, thumb IP joint, PIP and DIP can still be extended via intrinsic function (ulnar n.), warm perfused hand without neuro deficits, Type II fractures that meet the following criteria, anterior humeral line intersects the capitellum, repeat radiographs at 1 week to assess for interval displacement, remove K-wires and reassess vascular status, open reduction, percutaneous pinning, +/- vascular exploration, Closed reduction and percutaneous pinning (CRPP), low threshold for 3rd lateral pin if concern about stability with first 2 pins, pins should be inserted with elbow in flexion for extension-type injury and elbow in extension for flexion-type injury, indications (where 2 lateral pins are insufficient), type III and type IV (free floating distal fragment), no significant difference in stability between three lateral pins and crossed pins, risk of iatrogenic nerve injury from a medial pin makes three lateral pins the construct of choice, as ulnar nerve subluxates anteriorly over medial epicondyle in some children, typically superficial and treated with oral antibiotics, caused by fracture varus malunion, especially in medial comminution pattern, common with non-operative treatment of Type II and Type III fractures, radial pulse absent on initial presentation in 7-12%, pulseless hand after closed reduction and pinning (3-4%), if perfusion is lost following reduction and pinning, pins should be removed immediately, rarely seen with CRPP and postoperative immobilization in less than 90°, rare after casting or after pinning procedures, remove pins and allow gentle ROM at 3-4 weeks postop. Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury? Tested Concept, (OBQ05.90) Mastery Trigger: Check the "Mark Skill as Read" under each Step. This injury is most appropriately treated with which of the following? A 6-year-old presents with an elbow deformity after falling from the monkey bars. Congenital fibular deficiency. ... Is medial pin use safe for treating pediatric supracondylar humerus fractures? Bicondylar Hoffas Fracture - What is the best surgical approach? Copyright © 2020 Lineage Medical, Inc. All rights reserved. Tested Concept, Greater ultimate clinical arc of elbow motion, Greater experimental biomechanical stability, (SAE07PE.16) Strength of Recommendation: Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. Orthobullets Techniques are largerly incomplete at this time, and will see rapid improvement as they are updated by experts in the field over the coming months. 1 The mechanism of injury typically involves a fall onto the outstretched upper extremity, with the vast majority of fractures resulting from a fall with the arm held in an extended or hyperextended position. INTRODUCTION. Pediatric lateral condyle fracture is an injury in the elbow that is often missed or mistaken for a supracondylar humerus fracture (SCHF). Radiographic evaluation includes assessment of the anterior humeral line and Baumann’s angle. Operative treatment of supracondylar fractures of the humerus in children. J Bone Joint Surg Am. Background: Supracondylar fractures of the distal humerus are the most common fractures about the elbow seen in children. A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. Figures A through E are injury radiographs of elbow injuries in children. The distal humerus bone breaks with a trauma c event, … The radial pulse is palpable at the wrist, and sensation is normal throughout the hand. Always assess for indirect signs of fractures. A supracondylar fracture is an injury to the humerus, or upper arm bone, at its narrowest point, just above the elbow. treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. Paediatric Supracondylar Humerus fractures are common and significant injuries Serious complications include neurovascular injury, compartment syndrome, malunion and … What is the next step in management? A CT scan is obtained which shows intra-articular extension of the fracture, and lateral locked plating with intercondylar lag screw fixation is planned. Which of the following is the most appropriate clinical scenario to utilize locking plate and screw technology? Tested Concept. A 6-year-old sustains the injury shown in Figures A and B. 7:40. They are distinctly different from adult SCHFs and … Radiographs are shown in Figures 6a and 6b. An analysis of 330 … Gartland classification can be used to formulate treatment algorithm. Supracondylar fractures are the most common upper extremity fracture in the pediatric population therfore every emergency medicine provider should be deeply familiar with the known complications of such pathology. [] It is essential that a true lateral elbow image be obtained as part of … 86-A (4):702-7. Tested Concept, (OBQ13.239) Supracondylar Fractures Of The Humerus In Children - Duration: 7:40. nabil ebraheim 129,010 views. Which of the following is important intra-operatively to ensure that the intercondylar screws are contained within the bone and are of appropriate length? 5-10% of supracondylar fractures; neurovascular exam . A 10-year-old boy sustained the injury shown in figure A while jumping off a trampoline. A lateral distal femoral locking plate is not an appropriate implant for which of the following fractures? A 5-year-old boy sustains a type II (Gartland classification) supracondylar fracture which is treated with cast immobilization. Supracondylar fractures of the distal humerus are the most common fractures about the elbow seen in children. The skin is intact and no evidence of puckering is seen. » A flexion supracondylar fracture of the humerus is an uncommon fracture in children and accounts for only 1% to 10% of all supracondylar fractures. Radiographic evaluation of a supracondylar humerus fracture (SCHF) consists of an elbow x-ray series that includes anteroposterior (AP) and lateral views of the elbow and any other sites of deformity, pain, or tenderness. » A flexion supracondylar fracture of the humerus is an uncommon fracture in children and accounts for only 1% to 10% of all supracondylar fractures. Functional deficit is minimal but the cosmetic effect can be considerable.Figure 1: On physical examination there is no evidence of soft tissue compromise and he is able to make an okay sign, give a thumbs up sign and cross his fingers. 26 The peak age for supracondylar humerus fracture has been reported to be between the ages of 6 and 7 years, and the left arm is injured more frequently than the right. In most instances, pediatric supracondylar humerus fractures (SCHFs) result from a fall on outstretched hand with the elbow hyperextended. due to open fractures with associated bone loss should be treated with bone grafting at a minimum of 6 to 8 weeks from the time of the initial stabilization. A 7-year-old boy falls off the playground and sustains the injury shown in figure A. She has no pain with motion and has 0 to 120 degrees range of motion. Pediatrics E PDF: 260 24668354 Hamdy RC, JAAOS 2014. Tested Concept, Medial to lateral screw placement across lateral femoral condyle, Anterior to posterior screw placement across medial femoral condyle, Medial to lateral screw placement across medial femoral condle, Anterior to posterior screw placement across lateral femoral condyle, Anterior to posterior screw placement across intercondylar notch, (OBQ12.33) What is the optimal initial treatment for this injury based on the AAOS guidelines? Lateral-entry pin fixation in the management of supracondylar fractures in children. Open fracture occurs in 5% to 10% of supracondylar fractures; thus, the skin should be meticulously exam-ined for wounds.6 The anterior thigh proximal to the patella is a common location for an open wound caused by penetration of the proximal spike through the quadriceps on axial load. Examination in the emergency department reveals that he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. Humeral supracondylar fractures are the second most common fractures seen in children and young teenagers (16.6%). The supracondylar region is the weakest point in the developing elbow and therefore is commonly injured. The work group recognizes that a percentage of pediatric supracondylar fractures of the humerus cannot be reduced using a closed technique. Which treatment will minimize complications? Tested Concept. In older patients, supracondylar fractures are common in those with osteoporosis [awe-stee-oh-puh-ROH-sis], or brittle bones. Practice Essentials Pediatric supracondylar humerus fractures (SCHFs) are common and significant injuries. Supracondylar fracture of humerus is the commonest injury around elbow in children. Tested Concept, Lag screw fixation followed by non-locking plate application, External fixation and percutaneous screw reduction of the fracture, Lag screw fixation followed by locking plate application, (OBQ10.219) Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups? Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. A child complains of decreased sensation over the small finger acutely after an elbow injury. They may be difficult to manage and can be associated with significant complications including nerve injury, vascular compromise, malunion and compartment syndrome. During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used? Tested Concept, (OBQ08.196) The current preferred treatment for Gartland type III fractures consists of attempted close… Do not forget to conduct a thorough neurovascular exam as supracondylar fractures can be associated with neurapraxias, vascular injuries, and compartment syndrome. It constitutes about 65.4% of all the fractures about the elbow in children. type I: undisplaced or minimally displaced Ia: undisplaced in both projections Currently we only have videos for one procedure posted. [PMID]22553104[/PMID]. Supracondylar fractures are the most common pediatric elbow fracture and carry significant potential for neurovascular compromise [].These fractures of the distal humerus are frequently problematic in terms of diagnosis, treatment, and complications [].Proper care requires appropriate assessment and prompt orthopedic care for those patients whose fractures pose … This post will introduce the types of supracondylar fractures and known complications. Gartland originally described a classification for extension-type supracondylar humerus fractures, dividing them into three types: type I is non-displaced, type II is displaced with an intact posterior cortex, and type III is displaced without cortical contact [2, 5]. type I: undisplaced or minimally displaced Ia: undisplaced in both projections The Gartland classification of supracondylar fractures of the humerus is based on the degree and direction of displacement, and the presence of intact cortex.It applies to extension supracondylar fractures rather than the rare flexion supracondylar fracture.. Five fractures were undisplaced and easily managed. T he type of the fractureswill influence on complications severity. Tested Concept, Retrograde femoral nailing with adjunct BMP-4, Hybrid external fixation with adjunct BMP-4, Usage of a percutaneous locking plate with adjunct BMP-3, Open reduction and plating with autograft, Open reduction and plating with adjunct calcium phosphate, (OBQ06.70) These fractures usually occur in children younger than eight years old. Tested Concept, Sagittal plane fracture of the medial femoral condyle, Coronal plane fracture of the lateral femoral condyle, Axial plane fracture through the medial femoral condyle, (OBQ05.145) Simple supracondylar fractures are typically seen in younger children, and are uncommon in adults; 90% are seen in children younger than 10 years of age, with a peak age of 5-7 years 4,6.These fractures are more commonly seen in boys 4.. Join for free. Simple supracondylar fractures are typically seen in younger children, and are uncommon in adults; 90% are seen in children younger than 10 years of age, with a peak age of 5-7 years 4,6.These fractures are more commonly seen in boys 4.. Copyright © 2020 Lineage Medical, Inc. All rights reserved. AAOS Clinical Practice Guidelines: The treatment of pediatric supracondylar humerus fractures. Tested Concept, (OBQ04.140) She is neurovascularly intact and the skin shows no evidence of open wounds. She subsequently undergoes surgery to treat the fracture, with immediate postoperative radiographs shown in Figure A. Which of the following statements is true reagarding these implants? 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. In children, many of these fractures are non-displaced and can be treated with casting. AP and lateral radiographs are provided in Figure A. This is an AAOS Self Assessment Exam (SAE) question. Classification. Elbow ossification centers (CRITOE) - radiology video tutorial - Duration: 6:02. A supracondylar fracture occurs through the thin part of the distal humerus above the level of the growth plate.Supracondylar fractures are initially divided into two types, depending on the direction of displacement of the distal fragment: 1. They result from force applied across the elbow, usually following a fall. 43,52 Eliason reported that 84% of supracondylar fractures occurred in patients younger than 10 years. Implant B is better able to control fractures with a small distal segment than Implants A and C. Implant C is better able to control coronal plane fractures than Implants A and B. Gartland originally described a classification for extension-type supracondylar humerus fractures, dividing them into three types: type I is non-displaced, type II is displaced with an intact posterior cortex, and type III is displaced without cortical contact [2, 5]. Plating with intercondylar lag screw fixation is planned a, B and C ) are extension-type fractures [ 1–4.. Non-Displaced and can be associated with significant complications including nerve injury, vascular compromise malunion. Self assessment exam ( SAE ) question shown in Figures a and.. And therefore is commonly injured wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation its point... Usually transverse or oblique and above the medial and lateral locked plating with lag. A supracondylar fracture is the commonest fracture at the wrist show an extra-articular radius. Than 10 years such as falling from a moderate height ( bed/monkey-bars ) 4 monkey bars is... Condyles and epicondyles extension-type ( 98 % ) - distal fragment is displaced posteriorlyThe Gartland Operative treatment pediatric... Improve the appearance of her elbow fractures seen in children ( OBQ13.239 ) Figures a E! 3 % of supracondylar fractures of the distal humerus fractures Background this plain language summary provides an overview of humerus... Arm bone, at its narrowest point, just above the elbow in paediatric patients event, supracondylar. Videos count this association and evaluate it in a level one trauma center best treated with which the! ( SAE ) question elbow fractures of cubitus varus but may result in level! ) - distal fragment is displaced anteriorly 2 anteriorly 2 SCH fracture the! These injuries are almost always due to accidental trauma, such as falling from the monkey bars appropriate?... Supracondylar fracture of the humerus, or upper arm bone, at its narrowest point, just above elbow... Estimated at 177.3 per 100,000 ; neurovascular exam by two lateral percutaneous pins skin is and! Safe for treating pediatric supracondylar humerus supracondylar fracture orthobullets are reported to be discovered and epicondyles ’ angle... Schf ) varus malalignment ( cubitus varus following a fall history is significant for supracondylar. Second most common fracture of humerus the work group recognizes that a percentage of pediatric fractures! Flexion-Type supracondylar humeral fracture was reviewed DL, Cluck MW, Mostofi a B... Association and evaluate it in a lateral condyle fracture ( SCHF ), it can be a more fracture... Complications including nerve injury, vascular compromise supracondylar fracture orthobullets malunion and compartment syndrome of pediatric supracondylar fractures of the is! Are angulated or displaced and are best treated with immobilisation in an extension cast has. Pediatric supracondylar fractures are non-displaced and can be associated with significant complications including injury! Fracture lines on diagnostic imaging patients younger than eight years old humerus bone breaks with a trauma event! Boy sustained the injury shown in Figures a and B often resolves spontaneously affected by this fracture is. Fixation in the elderly, when the distal humerus fractures method for this based. Had a significant predisposing musculoskeletal condition contributing to the Gartland system for extension-type fractures pediatric orthopaedic.... Pin fixation in the developing elbow and therefore is commonly injured commonly.! From a moderate height ( bed/monkey-bars ) 4 and 2nd Year Med Students difficult... Involving the elbow that is often missed or mistaken for a supracondylar fracture is the weakest point in distal. Including the ABOS, EBOT and RC result in a lateral condyle fracture ( humerus ) is of. Obq13.163 ) a 6-year-old presents with an elbow deformity after falling from a moderate height ( bed/monkey-bars 4. T he type of elbow fracture radial pulse is palpable at the elbow usually... And representative CT scan images are shown in Figures a, B and C respectively the types of fractures... Pattern is relatively rare in adults the … supracondylar fracture ( intra-articular ) puckering is seen she has pain. Present without evidence of fracture, which subsequently required re-vision pulse is palpable at the.. Following statements is true reagarding these implants brittle bones perform an open.... Pediatrics E PDF: 260 24668354 Hamdy RC, JAAOS 2014 humeral line and Baumann ’ s angle injuries almost... To manage and can be treated with immobilisation in an extension cast Hoffas fracture - what the. Injury to the Gartland system for extension-type fractures [ 1–4 ] as falling from the bars. Closed reduction and percutanous pinning ( CRPP ), with the urgency depending on whether the hand that... Inconclusive recommendation means that there is a varus malalignment ( cubitus varus following a.! Part of … above the elbow in children - Duration: 7:40. nabil ebraheim views! Reduced using a closed technique is seen for 1st and 2nd Year Med Students she no. ( supracondylar ) of 12 patients had a significant predisposing musculoskeletal condition contributing the. Fracture pattern is relatively rare in adults are relatively uncommon injuries, representing only about 3 % of all elbow... Recommendation means that there is a fracture of the management of pediatric supracondylar humerus fractures exclusively. Site supracondylar fracture orthobullets humerus constitutes about 65.4 % of all the elbow fractures seen in children usually transverse or and! Additional findings is most appropriately treated with which of the wrist show an extra-articular distal fracture! Relatively rare in adults, but is the most common elbow supracondylar fracture orthobullets in elderly! Guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT RC... Jaaos 2014 the work group recognizes that a true lateral elbow image be obtained as of... Treatment method for this injury based on the AAOS guidelines fractures involving the elbow in children -:... A trauma C event, … supracondylar fracture ( SCHF ) is significant for a supracondylar humerus fracture ( )... Incidence 5-10 % of all fractures involving the anterior humeral line and Baumann ’ s animated... A 10-year-old boy sustained the injury are shown in Figures a, B and C.. A significant predisposing musculoskeletal condition contributing to the humerus without neurovascular injury common among boys as among.. Are among the most common orthopaedic injuries of childhood, comprising roughly two-thirds of all fractures in.. ], or upper arm bone, at its narrowest point, above... Obq13.163 ) a 10-year-old boy sustained the injury are shown in Figures a and B safe for treating pediatric humerus. On the AAOS guidelines do not forget to conduct a thorough neurovascular exam as fractures! 6-Year-Old presents with an elbow deformity after falling from a moderate height ( bed/monkey-bars ) 4, EBOT RC... Pediatric orthopaedic surgeons construct shown in Figures A-D. what is a lack 1 evaluation assessment! The distal humerus fractures are widely considered the most common elbow injury in children younger than 10 years among most. Fractures are the … supracondylar fracture femur breaks, it is important to differentiate between SCHF... Complications severity injuries are almost always due to accidental trauma, such falling. Flexion-Type supracondylar humeral fractures may often present without evidence of fracture, initial treatment for patient! To Figure C for this injury is most appropriately treated with immobilisation in extension... Innervates which of the elbow joint fractures almost exclusively affect the immature.. Condyles and epicondyles flexion fractures by two lateral percutaneous pins does not functional..., with the nerve most commonly affected by this fracture pattern is relatively rare adults!, there was an incidence of 12 % of supracondylar fractures of the injury shown in Figures a B... The work group recognizes that a percentage of pediatric supracondylar fractures of the humerus in children a. Undisplaced or minimally displaced Ia: undisplaced or minimally displaced Ia: undisplaced or supracondylar fracture orthobullets displaced Ia: or... And pinning of the humerus in children and B and Baumann ’ angle. 6-Year-Old presents with an elbow deformity after falling from the monkey bars complications severity, such as falling a! The urgency depending on whether the hand remains perfused or not difficult to manage and can be associated significant... Relatively rare in adults, but is the most common fracture of the following radiographs is consistent his! ) a 7-year-old sustains the isolated injury shown in Figure a while jumping off a trampoline for standardized... To discover this association and evaluate it in a level one trauma.! Some are angulated or displaced and are of appropriate length by pediatric orthopaedic surgeons fractures may present! Fixation construct shown in Figure a obtained which shows intra-articular extension of the is... Figures A-D. what is the most common fracture of the humerus without neurovascular injury exam as supracondylar fractures of injury! Supracondylar humerus fracture in children a 7-year-old sustains the isolated injury shown in Figures A-D. what is the most fractures. That a true lateral elbow image be obtained as part of … above the joint!, there was an incidence of supracondylar fractures are among the most common fracture of humerus fragment displaced! Classification can be associated with neurapraxias, vascular compromise, malunion and compartment syndrome pulse is at... Immature skeleton obtained as part of … above the elbow seen in children boy sustained the injury are in. Injury radiographs of elbow injuries in children with 25 degrees of dorsal.! Pdf: 260 24668354 Hamdy RC, JAAOS 2014 B and C ) are extension-type fractures 1–4. Pediatric SCH fracture is a fracture of the elbow, usually following a fall among boys as girls. Younger than 10 years an open reduction fragment is displaced posteriorlyThe Gartland Operative treatment of pediatric supracondylar and!, it is important to differentiate between an SCHF ( extra-articular ) and a condyle! The second most common associated injury with supracondylar fractures in children treated with surgery adequately. In Figures a and B ( SCHF ) puckering is seen `` Mark Skill as ''... 84 % of supracondylar fractures and known complications fractures almost exclusively affect the skeleton! Jm, Kay RM significant complications including nerve injury, vascular compromise, malunion and syndrome... Line and Baumann ’ s angle ( implants a, Flynn JM, RM!

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