Paediatric Supracondylar Fracture of the Humerus
Supracondylar fractures are the most common elbow fracture in children, especially in the first decade of life. The peak age is from 5-8 years.
A supracondylar humerus fracture occurs through the thin part of the distal humerus above the level of the growth plate.
Supracondylar fractures are divided into two types, depending on the direction of displacement of the distal fragment.
Extension type – 98%, the distal fragment is displaced posteriorly.
Flexion type – rare, the distal fragment is displaced anteriorly.
The Gartland classification system is used to describe the severity of displacement ox extension type supracondylar humerus fractures.
Type I – Undisplaced fracture
Type II – Angulated fracture with an intact posterior cortex
Type III – Displaced distal fragment posteriorly, with no cortical contact
Type IV – Multidirectional unstable fracture
The usual mechanism is a fall onto the outstretched hand with hyperextension at the elbow.
The child will present with pain, swelling, and limited elbow range of motion.
A displaced fracture in extension typically has an S-shaped deformity.
Swelling can increase very rapidly.
Younger children can present with the appearance of a dislocated elbow.
Always examine for associated injuries.
A thorough neurological examination including screening of the median, radial, and ulnar nerves should be undertaken and documented.
The radial pulse should be felt and documented.
The skin should be assessed for swelling and bruising.
All fractures should be assessed using the Advanced Trauma Life Support (ATLS) principles to ensure associated and potentially significant injuries are identified.
Anteroposterior and lateral x-ray of the distal humerus should be obtained. If there is any clinical suspicion of injury in the forearm or wrist then separate films of these areas should be ordered.
Before the x-ray evaluation, clinically deformed fractures should be immobilized in about 30 degrees short of full extension. This is important for pain management.
In the x-ray, look for the position of capitellum to anterior humeral line and displacement of the fracture.
Gartland Type I fractures do not require reduction.
Gartland Type II fracture can be gently reduced by pushing anteriorly on the distal fragment as the elbow is flexed to 90 degrees.
Gartland Type III, IV, and flexion type fractures are treated with reduction and percutaneous K –wire fixation.
Gartland type I and II fracture are treated with above elbow back slab with 90 degrees elbow flexion with slings for 3weeks.
Operative interventions are indicated in the following situations –
Gartland type III and IV fracture
Flexion type supracondylar humerus fractures
Neurovascular injury with fracture
Extreme swelling/compartment syndrome – extremely rare with humeral fracture
Associated same arm forearm or wrist injury
Emphasis should be placed on the elevation of the limb (elbow above the heart) for the first 48 hours and active finger mobilization.
Back slab and sling should be worn under clothing and not through the sleeve.
All supracondylar fractures result in marked elbow stiffness following the removal of the back slab. In the majority of cases, full ROM returns with time and physiotherapy is not required.
Poor outcomes result from vascular injury, compartment syndrome, Volkmann’s ischemic contracture of the forearm, permanent nerve palsy or malunion.
Stiffness/limited motion – This can occur through sagittal malalignment.
Pin tract infection.
Complications associated with the vascular injury include compartment syndrome followed by the later development of Volkmann’s ischaemic contracture of the forearm.
Malunion (Gunstock deformity/cubitus varus) can result from the tilt in the coronal plane.
Neurological injuries can result from the fracture itself or the treatment. The great majority of the neurologic injuries resolve with time.