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Updated: Dec 27 2021

Supracondylar Humerus Fracture

  • Snapshot
    • An 7-year-old girl falls from a jungle gym and lands on her outstretched left hand. She develops immediate-onset left elbow pain and swelling. On exam, her arm is held in 30 degrees of extension and she is unable to move her elbow due to pain. A radiograph is shown and demonstrate a dorsally displaced supracondylar humerus fracture.
  • Introduction
    • Clinical definition
      • fracture of the distal humerus proximal to the medial and lateral condyles
  • Epidemiology
    • Incidence
      • most common pediatric elbow fracture
      • accounts for 41% of all serious pediatric elbow injuries
      • extension type injury most common (95-98%)
    • Demographics
      • children aged 5-7 years of age
      • rare in adults
      • males and females equally likely
  • Etiology
    • Accidental trauma (e.g., fall from moderate height)
      • fall on outstretched hand
        • leads to an extension type injury
      • fall on posterior elbow
        • leads to a flexion type injury
    • Pathoanatomy
      • normal anatomy
        • humerus articulates with the radius and ulna at the elbow joint
        • medial and lateral condyles are located at the distal portion of the humerus
        • condyles represent the medial and lateral columns of the distal expansion of the humerus
        • supracondylar humerus is the part of the humerus just proximal to the medial and lateral condyles
      • fracture mechanics
        • in an extension type injury, the olecranon process is forced against the weaker metaphyseal bone of the supracondylar humerus
          • distal fracture fragment will be angulated and/or displaced posteriorly
          • accounts for 95-98% of supracondylar fractures
        • in a flexion type injury, a direct blow to the posterior elbow forces the distal condylar bone to displace anteriorly
          • distal fracture fragment will be angulated and/or displaced anteriorly
          • accounts for 2-5% of supracondylar fractures
      • Salter Harris classification - if through a growth plate
        • Type I: slipped growth plate
        • Type II: above the physis w/metaphysis fracture
        • Type III: below physis w/epiphysis fracture
        • Type IV: through the physis
        • Type V: crushed growth plate
    • Associated conditions
      • vascular
        • brachial artery can be damaged
      • neurapraxia
        • anterior interosseous nerve (AIN) neurapraxia
          • branch of median nerve
          • innervates flexor pollicis longus, pronator quadratus, and radial half of flexor digitorum profundus
          • most common neurapraxia in extension type fractures
        • radial nerve neurapraxia
          • second most common neurapraxia in extension type fractures
        • ulnar nerve neurapraxia
          • most common neurapraxia in flexion type fractures
  • Presentation
    • Symptoms
      • elbow pain and limited range of motion
    • Physical exam
      • inspection
        • gross deformity only in severe cases
        • swelling
        • ecchymosis
      • palpation
        • tender to palpation
      • motion
        • limited passive and active range of motion
      • neurologic exam
        • important to assess motor and sensory nerve function
          • AIN neurapraxia
            • inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can't make A-OK sign)
          • radial nerve neurapraxia
            • inability to extend wrist or digits
      • vascular exam
        • important to assess for vascular insufficiency
          • cold, pale, pulseless hand necessitates immediate reduction and pinning
          • if hand is still dysvascular after reduction and pinning, may require vascular exploration
  • Imaging
    • Radiographs
      • indications
        • anteroposterior (AP) and lateral radiographs always indicated if fracture is suspected
      • findings
        • fracture fragment may or may not be visible
        • positive anterior fat pad sign (sail sign)
          • anterior fat pad is normally visible
          • with supracondylar fracture, anterior fat pad is elevated because of hemarthrosis
        • positive posterior fat pad sign
          • posterior fat pad is normally NOT visible
          • with supracondylar fracture, posterior fat pad may be visible because of hemarthrosis
  • Treatment
    • Conservative
      • long arm posterior splint followed by long arm casting
        • indication
          • non-displaced fractures
          • minimally displaced fractures with no comminution and minimal swelling
    • Operative
      • closed reduction and percutaneous pinning
        • indication
          • displaced fractures
          • flexion-type fractures
          • dysvascular hand
  • Differential
    • Radial head subluxation (Nursemaid's elbow)
      • second most common serious pediatric elbow injury
      • arm held in flexion and pronation
      • commonly occurs due to excessive traction, not a fall
    • Lateral epicondyle fracture
      • third most common serious pediatric elbow injury
      • will be tender on lateral side with minimal tenderness on medial side
  • Complications
    • Malunion
      • cubitus varus (gunstock deformity)
        • malalignment resulting in change from physiologic valgus elbow alignment to varus alignment
        • cosmetic deformity with minimal functional impairment
    • Vascular injury
      • Volkmann ischemic contracture
        • damage to brachial artery leads to volar compartment syndrome and muscle necrosis
        • irreversible muscle contractures in the forearm, wrist, and hand
  • Prognosis
    • Favorable
      • non-displaced or minimally displaced fractures
    • Negative
      • poor anatomic reduction
      • vascular injury
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