Updated: 12/27/2021

Supracondylar Humerus Fracture

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  • 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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(M2.OR.15.4694) A 7-year-old child is brought to the emergency room by his parents in severe pain. They state that he fell on his outstretched right arm while playing with his friends. He is unable to move his right arm which is being supported by his left. On exam, his vitals are normal. His right extremity reveals normal pulses without swelling in any compartments, but there is crepitus above the elbow upon movement. The child is able to flex and extend his wrist, but this is limited by pain. The child has decreased sensation along his thumb and is unable to make the "OK" sign with his thumb and index finger. What is the most likely diagnosis?

QID: 107761

Midhumerus fracture

14%

(1/7)

Scaphoid fracture

0%

(0/7)

Distal radius fracture

14%

(1/7)

Distal ulnar fracture

0%

(0/7)

Supracondular humerus fracture

71%

(5/7)

M 6 E

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