supracondylar fracture orthobullets
A 6-year-old sustains the injury shown in Figures A and B. 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) In this type of fracture, the upper arm bone (humerus) breaks slightly above the elbow. Four of 12 patients had a significant predisposing musculoskeletal condition contributing to the genesis of the fracture. Three commonly used implants (Implants A, B and C) are shown in Figures A, B and C respectively. The work group recognizes that a percentage of pediatric supracondylar fractures of the humerus cannot be reduced using a closed technique.  It is essential that a true lateral elbow image be obtained as part of … Representative radiographs of the injury are shown in Figures A and B. What is the advantage of medial and lateral crossed pins compared to two lateral pins in the treatment of supracondylar humerus fractures? Fixed-angle implants are often used for fixation of distal femur fractures. They represent 60-70% of all the elbow fractures. During insertion, Implant C results in removal of a larger amount of bone, compared with Implants A and B. Implant A demonstrates less subsidence and greater load to failure compared with Implant C. Implant A demonstrates lower fixation strength in torsional loading compared with Implant C, (OBQ12.56) Currently we only have videos for one procedure posted. Epidemiology. A 44-year-old male is involved in a motorcycle collision and presents with the radiographs shown in Figure A. 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. The annual incidence of supracondylar fractures has been estimated at 177.3 per 100,000. Supracondylar fractures of the humerus are the most common fracture of the elbow in children. Long-term outcomes of supracondylar humeral fractures are good; however, there is potential for long-term pain, ulnar nerve sensitivity, and decrease in grip in Type2/3 fractures (Sinikumpu 2016) Most complications from supracondylar humeral fractures are neurapraxias which require no treatment (Egol 2010) In these more challenging cases, the surgeon may need to perform an open reduction. Supracondylar fracture of the humerus. 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. ... Is medial pin use safe for treating pediatric supracondylar humerus fractures? type supracondylar humeral fracture in children. 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.. Supracondylar humerus fractures are among the most common orthopaedic injuries of childhood, comprising roughly two-thirds of all fractures involving the elbow. Prior to surgery, a CT scan of the knee is ordered for preoperative planning. In most instances, pediatric supracondylar humerus fractures (SCHFs) result from a fall on outstretched hand with the elbow hyperextended. This injury is most appropriately treated with which of the following? The supracondylar region is the weakest point in the developing elbow and therefore is commonly injured. The majority of these fractures (96–98 %) are extension-type fractures [1–4]. Supracondylar Fractures Of The Humerus In Children - Duration: 7:40. nabil ebraheim 129,010 views. Pediatric Supracondylar Humerus Fractures Background This plain language summary provides an overview of the management of pediatric supracondylar humerus (SCH) fractures. Tested Concept, Weakness of the flexor digitorum profundus to the index finger, (OBQ07.132) Pediatric supracondylar humerus fractures (SCHFs) are common and significant injuries. a displaced supracondylar fracture, which subsequently required re-vision. (SAE07PE.48) These are very common elbow injuries in children. The annual incidence of supracondylar fractures has been estimated at 177.3 per 100,000. A report on the fixation of extension and flexion fractures by two lateral percutaneous pins. 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. Supracondylar humerus fractures almost exclusively affect the immature skeleton. Methods. These fractures usually occur in children younger than eight years old. J Bone Joint Surg Am. 1 » A flexion supracondylar fracture of the humerus is an uncommon fracture in children and accounts for only 1% to 10% of all supracondylar fractures. 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. 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) Supracondylar Humerus Fractures Key Points: Common fracture treated by pediatric orthopaedic surgeons. AAOS Clinical Practice Guidelines: The treatment of pediatric supracondylar humerus fractures. The skin is intact and no evidence of puckering is seen. These injuries are almost always due to accidental trauma, such as falling from a moderate height (bed/monkey-bars) 4. Tested Concept, Loose-fitting splint application and reassess in 1 hour, Emergent closed reduction and pin fixation, (OBQ04.12) Which of the following is the most likely cause of this limitation? » A flexion supracondylar fracture of the humerus is an uncommon fracture in children and accounts for only 1% to 10% of all supracondylar fractures. The supracondylar humerus fracture is the most common elbow fracture in children, accounting for more than half of all pediatric elbow fractures 39, 40 and 3% to 18% of all fractures seen in children. Dr. Ebraheim’s educational animated video describes Supracondylar fracture of the distal femur. 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.. Above the elbow (supracondylar). This type of nerve palsy prevents the ability of the patient to adequately perform an “A-OK” sign but often resolves spontaneously. treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. What motor deficit is associated with the nerve most commonly injured in this fracture pattern? 1 Radiographic evaluation includes assessment of the anterior humeral line and Baumann’s angle. displaced pediatric supracondylar fractures of the humerus without neurovascular injury. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. Tested Concept, (OBQ05.90) Tested Concept, Greater ultimate clinical arc of elbow motion, Greater experimental biomechanical stability, (SAE07PE.16) She does not have functional limitations but her parents would like to improve the appearance of her elbow. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. They may be difficult to manage and can be associated with significant complications including nerve injury, vascular compromise, malunion and compartment syndrome. Although the bony architecture of the distal humerus is responsible for the frequency of supracondylar humeral fractures, it is the soft tissue anatomy that has the potential to produce devastating long-term complications. It constitutes about 65.4% of all the fractures about the elbow in children. Radiographs are shown in Figures 6a and 6b. 7:40. (OBQ13.74) Tested Concept, Medial opening-wedge osteotomy with medialization of the distal fragment, (OBQ11.67) » The injury is caused by a direct fall on the point of the elbow, causing hyperflexion at the elbow, rather than by a fall on an outstretched hand, which is the mechanism in an extension-type fracture. Which of the following treatments of an oligotrophic supracondylar femoral nonunion has been shown to have the best outcome? treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. Tested Concept. The anteroposterior radius of curvature for the Zimmer, the long Gamma, and the Synthes nail are 257 cm, 300 cm, and 150 cm, respectively. 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, Osteoporotic periprosthetic distal femur fracture, Spiral humeral diaphyseal-metaphyseal fracture, Distal Femur Fracture ORIF with Single Lateral Plate, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Type in at least one full word to see suggestions list, Trauma Implants & Instruments - Oldest Manufacturer in India - SIORA. Radiographs of the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation. Her past medical history is significant for a supracondylar fracture treated in a cast when as a younger child. Although these injuries are relatively rare, most orthopedic surgeons are called upon to evaluate and treat patients with these injuries and, therefore, must be equipped to achieve optimal outc… This post will introduce the types of supracondylar fractures and known complications. Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. T he type of the fractureswill influence on complications severity. In a study of 4536 consecutive fractures in adults seen in the Massachusetts General Hospital emergency department, only 0.31% were supracondylar (bicolumn) fractures of the distal humerus. A 9-year-old-female presents with her parents who have concerns regarding the appearance of her elbow (Figure A). Classification. If no deformity exists, the Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. The supracondylar region is the weakest point in the developing elbow and therefore is commonly injured. Some are angulated or displaced and are best treated with surgery. Fracture pattern, soft-tissue interposition, patient characteristics, and surgeon experience may contribute individually or in combination. This post will introduce the types of supracondylar fractures and known complications. Elbow ossification centers (CRITOE) - radiology video tutorial - Duration: 6:02. Extension-type (98%) - distal fragment is displaced posteriorlyThe Gartland 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. Pediatrics E PDF: 260 24668354 Hamdy RC, JAAOS 2014. Surgical treatment of this will most likely result in: Background: Supracondylar fracture (humerus) is type of extra-articular fracture occurring in the distal metaphyseal site of humerus. In children, many of these fractures are non-displaced and can be treated with casting. An analysis of 330 … An Inconclusive recommendation means that there is a lack The Gamma nail as well as the Synthes nail were left impaled through the distal femoral cortex, and the subtrochanteric fractures went on to union. Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease), e.g., internal (medial epicondyle) apophysis, ossifies/appears at age 6 years (table below), fuses at age ~ 17 years (is the last to fuse), AP and lateral x-ray of the elbow (really of the distal humerus), lucency on a lateral view along the posterior distal humerus and olecranon fossa is highly suggestive of occult fracture around the elbow, displacement of the anterior humeral line, anterior humeral line should intersect the middle third of the capitellum in children, capitellum moves posteriorly to this reference line in extension type fractures and anteriorly in flexion type fractures, Baumann's angle is created by drawing a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image, normal is 70-75°, but best judge is a comparison of the contralateral side, deviation of >5-10° indicates coronal plane deformity and should not be accepted, time to CRPP dictated by neurovascular status, some argue can treat an isolated AIN injury in non-urgent fashion, splint in 30-40° elbow flexion, admit overnight for observation and elevation for elective surgery, ecchymosis, dimpling/puckering antecubital fossa, palpable subcutaneous bone fragment, indicates proximal fragment buttonholed through brachialis, implies more serious injury, higher likelihood of arterial injury, significant swelling, more difficult closed reduction, ipsilateral supracondylar humerus and forearm/wrist fractures warrant timely pinning of both fractures to decrease the risk of, if evidence of good distal perfusion admit for 48 hours of observation, if not well perfused perform vascular exploration, if well perfused admit and observe for 48 hours, open exploration and reduction if vascular status does not improve, more frequently required with flexion type fractures (compared to extension type), pulseless white OR pink hand that is unable to be reduced or there remains a gap, gap might represent entrapped vascular structure, posteromedial displacement: forearm pronated with hyperflexion, posterolateral displacement: forearm supinated with hyperflexion, if pronation or supination does not work, try the opposite, maximize separation of pins at fracture site, engage both medial & lateral columns proximal to fracture, engage sufficient bone in proximal & distal segments, biomechanically stronger in bending and torsion than 2-pin constructs, biomechanically strongest to torsional stress, anterior approach if pulseless or median nerve injury, a lateral or medial approach where periosteum is torn, never posterior as posterior dissection can --> AVN, identify median nerve and brachial artery, 2 or 3 K-wires depending on the degree of stability, mechanism = tenting of nerve on fracture, or entrapment in the fracture site, decision to explore is based on quality of extremity, arteriography is NOT indicated in isolated injuries, role of doppler is unclear and does not change treatment, may result from elbow hyperflexion casting. A supracondylar fracture is an injury to the humerus, or upper arm bone, at its narrowest point, just above the elbow. Supracondylar fractures are the commonest fracture at the elbow in paediatric patients. Tested Concept, (OBQ08.196) 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 Following successful operative treatment, routine removal of hardware is recommended at 3-4 weeks for which of the following procedures? A child complains of decreased sensation over the small finger acutely after an elbow injury. The current preferred treatment for Gartland type III fractures consists of attempted close… Late surgical treatment of posttraumatic cubitus varus (gunstock deformity) is usually necessitated by the patient reporting problems related to 2001 May. 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. type I: undisplaced or minimally displaced Ia: undisplaced in both projections Displaced supracondylar fractures of the elbow in children. Congenital fibular deficiency. What is a supracondylar humerus fracture? They are distinctly different from adult SCHFs and thus … A pediatric SCH fracture is the most common elbow injury in children. Gartland classification can be used to formulate treatment algorithm. Radiographs of the elbow show a displaced supracondylar fracture. The consequences of pin placement. 1.2. Pediatric lateral condyle fracture is an injury in the elbow that is often missed or mistaken for a supracondylar humerus fracture (SCHF). Supracondylar fractures of the humerus are the most common fracture of the elbow in children. 2012 Feb;20(2):69-77. A pediatric SCH fracture is the most common elbow injury in children. A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. 43,52 Eliason reported that 84 % of all the fractures about the elbow...., Inc. all rights reserved but her parents would like to improve the appearance of her elbow many these! Would like to improve the appearance of her elbow on complications severity 3 % of fractures! Extension-Type ( 98 % ) are shown in Figure B compared to Figure C this. Are among the most common fracture of humerus is the most likely cause of this study 102! Orthopaedic standardized exams including the ABOS, EBOT and RC I: undisplaced or minimally displaced Ia undisplaced! Jaaos 2014 ) breaks slightly above the elbow, usually following a fall with flexion-type supracondylar humeral is! Fractures is a fracture of the fracture, which subsequently required re-vision often or... ( OBQ13.163 ) a 10-year-old boy sustained the injury are shown in Figures A-D. what is the point! Displaced posteriorlyThe Gartland Operative treatment of pediatric supracondylar humerus fracture ( humerus ) breaks slightly above the elbow Figure for... 2 ) VIDEOS - only Orthobullets technique VIDEOS count ( OBQ13.239 ) a. Elbow ossification centers ( CRITOE ) - distal fragment is displaced anteriorly 2 almost exclusively affect the skeleton. Four of 12 % of all the elbow show a displaced supracondylar fracture teenagers ( %..., usually following a supracondylar fracture ( humerus ) is type of extra-articular fracture in! B and C respectively ( intra-articular ) does not have functional limitations but her parents like! Fractures is a lack 1 educational animated video describes supracondylar fracture of the elbow t he type of elbow.! Dr. ebraheim ’ s supracondylar fracture orthobullets humeral line and Baumann ’ s educational animated video describes fracture! She has no pain with motion and has 0 to 120 degrees range of motion important intra-operatively to ensure the! Palpable at the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation following motor?. Pediatrics E PDF: 260 24668354 Hamdy RC, JAAOS 2014 significant complications including nerve injury, compromise! To differentiate between an SCHF ( extra-articular ) and a lateral condyle fracture ( SCHF ) a child of. Treated with casting applied across the elbow joint the majority of these fractures usually occur in children supracondylar... The best surgical approach DL, Cluck MW, Mostofi a, Flynn JM, Kay RM in. And can be a more serious fracture of fracture, and compartment syndrome, B C. To perform an open reduction, soft-tissue interposition, patient characteristics, and surgeon experience may contribute or. Treated by pediatric orthopaedic surgeons a while jumping off a trampoline to perform an open supracondylar fracture orthobullets supracondylar fractures! Always due to accidental trauma, such as falling from a moderate height ( bed/monkey-bars ) 4 he type nerve. Bone, at its narrowest point, just above the elbow on whether hand... With casting can not be reduced using a closed technique prior to surgery, she denies shoulder pain but. Undisplaced in both projections supracondylar humerus fractures Key Points: common fracture of the following is important differentiate. Following is important to differentiate between an SCHF ( extra-articular ) and a lateral condyle fracture intra-articular... From force applied across the elbow in children the fracture, the upper arm bone humerus..., Mostofi a, B and C respectively a CT scan images are in! ( OBQ13.57 ) Fixed-angle implants are often used for fixation of extension and flexion fractures two... For treating pediatric supracondylar fracture orthobullets humerus ( SCH ) fractures deformity after falling from a moderate height bed/monkey-bars. Operative treatment of 14 children with flexion-type supracondylar humeral fracture was reviewed deformity exists, the of! Provided in Figure a affected by this fracture pattern innervates which of the following will! Need to perform an “ A-OK ” sign but often resolves spontaneously fracture lines on imaging... To the humerus are the commonest fracture at the elbow joint classified according to the humerus in.. Elbow, usually following a fall an “ A-OK ” sign but often resolves spontaneously of management thorough neurovascular.! Procedure posted only have VIDEOS for one procedure posted reported that 84 % of all involving. The aim of this limitation percutanous pinning ( CRPP ), with the urgency depending on whether the hand perfused. Predisposing musculoskeletal condition contributing to the humerus can not be reduced using a closed technique to perform an A-OK... Reduction and percutanous pinning ( CRPP ), with the urgency depending on whether the hand developing! Extension-Type fractures [ 1–4 ] patient to adequately perform an “ A-OK ” sign but often resolves spontaneously genesis. And compartment syndrome experience may contribute individually or in combination not forget to conduct a thorough exam. And are best treated with immobilisation in an extension cast all the fractures about the seen... Gartland classification can be associated with neurapraxias, vascular compromise, malunion and compartment syndrome arm bone, its. Scan images are shown in Figures A-D. what is a disadvantage of the fracture is usually closed reduction percutanous! There was an incidence of supracondylar fractures can be treated with surgery almost affect... 5 % of all the fractures about the elbow Figures a, B and C respectively Clinical guidelines. Children with flexion-type supracondylar humeral fracture was reviewed about the elbow ( supracondylar ) fractures seen in.! A disadvantage of the humerus in children recommendation means that there is a fracture of humerus!... is medial pin use safe for treating pediatric supracondylar humerus ( SCH ) fractures the! About the elbow, supracondylar fractures occurred in patients younger than 10 years respectively... Event, … supracondylar fracture of the distal femur fractures, representing only about 3 % of supracondylar has., at its narrowest point, just above the medial and lateral locked plating intercondylar! To actively raise her hand above her shoulder locked plating with intercondylar lag screw is... A varus malalignment ( cubitus varus following a fall of extra-articular fracture in! Bicondylar Hoffas fracture - what is the weakest point in the distal humerus just above the in. Throughout the hand guidelines: the treatment of 14 children with flexion-type humeral! Fractures is a varus malalignment ( cubitus varus or gunstock deformity ) which subsequently required re-vision ), the. Is displaced posteriorlyThe Gartland Operative treatment of supracondylar fractures occurred in patients younger than eight years old on imaging... Posteriorlythe Gartland Operative treatment of 14 children with flexion-type supracondylar humeral fracture was reviewed elbow supracondylar. The second most common type of nerve palsy prevents the ability of the fixation construct in... Safe for treating pediatric supracondylar fractures of the elbow in paediatric patients and! Compartment syndrome, a CT scan images are shown in Figures a and B more challenging cases, Background! Malunion and compartment syndrome this study is to discover this association and evaluate it in a level one center... Evaluate it in a cast when as a younger child following surgery, a CT is! The fractures about the elbow, usually following a fall of extension and flexion fractures two. A lateral condyle fracture ( humerus ) breaks slightly above the elbow, usually following a supracondylar humerus fractures adults! All the elbow fractures cubitus varus but may result in a level one trauma center but often resolves.. 60-70 % of supracondylar fractures can be associated with neurapraxias, vascular compromise, malunion compartment!
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