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Supracondylar Fracture

Clinical Station (Orthopaedics)

Scenario


A 6-year-old child presents to A+E with severe elbow pain following a fall whilst climbing monkey bars on the playground. A+E staff are concerned as they cannot palpate a pulse and the fingers appear very pale. Her lateral radiograph is shown:



Please interpret the radiograph 

A lateral radiograph of the left elbow is presented in a 6-year-old female. There is evidence of a supracondylar fracture with significant posterior displacement. The anterior humeral line does not intersect the capitate on the lateral radiograph.

What are you concerned about in this patient?


Key Concerns


How would you assess this patient in A+E?

ATLS 

“This patient has a potential high energy injury mechanism; I would therefore ensure that the patient was managed via ATLS principles. With a trauma call, introduction of team members and assignment of roles followed by a primary and secondary survey to identify and treat any life / limb threatening injuries.”

 

History

A  Allergies

M  Medications

P  Past Medical History

L  Last Ate

E Events


  • Mechanism of injury

  • Hobbies

  • Hand dominance

  • Must state with children to - exclude NAI

 

Examination

  • Exclude open / impending open injury

    • Check overlying skin viability

  • Examine neurological Status

    • Okay sign: AIN / Median Nerve

    • Starfish sign: Ulna nerve

    • Thumbs up: Radial nerve

    • Sensory distributions of each nerve (autonomous areas)

  • Examine vascular Status

    • CRT + Colour + Temperature

    • Radial pulse

    • Expanding haematoma

 

Investigations

  • Complete set of XRs - AP + Lateral Elbow

    • Anterior Humeral line - should intersect capitellum

    • Anterior and posterior fat pad signs

    • Baumann’s angle


What features on a radiograph of a supra-condylar should you look for?

 

AP + Lateral radiograph of the Elbow recommended

 

AP 

  • Baumann’s Angle

    • Line along axis of humerus

    • Line along lateral condylar physis

    • Normal 70-75 degrees (best judge is contralateral side)

    • Deviation >5-10 degrees indicates coronal plan deformity

  • Medial/lateral translation

  • Rotational deformity

 

 

Lateral 

  • Anterior humeral line

    • Anterior humeral line should intersect the middle third of the capitellum

    • Capitellum moves posteriorly in reference to anterior humeral line in extension type injuries

  • Posterior fat pad sign

    • Lucency along the posterior distal humerus

    • Suggestive of occult fracture of the elbow


What are the four indications for taking a patient with supracondylar fracture to theatre overnight?

As per BOAST guidelines initial assessment should determine whether patients should go immediately to theatre out of hours or whether they can wait until the next available trauma list

 

Immediate Theatre

  1. Absent Radial pulse

  2. Clinical signs of impaired perfusion of digits

  3. Open Injury

  4. Impending open injury

 

In patients with signs of vascular compromise reduction should be performed in theatre and vascularity reassessed. If ongoing vascular impairment vascular surgeons should be involved immediately - as these patients may require brachial artery exploration


If this patient presented with a cool and pulseless hand in A+E what would you do?

  • Vascular injuries may be seen with displaced supracondylar fractures

  • Around 10-20% of Gartland III injuries present with signs of impaired vascular perfusion

    • Immediate reduction and fixation will restore circulation in around 75% of cases

    • This is due to brachial artery spasm or trapping within the fracture site rather than true brachial artery injury

    • If there are ongoing concerns regarding perfusion post reduction and fixation - surgical exploration is required by a vascular surgeon

  • Vascular studies such as an angiogram should not delay urgent surgery or reduction of these injuries

What classification system do you know for these fractures? How does this dictate management?

Gartland’s Classification [link to original paper]

 

Introduced in 1959, initially a three-part classification system based on the degree of displacement and the presence of an intact posterior cortex for extension type injuries (Later a fourth type for multidirectional instability was added).

Can be used to dictate management:

  • Type 1Undisplaced = Conservative management

  • Type 2Angulated with intact posterior cortex = Fix if anterior humeral line doesn't intersect capitellum

  • Type 3: Completely displaced = Fix

  • Type 4Multidirectional instability (flexion + extension type) = Fix


What complications would you consent the parents for if this patient was going to theatre?

  • Pain

  • Infection 1-2% get pin site infections

  • Bleeding

  • Scarring

  • Stiffness / reduced ROM

  • Altered limb length / deformity (cubitus varus / valgus)

  • Non-union / mal-union

  • NV injury

  • Pin Migration - most common complication (2%)


Post-operatively if this patient presented with paralysis and loss of sensation in the ulna nerve distribution – what would you have done?

Post-operative Ulna Nerve Injury 

  • Iatrogenic ulna nerve injury is often due to constriction of the ulna nerve in the cubital tunnel rather than direct impaling of the nerve

  • Initial management would include removal of circumferential dressings, splitting of plaster and elevation of limb - reassess NV status

  • Ongoing neurological injury - consultant decision on whether surgical exploration is required

  • There is limited evidence of whether the medial wire should be removed

 

Early painful paralysis of nerve 

  • May be due to compartment syndrome / nerve compression (bone fragments / wires / haematoma)

  • Should be explored urgently as per BOAST: Peripheral Nerve Injury

  • These patients should be followed up closely in clinic

    • Nerve recovery generally takes around 2-3 months but may take up to 6 months

    • If ongoing concern patients should be sent for nerve conduction studies + referral to a peripheral nerve specialist

Images

Baumann's Angle
Anterior and posterior fat pad sign
Anterior humeral line intersecting Capitellum 
Gartland Classification

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