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
High energy injury - ATLS Principles
Supracondylar Fracture - manage as per BOAST Guidelines – SupraCondylar Fractures in Children
Exclude Neurovascular Injury – pale pulseless limb
Exclude NAI
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
Absent Radial pulse
Clinical signs of impaired perfusion of digits
Open Injury
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 1: Undisplaced = Conservative management
Type 2: Angulated with intact posterior cortex = Fix if anterior humeral line doesn't intersect capitellum
Type 3: Completely displaced = Fix
Type 4: Multidirectional 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