Supracondylar Fracture Humerus

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Supracondylar Fracture Humerus
Supracondylar Fracture Humerus AIIMS PGI AIPGMEE
  • Supracondylar fracture of humerus
    • caused by a fall on an out-stretched hand (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
    • As the hand strikes the ground, the elbow is forced into hyperextension resulting in fracture of the humerus above the condyles. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
    • The fracture line extends transversely through the distal metaphysis of humerus just above the condyles. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
    • Types: extension or flexion type
      • extension type (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
        • commoner of the two
        • distal fragment is extended (tilted backwards) in relation to the proximal fragment.
      • flexion type
        • distal fragment is flexed (tilted forwards) in relation to the proximal fragment.
    • Clinical signs
      • Unusual posterior prominence of the point of the elbow (tip of olecranon) because of the backward tilt of the distal fragment.
      • Since the fracture is above the condyles, the three bony points relationship is maintained as in a normal elbow. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
      • possibility of interruption of the blood supply to the distal extremity because of an associated brachial artery injury, must be carefully looked for in all cases. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
      • Radial and ulnar pulses may be absent with or without signs of ischaemia (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
      • One must look for an injury to the median nerve (pointing index) or the radial nerve (wrist drop).
    • Radiological examination:
      • Displacements seen on an X-ray
        • In an AP view, one can see the proximal shift, medial or lateral shift, medial tilt and rotation of the distal fragment.
        • In a lateral view, one can see the proximal shift, posterior shift, posterior tilt and rotation of the distal fragment.
    • Treatment
      • Undisplaced fractures
        • require immobilisation in an above-elbow plaster slab, with the elbow in 90° flexion. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
      • All displaced fractures
        • child should be admitted to a hospital because serious complications can occur within the first 48 hours.
      • Methods of treatment of displaced fractures
      • Closed reduction and percutaneous K-wire fixation: (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
        • Most displaced fractures are easily reduced by closed reduction, but they often slip. Hence, it is best to fix them with one or two K-wires, passed percutaneously under image intensifier guidance.
      • Technique of closed reduction of a supracondylar fracture
        • Traction with the elbow in 30-40° of flexion: (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • This manoeuvre corrects proximal displacement and medial-lateral displacements. If required, the ‘carrying angle’ of the elbow is corrected at this stage.
        • Flexion in traction
        • Pressure over the olecranon
        • Traction is maintained as the elbow is flexed to beyond 90°.(MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
        • Throughout this manoeuvre the radial pulse is felt(MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
        • If it is obliterated on flexion, the elbow- is extended again until, the pulse returns
      • It is necessary to make a check X-ray after 48 hours, and after 1 week in order to detect any redisplacement.
      • In case no redisplacement occurs, the plaster is removed after 3 weeks.
  • Open reduction and K-wire fixation:
    • Indications (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
      • If it is not possible to achieve a good position by closed methods
      • fracture gets redisplaced after reduction
      • as a first line of treatment in some open fractures
      • those requiring exploration of the brachial artery for suspected injury.
      • Continuous traction: no longer used.
      • required in cases presenting late with excessive swelling or bad wounds around the elbow.
      • The traction may be given with a (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
        • K-wire passed through the olecranon (Smith’s traction)
        • a below-elbow skin traction (Dunlop’s traction)
    • Complications
      • Immediate Complications
        • Injury to the brachial artery: (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • injured by the sharp edge of the proximal
          • Most often, enough blood gets through the collaterals around the elbow to keep the hand alive
          • flexor muscles of the forearm may suffer ischaemic damage leading to Volkmann’s ischaemia.
          • vascular compromise may result in gangrene.
        • Injury to nerves: (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • median nerve is the most commonly injured nerve (Frequently asked MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Radial nerve is also sometimes affected.
          • Spontaneous recovery occurs in most cases.
      • Early Complications
        • Volkmann’s ischaemia:
          • an ischaemic injury to the muscles and nerves of the flexor compartment of the forearm. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • caused due to occlusion of the brachial artery by a supracondylar fracture.
          • muscles supplied by the anterior interosseous artery, a branch of brachial artery, are most susceptible to ischaemic damage because this artery is an end-artery(MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Most commonly affected muscles are the flexor pollicis longus and medial half of flexor digitorum profundus. (Frequently asked MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Diagnosis:
            • The child complains of severe pain in the forearm.
            • He is unable to move the fingers fully.
            • Ischaemic pain is more severe than the pain due to the fracture.
            • A child needing more than usual doses of analgesics may be developing a compartment syndrome. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
            • Stretch pain:
              • The child complains of pain in the flexor aspect of the forearmwhen the fingers are extended passively.
            • Swelling and numbness over the fingers occur rather late. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
            • There is tenderness on pressing the forearm muscles.
          • Treatment:
            • Volkmann’s ischaemia is an emergency of the highest order
            • Any external splints or bandages that might be causing constriction are removed.
            • The   forearm   is   elevated   and   the   child encouraged to move fingers.
            • If no improvement occurs within 2 hours- fasciotomy is done(MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
      • Late Complications
        • Malunion
          • It is the commonest complication of a supracondylar fracture  (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • results in a cubitus varusdeformity. (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • This is because the fracture unites with the distal fragment tilted medially and in internal rotation.
          • Malunion may occur either because of
            • failure to achieve good reduction
            • displacement of the fracture within the plaster.
          • The cubitus varus deformity is often termed the Gun stock deformity(MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Sometimes, the distal fragment unites with an excessive backward tilt, resulting in hyperextension at the elbow along with limitation of flexion – basically a change in the arc of movement at the elbow.
          • Treatment is a supracondylar corrective osteotomy (French osteotomy). (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
        • Myositis ossificans:
          • This is an ectopic new bone formation around the elbow joint, resulting in stiffness.  (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Massage following  the  injuryis a major factor responsible for it.          (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Treatment:
            • In the early stages, the elbow is put to rest in an above-elbow slab for 3 weeks.
            • Following this, gentle elbow mobilisation is started.
            • In some late cases, excision of the myositic bone or excision arthroplasty of the elbow is required.
        • Volkmann’s ischaemic contracture (VIC):
        • marked atrophy of the forearm, with flexion deformity of the wrist and fingers
        • skin over the forearm and hand is dry and scaly.
        • nails also show atrophic changes.
        • Volkmann’s sign(MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • helps in deciding the cause of flexion deformity of the fingers.
          • In this sign, it is possible to extend the fingers fully at the interphalangeal joints only when the wrist is flexed
          • On extending the wrist, the fingers get flexed at the inter-phalangeal joints.
          • This is because when the wrist is extended, the shortened flexor muscle-tendon unit is stretched over the front of the wrist, resulting in flexion of the fingers.
        • Treatment:
          • Mild deformities
            • can be corrected by passive stretching of the contracted muscles, using a turn-buckle splint – (Volkmann’s splint) (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Moderate deformities
            • a soft tissue sliding operation
            • flexor muscles are released from their origin at the medial epicondyle and ulna, is performed (Maxpage operation). (MCQ AIIMS AIPGMEE PGI JIPMER COMEDK DNB CET)
          • Severe deformity,
            • bone operations such as shortening of the forearm bones, carpal bone excision etc. may be required.