Pediatric Supracondylar Humerus Fractures Clinical Presentation

Updated: Aug 27, 2018
  • Author: Jiun-Lih Jerry Lin, MBBS, MS(Orth); Chief Editor: Jeffrey D Thomson, MD  more...
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Presentation

History

In most instances, pediatric supracondylar humerus fractures (SCHFs) result from a fall on outstretched hand with the elbow hyperextended. [3, 2]  As in the assessment of any case of pediatric trauma, it is always necessary to consider the possibility of a nonaccidental injury, neglect, or both; however, these are rare with this fracture type.

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Physical Examination

In supracondylar elbow fractures, the olecranon is driven into the olecranon fossa, and the anterior humeral cortex fails in tension. The muscle action of the triceps brachii displaces the distal fragment posteriorly and proximally. [6]  Upon examination, the child is often distressed, the elbow may appear angulated, and the upper extremity may be shortened.

Neurovascular status must be carefully evaluated and monitored. Owing to the close proximity of the neurovascular structures in this region, injury to these structures is common. [10, 11]  It is worth noting that nearly all neurapraxia after an SCHF resolves spontaneously, and for this reason, further diagnostic studies and exploration are not indicated in the acute setting. [12]  In addition, clinicians must be aware that neurovascular status is dynamic and that repeat examination and documentation are therefore important.

Associated nerve injuries

Nerve injuries that may be associated with pediatric SCHFs include the following [12] :

  • Anterior interosseous nerve palsy - The most common nerve palsy seen with extension-type SCHFs
  • Radial nerve palsy - The second most common neurapraxia in extension-type SCHFs
  • Ulnar nerve palsy - The most common nerve palsy in flexion-type SCHFs

Associated vascular injuries

Displaced SCHFs can result in compromised distal circulation. The clinician must establish the vascularity of the injured limb by assessing the radial pulse as well as the perfusion of the fingers. A nonperfused hand is an orthopedic emergency that warrants reduction and fixation of the injury within 2 hours (see Approach to Pulseless Limb). However, because of the rich collateral circulation at the elbow, the incidence of true limb ischemia in this injury is low (~1%). [12, 13]

Clinical signs that mandate urgent orthopedic review include the following:

  • Compound fracture
  • Severe swelling
  • Neurologic injury
  • Absence of radial pulse
  • Ischemia of the hand

The patient should be kept on NPO (nil per os) status until a decision about surgical management has been made by the orthopedic team. [7]

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Classification

The Gartland classification system is used to categorize SCHFs on the basis of the degree and direction of displacement. [7, 5, 13]   [14]

Gartland type 1 SCHFs are characterized as follows:       

  • Undisplaced or minimally displaced fracture
  • Recommended treatment - Cast immobilization for 4-6 weeks; check radiograph at 1 week and 2 weeks post injury

Gartland type 2 SCHFs are characterized as follows:

  • Type 2A - Displaced fracture with posterior cortex and posterior periosteal hinge intact, with no rotational deformity or fragment translation (see the first image below)
  • Type 2B - Rotational deformity or fragment translation (see the second image below)
  • Recommended treatment - Closed reduction and collar and cuff in elbow hyperflexion (simple type 2A); closed reduction and percutaneous pinning (type 2A or 2B); check radiograph at 1 week and 2 weeks post injury; remove pins at 3-4 weeks
(A, B) Anteroposterior (AP) and lateral elbow radi (A, B) Anteroposterior (AP) and lateral elbow radiographs of 6-year-old girl with type 2A supracondylar humerus fracture with no rotational deformity on AP view. Anterior humeral line is crossing anterior to capitellum. (C, D) AP and lateral elbow radiographs of same patient after treatment with collar-and-cuff in elbow hyperflexion. Fracture is now reduced, and anterior humeral line now transects capitellum.
(A, B) Elbow radiographs of 5-year-old boy with ty (A, B) Elbow radiographs of 5-year-old boy with type 2B supracondylar humerus fracture (SCHF). Type 2B fracture differs from type 2A in that it has additional rotational component. (C, D) Postoperative radiographs of same patient showing cross Kirschner wire (K-wire) configuration in stabilization of SCHF. Intramedullary medial wire placement was done deliberately so as to provide valgus force and counteract any risk of fracture drifting into varus, leading to potential gunstock deformity. Lateral wire was placed to engage medial cortex as shown, for same reason.

Gartland type 3 SCHFs (see the image below) are characterized as follows:      

  • Completely displaced fracture, with no or minimal cortical contact; higher incidence of neurovascular injury
  • Recommended treatment -  Closed reduction and percutaneous pinning; check radiographs at 1 week and 2 weeks post injury; remove pins at 4 weeks and start elbow range of motion
(A, B) Elbow radiographs of 10-year-old girl showi (A, B) Elbow radiographs of 10-year-old girl showing type 3 supracondylar humerus fracture. (C, D) Intraoperative radiographs of same patient demonstrating reduction and fixation of fracture. Two Kirschner wires (K-wires) were used to stabilize lateral column, and one K-wire was used to stabilize medial column.

In 2006, Leitch et al proposed a modification to the original Gartland classification that added a fourth type. [14]  In this modification, Gartland type 4 SCHFs were described as multidirectionally unstable fractures that can displace into both flexion and extension. The management recommended by the authors consisted of closed reduction and percutaneous pinning. Complication rates associated with these unstable fractures were no higher than those associated with other, more stable fractures. 

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