Supracondylar Elbow
Introduction
Supracondylar fracture is the commonest elbow fracture in children.
Classification
Extension Vs Flexion.
Extension most common, flexion type rare, varies (2-11% of all supracondylar injuries)
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Gartland (1959)
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Wilkins (1984) modified the Gartland classification adding IIa and IIb depending on the presence of rotational displacement.
Treatment
Type I - Treatment is symptomatic in minimally displaced fractures, flexing the elbow just past 90 degrees and immobilizing in a collar and cuff and or backslab. for 3-4weeks.
Type II - This is a slightly grey area. With the elbow flexed just past 90 degrees past this injury should stable due to the intact posterior periosteal hinge. If swelling precludes flexion past 90 degrees then k wire fixation is indicated. It has been suggested to further breakdown the type 2 fractures into II A and II B.
- II A - posterior angulation with intact posterior cortex/hinge with no rotational deformity.
- II B - Posterior angulation with intact posterior cortex/ hinge with some degree of rotational deformity.
Clarke et al suggested that the II B with some rotational deformity is less stable than the II A and therefore should be held reduced with percutaneous k wire fixation.
Type III - Completely displaced fractures with no posterior intact hinge/ cortex, these are unstable and require some form of K wire fixation. Several patterns have been described.
K Wire configuration
Controversy remains on the configuration of the K wires, all lateral 2 or 3 wires, or crossed wires.
Biomechanically crossed wires are stronger, clinically very little difference, risk injury to ulna nerve if do crossed wires
medial in flexed 15%
Medial in extension 4%
Lateral wires alone 0%
Special situations
Ulnar nerve palsy following crossed percutaneous pinning
Injury to the ulna nerve from a medially placed pin is
a recognized yet rare complication.
A postoperative ulnar nerve palsy, can be the result of:
- Unrecognized preoperative palsy
- Manipulation during surgery
- Damage to the nerve by a medial pin
The options for management include exploration, medial pin removal,
or observation. Lyon believed in most cases that observation is the appropriate
way to manage these lesions. In all the cases they observed, without exploration
and pin removal, normal nerve function returned. In some it took >4 months, and
many of those had abnormal electromyograms. There is very little evidence that
immediate exploration is helpful for these children. In the recent literature it
has been noted no nerves explored required surgical repair.
Removal of the medial pin is controversial. Removal may lead compromise fracture
stability. On the other hand, if the
medial pin appears to be posterior or in the ulna notch, then it may be
appropriate to remove that pin and replace it with a pin in a more anterior
position, or place a further lateral pin.
Baumans angle (α) - ( `shaft-physeal' angle)
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The angle between the long axis of the humerus and a line through the physis of the lateral condyle. Normal α = 75–80° except for some minor individual differences, could use contra lateral elbow. Baumann believed the reciprocal angle (90-α) equalled the carrying angle, not entirely true, but angle still valid for measuring adequacy of reduction. There is variation among the Orthopaedic textbooks as to which angle should be labelled `Baumann's angle. This is the original version and the most commonly described ie.α (see Acton)
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References
De Boeck, Hugo; - Flexion-Type Supracondylar Elbow Fractures in Children. Journal of Pediatric Orthopedics. 21(4):460-463, July/August 2001.
Lyons, James P; Ashley, Edwin; Hoffer, M. Mark; - Ulnar Nerve Palsies After Percutaneous Cross-Pinning of Supracondylar Fractures in Children's Elbows. Journal of Pediatric Orthopedics. 18(1):43-45, January/February 1998.
Baumann's confusing legacy, Injury, Volume 32, Issue 1, January 2001, Pages 41-43; J. D. Acton and M. A. McNally
Wilkins KE. Fractures and dislocations of
the elbow region. In:
Rockwood CA, Wilkins KE, King RE, eds. Fractures in
children. Vol.
3. Philadelphia: JB Lippincott Co, 1984:363-575.
Clarke et al. Displaced supracondylar fractures of the humerus in children J Bone Joint Surg [Br] 2000 82-B: 204-210
Skaggs DL, Hale JM, Bassett J, et al. Operative treatment of supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 2001;83-A:735–40.