Pediatric Supracondylar Humerus Fractures

Pediatric Supracondylar Humerus Fractures

No Results

No Results

processing….

Pediatric supracondylar humerus fractures (SCHFs) are common and significant injuries. They are distinctly different from adult SCHFs and thus are approached differently. Complications include neurovascular injury, compartment syndrome, malunion, and Volkmann contracture.

Timely diagnosis and proper management can prevent postinjury complications. These injuries are diagnosed by means of anteroposterior (AP) and true lateral radiographs. Lateral condyle fractures are a differential for supracondylar humerus fractures (SCHFs).

Type 1 and type 2A fractures may safely be treated nonoperatively if patients and parents are compliant. Type 2B, type 3, and flexion-type fractures require closed or open reduction and pin fixation. Pulseless and ischemic limbs require emergency reduction and fixation with or without vascular exploration by a vascular surgeon. The duration of immobilization varies, depending on injury severity, patient age, and local hospital protocols.

Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children, accounting for approximately 12-17% of all pediatric fractures. [1, 2] The vast majority of SCHFs are seen in children younger than 10 years, with a peak incidence between 5 and 7 years. [2] The most common mechanism of injury is falling onto an outstretched hand with a hyperextended elbow. [3, 2] Rarely (< 5% of cases), SCHFs are seen with falls onto a flexed elbow, in which case they are referred to as flexion-type SCHFs. [4]

SCHFs have been associated with morbidity due to malunion, neurovascular complications, and compartment syndrome. Nonunion of an SCHF is rarely an issue, but if it does develop, it can result in long-term deformity and functional deficits.

Historically, the majority of SCHFs were treated by means of closed reduction and long arm casting with the elbow hyperflexed to greater than 100º. Although the hyperflexed position helped in maintaining reduction, it also led to problems associated with vascular compromise and subsequent Volkmann contracture.

Currently, management and follow-up of these fractures are determined on the basis of the Gartland classification (see Classification). [5]  Type 1 and type 2A fractures may safely be treated nonoperatively, provided that patients and parents are compliant with therapy. Type 2B, type 3, and flexion-type fractures require closed or open reduction and pin fixation. There is no clear international evidence on the proportion of pediatric SCHFs that are treated operatively as opposed to nonoperatively.

SCHFs may also be seen in the elderly population, where they commonly result from low-energy trauma (eg, falling from a flat surface and landing directly on the elbow). These fractures represent completely different injury entities and should be worked up, assessed, and managed as such. In the geriatric setting, fracture comminution and nonunion are major concerns, and the choices of fixation method and therapeutic approach are drastically different from those seen in the pediatric setting. [6]  For more detail on adult SCHFs, see Supracondylar Humerus Fractures.

The elbow is a synovial hinge joint between the distal humerus and the proximal radius and ulna. Radiographic evaluation of the pediatric elbow requires knowledge and understanding of the secondary ossification centers in the elbow so that normal anatomy can be distinguished from pathologic anatomy. The sequence of ossification follows a predictable pattern, as expressed in the acronym CRITOE (see Table 1 below). [7]

Table 1. Order of Ossification and Fusion of Elbow Ossification Centers (Open Table in a new window)

Ossification Center

Age at Ossification Appearance (y)

Age at Fusion (y)

Capitellum

1

12

Radius

3

15

Internal (medial)

epicondyle

5

17

Trochlea

7

12

Olecranon

9

15

External (lateral) epicondyle

11

12

It should be noted that the ages of ossification and fusion can vary between individuals and are generally earlier in females than in males. [8] The capitellum is the first ossification center to be noted, appearing around the age of 1 year in both males and females. It should also be noted that the elbow is primarily cartilaginous in patients younger than 2.5 years and that structural injuries may be difficult to assess on plain radiography alone. [9]

Pediatric SCHFs most commonly occur in children aged between 5 and 7 years, and their prevalence is similar in males and females. [2]  They are usually a result of falling from a height. In children older than 4 years, falls are commonly from play equipment, such as monkey bars, trampolines, and climbing frames, whereas younger children often fall from household furniture, such as beds and lounges. [1, 3]

If pediatric SCHFs are promptly diagnosed and treated, no long-term complications or functional deficits are expected.

Woon C, Souder C, Skaggs D. Supracondylar fracture – pediatric. Orthobullets. Available at http://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric. Accessed: July 18, 2018.

Barr LV. Paediatric supracondylar humeral fractures: epidemiology, mechanisms and incidence during school holidays. J Child Orthop. 2014 Mar. 8 (2):167-70. [Medline].

Farnsworth CL, Silva PD, Mubarak SJ. Etiology of supracondylar humerus fractures. J Pediatr Orthop. 1998 Jan-Feb. 18 (1):38-42. [Medline].

Flynn K, Shah AS, Brusalis CM, Leddy K, Flynn JM. Flexion-Type Supracondylar Humeral Fractures: Ulnar Nerve Injury Increases Risk of Open Reduction. J Bone Joint Surg Am. 2017 Sep 6. 99 (17):1485-1487. [Medline].

Alton TB, Werner SE, Gee AO. Classifications in brief: the Gartland classification of supracondylar humerus fractures. Clin Orthop Relat Res. 2015 Feb. 473 (2):738-41. [Medline].

Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002 Jul-Aug. 22 (4):440-3. [Medline].

Hill CE, Cooke S. Common Paediatric Elbow Injuries. Open Orthop J. 2017. 11:1380-1393. [Medline].

Iyer RS, Thapa MM, Khanna PC, Chew FS. Pediatric bone imaging: imaging elbow trauma in children–a review of acute and chronic injuries. AJR Am J Roentgenol. 2012 May. 198 (5):1053-68. [Medline].

DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI Jr. Radiographic Evaluation of Common Pediatric Elbow Injuries. Orthop Rev (Pavia). 2017 Feb 20. 9 (1):7030. [Medline].

Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am. 2001 May. 83-A (5):735-40. [Medline].

Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004 Apr. 86-A (4):702-7. [Medline].

Khademolhosseini M, Abd Rashid AH, Ibrahim S. Nerve injuries in supracondylar fractures of the humerus in children: is nerve exploration indicated?. J Pediatr Orthop B. 2013 Mar. 22 (2):123-6. [Medline].

Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008 May. 90 (5):1121-32. [Medline].

Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006 May. 88 (5):980-5. [Medline].

Shaath K. Lateral condyle fracture – pediatric. Orthobullets. Available at http://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric. Accessed: July 18, 2018.

Lampignano J, Kendrick LE. Bontrager’s Textbook of Radiographic Positioning and Related Anatomy. 9th ed. St Louis: Elsevier; 2018.

DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI Jr. Radiographic Evaluation of Common Pediatric Elbow Injuries. Orthop Rev (Pavia). 2017 Feb 20. 9 (1):7030. [Medline].

[Guideline] Supracondylar fracture of the humerus – fracture clinics. The Royal Children’s Hospital Melbourne Clinical Practice Guidelines. Available at http://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Outpatient_fracture_clinics/. Accessed: July 18, 2018.

[Guideline] Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012 May. 20 (5):328-30. [Medline]. [Full Text].

Yen YM, Kocher MS. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. Surgical technique. J Bone Joint Surg Am. 2008 Mar. 90 Suppl 2 Pt 1:20-30. [Medline].

Kocher MS, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, et al. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Joint Surg Am. 2007 Apr. 89 (4):706-12. [Medline].

Ossification Center

Age at Ossification Appearance (y)

Age at Fusion (y)

Capitellum

1

12

Radius

3

15

Internal (medial)

epicondyle

5

17

Trochlea

7

12

Olecranon

9

15

External (lateral) epicondyle

11

12

Jiun-Lih Jerry Lin, MBBS, MS(Orth) Clinical Associate Lecturer, MD Program Research Supervisor, Sydney Medical School, University of Sydney; Orthopaedic Registrar, Mona Vale Hospital, Australia

Disclosure: Nothing to disclose.

Katherine A Vail Radiographer, Mona Vale Hospital

Disclosure: Nothing to disclose.

Matthew F W Sherlock, MD Orthopaedic Surgeon, Peninsula Orthopaedics

Matthew F W Sherlock, MD is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, Australian Society of Orthopaedic Surgeons, Royal Australasian College of Surgeons, Shoulder and Elbow Society of Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey D Thomson, MD Professor of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Connecticut Children’s Medical Center; Vice President of Medical Staff, Connecticut Children’s Medical Center

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America, Scoliosis Research Society

Disclosure: Nothing to disclose.

Pediatric Supracondylar Humerus Fractures

Research & References of Pediatric Supracondylar Humerus Fractures|A&C Accounting And Tax Services
Source

Leave a Reply