Symposium on Childhood Trauma
Supracondylar Fractures of the Humerus Treatment and Complications
Paul P. Griffin, MD.*
Supracondylar fractures are the most frequent fractures about the elbow in the child, accounting for 60 per cent of elbow fractures in children! It is one of the most difficult to manage and is frequently associated with significant residual complications. The fracture occurs at the level of the condylar masses and through the olecranon fossa with the exact level varying little from patient to patient. These are in fact transcondylar fractures. The typical fracture line extends obliquely distal to proximal, going from anterior to posterior, but the degree of obliquity varies considerably. Due to the shape of the humerus, the fracture edge is thin in the middle and wide on the medial and lateral sides so that if rotation is present, angulation of the distal fragments occqrs easily. In 70 per cent to 80 per cent of displaced fractures, the distal fragment is displaced medially and posteriorly. The remainder are posteriorly and laterally displaced, with the exception of I per cent that are displaced anteriorly.
TREATMENT Most supracondylar fractures, if seen early and before massive swelling, can be reduced by manipulation. The technique of closed reduction consists of gentle traction to the extremity with the elbow extended and the forearm supinated (Fig. IA). While traction is maintained the medial or lateral displacement is corrected by direct pressure on the fragments (Fig. IB). The elbow is then gradually flexed beyond a right angle as direct pressure is being applied to push the distal fragment anteriorly (Fig. Ie). The elbow is flexed beyond a right angle, as acute flexion makes the reduction more stable. After the elbow is flexed, the forearm is pronated if the fracture had been displaced posteriorly and medially, and is supinated if the displacement had been lateral (Fig. ID). With the forearm held firmly pronated 'Professor and Chairman, Department of Orthopedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee
Pediatric Clinics of North America- Vol. 22, No.2, May 1975
477
478
PAUL P. GRIFFIN
Figure 1. A, Manual traction with forearm upinated. B, Direct pre ure on the proximal fragment to correct lateral or medial displacement. C, Completion of reducing posterior di placement by direct pre ure. D , Pronation of forearm in medially displaced fracture.
or supinated, depending upon the direction of displacement, an anteroposterior and a horizontal lateral x-ray are taken (Fig. 2A and B). The lateral should be made horizontal so as to avoid the rotational force created at the fracture site, if the shoulder is externally rotated sufficiently to lay the arm and elbow flat on the table for lateral view. If the fracture is shown by x-ray films to be well reduced, a plaster cast is applied that will not only hold the elbow flexed but will also
Figure 2. Anteroposterior (A) and lateral ( B) view of di tal humerus.
PRACO
DYLAR FRACTURES OF TH ' HUMER
479
maintain the forearm supinated or pronated depending upon the position desired. The cast applied after the reduction encircles the distal part of the forearm and wrist but not the upper forearm. Both the soft padding and the plaster go around the flexed elbow encasing the upper forearm and arm in the same turns, leaving the anticubital area free (Fig. 3A and B). Before the cast is applied, a soft pad is placed in the anticubital crease to prevent maceration of the skin. The cast is cut away at the wrist to expose an area to palpate the radial artery, and the fingers are left free. The elbow must be flexed to at least a right angle. Flexion is stopped ju t short of obliterating the radial pulse. If acute flexion is not
Figure 3. A, Soft padding encircles wlist but not upper forearm. B, Ca t will hold forearm pronated or upinated. Note: Anticubital fossa is open and free from pIa tel'.
480
PAUL P. GRIFFIN
possible after the reduction, a cast is applied and the patient kept in bed for three days. The cast is then changed and the elbow further flexed. Salter has recently pointed out that the position of the forearm is the key to completing and maintaining the reduction.4 The stability of the reduction depends upon the use of the intact periosteum to reduce the fracture and maintain the reduction so as to prevent the angulation of the distal fragment that is responsible for the development of cubitus varus or valgus. In a fracture that is displaced medially and posteriorly, the periosteum is torn on the lateral and anterior surface but is intact on the medial and posterior surfaces. With medial displacement, the distal fragment has a tendency to angulate medially which causes varus deformityat the elbow, To prevent medial angulation of the fracture, the forearm is pronated as the last maneuver in the reduction of the fracture. Pronation with the elbow flexed closes the fracture surface laterally and prevents medial angulation. The force of pronation with the olecranon gripping the distal humerus and the elbow ligaments intact, pulls distally on the medial side and compresses the lateral side. This force would angulate the fracture laterally but the intact periosteum on the medial side resists the force and the lateral fracture surface is closed. In laterally displaced fractures the periosteum is torn on the medial and anterior surfaces and is intact laterally and posteriorly. To maintain the reduction in a laterally displaced fractu;re the forearm should be supinated as supination will close the medial fracture surface and prevent the valgus deformity that is a complication in laterally displaced supracondylar fractures. Compression fractures that appear stable and minimally displaced are frequently misleading. Since varuS ang valgus deformities result from angulation of the distal fragment, a fracture that is compressed on the medial or lateral side will cause varus or valgus deformity, respectively. K1:0st fractures,of this type must be freed by traction on the arm for se~~ra1 rnhiut~sand .the fracture reduced with the same principles ~ppliel:Itotlie ,redpctioh~ that are used in the displaced fractures. In someirtst~hbEJS; however, pronation or supination alone with the elbow flexed may correct the medial or lateral compression, respectively. The importance of an accurate reduction and maintenance of the reduction in the prevention of varus and valgus deformities, has been emphasized by Blount. 1 Although accurate reduction is important in the fracture treated by manipulation and immobilization, the forearm position as related to pronation-supination is equally if not more important. In Europe, orthopedists have for years recommended that supracondylar fractures be reduced in pronation. 2 In America, supination is the position most popular. D' Ambrosia, in reviewing supracondylar fractures, found that cubitus varus occurred only in fractures that were treated with the forearm supinated.3 He used a cadaver to demonstrate that in supracondylar fractures the lateral fracture surface is approximated by pronation of the forearm when the elbow is flexed. He found that the ligamentous structure on the lateral side of the elbow joint became tight when the forearm was pronated, and interpreted this tightness as the cause for the approximation of the distal fragment to the proximal fragment on the lateral side.
SUPRACOl';DYLAR FRACTURES OF THE HUMERUS
481
It i~ true that pronation approximates the fracture surface laterally, but the reason for this does not appear to the author to be related to tighteiIjng of the lateral joint ligaments, as suggested by D'Ambrosia, but rather is brought about by the force pronation creates on the distal hUmerus as a result of the olecranon's grip on the trochlea in an elbow With intact ligaments. Pronation with the elbow flexed tends to tilt the distal fragment laterally aJld puts tension on the medial joint ligaments. If the medial perio$teuin is intact to control the degree of lateral tilt, the fracture surface closes laterally. However, if the medial periosteum is torn as it is iIi a laterally displaced fracture, pronation Will tilt the distal fragmeI,lt irito valgus. This principle would dictate that the medially displaced supracondylar fracture should be pronated and the laterally
Supracondylar Fractures of the Humerus Treatment and Complications
Paul P. Griffin, MD.*
Supracondylar fractures are the most frequent fractures about the elbow in the child, accounting for 60 per cent of elbow fractures in children! It is one of the most difficult to manage and is frequently associated with significant residual complications. The fracture occurs at the level of the condylar masses and through the olecranon fossa with the exact level varying little from patient to patient. These are in fact transcondylar fractures. The typical fracture line extends obliquely distal to proximal, going from anterior to posterior, but the degree of obliquity varies considerably. Due to the shape of the humerus, the fracture edge is thin in the middle and wide on the medial and lateral sides so that if rotation is present, angulation of the distal fragments occqrs easily. In 70 per cent to 80 per cent of displaced fractures, the distal fragment is displaced medially and posteriorly. The remainder are posteriorly and laterally displaced, with the exception of I per cent that are displaced anteriorly.
TREATMENT Most supracondylar fractures, if seen early and before massive swelling, can be reduced by manipulation. The technique of closed reduction consists of gentle traction to the extremity with the elbow extended and the forearm supinated (Fig. IA). While traction is maintained the medial or lateral displacement is corrected by direct pressure on the fragments (Fig. IB). The elbow is then gradually flexed beyond a right angle as direct pressure is being applied to push the distal fragment anteriorly (Fig. Ie). The elbow is flexed beyond a right angle, as acute flexion makes the reduction more stable. After the elbow is flexed, the forearm is pronated if the fracture had been displaced posteriorly and medially, and is supinated if the displacement had been lateral (Fig. ID). With the forearm held firmly pronated 'Professor and Chairman, Department of Orthopedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee
Pediatric Clinics of North America- Vol. 22, No.2, May 1975
477
478
PAUL P. GRIFFIN
Figure 1. A, Manual traction with forearm upinated. B, Direct pre ure on the proximal fragment to correct lateral or medial displacement. C, Completion of reducing posterior di placement by direct pre ure. D , Pronation of forearm in medially displaced fracture.
or supinated, depending upon the direction of displacement, an anteroposterior and a horizontal lateral x-ray are taken (Fig. 2A and B). The lateral should be made horizontal so as to avoid the rotational force created at the fracture site, if the shoulder is externally rotated sufficiently to lay the arm and elbow flat on the table for lateral view. If the fracture is shown by x-ray films to be well reduced, a plaster cast is applied that will not only hold the elbow flexed but will also
Figure 2. Anteroposterior (A) and lateral ( B) view of di tal humerus.
PRACO
DYLAR FRACTURES OF TH ' HUMER
479
maintain the forearm supinated or pronated depending upon the position desired. The cast applied after the reduction encircles the distal part of the forearm and wrist but not the upper forearm. Both the soft padding and the plaster go around the flexed elbow encasing the upper forearm and arm in the same turns, leaving the anticubital area free (Fig. 3A and B). Before the cast is applied, a soft pad is placed in the anticubital crease to prevent maceration of the skin. The cast is cut away at the wrist to expose an area to palpate the radial artery, and the fingers are left free. The elbow must be flexed to at least a right angle. Flexion is stopped ju t short of obliterating the radial pulse. If acute flexion is not
Figure 3. A, Soft padding encircles wlist but not upper forearm. B, Ca t will hold forearm pronated or upinated. Note: Anticubital fossa is open and free from pIa tel'.
480
PAUL P. GRIFFIN
possible after the reduction, a cast is applied and the patient kept in bed for three days. The cast is then changed and the elbow further flexed. Salter has recently pointed out that the position of the forearm is the key to completing and maintaining the reduction.4 The stability of the reduction depends upon the use of the intact periosteum to reduce the fracture and maintain the reduction so as to prevent the angulation of the distal fragment that is responsible for the development of cubitus varus or valgus. In a fracture that is displaced medially and posteriorly, the periosteum is torn on the lateral and anterior surface but is intact on the medial and posterior surfaces. With medial displacement, the distal fragment has a tendency to angulate medially which causes varus deformityat the elbow, To prevent medial angulation of the fracture, the forearm is pronated as the last maneuver in the reduction of the fracture. Pronation with the elbow flexed closes the fracture surface laterally and prevents medial angulation. The force of pronation with the olecranon gripping the distal humerus and the elbow ligaments intact, pulls distally on the medial side and compresses the lateral side. This force would angulate the fracture laterally but the intact periosteum on the medial side resists the force and the lateral fracture surface is closed. In laterally displaced fractures the periosteum is torn on the medial and anterior surfaces and is intact laterally and posteriorly. To maintain the reduction in a laterally displaced fractu;re the forearm should be supinated as supination will close the medial fracture surface and prevent the valgus deformity that is a complication in laterally displaced supracondylar fractures. Compression fractures that appear stable and minimally displaced are frequently misleading. Since varuS ang valgus deformities result from angulation of the distal fragment, a fracture that is compressed on the medial or lateral side will cause varus or valgus deformity, respectively. K1:0st fractures,of this type must be freed by traction on the arm for se~~ra1 rnhiut~sand .the fracture reduced with the same principles ~ppliel:Itotlie ,redpctioh~ that are used in the displaced fractures. In someirtst~hbEJS; however, pronation or supination alone with the elbow flexed may correct the medial or lateral compression, respectively. The importance of an accurate reduction and maintenance of the reduction in the prevention of varus and valgus deformities, has been emphasized by Blount. 1 Although accurate reduction is important in the fracture treated by manipulation and immobilization, the forearm position as related to pronation-supination is equally if not more important. In Europe, orthopedists have for years recommended that supracondylar fractures be reduced in pronation. 2 In America, supination is the position most popular. D' Ambrosia, in reviewing supracondylar fractures, found that cubitus varus occurred only in fractures that were treated with the forearm supinated.3 He used a cadaver to demonstrate that in supracondylar fractures the lateral fracture surface is approximated by pronation of the forearm when the elbow is flexed. He found that the ligamentous structure on the lateral side of the elbow joint became tight when the forearm was pronated, and interpreted this tightness as the cause for the approximation of the distal fragment to the proximal fragment on the lateral side.
SUPRACOl';DYLAR FRACTURES OF THE HUMERUS
481
It i~ true that pronation approximates the fracture surface laterally, but the reason for this does not appear to the author to be related to tighteiIjng of the lateral joint ligaments, as suggested by D'Ambrosia, but rather is brought about by the force pronation creates on the distal hUmerus as a result of the olecranon's grip on the trochlea in an elbow With intact ligaments. Pronation with the elbow flexed tends to tilt the distal fragment laterally aJld puts tension on the medial joint ligaments. If the medial perio$teuin is intact to control the degree of lateral tilt, the fracture surface closes laterally. However, if the medial periosteum is torn as it is iIi a laterally displaced fracture, pronation Will tilt the distal fragmeI,lt irito valgus. This principle would dictate that the medially displaced supracondylar fracture should be pronated and the laterally
