Supracondylar fracture of humerus- Classification, clinical features & Treatment

Supracondylar fracture of humerus- Classification, clinical features & Treatment
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Supracondylar fracture of humerus

It is very common fracture in children, because at this age the body architecture  at (SC) region is weak.

Mechanism of injury 
Fall on out stretched hand as hand strikes the ground, the elbow is forced into hyperextension resulting in fracture of humerus above the condyles. Fall on the point of elbow direct injury. The distal fragment can be displaced anterior or posterior.
Classification 
Flexion type: Fracture line runs downward and forwards
Extension type: Fracture line runs upwards and backwards (Common type)
Garland’s classification (In children)
Type I – Undisplaced
Type II – Displaced, but Posterior cortex is intact
Type III – Displaced , but is not intact and distal fragment could either displaced posteromedial or posterolateral.
Clinical features
Gross pain and swelling
S-Shaped deformity of upper arm with loss of active and passive movement of elbow.
Patient may also complaint act pseudo paralysis
Check should be done to check brachial artery, radial nerve, median nerve and ulnar nerve.
Clinical signs
Arm is short, forearm is normal
Gross swelling and tenderness
Crepitus is present
Dimple sign due to spike of proximal fragments penetrating muscle and tethering skin
Soft spots
Posterior prominence of elbow
 
Radiographs
X-rays of elbow is important
1. Anterior – posterior view – Bauman’s angle -Angle between horizontal line of elbow and line drawn through lateral epiphysis and long  axis of arm, normally less than 5° and should always be compared with other side.
Angle between humerus and transverse axis of elbow  is normally 90°
-Less than 90° cubitus varus
-More than 90° cubitus valgus
2. Lateral view
Tear drop sign: It is disturbed (SCF) but seen normal in radiograph.
Anterior humeral line- Line drawn along anterior border / distal humerus shaft passes through the middle 1/3rd of capitulum, if passes through anterior 1/3 rd indicates posterior displacements of distal fragemt.
Coronoid line – Line directed proximally a long anterior border of coronoid process of ulna should  just barely touch anterior portion of lateral condyle.
Fat pad sign
Fish fall sign
Crescent sign
Managment 
1. Conservative  management 
Initially (CR) under (GA) by traction and counter traction method.
Method and lateral tilt should be corrected first and part displacement next
2-3 attempts can be made under anaesthesia  and elbow is immobilized in types flexion, were tricpes act as internal splint.
Modified  shoulder spica for 3-4 weeks.
Traction methods
Indications in (CM) fails
Consist of skin and skeletal traction
Fracture can be treated  with duntop traction
3. Surgery
Closed reduction and percutaneous fixation.
For most displaced fracture,1/2K wire are passes percutaneously under image intensifier guidance.
In cases wire hyperflexion if elbow cannot be done  due to gross swelling and is grossly unstable fracture.
The extension tyoe fracture is immobilization in an above elbow plaster cast /slab with elbow in flexion.
In flexion type fracture the elbow is immobilized in extension.
 
Open reduction
Rarely indicated in certain cases.
ORIF is done with plates and screws
Indicated also when brachial artery i injured and needs explanation.
Nerve palsy.
 
Continuous traction
Required in cases with late exercissive swelling
Traction may be given with k-wire passing the olecranon or below skin traction.
Complications
1.Complication causing functional  impairment 
Radial nerve- Most commonly affected.
Injury to brachial artery
Median nerve – Due to injury kf posterior displacement
Anterior interosseous nerve injury
Injury to ulnar nerve
Vascular injuries
Loss  of mobility
2. Early complications
Volkmann’s ischemic contracture
Injury to brachial artery
Injury to peripheral nerve
3. Late complications 
Malunion
Myositis ossificans
VIC
 
Physiotherapy management 
The basic objective into achievie full ROM of elbow and  forearm.
1. Conservative  management
During immobilization ( First 3 weeks)
a. Manipulations with closed reduction
b. Duntop traction
– Proper checking of plaster slab
-Vigorous strong full ROM to reduce inflammation and segment healing
Mobilization (After 3 weeks)
a. Evaluation of Rom at elbow and forearm
b. Before mobilization,  thermotherapy, hotpack , wax bath should be done to reduce pain and induce relaxation.
c. Active assisted rythmic movement in gravity eliminated position
d. Flexion is an important complication of elbow movement
-Tendency for cubital varus, and valgus should be check at extension range of extension
e. Relaxed swinging of elbow flexion with supination and extension with pronation
f. Later sustained  stretching should be started
-The progress of movement should be maintained at regular intervals.
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