A supracondylar fracture is one of the most common types of elbow fractures in children though rarely seen in adults. This type of fracture usually results from breaking a fall with an outstretched hand. The supracondylar area, or the distal humerus, is prone to fractures from excess stress due to its thinness.
Since the brachial artery, radial nerve, median nerve, and ulnar nerve can be found at the site of a supracondylar fracture as well, further complications can arise if the fracture disrupts these structures. It is worth noting that a supracondylar fracture typically can be treated with a cast for three to four weeks.
What is a Supracondylar Fracture?
The supracondylar fracture is a fracture of the distal humerus, a long bone in the arm that connects the scapula, or shoulder bone, to the radius and ulna, the two bones in the lower portion of the arm. It's a more severe fracture compared to a wrist fracture or sprain.
The extension type of fracture is the most common type of supracondylar fracture and results from forced hyperextension of the elbow, which focuses stress on the distal humerus.
The second type of supracondylar fracture is the flexion type that occurs from falling with the arm twisted behind the back or falling directly on the elbow. This fall causes dislocation of a fragment of the humerus. Most supracondylar fracture cases occur in children between the ages of five and seven. It is more commonly seen in males than females and makes up over half of pediatric elbow fractures.
Generally, a supracondylar fracture occurs from a fall onto an outstretched hand(May related with Scaphoid Fracture), which results in an extension type of fracture. This is why the fracture is much more common in children than adults.
Another cause of supracondylar fractures results from falling directly onto the point of the elbow or falling with the arm behind the back. This fall will result in the less common fluxion type of fracture.
Types of Supracondylar Fractures
By the Gartland Classification, there are five types of supracondylar fracture:
Type I - Type I fractures in the supracondylar area are nondisplaced; however, subtle medial comminution and cubitus varus may be present, which indicates that the fracture is not Type I, and will require more extensive treatment.
Type II - Supracondylar fractures of the Type II classification are displaced, but with the posterior cortex and posterior periosteal hinge intact. Deformity in a Type II fracture will be located in the sagittal plane only.
Type III- In Type III, the bone will often be displaced in two or three places.
Type IV - This type of fracture is diagnosed intraoperatively when the capitellum is anterior to the anterior humeral line with elbow flexion and posterior with an extension on lateral XR.
Flexion Type - Generally, the injury results from a fall on the olecranon or the point of the elbow.
Additionally, while not a part of the original Gartland classification, medial comminution may occur, which is the collapse of the medial column and loss of Baumann angle, which is the angle between a line that runs parallel to the longitudinal axis of the humeral shaft and another line parallel to the lateral epicondyle. Typically, this ranges from 70-75 degrees.
If you are concerned that you or your child may have a supracondylar fracture, there are a few ways to know:
Depending on the type of fracture it may be elbow fracture, hand fracture or even broken toe fracture, a deformity of the arm may be present. Caused by the proximal bone end being trapped in the biceps. However, the skin will typically not be broken. But if it is an open fracture, the risk of infection increases. These open fractures account for 30% of supracondylar fractures.
Upon physical examination, you may notice a gross deformity, swelling, or ecchymosis in the antecubital fossa, or the bleeding under the skin on the interior of your elbow. There may also be an associated limited range of motion in the elbow.
Before any reduction maneuver, the doctor must perform a neurovascular exam. This is to verify any nerve or vascular injury that may be present in the fracture site.
During this exam, the ability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (make the "OK" hand signal) is evaluated. The doctor also checks the patient for loss of sensation over the volar index finger and the ability to extend the wrist.
During the vascular portion of the exam, the pulse will be assessed by palpation or by Doppler ultrasound. Vascular perfusion, or the flow of blood to a capillary bed, will also be evaluated. If the area is well perfused, it will be warm and pink.
If poorly perfused, it will be cold, pale, and have an arterial capillary refill more significant than two seconds. Also, if poor perfusion is present, treatment can begin with immediate gentle traction and elbow flexion to 20-40 degrees.
Often, this will restore perfusion and pulse. However, whether gentle traction and flexion do not restore the blood supply, it is a surgical emergency. And should be treated with emergent reduction and pinning in the operating room. Well-perfused but pulseless, while not as critical of an emergency, treatment should be conducted in a timely fashion.
After a supracondylar fracture has occurred, a medical professional will check for the functionality of the affected limb.
Typically, the temperature of the limb extremities, oxygen saturation, capillary refilling time, the presence of distal pulses, assessment of peripheral nerves such as radial, median, and ulnar. Also, any wounds that would indicate open fracture will be taken into account during the examination process.
Additionally, a Doppler ultrasound should be performed to verify the flow of blood in the damaged limb. If distal pulses are not able to be felt. This type of ultrasonography uses the Doppler effect to create imaging of blood movement. And will help your doctor determine if any of the structures in the proximity of the fracture have been damaged in the process.
Surgery is not always required for these fractures. Nonoperative treatment for Type I fractures as well as Type II fractures in which the anterior humeral line intersects the capitellum and minimal swelling is present means that there is no medial comminution. The arm can be put in a cast with less than 90 degrees of elbow flexion for three weeks.
There are several operative procedures if the fracture is severe enough:
Closed Reduction and Percutaneous Pinning, or CRPP - Type II and II supracondylar fractures, flexion type, and medial column collapse will require closed reduction and percutaneous pinning. Pulseless and poorly perfused hands require emergency attention. The injury should not go unattended for more than eight hours.
Antecubital fossa ecchymosis, sensory nerve injury, and excessive swelling, also known as "Brachialis sign" and "floating elbow," are also injuries that should be attended to urgently.
Non-urgent matters include isolated anterior interosseous nerve injury. The recommendation for this is a splint in 30 to 40-degree elbow flexion. And then overnight admission for observation, and elevation. Elective surgery may be needed.
Open Reduction and Percutaneous Pinning - Indications that open reduction and percutaneous pinning may be necessar. Including unacceptable closed reduction, flexion type fractures, and open fractures. Open reduction and percutaneous pinning may also be required to perform vascular exploration as well.
As supracondylar fractures occur the most often in children. It is necessary to seek medical attention as soon as possible if you believe that your child has suffered from this type of fracture.
Although it is not always a medical emergency, seeking immediate medical assistance can prevent further trauma, injury, and complications. It should be noted that supracondylar fractures left unattended for over eight hours are not advisable.
If you are unable to reach a medical professional immediately, you may begin checking for visible symptoms of a supracondylar fracture. They are: refusal to move the elbow, a gross deformity, excessive swelling, or blood under the skin in the pit of the elbow. You may also be able to check for warmth and pinkness in the hands.
If the hand of the affected limb is cold and pale, the situation may be dire and call for urgent care.
Adults may not need to worry about their safety when it comes to supracondylar fractures. However, children's restructuring bones are prone to fracturing. And great care should be taken to prevent this type of injury from occurring mainly if your child is between the age of five and seven. As this is the period in a human's life that the supracondylar area reforms.
Requiring your child to wear protective equipment like elbow pads when taking part in physical activities where they could be injured, such as bike riding, is an excellent idea.