|Year : 2022 | Volume
| Issue : 3 | Page : 2-8
Atypical supracondylar fractures – How to recognize and treat?
K Venkatadass1, Deepak Jain2
1 Head of Paediatric Orthopaedics, Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamilnadu, India
2 Fellow in Paediatric Orthopaedics, Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamilnadu, India
|Date of Submission||29-Mar-2022|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||25-May-2022|
Head of Paediatric Orthopaedics, Department of Orthopaedics and Spine Surgery, Ganga Hospital 313, Mettupalayam Main Road, Coimbatore
Source of Support: None, Conflict of Interest: None
Atypical supracondylar fractures are defined as those supracondylar fractures which pose a challenge in either reduction or fixation or both. Hence, a supracondylar fracture which is not amenable for the standard closed reduction and lateral divergent pinning may be classified as atypical. We have included the following fracture patterns as atypical in this article: 1) Reverse oblique fractures, 2) Rotationally unstable fractures, 3) Comminuted supracondylar fractures, 4) Supracondylar fracture with intra-articular extension and 5) Flexion type fractures. We have described ways to recognize these fractures with tips and tricks to reduce and stabilize them with relevant literature and case examples. It is important to be aware of these atypical injuries to identify them and manage them appropriately.
Keywords: Atypical, Supracondylar, Fracture, Comminuted, Unstable
|How to cite this article:|
Venkatadass K, Jain D. Atypical supracondylar fractures – How to recognize and treat?. J Orthop Assoc South Indian States 2022;19, Suppl S1:2-8
|How to cite this URL:|
Venkatadass K, Jain D. Atypical supracondylar fractures – How to recognize and treat?. J Orthop Assoc South Indian States [serial online] 2022 [cited 2022 Jul 6];19, Suppl S1:2-8. Available from: https://www.joasis.org/text.asp?2022/19/3/2/346028
As supracondylar fracture is the most common pediatric fracture, it is not uncommon to encounter atypical supracondylar fractures. However, there is no specific definition of an atypical supracondylar fracture described in the literature. The idea of this article is to help readers to identify those unusual fractures and provide some guidelines for their appropriate management. We would like to define a typical supracondylar fracture of humerus (SCFH) as “a straightforward supracondylar fracture which is amenable for a simple closed reduction and lateral divergent pinning.” All those fractures that are outliers from the above definition may be considered “Atypical Supracondylar Fractures.” The following fracture patterns and scenarios are considered atypical and are discussed in this article with case examples.
- Reverse oblique fractures (ROFs)
- Rotationally unstable fractures
- Comminuted supracondylar fractures
- Supracondylar fracture with intra-articular extension
- Flexion-type fractures.
Pulseless supracondylar fractures and open supracondylar fractures, though by the above definition are atypical, are not discussed here as they are beyond the scope of this article and are covered in detail separately elsewhere in this monogram. The principles of management of these atypical fractures remain the same though there are technical differences in achieving the ultimate goal, which is “acceptable reduction and stable fixation.”
| Incidence|| |
The exact incidence of atypical supracondylar fracture cannot be calculated as we know that it includes many types. We do know that the incidence of flexion-type fractures is about 1%–2%, and hence, the approximate incidence of atypical supracondylar fractures would be between 10% and 15%. Based on our institutional data from 2016 to 2020, the incidence of atypical supracondylar fractures was 13% of 486 supracondylar fractures. The mechanism of the injury that causes atypical supracondylar fractures is usually high-violence injuries, which leads to atypical and comminuted fracture patterns.
| Reverse Oblique Fractures|| |
The ROF described in the literature is the reversal of obliquity of the fracture in the sagittal plane or the coronal plane. These fractures pose a difficulty with routine methods of reduction or stabilization and need assisted techniques for reduction or different pin configurations.
Sagittal plane reverse oblique
In this fracture, the distal fragment is posteriorly displaced and has an anterior spike abutting the posterior metaphyseal spike of the proximal fragment seen on the lateral radiograph. This pattern poses challenges during fracture reduction and might be difficult to reduce with traditional reduction methods.
In the study conducted by Heffernan et al., the ROF group had significantly higher rates of anterior interosseous nerve palsies, antecubital ecchymosis, and compartment syndrome than non-reverse oblique (RO) group. The ROF presents a unique reduction challenge because of the sagittal orientation of the fracture, and reduction can be made simple by simply allowing the distal fragment to maintain its lateral position and translating the spike anterior to proximal fragment and then followed by traditional reduction method or can be reduced using an intrafocal pin technique [Figure 1].
|Figure 1: (a) Lateral view in fluoroscopy showing sagittal reverse oblique-type fracture, (b) intrafocal pin-aided reduction, (c and d) lateral view in external and internal rotation showing stable fixation in good alignment|
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Coronal plane reverse oblique
In these fractures, the fracture line runs obliquely, which starts proximally at the medial cortex and ends distally at the lateral cortex. These are also called medial oblique fractures, as described by Bahk et al. in 2008.
In their paper, Bahk et al. described four patterns of fracture in the coronal plane which are (1) typical transverse, (2) lateral oblique, (3) medial oblique, and (4) high fractures (above the olecranon fossa) [Figure 2]. Classical transverse is purely transverse or coronal obliquity of less than 10°. Lateral oblique fractures start at the medial epicondyle and exit proximally laterally with a coronal obliquity of 10° or greater. Medial oblique fractures start at the lateral epicondyle and exit proximally medially with a coronal obliquity of 10° or greater. High fractures are near or above the olecranon fossa but stay within the metaphyseal region of the distal humerus; they tend to have varying degrees of coronal obliquity.
|Figure 2: Bahk's classification: (a) transverse, (b) lateral oblique, (c) medial oblique (reverse oblique), (d) high fracture|
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Fractures with significant obliquity could pose a significant challenge for achieving closed reduction and might need assisted reduction methods. The conventional pin configuration of lateral divergent pins may not be ideal for medial oblique (RO) fractures. The basic principle of pin stabilization should be followed to achieve stable fixation. Stabilizing the medial column will either need a medial wire [Figure 3] or a Dorgan's pin [Figure 4] which is placed retrograde from the lateral cortex into the medial column. One must be wary of the chance of injuring the radial nerve while placing the Dorgan's pin.
|Figure 3: (a) Preoperative anteroposterior and lateral radiographs of the elbow in a 13-year-old female showing a medial oblique (coronal reverse oblique) type of supracondylar fracture, (b) postoperative anteroposterior and lateral radiographs showing medial oblique supracondylar humerus fracture fixed with cross-pinning|
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|Figure 4: (a and b) Preoperative anteroposterior and lateral radiographs of the elbow in a 12-year-old boy showing a reverse oblique type of supracondylar fracture with medial comminution. (c and d) Postoperative anteroposterior and lateral radiographs showing fracture fixed with cross-pinning and a Dorgan's pin. (e and f) 2-month follow-up anteroposterior and lateral radiographs of the elbow showing healing in good alignment|
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| Rotationally Unstable Fractures|| |
The fractures that are rotationally unstable after stabilization with two lateral divergent pins are termed as “rotationally unstable fractures.” Typically, one would be able to appreciate an anterior spike in the internal rotation oblique view, though the alignment in the anteroposterior and external rotation oblique looks good. These fractures can potentially collapse into varus as the contact surface area in the supracondylar region substantially decreases due to the rotational malalignment. Routinely, the child is immobilized with a plaster slab/cast and an arm sling which maintains the limb in internal rotation, which would increase the malalignment eventually, leading to loss of reduction.
Gordon et al. in their article on fracture stability after supracondylar pinning mentioned a new method to quantify rotation – lateral rotational percentage. This was defined as the absolute amount of displacement of the proximal humeral metaphysis at the fracture site (A) divided by the width of the distal humerus just distal to the fracture site (B) as measured on the lateral radiograph [Figure 5]. This number was then multiplied by 100 to yield a percentage.
|Figure 5: Measurement of the lateral rotational percentage of a lateral radiograph of the elbow. The displacement (A) is measured and divided by the width of the humerus distal to the fracture site (B). This figure is then multiplied by 100 to yield a percentage of rotation|
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Based on the above paper, we feel that any rotational discrepancy more than 30% would be potentially unstable. We recommend that after pinning with two lateral divergent wires, the rotational stability should be checked in internal oblique and external oblique views. If the anterior spike is more than 30%, these fractures often need a third lateral pin or a medial pin to increase the rotational stability. A Kirschner wire (K-wire) inserted into the proximal fragment helps correct the rotational malalignment, after which a third wire could be inserted [Figure 6] and [Figure 7].
|Figure 6: (a and b) Radiograph of the elbow anteroposterior and lateral view showing Gartland type III supracondylar humerus fracture, (c) anteroposterior fluoroscopy view after reduction and pinning with two lateral divergent wires, (d) lateral fluoroscopy view in external rotation showing good alignment, (e) lateral view in internal rotation showing anterior spike|
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|Figure 7: Intraoperative fluoroscopy images. (a) Lateral view after derotational pin inserted into the proximal fragment and proximal fragment rotated, (b) anteroposterior view after medial pin, (c) lateral view in external rotation showing good alignment, (d) lateral view in internal rotation shows good alignment and no rotational instability|
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| Comminuted Supracondylar Fractures|| |
Comminuted supracondylar fractures of the humerus are seen following high-velocity injuries. The classical approach of closed reduction and lateral divergent pinning may not be feasible in these situations to achieve stable fixation. The fixation options need to be chosen based on the age of the patient. In younger patients with open growth plates, a JESS fixator is a good choice for stabilization. The aim of stabilization would be to maintain the alignment in sagittal and coronal planes and not achieve perfect anatomical reduction of the fragments [Figure 8]. In older patients, stabilization with TENS or plate fixation may be considered [Figure 9].
|Figure 8: (a and b) Preoperative anteroposterior and lateral view radiographs of a 9-year-old girl showing comminuted supracondylar humerus fracture, (c and d) postoperative radiograph showing anteroposterior and lateral views in which the fracture is stabilized with a medial wire and JESS fixator on the lateral side|
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|Figure 9: (a and b) Preoperative anteroposterior and lateral view radiographs of a 14-year-old boy showing comminuted supracondylar humerus fracture. (c and d) Intraoperative fluoroscopy images showing the fracture stabilized with retrograde TENS nails in good alignment (note – arthrogram showing good intra-articular congruity). (e and f) 2-month follow-up radiographs showing anteroposterior and lateral views in which the fracture has healed uneventfully|
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| Supracondylar Fracture with Intercondylar Extension|| |
Extension type supracondylar humerus fracture with vertical intra-articular extension into the joint can be of 3 types based on the area of extension of the fracture line: a) medial condyle b) lateral condyle c) intercondylar area. These fractures can be difficult to visualize in younger age groups because of the cartilaginous bone stock and might benefit from intraoperative arthrogram to visualize the articular margins. These fractures can be managed by closed reduction and percutaneous pinning or may sometimes need an open reduction to achieve perfect reduction of the articular surface. The intra-articular fracture may be fixed with a K-wire or a screw [Figure 10] and [Figure 11].
|Figure 10: (a and b) Anteroposterior and lateral radiographs of the elbow in an 8-year-old male child showing comminuted supracondylar fracture with intra-articular extension, (c and d) postoperative anteroposterior and lateral radiographs showing the fracture reduced and pinned with cross Kirschner wire and a transverse Kirschner wire for the intra-articular extension|
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|Figure 11: (a and b) Anteroposterior and lateral radiographs of the elbow in a 13-year-old male child showing supracondylar fracture with intra-articular extension, (c) fluoroscopy anteroposterior view after percutaneous reduction with thumb pressure and fixation with Kirschner wire, (d and e) fluoroscopy anteroposterior and lateral radiographs showing the fracture reduced and pinned with two lateral Kirschner wire and a 4 mm cancellous screw for the intra-articular extension|
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Ippolito et al. reported six cases with displaced type III supracondylar fracture with nondisplaced intra-articular extension managed by overhead olecranon skeletal traction for up to 10 days, followed by the placement of a long arm cast for 3 weeks. One patient developed 10° varus, and another patient developed 26° valgus, but both remodeled to 3° of valgus. Green reported excellent outcomes in a 9-year-old female with displaced SCH with intra-articular extension. He used a posterior triceps splitting approach to reduce the fracture and a transcondylar compression screw and two K-wires to reduce the fracture. Ogden recommended olecranon skeletal traction for the severely comminuted fracture or in the presence of marked soft tissue swelling for intercondylar injuries in the younger child. Abraham et al. concluded that the supracondylar fracture with the lateral condyle fracture extension is best fixed first with one medially placed K-wire, followed by two lateral ones. The medial condyle fracture is better fixed first with two lateral wires and followed by two medial K-wires. In the case of the supracondylar fracture with the intercondylar extension, it is best to first fix laterally and then medially.
| Flexion-Type Fractures|| |
Flexion type remains an uncommon variant of the common extension type, accounting for about 2% of supracondylar fractures. The mechanism of injury is generally believed to be a fall directly onto the elbow, rather than a fall onto the outstretched hand with hyperextension of the elbow. They are often considered difficult injuries to achieve closed reduction and may be associated with neurovascular injuries. Ulnar nerve palsy can be present in around 10% of cases.
Classification of flexion-type SCH fractures is similar to extension type: type I, nondisplaced fracture; type II, minimally angulated with cortical contact; and type III, totally unstable displaced distal fracture fragment.
In extension-type injuries, the periosteum is intact posteriorly which can be tensioned by flexing the elbow; however, it is opposite in cases of flexion-type injuries wherein the periosteum is intact anteriorly, and sometimes, the periosteum is torn on both the sides making it globally unstable.
The ulnar nerve is vulnerable in these fracture pattern injuries or later in the healing callus, and it may be entrapped. A meta-analysis of 146 flexion-type SCH fractures found an overall neuropraxia rate of 15%, with the ulnar nerve injury as the most common nerve-injured (91%).
The rate of open reduction of type III fractures in extension-type injuries was significantly lower (19/167 [11%]) than in flexion-type injuries (17/44 [39%]).
There could be considerable overlap between type IV supracondylar fractures and flexion-type fractures. Mitchell et al. in their study conclusively proved that there are no significant patient or injury characteristics that can differentiate between type IV injuries from flexion type injuries, but certain radiographic parameters can help determine the differences preoperatively. Diagnosis of type IV fracture was significantly more likely given the presence of the following: (1) flexion angulation of the distal fragment, (2) valgus angulation of the distal fragment, (3) lateral translation of the distal fragment, (4) osseous apposition (cortical contact) between the proximal and distal fragments, and (5) fracture propagation toward the diaphysis. There were no significant associations with comminution or whether the fracture fragment was abutting the skin. Preoperative identification of this rare fracture type would allow for improved preoperative planning (e.g., anticipation of longer operative time and higher likelihood of Open Reduction and Percutaneous Pinning (ORPP)) and more accurate counseling of patients and their families about the likelihood of open reduction when a type IV fracture is suspected [Figure 12].
|Figure 12: (a and b) Anteroposterior and lateral radiographs of the elbow in a 10-year-old male child showing type III supracondylar fracture, (c) fluoroscopy lateral view after attempted reduction with routine maneuver showing a type IV supracondylar fracture, (d and e) fluoroscopy anteroposterior and lateral radiographs showing the fracture reduced and pinned with three lateral Kirschner wires|
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]