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Fracture Supracondylar Humerus (Malgaigne’s Fracture)

The elbow has very high frequency of fractures in children. Most of these injuries are supra condylar fracture.
It is the most common fracture around elbow in children and adolescent




- Most common (95-97%)

- Less common

- Distal fragment is tilted backward & shifted backward (posterior angulation & displacement)

- Anterior (or forward) displacement & angulation (tilt)

  • Displacements: Commonly distal fragment has following displacements
    1. Posterior (Dorsal or backward) tilt and shift
    2. Proximal shift
    3. Medial tilt
    4. Medial / Lateral shift
    5. Internal rotation
Most commonly involve 5-8 years age group
Fig: Posteromedial displacement of supracondylar fracture:
Gartland classification:

Mechanism of Injury

  1. Fracture Supracondylar Humerus
    1. Hyper extension injury because of fall on outstretched hand causing “extension type” (~98%) fracture with posterior displacement of distal fragment.
    2. Direct blow on posterior aspect of flexed elbow result in flexion type supracondylar fracture (~2%) with anterior displacement of distal fragment.
  2. Treatment:
    1. It is usually managed by close reduction & cast immobilizationQ if the fracture is stable & CR & percutaneous pinning if fracture is unstable.
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  1. Open reduction is indicated only if the close reduction is not possible d/t soft tissue inter position.
  2. There are two potential problem with close reduction & cast management of fracture supra condylar humerus. The first is loss of reduction and 2nd is increased swelling and potential development of compartment syndrome, secondary to immobilization with the elbow in flexion. That’s why admission to hospital is essential following reduction.

Complications of Fracture Supracondylar Humerus

  1. Most Common -Malunion
    1. Posteromedially displaced fracture tend to develop cubitus varus = Gun stock deformity (most common)
Cubitus varus = Gun stock deformity
French osteotomy
  1. Other complications
    1. Vascular (brachial artery) injury
    2. Nerve injury (anterior interosseous n.> median n. > radial n.)
    3. Volkman’s ischemia & compartment syndrome
    4. Elbow stiffness
    5. Myositis ossificans
    6. Avascular necrosis of trochlea. (rare)
    7. Tardy ulnar nerve palsy
    8. Least common-Nonunion

Nerve Injuries In Fracture Supracondylar Humerus

Mnemonic = AMRU (Anterior Interosseous Nerve, Median Nerve, Radial Nerve, Ulnar Nerve)
Most common to least common.
  1. Anterior Interosseous Nerve (AIN)
    1. Over all most commonly involved nerve in # supracondylar humerus
    2. Most commonly involved nerve in extension type #
  2. Median Nerve  
    1. Over all 2nd m.c. involved nerve
    2. 2nd mc. involved nerve in extension type fracture
  3. Radial Nerve  
    1. Over all 3rd m.c. involved nerve
    2. 3rd m.c. involved nerve in extension type
    3. If distal fragment is displaced postero medially, the radial nerve is more likely to be injured
  4. Ulnar Nerve  
    1. More commonly injured iatrogenically from a medial pin
    2. In flexion type supracondylar fracture, ulnar nerve is most likely to be injured.
Extra Edge
Fracture supracondylar humerus is:
  1. Most common fracture associated with vascular injury .
  2. Most common fracture to involve branchial artery.
  3. Most common cause of volkrnan’s ischeinia & compartment syndrome in children.
  4. Most common cause of volkman’s ischemic contracturs
  1. Elbow Dislocation
    1. The most common dislocation is posterior or posterolateral and is usually the result of a fall with forearm supinated & the elbow either extended or partially flexed.
  2. Fracture- Olecranon 
    1. Mostly caused by hyperextension injury
    2. Sometimes direct blow to flexed elbow, & hyperfiexion injury may also produce it
Extra Edge
Fall on outstretched hand with elbow in extension & valgus can produce following:
  1. Fracture radial neck/head
  2. Fracture medial epicondyle
  3. Fracture olecranon
  4. Rupture of medial collateral ligament (less common)
  1. Compartment Syndrome.
    Deep Posterior Compartment of LEG> Deep Flexor Compartment of FOREARM
    Compartment syndromes increased pressure in a close fascial space causes compromise of microcirculation.
Clinical Feature
  1. The diagnosis of compartment syndrome is based on dramatically increasing pain after injury
  2. Pain out of proportion to injury.
  3. Pain on passive stretching of fingers (at the distal most joint) .(1st sign)
  4. In compartment syndrome the order of compression of vascular structures with increase of intra compartmental pressure is: capillary compression — venous compression - arterial compression. That’s why pulselessness is a late feature and it can’t be used as a reliable indicator of compartment syndrome.
Compartment syndrome most commonly seen in leg (shown above) followed by forearm
The presence of pulse does not exclude the diagnosis
  1. Best treatment of compartment syndrome is avoidance
  2. The limb should be kept at the level of heart rather than elevated.
  3. Removal of all circumferential dressing reduces pressure upto 85%
  4. Surgical decompression by fasciotomy is indicated as early as possible as the definitive treatment.
  5. Exercise may increase intra compartmental pressure & muscle edema, so it is avoided in cases of acute compartmental syndrome.
Surgical decompression by fasciotomy
  1. Sequelae of compartment syndrome is ischemic contracture of muscles called as Volkman’s ischemic contracture which most commonly involves forearm - flexor digitorum profundus muscle & Anterior interosseous nerve The management involves turn buckle splint in early stages and later stages may require maxpage muscle sliding surgery or tendon transfer or osteotomies.

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