supracondyler تأشيرات

2. The distal fragment is in valgus.

3. The medial spike of the proximal fragment is usually posterior.

Supracondylar Fractures

of the Humerus
Inter-active
Part I

The incidence peaks at

I. Incidence
At what age do supracondylar fractures
most commonly occur ?
Why?
3 years
7 years.
10 years


That is the age when children reach
their maximum ligamentous laxity.

Mechanism of Injury

What other factor contributes
to the development of
fractures in the supracondylar area?
The supracondylar area consists
of weak metaphyseal bone.

Very thin

cortical
structure

II. Mechanism of Injury

What is the mechanism of injury

for extension type supracondylar fractures ?

As the

extended extremity
attempts to break
the fall,
the olecranon
is forced
deep into its fossa.

This causes

the humerus to fail
in the weak metaphyseal
supracondylar area.

How are the extension type supracondylar

humeral fractures further classified?
*
*Gartland,JJ:.
Surg Gynecol Obstet 109:145,1959.
What does his classification represent ?

How are the extension type supracondylar

humeral fractures further classified?
His types represent
no more than the
three stages
of displacement.
What are the
three stages
of displacement?

Type I

No displacement
Type II
Incomplete
displacement
Type III
Complete
displacement

Why all this

emphasis
on the classification?
It dictates
the
method of
treatment.
*
*Abraham E, Powers T, Witt P, Ray RD
Clin Orthop 171:309, 1982.


Let us examine the treatment

based upon the

Gartland Types.
IV. Extension type supracondylar fractures

How are the Type I

fractures usually treated?

How must Type II fractures

be managed?
Treatment
1. Manipulate to obtain a reduction
then
2. Stabilize the reduction

Treatment

150
What must be accomplished with
the manipulative process?
First

This is usually accomplished

by first forcing the forearm
into pronation.
The deformities in both planes
need to be corrected.
Some manipulative correction
may need to be accomplished
in the coronal plane as well.










150

One usually meets resistance,

at the point where the shaft condylar malalignment limits flexion.
First

Then

The deformities in both planes

need to be corrected.

This usually re-establishes the saggital

alignment (shaft-condylar angle) of the distal fragment.
To obtain a complete reduction in the
saggital plane, one must
To obtain a complete reductionin the
saggital plane one must






400

How does one determine

if this fracture can be
immobilized with a cast
alone?
Following this hyper flexion, the elbow is then extended
and examined to be sure the carrying angle
has been corrected as well.

Full

.

The reduction has been maintained

at 1200 of flexion
and 900 of external rotation.

Determine if it is

400
.

If the reduction is stable

at 1200 of flexion,
and there is no evidence
of
vascular compromise,
how can these fractures
be best immobilized
post reduction?

Stabilization with a

may not be adequate !!

The elbow must be flexed to 120 0

Injury film

Reduced at 1200

Reduction lost

at 900

WARNING

Flexing to > 1200 may increase the risk
of vascular problems.
*
*Millis MB, Singer IJ, Hall JE.
Clin Orthop 188:90–97,1984.
to maintain the reduction .


Thus these fractures need to be immobilized

with a figure

8
cast.

Always incorporate

the sling into
the cast.

Mommy,

this sling
is
bothering me!

That’s

much
better !
But,
loss of
elbow
flexion
may
result in
a loss of
reduction.

What are the criteria for

fractures?

How are Type III extension supracondylar

fractures sub-classified?









Yes


Posteromedial vs. Posterolateral
• Nerve, Vessel Injured
• Surgical Approach
• Rate of Complications
In what aspects is there a difference?
What type has a greater
potential for complications?

The rate of complications is greater with the posterolateral fractures.

What is the major concern

with the posteromedial fractures ?

The radial nerve

is more vulnerable
to injury.

Treatment

How are Type III fractures
best treated?

Simple

1. Obtain the reduction
then
2. Maintain the reduction

It consists of four steps:

Reduction of the fracture
What does the manipulative
process entail ?

With the elbow in extension, align the distal fragment

to the proximal fragment in the coronal plane.

1. Correct coronal plane alignment

2. Re-establish Length

Traction

Counter-Traction

This usually requires
an assistant.

3.Correct Angulation

and
Posterior Displacement

Apply longitudinal traction

with the elbow semi- flexed,
while applying posterior
pressure on the proximal fragment.

Then, slowly flex the elbow to bring

the distal fragment into alignment.

4. Temporary stabilization and assessment

to lock the distal
fragment to the
proximal fragment.
Once the fragments are reduced,

hyper-flex the elbow

with
hyper-pronation

Then, confirm the reduction

in full external rotation
on the monitor.

Warning!!

If unable to obtain
full flexion
STOP!!
There may be
interposed tissue
between the fragments!!


Percutaneous
pin
fixation
If a cast is inadequate,
then what is the standard for maintaining the reduction?

• Advantages ?

• Most stable construct
• Post-operative, one is able to fully extend elbow to visualize coronal alignment
• Disadvantages ?
• Ulnar nerve injury
Medial-lateral
pins
In what manner may the pins be used?


What about late-appearing fractures ?

2 wks. post

closed reduction
What now?
Repeat
closed reduction?
Open reduction?

Periosteal

new bone

Wait. Remodeling can change things.

He had only slight valgus alignment with full elbow motion

Thank you for participation!