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Supracondylar fracture of the humerus - Fracture clinics

  • Fracture Guideline Index

    See also: Supracondylar fracture of the humerus - Emergency Department

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the potential complications associated with this injury?
    4. When should I refer for an orthopaedic consultant opinion?
    5. What are the indications for discharge?
    6. Parent information fact sheet

    1. How often should these fractures be followed up in fracture clinics?

    Table 1: Recommended follow-up schedule for supracondylar fractures of the humerus.

    Fracture type

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    /uploadedImages/Main/Content/clinicalguide/Fracture-Supracondylar-ED_Section-1_GARTLAND-FRACTURE-T2-with-line.jpg

    At 7 days post-injury with x-ray of distal humerus in backslab

    Check for any loss of position

    At 3 weeks post-injury. Removal of backslab and x-ray out of backslab. Check for adequate callus. Allow gentle ROM.

    At 6 weeks post-injury with x-ray.

    If there is any concern about the change in the carrying angle of the elbow (cubitus varus), longer follow-up may be required.

    Return if any subsequent concern re deformity

    Likely to have prolonged period (months) of inability to fully extend elbow. This does not cause functional disability and should not be treated with physiotherapy

     

    Fracture-Supracondylar-ED_Section-1_GARTLAND-FRACTURE-T3-with-line.jpg

    At 3 weeks post-operative reduction

    Removal of backslab and K-wires

    X-ray of distal humerus out of backslab

    At 6 weeks post-operative with x-ray. Examine for coronal and axial alignment

    As above

    Modify activities to avoid heavy arm use (e.g. climbing) for one month post-removal of cast


    2. What should I review at each appointment?

    See above.

    3. What are the potential complications associated with this injury?

    1. Malunion
      The typical deformity is a varus malalignment (cubitus varus or gunstock deformity). This is seen as a reverse of the normal carrying angle of the arm (Figure 1) with an unsightly prominence of the lateral aspect of the elbow. Functional deficit is minimal but the cosmetic effect can be considerable.
      Fracture-Supracondylar-Figure-5_CUBITUS-VARUS.jpg


      Figure 1: Cubitus varus (red arrow) deformity (or gunstock deformity) of the elbow can result from malunion of a supracondylar humeral fracture. The normal carrying angle of the arm is reversed and the forearm deviates to the midline when the elbow is extended.

    2. Malalignment
      Malalignment in the sagittal plane (i.e. flexion or extension) is usually not a cosmetic or functional problem because of the large ROM in the elbow and compensation through shoulder movement.

    3. Stiffness/limited motion
      A lack of full elbow extension is common. This can occur through sagittal malalignment. It can slowly remodel over years and is not improved with physiotherapy.

    4. Neurological injury
      The most common is anterior interosseus nerve palsy, followed by median nerve, ulnar nerve, and less commonly radial nerve palsy. The majority will resolve. If neurological injury occurs after surgical reduction then a full evaluation should be performed immediately, including return to theatre. Persistent neurological injury should be investigated with nerve conduction studies if still unchanged three months after injury.

    5. Volkmann's ischaemic contracture
      Occurs through vascular compromise at the time of injury, causing the death and ultimately fibrous contraction of the affected muscle. Typically the fingers, thumb and wrist become fixed in flexion.

    6. Infection
      May occur in operative cases with percutaneous K-wires. To reduce the risk, avoid skin tension around the K-wires, use sterile dressings and remove K-wires three weeks post-operatively.

     

    4. When should I refer for an orthopaedic consultant opinion?

    Indications for a consultant orthopaedic surgeon opinion are:

    • loss of position
    • complications as per above list

    5. What are the indications for discharge?

    A patient can be discharged when they have met the following criteria:

    • clinical and radiological evidence of union
    • no tenderness at the fracture site
    • painless ROM from 30 to ≥90 degrees elbow flexion

    6.  Parent information fact sheet

     Supracondylar fracture (with displacement)


    References (Outpatient setting)

    Skaggs DL, Flynn JM. Supracondylar fractures of the distal humerus. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.487-532.

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    Content developed by Victorian Paediatric Orthopaedic Network
    To provide feedback, please email rch.orthopaedics@rch.org.au