Elbow fractures in Children - Supracondylar fracture of the humerus

We see a fair number of children's injuries in the hospital, the reason being that the hospital is situated in a residential neighbourhood.

Children frequently fall, and in the process, has the tendency to extend their arms out to protect themselves.
This fact makes injuries involving the upper limbs more frequently seen in the ER (Emergency Room) as compared to the lower limb. The force from the fall, if large enough, can fracture the bone in two common places - the wrist or the elbow.

For the elbow, the forces from the fall travel through the forearm, levers the elbow joint in extension and the bone breaks at the weakest part of the arm - the supracondylar part of the humerus.
This is the so-called supracondylar fracture of the humerus and is the commonest elbow injury seen in children, seen most frequently in the 3 to 8 year old age group. It is also the 2nd most common children's fracture, second only to wrist fractures.

Patients with a suspected supracondylar fracture of the humerus frequently present to the ER with a history of fall, with associated swelling of the elbow and inability to bend the elbow.

*For the parent, if there is a suspicion of an elbow injury or fracture, one should ideally immobilize the limb in a sling prior to bringing to the ER. Besides providing comfort to your child, it limits further movement and displacement (moving out of alignment) of the suspected fracture. Dont know how to do it? look it up here. *

And that was how I met my 7 year old patient in the ER a couple of months ago. He had a nasty fall and was brought to the ER by his parents. His left elbow was deformed and swollen, and painful to the touch.

Swollen left elbow

X rays confirmed my suspicions: a supracondylar fracture of the left humerus.

Now fractures which are minimally displaced, or better yet, undisplaced, can be treated with nothing more than a plaster slab and an armsling. However our patient had what is known as a type III Gartlands fracture, where the fracture ends are totally not in contact with each other. This necessitates an operative reduction (where the surgeon manipulates the fracture ends into place) and fixation with wires.

Fortunately the parents understood the gravity of the situation and agreed for surgery that night. Here are the before and after pics of the X rays:

fracture site (arrowed)

frontal view of the elbow showing the fracture

Fracture reduced (put back) and temporary wires in place. Compare with the first picture

You can see that humpty-dumpty the bone ends has been put back together again.
The wires were removed after a month -   on the x rays below you will note that the fracture is healing well with new bone around the fracture site.

after 2 months

There was still some slight stiffness of the elbow on the last day of treatment which should go away after some physiotherapy. Now our patient is well on his way to playing football again and probably has a nice story to tell his kids later!

- the BomohTulang -

references:


Clinical Practice Guidelines
The Treatment Of Pediatric Supracondylar Humerus Fractures
American Academy of Orthopaedic Surgeons 2011

Current Concepts Review Supracondylar Humeral Fractures in Children
J Bone Joint Surg Am. 2008;90:1121-32

Crossed-pin versus lateral-pin fixation in pediatric supracondylar humeral fractures.
Shamsuddin SA, Penafort R, Sharaf I. Med J Malaysia. 2001; 56(Suppl D):38–44.

Wheeless' Textbook of Orthopaedics (online)