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Update on the Diagnosis and Treatment of Pediatric Elbow Fractures
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Posted on: 05/22/2008
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In this review article, orthopedic surgeons from Childrens Hospital in Los Angeles, California bring us up-to-date on supracondylar humeral fractures in children. This fracture occurs in the humerus (upper arm bone) just above the elbow.
Most of these fractures are caused by a fall onto the outstretched arm. The elbow is extended at the time of the trauma. Force through the forearm causes the elbow to act as a fulcrum (lever arm) on the lower end of the humerus. The result is a supracondylar humeral fracture.
The break doesn't go all the way through the bone. Instead, it forms a hinge with the anterior (front part) of the humerus broken open. The posterior (back side) of the humerus remains intact.
These fractures are divided into four types based on how much of the bone is displaced. More severe fractures (Type III and IV) have bone, soft tissue, blood vessel, and nerve damage. Type IV fractures are unstable in all directions.
After a thorough exam, X-rays are taken, and a treatment plan is formed. The child may only need a splint to hold the arm in the correct position for healing. Tight splinting or bandaging should be avoided to prevent loss of blood flow or pressure within the soft tissues.
Traction has been replaced by pin fixation to hold the bones in place until healing can occur. Surgery is required to do this. A special imaging technique called fluoroscopy allows the surgeon to realign the bones without using an incision. This is called a closed reduction. A pin or wires are used to hold the bones in place during the healing phase.
In some cases, open reduction is needed. The authors review in detail treatment by fracture type. They offer an in-depth discussion of special cases and what to do in case of complications. The most common problems that occur include infections along the pin or wire tracks, blood vessel or nerve injury, and deformity.
Less often, compartment syndrome of the forearm develops. Severe swelling inside the fascia (fibrous connective tissue) and within the soft tissues leads to increased pressure. Blood supply can get cut off to the arm. Death of tissue, is a possible consequence of severe compartment syndrome.
The authors also offer surgeons their thoughts on current controversies in the surgical treatment of supracondylar humeral fractures. For example, pins used to hold the bones in place can injure nerves traveling through the area down the arm. The most common pin-fixation errors are described. Ways to prevent nerve damage are offered.
The position of the immobilized arm is also important. Elbow flexion versus extension and forearm supination (palm up) versus pronation (palm down) can make a difference in stabilizing the arm. Treatment decisions are made on a case-by-case basis. Surgery should not be delayed if there is a risk of compartment syndrome or loss of blood supply to the forearm.
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References:
Reza Omid, MD, et al. Supracondylar Humeral Fractures in Children. In The Journal of Bone & Joint Surgery. May 2008. Vol. 90-A. No. 5. Pp. 1121-1132.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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