Supracondylar fracture is the commonest injury at the lower end of the humerus. This is more common in children. The management is based upon the proper knowledge of the area of the fracture, proper radiological interpretation, and care. The fracture can unite even in cases where management is not done properly but the result of this mal- handling can be the disabled limb.
Types of Fracture: The distal segment of the humerus may be displaced anteriorly or posteriorly.
Posterior displacement: This is more common and seen in 95⁰ of cases. This is also known as an extension type of fracture.
Anterior displacement: Anterior displacement of the distal segment is uncommon. This condition is known as flexion type of fracture.
MECHANISM OF INJURY
A fall on an outstretched hand transmits the force of injury to the distal end of the humerus which is displaced posteriorly following a fracture.
NATURE OF DISPLACEMENT
The fractured segment besides being posteriorly displaced is also shifted towards the lateral or medial side. The nature of displacement depends upon the nature violence and position of the limb at the time of injury.
In posterolateral displacement, the distal fracture segment is displaced posteriorly and laterally, whereas in the case of posteromedial displacement there is displacement towards the posteromedial direction. There may be an undisplaced supracondylar fracture.
SITE OF FRACTURE LINE
The fracture may pass at a variable distance from the epiphyseal line.
- Through the metaphysics: The lesion is situated at the distal end of the metaphysis. In children, this line is above the epiphysis.
- Transcondylar fracture: The fracture passes through both condyles of the humerus. Anteriorly the line runs through the coronoid fossa and posteriorly through the olecranon fossa. In children, this is immediately above the epiphyseal line.
- Epiphyseal separation: The fracture passes through the epiphyseal line. The distal segment includes the epiphyseal cartilage and the articular surface forming the elbow joint.
Clinical examination: There are swelling and deformity of the elbow. The joint is in a flexed position and the forearm is supported by the patient. The triangular relation of the bony points disappear. Prominence is seen and felt posterior displacement. The circulatory efficiency is tested by nothing the color, temperature, and radial pulsation. The median nerve is the one which is injured more than the radial and ulnar nerves. Motor and sensory functions are tested.
Radiological evidence: X-ray appearance confirms the nature of fracture, displacement and any associated injury to the adjoining bones and joints.
Management: Undisplaced supracondylar fracture needs no reduction. Plaster immobilization is all that is required.
Pre-reduction examination: Observe the amount of swelling around the elbow and the area below. Feel for the radial pulsation and mobility of the finger joints are noted. Make a visual impression about the shortening, deformity, and type of displacement by comparing with the normal side.
Reduction: Manipulative reduction is successful in most cases. This is done under general anesthesia with the administration of muscle relaxants.
The technique of Reduction: There are three types of deformities which need to be corrected.
- Posterior displacement.
- Lateral or medial displacement.
The carrying angle of the affected side is compared with the normal one. This is done before proceeding to perform the manipulation.
- Correction of shortening: Apply traction and counter traction. The surgeon exerts traction by holding the forearm while the assistant exerts traction on the arm. It is important that the forearm of the patient should be maintained in the supinated position.
- Correction of lateral displacement: Traction on the supinated forearm will correct the lateral or medial displacement to some extent. Further correction of lateral or medial displacement is made by exerting pressure on the distal end of the humerus.
- Correction of the posterior displacement: As the traction is maintained on the forearm, the elbow is flexed while pushing the distal end of the humerus forward. The elbow is flexed at an angle of more than 90⁰. The radial pulse is felt at the wrist. When pulsation is absent the elbow is made to extend from the above-flexed position till the pulsation is felt.
Plaster slab: The forearm is maintained midway between prone and supine position. The dorsal slab is applied to extend from the axilla to the metacarpal heads. The dry cotton bandage is wrapped around the plaster.
Check x-ray: Check x-ray is done. Remaining pulsation may be required in some cases.
Admit and observe: In doubtful cases, the patient is admitted to the hospital for observation. The circulatory condition of the limb is noted carefully. Observation for pain, pallor, paraesthesia, paralysis, and pulselessness is made. Complete the plaster when the swelling has subsided. This takes usually 2-3 days. The forearm should remain in the position midway between prone and supine.
Cases for manipulation: There is often difficulty in reducing the fracture properly. The reduction is difficult due to gross edema. In the case of a very oblique fracture when the distal segment tends to glide up even after reduction, muscles or sometimes neurovascular bundles may be interposed between the fractured segments and interfere with reduction.
Technique of manipulation
- Remanipulation must be gentle.
- When severe edema is present, manipulation may be delayed for 24-28 hours. The limb is kept elevated until the swelling subsides.
Duration of plaster: In children, plaster immobilization is usually maintained for a period of 3-4 weeks, whereas in adults, this takes a period of 6 weeks. Exercise is advised following removal of the plaster.
Immobilization by traction: Treatment by traction is indicated where gross edema is present or where circulatory impairment will develop by putting the elbow in a flexed position. Unstable fracture is another indication.
- Skeletal traction: Overhead skeletal traction is applied by inserting a pin through the subcutaneous border of the ulna, at a distance of 3 cm. from the tip of the olecranon process. Traction is maintained usually for a period of 3 weeks. Frequent x-rays are done during this period. After 3 weeks, traction is removed and the limb is immobilized in plaster with the elbow at 90⁰ for another 3 weeks.
- Skin traction: Dunlop skin traction can be applied on the forearm with the shoulder abducted at 90⁰ and the elbow- joint at 45⁰ flexion. The traction is maintained for 2½ to 3 weeks. After the release of traction, plaster immobilization is done and maintained for a period of another 3 weeks.
This article is edited by Siora Surgical team for the knowledge purpose. Siora is a top orthopedic implant manufacturing company in India. We manufacture our orthopedic implants from high-quality stainless-steel and titanium.
Mvunjiko wa supracondylar ni jeraha la kawaida zaidi kwenye mwisho wa chini wa humerus. Jambo hilo hutukia zaidi kwa watoto. Usimamizi huo unategemea ujuzi unaofaa wa eneo la kuvunjika, tafsiri inayofaa ya mionzi, na utunzaji. Mvunjiko unaweza kuunganishwa hata katika visa ambapo usimamizi haufanyiwi vizuri lakini matokeo ya utunzaji huu mbaya yanaweza kuwa mguu uliopooza. Aina ya Mvunjiko: Sehemu ya mbali ya humerus inaweza kuhamishwa mbele au nyuma. Uhamisho wa nyuma: Hii ni ya kawaida na inaonekana katika kesi 950. Hii pia inajulikana kama aina ya upasuaji wa upasuaji. Mabadiliko ya mbele: Mabadiliko ya mbele ya sehemu ya mbali si ya kawaida. Hali hii inajulikana kama aina ya flexion ya fractures. Mfumo wa jeraha: Kuanguka kwa mkono ulioinuliwa husambaza nguvu ya jeraha kwa mwisho wa mbali wa humerus ambayo inahamishwa nyuma baada ya kuvunjika. Utaratibu wa kuhamisha: Sehemu iliyovunjika, pamoja na kuhamishwa nyuma, pia hubadilishwa kuelekea upande wa upande au wa kati. Asili ya uhamisho inategemea asili ya vurugu na nafasi ya mguu wakati wa jeraha. Katika posterolateral displacement, distal sehemu ya kuvunjika ni displaced posteriorly na lateral, wakati katika kesi ya posteromedial displacement kuna displacement kuelekea posteromedial mwelekeo. Huenda kukawa na kuvunjika kwa supracondylar kusikohamishwa. Sehemu ya msalaba: Msalaba unaweza kupita kwa umbali tofauti kutoka kwa msalaba wa epiphysis. - Kupitia metaphysics: uharibifu iko katika mwisho distal ya metaphysics. Katika watoto, mstari huu uko juu ya epiphysis. - Transcondylar fractures: Mvunjiko hupita kupitia condyles zote mbili za humerus. Mbele mstari unaenda kupitia fossa ya coronoid na nyuma kupitia fossa ya olecranon. Katika watoto, hii ni mara moja juu ya mstari epiphyseal. - Epiphyseal kutenganishwa: fracture hupita kupitia mstari epiphyseal. Sehemu ya mbali inajumuisha cartilage epiphyseal na uso articular kuunda kiungo elbow. Uchunguzi wa kliniki: Kuna uvimbe na kasoro ya kiwiko. Kiungo hicho kiko katika hali ya kutikiswa na mkono wa mbele unategemezwa na mgonjwa. Uhusiano wa pembetatu wa ncha za mifupa hutoweka. Utukufu ni kuonekana na kuhisi uhamisho wa nyuma. Ufanisi wa mzunguko wa damu haujaribiwa na chochote rangi, joto, na pulsation radial. Mishipa ya neva ya katikati ndiyo inayodhoofika zaidi kuliko mishipa ya neva ya radial na ulnar. Kazi za motor na sensory zinajaribiwa. X-ray: X-ray inaonyesha jinsi mfupa ulivyovunjika, kuhamishwa, na majeraha yoyote yanayohusiana na mifupa na viungo. Usimamizi: Upasuaji wa kuvunjika kwa supracondylar usio na mahali hauhitaji kupunguzwa. Plastiki tu ndiyo inahitajika ili kuzuia mwili usiondoke. Uchunguzi wa kabla ya kupunguzwa: Angalia kiasi cha uvimbe kuzunguka kiwiko na eneo lililo chini. Hisia kwa pulse radial na mwendo wa viungo vya kidole ni alibainisha. Kufanya hisia ya kuona kuhusu upungufu, deformity, na aina ya uhamisho kwa kulinganisha na upande wa kawaida. Kupunguza: Kupunguza manipulative ni mafanikio katika kesi nyingi. Hii hufanywa chini ya anesthesia ya jumla na utawala wa relaxants misuli. Mbinu ya Kupunguza: Kuna aina tatu za deformities ambayo zinahitaji kurekebishwa. - Uhamisho wa nyuma. - Mabadiliko ya upande au ya kati. Angle kubeba ya upande walioathirika ni ikilinganishwa na moja ya kawaida. Hii ni kufanyika kabla ya kuendelea kufanya udanganyifu. - Marekebisho ya kufupisha: Tumia traction na counter traction. Daktari-mpasuaji hufanya kazi ya kuvuta kwa kushikilia mkono wa mbele huku msaidizi akifanya kazi ya kuvuta mkono. Ni muhimu kwamba mkono wa mgonjwa unapaswa kudumishwa katika nafasi ya supinated. - Marekebisho ya lateral displacement: traction juu ya supinated mkono wa mbele itarekebisha lateral au medial displacement kwa kiasi fulani. Marekebisho zaidi ya upande au katikati ya kuhamishwa ni kufanywa kwa kutumia shinikizo juu ya mwisho distal ya humerus. - Marekebisho ya uhamisho wa nyuma: Kama traction ni kudumishwa juu ya mkono, kiwiko ni flexed wakati kushinikiza mwisho distal ya humerus mbele. Mkono wa mguu umepigwa kwa pembe ya zaidi ya 900 Mpigo wa radial huhisiwa kwenye mkono. Wakati pulsation haipo elbow ni kufanywa kupanua kutoka juu-flexed nafasi mpaka pulsation ni waliona. Pamba ya plaster: Mkono wa mbele huhifadhiwa katikati kati ya hali ya kulala na ya kulala. Bamba la mgongo hutumiwa kupanua kutoka axilla hadi vichwa vya metacarpal. Bamba kavu la pamba limefungwa kuzunguka plaster. X-ray: X-ray ya uchunguzi imefanywa. Katika visa fulani, huenda ikawa lazima kudumisha msukumo. Kuandikisha na kuchunguza: Katika visa visivyo hakika, mgonjwa huandikishwa hospitalini kwa ajili ya kuchunguza. Hali ya mzunguko wa damu katika kiungo huangaliwa kwa uangalifu. Mtazamo wa maumivu, upofu, paresthesia, kupooza, na kutokuwa na msukumo wa moyo hufanywa. Kumaliza plaster wakati uvimbe umepungua. Hii kwa kawaida huchukua siku 2-3 Mkono wa mbele unapaswa kubaki katika nafasi ya katikati kati ya kupooza na kulala. Matukio ya udanganyifu: Mara nyingi kuna ugumu wa kupunguza kuvunjika kwa usahihi. Kupunguzwa ni vigumu kwa sababu ya edema kubwa. Katika kesi ya mfupa wa mviringo, ambapo sehemu ya distal inaelekea kuelea juu hata baada ya kupunguzwa, misuli au wakati mwingine bundles neurovascular inaweza kuingizwa kati ya sehemu zilizovunjika na kuingilia kati kupunguzwa. Mbinu ya udanganyifu - Udanganyifu wa pili lazima uwe laini. Wakati wa kuambukizwa kwa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa wa ugonjwa. Sehemu ya mguu huhifadhiwa juu hadi uvimbe utakapopungua. Kwa watoto, plaster imobilization ni kawaida kudumishwa kwa kipindi cha wiki 3-4 wakati katika watu wazima, hii inachukua kipindi cha wiki 6. Mazoezi yanashauriwa baada ya kuondolewa kwa plaster. Ugonjwa wa traction: Matibabu ya traction yanaonyeshwa wakati wa edema kubwa au wakati ugonjwa wa mzunguko wa damu utaendelea kwa kuweka kiwiko katika nafasi ya flexed. Mvunjiko usio thabiti ni dalili nyingine. - Skeletal traction: Overhead skeletal traction ni kutumika kwa kuingiza pini kupitia subcutaneous mpaka wa ulna, katika umbali wa 3 cm. Mfano wa mchakato wa olecranon. Kwa kawaida traction huhifadhiwa kwa muda wa wiki tatu. Picha za X-ray hufanywa mara nyingi wakati huo. Baada ya wiki tatu, traction huondolewa na mguu unasimamishwa katika plaster na kiwiko katika 900 kwa wiki nyingine tatu. Dunlop Skin Traction: Dunlop Skin Traction inaweza kutumika kwenye mkono wa mbele na bega abducted katika 900 na kiwiko-kuunganisha katika 450 flexion. Mshtuko huo huhifadhiwa kwa muda wa majuma mawili na nusu hadi matatu. Baada ya kuondolewa kwa traction, plaster immobilization ni kufanyika na kudumishwa kwa kipindi cha wiki nyingine tatu. Makala hii imerekebishwa na timu ya upasuaji ya Siora kwa kusudi la maarifa. Siora ni kampuni ya juu ya utengenezaji wa implants ya mifupa nchini India. Sisi hutengeneza implants zetu za mifupa kutoka kwa chuma cha pua cha hali ya juu na titani.