Analysis of supracondylares Fractures of the Humerus in Children

Abstracts

Os autores realizaram um levantamento retrospectivo dos atendimentos de crianças com fratura supracondiliana do úmero, com o objetivo de analisar as características deste tipo de fratura, e comparar com a literatura. Foram revistos fichas e prontuários de pacientes atendidos no serviço de Traumatologia e Ortopedia do Hospital São Lucas da PUCRS que preencheram todos os dados do levantamento: idade, raça, lado acometido, classificação da fratura, complicações e tratamento. Os resultados encontrados são de 63 pacientes numa população que variou de 1 ano a 11 anos de idade. Lesões em extensão e flexão ocorreram em 78,5% e 10,5% dos casos, respectivamente. Houve predomínio do sexo masculino (63,4%) e da raça branca (95,2%). O lado esquerdo foi o mais acometido, em 55,6% dos casos. Foi realizado tratamento cirúrgico em 76% e conservador em 24%. Quanto a classificação de Gartland, encontrou-se 8% do tipo I, 17,4% do tipo II, e 74,6% do tipo III. Observou-se ainda complicações nervosas em 6,35% dos casos, enquanto complicações vasculares ocorreram em 3,2%. Os resultados obtidos vão ao encontro dos dados descritos na literatura, constatando a importância desta patologia em crianças e a necessidade de conhecimento das características, classificação e manejo dessa patologia.

Fratura supracondiliana; úmero; trauma pediátrico; fratura de cotovelo

ARTIGO ORIGINAL

Analysis of supracondylares fractures of the humerus in children

Rodrigo Klafke Martini^I; Gisele Finkler da Fonseca^I; Rafael Klafke Martini^I; Mauro Azeredo Filho^II; Osvaldo André Serafini^III

^IMedical Student

^IIOrthopedic Surgeon

^IIIPhD Professor

^{Correspondence}

SUMMARY

The authors made a retrospective review of children with supracondylar fracture of the humerus with the purpose of analyzing these fractures characteristics and comparing them with the literature. The registers from patients attended at the Trauma and Orthopedics Service, São Lucas Hospital, PUCRS, containing the data necessary for the survey (age, race, affected side, fracture classification, complications and treatment) were reviewed.

Sixty-three 1 to 11 year-old patients were studied. Extension and flexion lesions occurred in 78.5% and 10.5% of the cases, respectively. Most of the cases were observed in males (63.4%) and whites (95.2%). Lesions at the left side (55.6%) were more frequent. Surgical treatment was carried out in 76% of the cases and conservative treatment in 24%. As concerns the Gartland Classification, 8% were type I, 17,4% type II, and 74,6% type III. Nerve complications were observed in 6.35% of the cases, and vascular complications in 3.2%. The results of the survey are consistent with the literature outlining the importance of this pathology in children and the need of acknowledging the characteristics, the classification, and the management of this pathology.

Key Words: supracondylar fracture, humerus, pediatric trauma, elbow fracture.

INTRODUCTION

The authors reviewed the supracondylar fractures of the humerus in children, associating the findings to cases attended at the São Lucas Hospital, PUCRS. The aim of the study was to stratify the characteristics of presentation and treatment of these fractures and compare them to data found in the literature.

The distal fractures of the humerus, just above the condyles, correspond to the so called supracondylar fractures. This kind of lesion is one of the most common in children, however, seldom it occurs in adults⁽⁶⁾.

The supracondylar fractures are classified in two types according to the elbow position at the moment of the trauma: extension or flexion fractures. The extension fractures occur after frontal fall supported by the hand, followed by hyperextension of the elbow, and they correspond to the majority of the lesions, occurring in up to 95% of the cases⁽⁸⁾. Blood vessels and nerves of this region can be injured, compressed or even lacerated by bone fragments. Considering this, it is not recommended to palpate or mobilize the fracture to make the diagnosis, since this can put into risk the neuro-vascular structures of the elbow⁽⁴⁾. Anterior-posterior X-rays and elbow profile are compulsory to visualize the fracture, to evaluate the degree of displacement, rotation and deviation of the bones, as well as to identify possible bone fragments. Flexion fractures occur in 5 — 10% of the cases⁽⁸⁾. Falls and impacts with a bent elbow are the most common cause of this kind of fracture⁽⁴⁾.

As a consequence of the supracondylar fractures, the neuro-vascular structures can be compromised, depending on the intensity and kind of the trauma. The brachial artery lesion is relatively frequent in the type III kind of fracture, and vascular alteration is more common in that kind of trauma. It occurs due to compression or rupture caused by a bone fragment, and may provoke circulatory deficit in the forearm and hand. In the cases of compression of the artery, decompression must be considered an emergency, since after a few hours the damage can be irreversible⁽⁶⁾. The radial nerve lesion is the most common alteration, though the posterior-lateral displacement can also cause lesions to the brachial artery and median nerve. The neurological exam considering the motor aspect must be performed with precaution, to detect transient or permanent nerve alterations.

MATERIAL AND METHODS

The Gartland Classification, a useful diagnostic tool, implies directly in the form of treatment, classifying the extension fractures in 3 types^(2,7). Notwithstanding, the flexion fractures also can be classified according to the Gartland criteria⁽⁸⁾.

Type 1: although a supracondylar fracture, displacement is absent or minimum; the fractures can be visualized in oblique X-rays.

Type II: although the fracture presents posterior displacement, the posterior integrity of the bone cortex is preserved; it is necessary to consider contralateral X-rays to determine the normal anatomy of the elbow.

Type III: displacement and discontinuity of the bone posterior cortex are present with loss of cortical contact between the fragments. The distal fragment is posteriorly and proximally displaced by the triceps contraction in the extension fractures. In the flexion fractures the distal fragment displacement occurs forwardly (Figure 1)⁽⁴⁾. In the AP X-rays the displacement can be posterior-lateral or posterior-medial; the distal fragment rotation also must be considered, though difficult to determine. In these cases, computerized tomography can be of great help, but it usually is not ordered in emergency attendances.

The registers of one to eleven year-old patients attended in the Trauma and Orthopedics Service of the São Lucas Hospital, PUCRS, were reviewed summing up 97 cases of children with supracondylar fracture of the humerus. Among these, 34 were excluded since the data or radiological exams were insufficient to determine the kind of fracture. The authors considered age, sex, race, affected limb, fracture classification, neurovascular complications, as well as treatment (surgical or conservative) according to the classification proposed by Gartland. Considering surgical treatment, the quantity and position of the pins were determined; considering the conservative treatment, the need to reduce or not the fracture was considered. Sixty-three patients who met the above mentioned statistically analyzed conditions were the subject of this study.

RESULTS

The results have shown that in a sample of 63 patients with supracondylar fractures aged 1 to 11 years the mean age was 6.2 years. Statistically, the mean age is between 5.7 and 6.9 years, with 95% confidence. Males (63.4%) and whites (95.2%) predominate. Considering the affected limb, the left side showed moderate predominance (55.6%). According to the Gartland Classification, type I was found in 8%, type II in 17.4% and type III in 74.6% of the cases. Displacement was observed in 89% of the fractures. Among the cases with deviation, 78.5% were extension fractures. Among these, displacement was posterior-medial in 37.5% of the cases, posterior-lateral in 30.3%, and posterior in 10.7%.

In the cases with flexion fractures, these represent 10.5% of the cases with displacement, with anterior-medial deviation in 5.3%, anterior in 3.5%, anterior-lateral in 1.7% of the cases. Cases with no anterior or posterior deviations were observed, presenting medial deviation in 7.1% and lateral in 3.5% of the cases.

As concerns treatment, surgical intervention was the treatment of choice in most cases (76%). In 48% crossed pins were placed, 48% received lateral and parallel pins, 2% received 3 crossed pins (2 lateral and 1 medial) and in the remaining 2% the pins were medial. Conservative treatment was effected in 24% of the 63 studied patients, demanding reduction in 66.6%.

The results of the retrospective survey of the patients registers were submitted to descriptive statistical analysis, with estimation by interval, using the chi-square test of adherence. Statistically significant difference was observed in all items, with p<0.05 and 95% confidence. No significant difference was found in the affected side, the incidence being casual (p = 0.377).

Nerve complications were found in 6.35% of the cases, all of them affecting the median nerve; vascular complications were observed in 3.2% of the sample. When compared with the scientific literature, 7.6% and 3.3%, respectively, the test for a proportion of adherence did not present a statistically significant difference (p = 0.711).

DISCUSSION

The supracondylar fracture of the humerus is mostly found in children, summing up 52.3 to 69% of the elbow fractures⁽⁵⁾. It is more frequently observed in 3 to 10 year-old boys, more frequently between 4 and 7 years (peak: 6.5 years)^(1,5,6). The literature confirms the findings as concerns prevalence of males, mean age and affected side in the surveyed cases. However, the authors did not find references related to the prevalence of race in the literature.

Due to the fracture mechanisms in the cases of extension trauma, 95% of the cases, the support of the distal part of the humerus in the radius and ulna leads to a fracture in the supracondylar region of the humerus; if there is deviation, it will be primarily posterior, occurring in up to 94% of the cases mentioned in the literature⁽¹⁾. The distal fragment is posteriorly and medially displaced, because the forearm is, in general, in complete pronation^(1,3). Prevalence occurs with medial or lateral rotation associated to posterior deviation. These data from the literature also confirm the authors' findings where the posterior deviations were found in 78.5% of the surveyed cases, 10.7% only posterior, 37.5% posterior-medial and 30.3% posterior-lateral. If, on the contrary, the mechanism occurs in flexion, the primary deviation will be anterior, the fall over the hand with the elbow in straight position^(1,3). This lesion occurred in 10.5% of the studied cases; in the literature, this kind of trauma occurred in 6% of the supracondylar fractures of the humerus. In 85.4% of our patients some degree of rotation was observed. Literature mentions 63%⁽¹⁾ .

Valgus deviation was found in 49.9% and varus in 35.5% of the patients, as compared to 40% and 36% found in the literature, respectively. Both rotational deviations in valgus and in varus must be corrected, since even during growth these deviations do not resume their anatomical shape⁽¹⁾.

In traumas of the elbow, important vascular damages can occur due to the vascular volume in this region. Thus, edema and echymosis can be considerable, since the fracture 24 hours after the accident promotes a big hematoma showing a linear echymosis in the anterior fold of the elbow, known as the Kirmissom signal⁽¹⁾. Depending on the intensity of this hematoma and consequent edema, manipulation of the area becomes difficult after 12 hours.

In the cases of severe fractures when the bone is fragmented in proximal and distal sites, attention must be paid to possible lesions in the muscles, nerves or vessels. If the distal portion was posteriorly deviated, the tip of the proximal portion can cause rupture of the brachial muscle. If medial deviation occurs in the proximal portion, the radial nerve can also be lesioned. In cases of lateral deviation, the tip of the proximal fragment can lesion the median nerve and/or the brachial artery⁽¹⁾. The literature^(1,5) mentions on average^(1,5) 7.6% cases of nerve lesions, 3.3% of vascular lesions, values very similar to those found by the authors, 6.3 and 3.2%, respectively.

Considering that surgical treatment was effected in 76% of the cases, we must mention that as in fracture type II the posterior bone cortical is intact with mantained stability, the use of 2 lateral pins is considered. The pins can be used in parallel or crossed close to the fracture. Thus, in parallel, there is no risk of lesion to the ulnar nerve, a complication of the surgical treatment⁽⁸⁾. In fracture type III, treatment is similar to type II fractures when surgery is necessary. However, the greater probability of neurovascular lesions in the fractures with discontinuity of the cortical demands almost compulsory surgical procedures in all cases of type III fracture. The treatment of choice is reduction and percutaneous fixation with two threads of Kirschner crossed, and it is carried out in 48% of the surveyed cases (Figures 2,3,4,5). To avoid the risk of ulnar nerve lesion, 2 pins can also be used by the side of the lateral epycondile, also crossing the fracture, going in the direction and perforating the opposite proximal cortical⁽⁸⁾.

CONCLUSION

The results of surveying the characteristics of the supracondylar fractures of the humerus in children in the São Lucas Hospital, PUCRS, confirm the data found in the literature. The knowledge of that kind of fracture and its peculiarities, as age, sex and affected limb, is important not only for the traumatologists and orthopedists but also for the doctors who work in the emergency services. Due to the high frequency of trauma in the elbow and, consequently, the high number of supracondylar fractures of the humerus, the initial procedures according to the Gartland Classification provide more certainty of an effective treatment with less risk of future deformities mainly due to the neuromuscular complications related to that kind of fracture.

REFERÊNCIAS BIBLIOGRÁFICAS

Trabalho recebido em 09/08/2001. Aprovado em 28/03/2002

*Work performed at the College of Medicine, PUCRS - Trauma and Orthopedics Service, São Lucas Hospital.

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• 3. Gartland, J.J.: Management of Supracondylar Fractures of the Humerus in Children.Surg. Gynecol. Obstet. 109: 145-54, 1959.
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• 7. Rockwood, C.A., Wilkins K.E., King R.E.: "Fraturas e Luxações da Região do Cotovelo" in Fraturas em Crianças, 1Ş ed. Brasileira. Volume 1, Editora Manole, 1993, p. 497-808.
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Publication Dates

• Publication in this collection
  02 Sept 2005
• Date of issue
  June 2002

History

• Accepted
  28 Mar 2002
• Received
  09 Aug 2001