Supracondylar humerus fracture mainly refers to the fracture within 2cm above and below the inner and outer humerus condyles, mostly seen in children aged 3-12 years old, with the extensor type being the most common. This fracture can combine with nerve and blood vessel injury, and improper treatment can cause ischemic muscle contracture, elbow inversion and valgus deformity, and ossifying myositis.
I. Diagnostic basis
This disease is diagnosed with reference to the criteria for pediatric supracondylar humerus fracture developed by the Chinese Orthopedic Association of Chinese Medical Association (1995) Diagnostic and Therapeutic Criteria for TCM Diseases.
1.Age Most often occurs in children aged 3-12 years old.
2.History All have a history of trauma.
3.Symptoms Swelling, pain and inability to move the elbow of the affected limb after the injury.
4.Signs
(1) The affected elbow refuses to be pressed and has functional impairment.
(2) Deformity of the affected area, bone rubbing sound or abnormal activity, normal posterior triangular relationship of the elbow.
(3) Severe local swelling or even tension blisters and subcutaneous ecchymosis; if a “potentially open” fracture can be palpated near the fracture end, it indicates severe displacement of the injury.
(4) Check the wrist and hand sensation and movement, and whether there are hand deformities such as “drooping wrist”, “claw hand” and “ape hand”, in order to determine whether there are combined radial, ulnar and median nerve injuries.
(5) Pay attention to the “5p” signs of vascular injury (pain, pallor, cyanosis, pulselessness, and terminal coldness).
(6) The main sign is circumferential crushing pain at the supracondylar area for green branch insertion type fractures.
5. Imaging X-ray frontal and lateral radiographs can determine the type of fracture, and CT, MRI, and healthy side contrast can confirm the diagnosis if necessary.
Fracture typing
Referring to the third edition of Bone and Joint Injuries published by People’s Health Publishing House, the fractures are classified according to the mechanism of injury as follows
1.Extension fracture, this type is common, accounting for more than 90%; and according to the different lateral displacement, it is divided into extension ulnar deviation type and extension radial deviation type, with extension ulnar deviation type being more common.
2. Flexion fracture.
Treatment
1. Rectification
1.1 Non-displaced fracture (cleft fracture): This type of fracture does not require revision.
1.2 Green branch fracture: This type mainly shows forward angulation, i.e. the posterior bone and periosteum of the distal humerus are not damaged and the interconnection is normal, but the anterior inclination angle decreases or disappears or the posterior inclination angle must be corrected, otherwise the elbow flexion function is limited. The elbow joint is straightened by antagonistic traction, and then the fracture is repositioned by hand pressure.
1.3 Extension fracture: The patient lies supine, and two assistants hold the upper arm and forearm respectively, and do homeopathic extraction and extension traction to correct the overlapping displacement. If the distal end is rotated anteriorly (or posteriorly) the rotational displacement should be corrected first so that the forearm is rotated posteriorly (or anteriorly). Then the operator holds the distal and proximal ends of the fracture with both hands and squeezes them relative to each other to correct the lateral displacement, then pushes the distal end forward from behind the elbow with both thumbs, and pulls the proximal segment of the fracture backward with the remaining four fingers of both hands overlapping around the fracture, and makes the assistant flex the elbow joint slowly under traction, and often feels the bone rubbing sensation when the fracture is reset. The ulnar deviation fracture repositioning method: the operator fixes the fracture with one hand, holds the forearm with the other hand to slightly straighten the elbow joint, and extends the forearm to the radial side so that the radial cortex of the fracture end is embedded and slightly radially inclined to prevent the occurrence of elbow inversion deformity, the distal radial deviation of the radial deviation fracture does not need to be overcorrected, and the mild radial deviation can not be rectified to avoid elbow inversion.
1.4 Flexion type fracture: After correcting the overlap, rotation and lateral displacement according to the extension type fracture repositioning method, the distal end should be pressed down dorsally after traction and the elbow joint should be straightened slowly.
2. Fixation
2.1 Non-displaced fracture: After fixation with a small splint, place the affected limb in a 90° flexed elbow position for 2 to 3 weeks. The splint length should reach the middle level of the deltoid muscle, the medial and posterior splints should exceed the elbow joint, and the anterior splint should reach the transverse elbow. To prevent elbow inversion, tower pads can be added to the proximal lateral and distal medial sides of the fracture respectively, and the splint should be fixed with 3 strips of cloth and suspended in front of the chest for 2-3 weeks.
2.2 Green branch fracture: This type of fracture is splinted as a nondisplaced fracture after fracture revision, but pressure pads should be added to this fracture that has a tendency to displace to prevent fracture displacement.
2.3 Extension fracture: After repositioning, the extension fracture is fixed with the elbow joint flexed at 90° to 110° with the forearm rotated posteriorly for 3 weeks, which can effectively prevent the elbow inversion deformity. First, the fracture end is fixed with 4 splints, and then the forearm is fixed in a flexion 90° forearm rotation posterior position with a straight angle pallet. The upper end of the length of the 4 splints reaches the level of the middle deltoid muscle, the medial and lateral splints reach the elbow joint, the anterior splint reaches the transverse elbow, and the posterior splint reaches the ulnar hawk; to prevent the distal end of the fracture from posterior displacement, a trapezoidal pad can be added behind the hawk, and the ulnar deviated fracture can be added to the lateral side of the proximal end of the fracture and the distal end of the fracture The medial and lateral sides of the radially deviated fracture are usually fixed with 3 strips of cloth without the placement of a fixation pad.
2.4 Flexion fracture: The flexion fracture should be fixed in semi-flexion and extension at 40-60° for 2 weeks, with the anterior and posterior pads placed opposite to the extension type, and then the elbow joint should be gradually flexed to 90° for 1-2 weeks.
2.5 Splint fixation: Our original “rotating posterior radial splint” can be used to prevent the purpose of elbow inversion deformity. The width of the splint is 4/5 of the diameter of the upper arm. A horizontal line is drawn from the upper humerus to the elbow joint, and the splint is fixed at 90 degrees with a wide adhesive tape. The medial and lateral splints start from the middle and upper third of the humerus and reach the elbow joint with a width of 1/2 the diameter of the upper arm.
3.Surgical treatment
1.Indications.
1.1 Fracture combined with vascular nerve injury, the fracture still has the “5P” sign after the manual repositioning.
1.2 Failed manipulation.
1.3 The patient’s family requires surgical anatomical repositioning.
1.4 Open fracture with internal fixation at the same time of debridement.
1.5 Old fracture with deformity of elbow joint.
2. The main procedures are: neurovascular exploration and internal fixation; internal fixation with crossed kerf pins; fishtail surgery, which is suitable for those whose deformity is not very solidly healed (4-6 weeks after fracture); osteotomy, which is usually performed 4 months after fracture to remove the anterior bone block affecting the elbow joint; osteotomy, which is suitable for elbow inversion of 15° (usually operated after 14 years old).
4.Functional exercise
After the fracture is reset and fixed, you can start practicing activities, you should make more fist clenching, wrist flexion and extension activities, and actively exercise the flexion and extension activities of the elbow joint after the release of fixation, passive activities of violence are strictly prohibited to avoid injury ossification, which will affect the function of elbow joint activities. As the child is young, the parents can assist in the flexion and extension exercises of the elbow joint, but they should be performed during play. If necessary, fumigation of the affected limb can be combined with the external washing formula of the upper limb to unblock the tendons and channels, soften and disperse the knots, and promote functional recovery.
5. Care.
5.1.1 Common problems of patients and families
5.1.2 Lack of knowledge ;
5.1.3 Pain;
5.1.4 Fear;
5.1.5 Self-care deficits ;
5.1.6 Potential complications.
5.2 Nursing measures
5.2.1 This disease is common in children. Warmly welcome the child and family, introduce the hospital environment in detail, pay attention to the kind attitude, make the child adapt to the hospital environment as soon as possible, and gain the child’s trust and cooperation;
5.2.2 Do the necessary explanation work to the child’s family, introduce the treatment method and prognosis, and enhance the confidence to overcome the disease;
5.2.3 Guide and assist the child to do a good job in life care, care for the child and help solve practical problems;
5.2.4 Closely observe the condition of the injured limb, including skin temperature, skin color, sensation, arterial pulsation, swelling and pain, etc. If the child is crying, carefully check the condition of the injured limb and inform the doctor to adjust the fixation if there is any abnormality;
5.2.5 Instruct the child to perform functional exercises, starting with the distal joint, fist clenching, finger extension, grasping, wrist flexion and extension and shoulder shrugging activities, and practice elbow flexion and extension activities after removal of fixation, paying attention to gradual progress, so as not to feel pain.
5.3 Health education
5.3.1 Inform the patient and family members to observe the symptoms/signs of abnormal blood flow in the affected limb and report any abnormality to the medical staff in time;
5.3.2 Instruct the patient to perform daily life training and techniques to move with one hand;
5.3.3 Diet should be high in protein, vitamins and calcium-rich foods, such as lean meat, eggs, fish, bone broth, etc.
5.3.4 Pay attention to the gradual progress of functional exercise, so as not to feel pain is preferred.
IV. Analysis of treatment difficulties and countermeasures
Pediatric supracondylar humerus fracture is a common fracture of the pediatric elbow, the incidence of which accounts for more than 60% of elbow fractures. The fracture has many complications, with injury to the vascular nerve in the early stage, and the occurrence of internal and external deformity and joint dysfunction in the late stage. Especially when the child cannot express the symptoms of the disease correctly and maintain effective fixation, how to manage and prevent complications is our main problem in treating the disease.
The preferred treatment for supracondylar humerus fractures should be external fixation with a four-in-one shaped splint, and internal fixation with incision is generally not recommended. This is because surgical treatment of supracondylar humerus fractures has been reported in the literature to be unable to completely correct elbow inversion in the pediatric affected limb. The need for surgical exploration of supracondylar humerus fractures combined with vascular injuries should be carefully considered. When examining the child, the signs and symptoms of vascular injury should be noted for severe displacement. Usually the affected limb has pain, pallor, cyanosis, no pulse, and terminal chill, and gentle closed repositioning is performed first, and the elimination of vascular symptoms suggests that the compression of the blood vessels has been released, after which the treatment can be performed as usual, but strict observation is required. If the signs and symptoms of vascular injury do not disappear after repositioning then prompt surgical exploration is performed, using an anterior elbow incision. Supracondylar fractures combined with nerve rupture injuries are extremely rare, and most nerve contusions can be recovered after the fracture is displaced and repaired.
Elbow inversion is the most common complication of pediatric supracondylar humerus fracture, and although scholars at home and abroad have done a lot of research on it for a long time and made some progress, no definite and recognized prevention method has been made so far. How to prevent elbow inversion is a key research topic today. The cause of elbow inversion deformity in pediatric supracondylar humerus fracture is generally considered to be the “one-time occurrence theory” of both ulnar deviation or ulnar tilting after revision of the distal humeral fracture. Therefore, to prevent the formation of elbow valgus, the main problem is to solve the problem of ulnar deviation or ulnar tilt into the angle, together with the special anatomical structure of the lower humerus, the inner and outer epicondyles of the humerus are the attachment points of the total tendons of the flexor and extensor muscles respectively. After the supracondylar fracture, the distal fracture end is controlled by the above muscle groups and the pulling action of the lateral collateral ligament of the elbow joint and the joint capsule, and participates in the forearm activity together, so that the axis of the elbow activity is shifted upward from the elbow joint to the fracture, causing the distal fracture end to be very unstable. When the forearm rotates, the humeral condyle also rotates, causing the distal fracture end to ride on top of the proximal fracture end. The forearm is suspended from the chest with a triangular scarf, and the forearm is not fixed and is mostly in the internal rotation position. Therefore, the distal fracture end also rotates inward and tilts medially and elbow inversion occurs. We believe that only good repositioning and proper external fixation are the keys to prevent elbow inversion.
V. Minimally invasive closed reduction crossed kyphotic pins for the treatment of supracondylar humerus fractures in children
For children’s supracondylar humerus fracture without vascular nerve injury can be treated by minimally invasive technique of closed repositioning crossed kyphotic pins, which is the most advanced technology at home and abroad with little trauma, no surgical incision, fast recovery and almost no scar.