Q: Which are the most common elbow fracture in children?
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A: Supracondylar humeral fractures are the most common elbow fractures in children, usually between 2-10 years, which are more common in boys.
Q: What is the definition of supracondylar humeral fractures?
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A: Supracondylar humeral fracture is an extra-articular fracture affecting the distal metaphysis of the humerus, involving the medial and the lateral columns.
Q: How is the mechanism of supracondylar humeral fractures?
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A: There are the extension and the flexion mechanisms of supracondylar fractures. Extension-type supracondylar fractures are more common and occur due to a fall onto the hyper-extended elbow. The elbow displaces posteriorly. They are common in children. Flexion types occur more frequently in older patients due to a trauma onto the flexed elbow. The elbow is displaced anteriorly.
Q: What are the clinical manifestations of supracondylar humeral fractures?
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A: The clinical manifestations are ecchymosis, skin puckering, swelling, deformity, and pain. Occasionally there are associations with neurovascular injuries and compartment syndrome. Diagnosis is by clinical findings and plain radiographs.
Q: What are the plain radiograph features of supracondylar humeral fractures?
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A: Lateral and AP radiographs of the elbow are usually sufficient to demonstrate the fracture. Sometimes, these fractures may be subtle and very difficult to diagnose on radiographs, so it is essential to look for indirect signs. In occult radiographic supracondylar fractures, computed tomography may be of value to clarify the diagnosis.
Q: Which are the plain radiograph indirect signs of supracondylar fractures?
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A: The indirect signs are the anterior fat pad sign (sail sign) and posterior fat pad sign. A positive posterior fat pad sign suggests occult fracture when no radiological fracture line is obvious. However, the anterior fat-pad sign can be present in a normal flexed elbow and is not specific for fracture diagnosis. Other indirect signs are the anterior humeral line, the Baumann’s angle, and the ulnohumeral angle or radiological carrying angle.
Q: How can CT contribute to the diagnosis and management of supracondylar humeral fractures?
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A: CT is usually performed when the plain radiographs are not clear to understand the displacement. CT imaging is superior to plain radiographs to demonstrate the configuration of supracondylar humeral fractures, contributing to a better understanding of these fractures, which is helpful in their management and may have a beneficial influence on the choice of the surgical procedure. In addition, MPR images in coronal, sagittal, and sometimes in oblique planes are an important tool to define the fracture extent in each plane.
Q: How is the Gartland classification of supracondylar fractures?
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A: The Gartland classified extension injuries as non-displaced, moderately displaced, and severely displaced. This classification distinguishes four types based on the extent of distal fragment displacement: type I – undisplaced or minimally displaced (< 2mm); type II – moderately displaced (> 2 mm), with intact posterior cortex, without rotational deformity (IIa) or with rotation (IIb); type III – complete displacement, anterior and posterior cortices disrupted, and the posteromedial displacement is more common than the posterolateral displacement; type IV – intra-operative multidirectional instability.
Q: How is the treatment of supracondylar fractures?
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A: There is no universal agreement about the optimal management of this injury. Gartland type I fracture requires a splint or cast immobilization for approximately three weeks. Type II treatment is with close reduction, cast immobilization, and occasionally with percutaneous pinning fixation. Type III and type IV fractures usually require surgical treatment. Closed reduction associated with percutaneous pinning is a reliable technique for the majority of displaced supracondylar humeral fractures. Open reduction is indicated for open fractures, absence of the distal vascular flow 10-15 minutes after closed reduction, and failed closed reduction.
Q: Which are the complications of supracondylar fractures?
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A: The correct management of supracondylar humeral fractures is crucial because they can cause catastrophic complications. The complications related to supracondylar fractures are malunion, neurovascular injuries, compartment syndrome, Volkmann’s ischemic contracture, floating elbow, cubitus varus or “gunstock” deformity, and fishtail deformity, which is osteonecrosis of the trochlear ossification center.