Continue reading »]]> Here is an interesting case of a 10 year old who fell while riding his bike and came to the emergency department with a fracture of the radius and ulna. In this case, because the fractures were open and the child needed to go to the operating room in order to have the fracture site cleaned up, a decision was made to fix the fractures with an intra-medullary flexible nail technique.

These are the pre-operative xrays of the left forearm.

the child was taken to the emergency department and whisked off to sleep by the anesthesiologist.  The left arm was prepared for surgery with a surgical prep solutions.

After the open portion of the fracture was cleaned, a small 3mm hole was drilled in the end of the ulna so that a flexible intramedullary nail could be inserted inside the ulna, acting as an internal splint.  This type of treatment is called flexible nailing of pediatric fractures.

One week later he returned to clinic to have the sutures removed and a cast applied.  The sutures were removed without difficulty, there was no evidence of infection, and he was placed in a cast to remind him that his arm that been broken, he shouldn’t use it to his his brother, and to slow down a little bit while the fracture heals!

Continue reading »]]> Here are the x-rays from a four year old child who has a fracture of the lateral epicondyle.  The fracture occurred when the child fell onto her out-stretched hand (a mechanism of injury that we call a FOOSH) while running on a playground.  Here are the films taken in the emergency department….

The child was evaluated in the emergency department and taken to the operating room on the same day for closed reduction and percutaneous pin fixation of her lateral epicondyle fracture.  Here are the intra-operative C-arm pictures of the fracture after percutaneous pinning….

In this instance, anatomic reduction was achieved, which means that the normal anatomy of the distal humerus was restored and the bone were lined up again before the pins were inserted.  3 weeks later the pins were removed, but this child had a lot of difficult regaining full range of motion of the elbow.  Nearly a year later, she still had less than full flexion of the elbow, which is sometimes encountered in pediatric elbow fracture.

Continue reading »]]> First Aid after a fall

Kids are active creatures; daring, curious, creative, innovative, but don’t always have the best judgment in the ‘heat of the moment’…..The result is often a broken bone. Most fractures in kids are treated with relatively simple care such as a cast; others may need more advanced care or surgery. Kids fractures.com is designed to provide you all of the information that you need to insure that your child receives optimal care and a complete recovery.

If your child has a crooked appearing arm or leg and is screaming in pain, this is not the place for you to be! Most fractures are obvious to a parent and an Emergency Department should be your next stop!  However, if you find yourself in this situation in the future, here’s what we would suggest:

• Look at the arm or leg carefully
• Does it appear crooked?
• Are there any cuts in the skin?
• Are the fingers or toes pink, warm, and “blush” when you touch them?
• Can the child feel their fingers or toes?
• How did the fracture happen?
• Was the child knocked out?  (loss of consciousness)
• How far did they fall?
• How fast were they going?

Splinting the fracture…

No matter how crooked the arm or leg looks, it will be more comfortable for the ride to the hospital if you make a splint for it.  Broken bones are painful, and any bumps or movement tends to be very painful.  This pain is lessened when you apply a splint to the arm or leg. Splints can be made from all sorts of things. For a broken arm, something as simple as a magazine or folded piece of cardboard and duct tape will be enough to make the arm comfortable. This improves the safety of taking the child to the hospital.

If you have to travel a long distance, it is sometimes better to gently straighten the alignment of the arm or leg before putting it in the splint.  This always seems like a scary prospect, but will result in better comfort during your trip to the hospital.  There is very little that you can do in this situation that will harm the arm, so don’t be afraid to gently move the arm.

If there is an cut or visible bleeding over where the bone is broken, this is an emergency!  When a broken bone cuts through the skin, the bone can be contaminated with all sorts of bugs that you don’t want.  Open fractures always need surgery to clean the bone and make sure that it does not become infected.

DO NOT EAT ON THE WAY TO THE HOSPITAL!  If your child needs surgery to fix their fracture, it is safest if they have an empty stomach before needing sedation or a general anesthetic to fix the broken bone.

Continue reading »]]> How do I know if my child has a broken bone?

The only sure way to tell if your child has a broken bone is to take an x-ray. If the arm or leg is obviously deformed, then the problem is obvious.   However, some fractures are so minor that they cannot be detected by just looking at the arm.  Typical hints that the bone is broken are persistent pain after a fall, point tenderness directly where the child says it hurts, swelling, or the a young child refusing to use the arm at all.  With these findings, it is advisable to see your doctor and have an x-ray.

How do fractures heal?

When you break a bone, your body is programmed to begin a process that will “knit” the bone back together and heal.  Bone is a living tissue, just like your heart, brain, liver, or skin. When you break a bone, it is not like breaking a stick of wood; the bone will bleed, and immediately the healing process begins by recruiting cells from the bloodstream that are capable of healing the fracture.

Technically speaking, a fracture triggers a process in which cells in your bone change from a resting state and become very active at making new bone.  This process produces what is called “fracture callus”.  When your doctor shows you the x-ray of your fracture healing, it will look like a big ‘lump’ of bone where the fracture occurred. Sometimes when you feel your arm during the healing process, you can feel this lump, which is normal.  Once the ends of the bone have knitted themselves together, your body will then begin a process of remodeling of the fracture callus.  In most kids, the bone will eventually return to its normal appearance and it will be difficult to tell if there ever was a fracture.

What is a growth plate?

Every long bone in the body has a growth plate at each end.  This is a remarkable structure made up of a highly specialized growth cartilage that allows the bone to grow longer as the child gets older.  Growth plates function until the child completes their growth (girls at about 14 and boys at 16), and then the growth plates close.

How does the growth plate work?

Growth plates are made up of a highly specialized material known as cartilage.  This cartilage has cells that are programmed to divide and then undergo a process in which the body changes the cartilage to bone.  This is a very orderly process, and continues until you finish growing.

What happens if the growth plate is injured?

Some fractures in children will involve the growth plate.  If this is the case, then there is some chance that the growth plate will no longer work properly.  Fortunately, this is usually not the case.  Anytime a fracture involves the growth plate, it will need to be watched by your doctor until it is certain that normal growth has returned.

If the growth plate is permanently damaged, it can result in the arm or leg either growing crooked or not growing at all.  These problems can be very complicated, depending on the age of the child when the injury occurs, and require the expertise of an orthopedic surgeon used to dealing with these types of problems.

My childs arm looks crooked.  How can it grow straight?

Kids have an incredible capacity for their arm or leg to grow straight after their broken bone has healed. Orthopedic surgeons call this process “remodeling”.  Remarkably, your child’s bones are genetically programmed to grow back into their original shape over time.  This is often an important issue because when you look at an x-ray and your child’s arm or leg does not look perfectly aligned, you will wonder if it will ever be “right” again. Ask your surgeon to show you an example of how kids bones remodel with growth and you will be amazed at their capacity to grow straight again.

Do the bones have to be perfectly aligned on the x-ray to heal properly?

No.  The  bones will heal regardless if they are aligned end to end, side-to-side, etc.  The overall alignment of the bone is more important than the position of the ends of the broken bones themselves.  Kids have an incredible ability to heal their broken bones quickly.

Is the bone stronger after it has been broken?

This is a tricky question.  In general, we don’t go out and try to re-break your child’s broken bone to see how strong it actually is!  However, there is an time right after the final cast is removed that your child’s bone is probably weaker than it was before the break.  This is a time when you may want to try to limit your child’s more dangerous activities.  When the bone is completely healed, the diameter of the bone can be bigger; in this instance, the bone is actually stronger until is completely remodels back to the normal, pre-fracture state.

How do I tell if the growth plate is growing properly?

If the growth plate was involved in your child’s fracture, then your orthopedic surgeon will need to watch the growth of the arm or leg over time.  As the fracture heals, growth usually returns.  You can see this on an x-ray. The body will form what doctors call a “growth line” right next to the growth plate.  Over time, this growth line will move away from the growth plate, confirming that normal growth has resumed.  Growth lines are interesting. They are essentially an archeological record of an injury, somewhat like the growth rings on a tree.  They will help you remember the good and the bad years of growth! (or the ones where you spent your summer in a cast…)

If my child has a growth arrest, what can be done?

Unfortunately, a growth arrest after a fracture can occur from time to time.  The significance of a growth arrest depends on many factors, including the age of your child, the bone involved, and the type of growth plate injury.  In certain cases, only part of the growth plate is injured and this can be repaired with surgery.  This requires the expertise of a pediatric orthopedic surgeon who is familiar with treating these types of injuries.

Why does my child have to wait to have an anesthetic if they are in pain?

When an anesthetic is administered the sphincter at the bottom of the esophagus relaxes and if the stomach is full, those contents can be regurgitated and spill into the trachea and contaminate the lungs.  This is called an “aspiration” and it can cause severe problems such as a terrible pneumonia or inflammatory reaction in the lungs that can be life threatening.  In order to reduce the chance of aspirating, the American Society of Anesthesiologists have developed a set of guidelines for how long someone should go without food before having an anesthetic.  The suggested times are as follows:

Ingested Material Minimum Fasting Period

clear liquids — 2 hours

breast milk — 4 hours

infant formula — 6 hours

non-human milk — 6 hours

light meal —  6 hours

• These recommendations apply to healthy patients who are undergoing elective procedures.  They are not intended for women in labor.
• Following the guidelines does not guarantee that complete gastric emptying has occurred.
• The fasting periods apply to all ages.
• Examples of clear liquids include, water, fruit juices without pulp, carbonate beverages, clear tea, and black coffee.
• Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.
• A light meal typically consists of toast and clear liquids.  Meals that include fried or fatty foods or meat may prolong gastric emptying time.

Continue reading »]]> Here are the answers to the most commonly asked questions about how to take care of casts…

Can I get my cast wet?

It depends…If you have a plaster cast, it definitely cannot get wet.  The plaster will become soggy and soft and no longer will it hold the fracture.  A fiberglass cast will not fall apart if it gets wet.  However, it can be difficult to get the inside of the cast dry again.  This causes your skin to become soft and usually rather smelly.  A blow dryer on the cool setting can help, but the smell and itching usually stay.

Cast covers can be hard to find. You can order them directly from Amazon.com by going to amazon.com and typing in “cast covers”.

Certain casts use a special gore-tex underlining, making it possible to swim, shower, etc.  While this seems like a great idea, not every orthopedic surgeon will use gore-tex because it costs 10 times more than the usual underlining and is not especially “user-friendly”.  If you must have a gore-tex underlining, expect to pay out of pocket for it because most insurance will not pay for it.

What can I do about itching?

Itching is a common problem under a cast!  There are not great solutions, but we often see some rather creative but unsuccessful attempts to solve the problem.  First, it is generally not a good idea to stick something down your cast so scratch your itch.  The reason is that it can mess up the underlying padding of your cast making the problem worse, and scratch your skin causing a sore that you cant see.  If you must scratch, a smooth butter knife rather than a coat hanger or pen is the best tool.  We DO NOT recommend this, however.  Try distraction, mental exercises, or scratching the other arm rather than sticking something down your cast.

Can I stick anything down my cast to scratch?

Bad idea.  This can scratch your skin or worse yet, get stuck in your cast so you cant get it out!  If you absolutely have to stick something down your cast to scratch, use a smooth butter knife, not a coat hanger or other sharp object.  Things have a curious way of getting stuck in a cast.  When this happens, it is likely to cause sores or breakdown of the skin under the cast.

Are there waterproof casts?

Yes, but their use is limited. Gore-tex underlining for a fiberglass  cast allows it to get wet and dry out.  However, gore-tex costs about 10 times more than regular cast material and insurance will usually not pay for it.  Therefore, if you must have a “swimming cast”, expect to pay extra out-of –pocket for it\.

I got something stuck in my cast.  How do I get it out?

We find an incredible assortment of things that have seemingly jumped into kid’s casts or were placed there by Aliens!  The problem with having something stuck in your cast is that it can cause a sore in the skin.  Once something is caught up in the cast, it is very difficult to get out without removing the cast.  Therefore, it is best to “fess up” that something is stuck in the cast and have it removed.  Don’t try to do this at home;  it can be dangerous and the fracture may lose alignment in the process.

Can I write on my cast?

Yes.  Cast decorations, signing, and other forms of artwork will not damage your cast.  Remember, what ever you put on your cast, you’ll have to live with until you have it off.  This is one of the great advantages of cast decoration over tatoo’s:  they don’t last forever.

How do I care for a SPICA CAST?

A SPICA cast is the hardest cast to care for.  When the entire lower half of your body is in a cast, toileting is obviously an issue, especially if your child is not “potty trained”.  The hardest problem is keeping the cast clean and dry so the surrounding skin does not get a severe diaper rash.

The trick is to keep the cast as dry as possible.  A repeatedly soiled cast can develop an odor that can clear a room in a few seconds! The harder you try to keep it clean, the better you will be.  However, you should accept the fact that even if you are the most perfect parent in the world, the cast will have a certain “bouquet” and the time of removal that you will be ready to forget.

Here are some tips that we find helpful:

• Use two diapers.  Use a smaller one and tuck it up inside of the cast as a “first defense” against urine.  Use a second diaper around the cast.
• Change the diapers often.  Sorry, this is not the time to save the landfills from too many diapers.  The sooner you change the diaper, the drier the cast will remain.  In terms of overall all odor, you will be rewarded by frequent diaper changes.
• Elevate your child’s head slightly when they sleep.  This prevents urine from immediately running up the back of the cast and getting the underlining wet.  This can be like not changing a diaper for two months…very hard on the skin.
• When the cast gets wet, get it dry.  The best way to protect the skin is to keep the skin dry.  If the cast does get wet, then use a blow dryer on the cool setting to help dry it out.  Place the child on their stomach, and this will help get  air to the bottom area.
• Be careful about using powder or salves to dry the skin.  These can accumulate just out of reach and turn into sludge……

How is a cast removed?

A cast is removed using a special device known as a cast saw.  Cast saws are rather scary to children, because they make a lot of noise and would in their eyes appear to have the capability to cut their entire arm or leg off while removing the cast!   A cast saw works by having the saw blade vibrate very fast.  This makes it so when it comes in contact with something very hard like fiberglass, it will cut it, but when it touches something soft, it can’t cut that.

Will the cast saw cut me?

No. The cast saw vibrates very fast, but won’t cut through the skin.  Have you doctor show you this before removing the cast so you won’t be scared by the saw.

Can I remove my own cast?

No.  This is a bad idea.  Cast material is very hard. With a lot of work, using sharp tools around the home, you could probably get your cast off, but at significant risk of life and limb.  It is much safer to have your doctor remove your cast using tools specifically designed to do this.

How can I tell if there is too much swelling in the cast?

A properly applied cast should feel snug, but not painfully tight.  If your cast was placed immediately after the break happened, then it is possible for there to be some further swelling inside the cast.  Casts are rigid and unyielding.  If the cast is too tight, you will experience increasing pain, and you will have more swelling in your fingers or toes.  If this does not improve with elevation, your fingers or toes turn purple, or you lose feeling in your fingers or toes, you should seek immediate attention to have the cast split to allow for swelling.

What should I do if the cast seems too tight?

If the cast is too tight, and you are having symptoms such as excessive pain, swelling in the fingers, of loss of feeling in them, then the cast should be split or “bivalved”.  This will allow for swelling to occur without putting too much pressure on  your arm or leg.

If  I had surgery on the arm and it is in a cast, how do I know that the incision is OK?

 This is a common worry after surgery.  Most incisions will heal very well under the protection of a cast.  There is generally no need to change bandages, etc while the cast is in place.  If you were do develop new onset of pain, a foul odor, or started having high fevers 5 days after your surgery, then you should seek immediate attention to check for infection of the surgical wound.

What are the signs of infection after surgery?

The signs of infection after surgery are usually not subtle.  The typical signs of developing and infection after surgery are high fevers, new onset of pain once the initial surgical pain had resolved, drainage of pus like material from the wound, or a breakdown of the incision site. In this situation, you should immediately contact your doctor.

Continue reading »]]> One of the biggest controversies in the management of pediatric elbow fractures has to do with the timing of operative intervention for supracondylar humerus fractures.

In 2001, in the American edition of the Journal of Bone and Joint Surgery (March Issue, 83-A, page 323-7), Dr. Alan Crawford published a very interesting study entitled “The effect of surgical timing on the preoperative complications of treatment of supracondylar humerus fractures in children”.

This study was designed to evaluate whether or not there was a higher rate of complications associated with delayed treatment after a supracondylar elbow fractures. The authors defined early treatment as surgical reduction that occurred within 8 hours, and delayed treatment as surgery that occurred more than eight hours after the injury.

Fifty two children had early surgery (within 8 hours) and 146 children had late surgical treatment (after 8 hours). The study found that there was no difference between the two groups, which established for the first time that pediatric elbow fractures did not necessarily need to be treated in the middle of the night. This is an important finding, because many other studies have shown that the overall rates of operative complications increase when surgery is performed “after hours” or in the middle of the night, and often, it is better to wait till the morning when the operating room is in the normal swing of activity.

This was a really important study because prior to this study, the orthopedic community used to believe that there was a principle that you should never “let the sun set on a supracondylar fracture of the humerus”, which obligated the vast majority of cases to be treated in the middle of the night.  With this study, there was at least some scientific basis to waiting throughout the night and treating the fracture in the morning.  However, this treatment option is not without its risks.  The child has to be under the care of someone who is cognizant of the risks of a vascular injury in the setting of a supracondylar elbow fracture, and in one of our case law examples, we present the narrative of a child who ended up developing a catastrophic complication as the result of a delay in treatment.  For full details of this narrative, read the entire story here.

The full abstract for the study on delayed versus immediate treatment of supracondylar humerus fractures is as follows:

J Bone Joint Surg Am. 2001 Mar;83-A(3):323-7.

The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children.

Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH.

Source

Division of Pediatric Orthopaedic Surgery, Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Ohio 45229-3039, USA.

Abstract

BACKGROUND: The purpose of this study was to evaluate the perioperative complication rates associated with early surgical treatment (eight hours or less following injury) and delayed surgical treatment (more than eight hours following injury) of displaced supracondylar humeral fractures in children.

METHODS: Fifty-two patients had early surgical treatment and 146 patients had delayed surgical treatment of a displaced supracondylar humeral fracture. The perioperative complication rates of the two groups were compared with the use of bivariate and multivariate statistical methods.

RESULTS: There was no significant difference between the two groups with respect to the need for conversion to formal open reduction and internal fixation (p = 0.56), pin-track infection (p = 0.12), or iatrogenic nerve injury (p = 0.72). No compartment syndromes occurred in either group. Power analysis revealed that our study had an 86% power to detect a 20% difference between the two groups if one existed.

CONCLUSIONS: We were unable to identify any significant difference, with regard to perioperative complication rates, between early and delayed treatment of displaced supracondylar humeral fractures. Within the parameters outlined in our study, we think that the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

Continue reading »]]> This is a list of the fractures that are described in this website, with quick links to the relevant pages:

• collar bone
• upper arm (humerus)
• elbow
• foream
• wrist
• upper leg bone (femur)
• knee
• lower leg bone (tibia)
• ankle
• pediatric sports medicine
• fractures associated with child abuse

The most frequently asked questions about fracture care are listed here: FAQs

Continue reading »]]> Broken Wrist – Fractures of the wrist and distal radius:

Distal radius fractures occur at the end of the bone near the wrist joint. These are among the most common fractures that we see in children. These fractures typically occur after a fall on the outstretched arm. If you watch the kinds of activities that your child does every day, it is remarkable that broken wrists aren’t more common! Distal radius fractures come in several varieties, ranging from mild to severe.

Torus or buckle fractures

Torus fractures are common. When the child falls on the outstretched hand, the bone buckles under the weight of the body. Typically, you will see a slight bend in the bone, but only on one side. It literally looks like the bone buckled, but didn’t break all the way through. Torus fractures hurt, but will not cause a visible deformity. If you push directly on the arm where it is broken, it will hurt, and the child can localize the spot very clearly. However, they can usually move the wrist joint without much trouble. Because of this, many of these fractures are diagnosed late because it can be difficult for parents to tell if it is broken or not.

Treatment

Torus fractures need protection from further injury and for relief of pain. Although a splint may be sufficient, most kids are so active that the safest treatment is to place them in a non-removable cast below the elbow for about 3-4 weeks.

Displaced Distal Radius fractures

Some falls are severe enough to completely fracture the end of the radius, producing both displacement (the bones don’t line up end to end) and angulation (the arm is crooked). In this case the arm will look visibly deformed; deciding whether or not your child has a fractures is usually not difficult. Often termed “Colles Fractures”, they are said to have a ‘dinner fork’ deformity to the arm.

Treatment

Displaced fractures of the distal radius are usually treated with manipulation of the arm to attempt to restore normal alignment to the bones. Because the fractures occur very close to the growth plate, they have an excellent capacity to remodel with time. If there is any residual angular deformity after the fracture has healed, it will remodel as long as it is in the place of motion of the wrist joint.

Growth plate fractures at the wrist

The distal end of the radius is a common site for children to sustain a fracture that actually involves the growth plate itself. These can occur in several varieties. However, it is a very forgiving growth plate to injure. The incidence of have residual problems with growth is usually less than 5 percent with the exception of very severe injuries.

Treatment

The principles of treatment for any fracture involving the growth plate are to restore anatomic alignment of the growth plate with the minimum amount of trauma. Most displaced growth plate fractures in the distal radius can be manipulated back into normal alignment and held there with a cast. The growth plate will heal very quickly, so prolonged casting is not necessary. Very few fractures of the distal radius will require surgery. Severe growth plate injuries should be followed with x-rays to confirm that normal growth has returned.

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Continue reading »]]> Clavicle Fracture, AKA Broken Collar Bone:

Clavicle Fractures are among the most common broken bones in kids.  These usually happen after a fall on the shoulder or arm, with falls off a bicycle being a particularly common cause of the injury.

It is usually easy to tell if it’s broken; there is pain over the collarbone and there may be obvious deformity such as the ends of the broken bone pressing up on the skin.  An x-ray will confirm the diagnosis.

The treatment of a clavicle fracture is quite simple.  It is often said that if the ends of the broken collarbone are in the same room, they will heal!  All that is usually required is a sling for comfort or perhaps a clavicle strap, a form of brace that puts pressure over the collar bone and provides some stability for comfort during healing.  Clavicle fractures heal by making a “lump” of bone known as fracture callus, which serves to knit the two ends of the bone back together.  Over time, the lump of bone will go away as the clavicle remodels back into its original shape.

Clavicle fractures in children almost never require surgery, and are generally well on their way to healing by 3 weeks (which is about as long as you can continue to keep your child in a sling, anyway).  There are a few exceptions; if the bone comes through the skin (rare), it will need surgery right away.  In the rare instance that the fracture does not heal on its own, we often think that there might be a rare condition known as congenital pseudoarthrosis of the clavicle (which is always on the right side). This is shown in the next two pictures, and surgery with a plate and screws is often needed to fix this problem.

This is the pre-operative xray of a clavicle fracture that has not healed. Notice how the ends of the bone are rounded and remodeled and there is still a gap between the two ends of the fracture.

While this procedure is rarely used, this is an example of surgery in which a plate and four screws were used to stabilize the fracture fragments, close the gap between them, and allow for ultimate healing of the broken bone.

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Continue reading »]]> Fractures ABOVE the elbow in children — Supracondylar Humerus Fractures

Elbow fractures are common in active kids.  The elbow is a particularly complicated joint in children because during growth, much of the ‘bone’ is still made of cartilage, which you can’t see on an x-ray.  Because of this, it is easy to miss minor fractures on an x-ray, and occasionally some more serious injuries.

Evaluation:  The first sign of a significant elbow fracture is pain. Kids will not want to move the elbow, and there may be swelling and bruising or other signs of a significant injury.  With severe injuries, the deformity is obvious. Thee diagnosis is confirmed with an x-ray.  The tricky thing about elbow fractures in kids is that there are times where the fracture is there but difficult to see on the x-ray.  Sometimes you can only see the swelling in the joint and not the fracture itself.  There are several tricks that doctors will use to sort this out, including taking a comparison view of the other  non-injured side, x-rays from different angles, etc.  Rarely, more advanced studies like an MRI are necessary.

Treatment:  The type of treatment of an elbow fracture in your child depends on the specific type of fracture, its location in the bone and the growth plate, and the potential for healing.  Treatment options range from a simple splint to surgery

Different types of elbow fractures need different treatments.  Here is an overview of some of the common ones.

Supracondylar fractures of the elbow

Supracondylar fractures occur just above the elbow and the growth plate in the end of the humerus.  These fractures occur by over-extending the elbow during a fall.  The most common age is between 5-8 years old, but they can happen at any age.  The trampoline is a particularly common way that this fracture happens.  Severe injuries are dramatic!  The arm looks terrible and the child will be in significant pain.  A trip to the hospital is usually not a difficult decision to make.  Milder forms can be more subtle.  X-rays confirm the diagnosis.

Doctors think about supracondylar fractures as three types; the type determines the type of treatment needed.

Type 1 Fractures:  This is simply a crack in the bone in the supracondylar region.  Although the child will hurt, the bone is basically straight and the fracture is unlikely to change in its alignment.  The concern is that as soon as the child doesn’t hurt anymore, they will return to their normal activities and are at risk of a more severe break…..(see Type III)  These fractures require a cast and are usually healed in about three weeks.  If the cast stays on much longer than that, the elbow can become rather stiff.

This is an x-ray of a Type 1 Supracondylar fracture of the elbow. The crack is almost impossible to see, but the capitellum (indicated by the arrows) is located behind a line drawn along the front of the humerus, indicating that the bone has been broken. This type of an injury can be treated in a cast.

This is also an x-ray of a Type 1 Supracondylar fracture of the elbow. This child is older, which makes the fracture lines (indicated by the arrows) easier to see. This type of fracture can also be treated in a cast.

Type 2 Fractures:  This version of the supracondylar fracture is moderately displaced, meaning that the bone will look crooked on the x-ray, but the ends are still attached or “hinged”.  With very minor displacement, these can be gently pushed back into alignment and treated in a cast.  However, if the angulation is significant, the fracture will require an operation and placement of pins to hold the bone in proper alignment.

This is an x-ray of a Type 2 Supracondylar fracture. The fracture in the humerus is shown with the arrows, and the end of the humerus appears to be bent backwards.

Type 3:  This is the most severe form of the supracondylar fracture.  The arm will look very crooked and swelling will occur quickly. These fractures are very unstable and always require surgery.

This is an x-ray of the most severe type of supracondylar fracture, a Type 3. The arrows indicate where the bone is broken, and the elbow is no longer connected to the humerus.

How are Type 3 injuries treated?

Surgery for Type 3 supracondylar fractures has evolved significantly in the past 20 years.  In years past, these fractures were treated with traction in the hospital for as long as three weeks!  (Imagine how your HMO would feel about that….) Although the fractures would heal, the arm often ended up crooked and stiff.  Complications were common. With the development of specialized x-ray equipment known as the “fluoroscope”, surgeons began to treat these fractures be aligning the bones and placing pins to hold the correct position during healing. This is usually done without making an incision (cut) in the skin, which doctors call “percutaneous pinning”. This is now the most common way that these fractures are treated.  Most recently trained orthopedic surgeons are familiar with these techniques.

Most Type 3 supracondylar fractures are treated within 24 hours of the injury.  Your surgeon will want to watch for swelling and other problems for and additional 12-24 hours before sending your child home.  The pins are usually removed in the office at 3-4 weeks after surgery, and the child is allowed to move the elbow.  The goal is to have a completely healed elbow and full range of motion by 6 weeks after the injury.

This next set of pictures illustrates the surgical treatment of a type 3 supracondylar fracture. Pins have been placed across the fracture, and four weeks after surgery there is enough evidence of healing to remove the pins. Once the pins have been removed, the bones will heal the rest of the way.

Complications:  There are several potential things that can go wrong when your child has this fracture.  Some are preventable and others are not.  Your surgeon will be very concerned about making sure that these problems are discovered and treated quickly.

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