A 9-year-old child presents to your clinic with the following deformity. Which is the most likely fracture leading to such a defect?
Ans. d. Supracondylar Fracture (Ref: Apley's 9/e p371, 760)The given picture shows cubitus varus or gun-stock deformity. The most common cause is matunion of a supracondylar fracture."Cubitus Varus ('Gun-Stock' Deformity): The deformity is most obvious when the elbow is extended and the arms are elevated. The most common cause is malunion of a supracondylar fracture. The deformity can be corrected by a wedge osteotomy of the lower humerus but this is best left until skeletal maturity."-- Apley's 9/e p371"Cubitus Valgus: The normal carrying angle of the elbow is 5-15 degrees of valgus; anything more than this is regarded as a valgus deformity, which is usually quite obvious when the patient stands with arms to the sides and palms facing forwards. The commonest cause is longstanding non-union of a fractured lateral condyle: the deformity may be associated with marked prominence of the medial condylar outline. The importance of cubitus valgus is the liability to delayed ulnar palsy; years after the causal injury the patient notices weakness of the hand, with numbness and tingling of the ulnar fingers. The deformity itself needs no treatment, but for delayed ulnar palsy the nerve should be transposed to the front of the elbow. Great care is needed in performing the operation. Excessive dissection of the nerve or rough handling can impair nerve function. "-- Apley's 9/e p371Supracondylar Fracture Humerus (Malgaigne's Fracture)MC fracture around elbow in children & adolescentsQMC age of presentation: 5-7 yearsQMechanism of Injury:MC mechanism of injury: Fall on outstretched hand with elbow in full extensionQType of injury:MC type of injury : Extension type (96%) >Flexion type (4%)QNerve Injury:MC nerve to be injured: Median nerve (Anterior interosseous branch) > Radial > UlnarQMC nerve to be injured in flexion type of supracondylar fracture: Ulnar nerveQVessel Injury:MC vessel to be injured: Brachial arteryMC immediate complication: Brachial artery injuryQOn Examination:Unusual posterior prominence over point of elbow ( tip of olecranon)QThree point bony relationship: Maintained with respect to each other but not with respect to shaft of humerusQComplications:MC complication/ delayed complication: Cubitus varus deformity or gun stock deformity in malunionQCubitus varus deformity or gun stock deformity is managed by French osteotomyQComplication of Colie's Fracture* Joint Stiffness- Finger stiffness is MC complicationQ- Wrist, elbow. & shoulderQ are other joints to become stiff.* Malunion is 2nd MC complicationQ & it leads to dinner fork deformity* Sudeck's osteodystrophy / Reflex sympathetic dystrophy:- It is quite common but seldom progress to full-blown picture of sudeck's atrophy.- Code's fracture is the commonest cause of sudeck's dystrophy in upper limbQ.* Shoulder Hand Syndrome:- Characterized by a swollen, painful, stiff hand and a 'frozen shoulder'.* Rupture of extensor pollicis longus tendonQ* Carpal tunnel syndrome causing median nerve compressionQ.* Carpal instabilityQ* Triangular-fibrocartilage complex injuryQ and * bluxation of inferior radioulnar joint* Delayed union and nonunion are extremely rare. Complications of Epicondyle FractureLateral Epicondyle FractureMedial Epicondyle Fracture* Nonunion & malunion: If the condyle is left capsized, nonunion is inevitable; with growth, elbow becomes increasingly valgus & tardy ulnar nerve palsy is then likely to develop.* The fracture is a Salter-Harris Type IV injury and so imperfect reduction can result in growth arrest.* Recurrent dislocation: Occasionally condylar displacement results in posterolateral dislocation of elbow.* Early:- Lateral dislocation of elbow occasionally occurs with a severe valgus strain & avulsion of medial condyle.- Ulnar nerve damage is not uncommon, but recovery is usual unless nerve is left kinked in joint.* Late:- Stiffness of elbow is common & extension often- limited for months. InjuryCommon nerve involvedSurgical neck of humerus* Axillary nerveQShaft of humerus* Radial nerveQMedial condyle of humerus* Ulnar nerveQMonteggia fracture dislocation* Posterior interosseus nerveQVolkmann's ischemic contracture* Anterior interosseus nerveQLunate dislocation* Median nerveQHip dislocation* Sciatic nerveQ
Colle's fracture
Lateral epicondyle fracture
Medial epicondyle fracture
Supracondylar fracture
Supracondylar Fracture