72.9 Other difficulties with supracondylar fractures in children

These include nerve injuries, post-traumatic ossification, a persistent varus deformity, and severe malunion. Most of these complications are difficult to treat. The principle is to prevent them by the methods described above if you possibly can.

OTHER DIFFICULTIES WITH A SUPRACONDYLAR FRACTURE

If a child has NERVE INJURIES after a supracondylar fracture, they probably recover. They are more common than injuries to the brachial artery, but are less serious. Nerve injuries alone are not an indication for an immediate operation. If there is no recovery in a month, refer the child to have his elbow explored.

If the child’s ELBOW WiLL NOT MOVE after a supracondylar fracture, he is suffering from POST TRAUMATIC OSSIFICATION. After 3 weeks, when the collar and cuff are removed, his elbow will not move, or perhaps there is some movement which gradually becomes less. The front of his elbow is tender, there is muscle spasm and the tendon of his biceps stands out as a taut band. X–rays may show a vague shadow like callus in front of the joint, or it may be so dense that it looks like bone. Sometimes a stiff painful elbow with new bone around it is his presenting symptom.

Encourage his parents to put his injured elbow through several 15 minute periods of gentle active movements each day, both flexion and rotation. His parents must be patient, persistent and gentle. Forced movements and even too vigorous passive movements will make his elbow worse. Make this clear to them. If the movements of a child’s arm are diminishing, put his arm in a collar and cuff until muscle spasm has disappeared, which may take months. If he cannot flex his elbow enough to get his hand to his mouth, put it in a loose collar and cuff and gradually tighten it until he can. After prolonged rest the spasm disappears and movement returns, but there is usually some permanent loss of movement. Unfortunately, post–traumatic ossification is common, and is a major disability, especially when pronation is lost. Osteotomy followed by an arthrodesis in the position of function (about 90, see Fig. 7-16) may be necessary.

Figure 72.13: A COMMINUTED SUPRACONDYLAR FRACTURE treated by active movements showing the range of movement possible 18 months later. Note that the range of active movement is around the position of function (about 90). This patient is right handed, to this enables his right hand to reach his mouth. Kindly contributed by Peter Bewes.

If SEVERE VARUS DEFORMITY PERSISTS, refer the child for corrective osteotomy not earlier than a year after the injury.

If the fracture was never property reduced, and he now has MALUNION with only 30 of movement or less, management depends on where the movement is. If it is around the position of function (90) an osteotomy is unlikely to improve him. But if it is around full extension, an osteotomy may bring it into a more useful range.