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Supracondylar Fracture of the Humerus

15-Mark Structured Answer (Theory)

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1. Definition and Introduction

• Most common elbow fracture in children (age 5-7 years peak incidence)
• Accounts for approximately 60% of all elbow fractures in the pediatric age group
• Extension-type constitutes 97-98% of all cases
• Rosen's Emergency Medicine, p. 3304

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2. Surgical Anatomy (Relevant)

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3. Mechanism of Injury

Extension Type (97-98%)

• Fall on an outstretched hand with elbow hyperextended
• Force drives the distal fragment posteriorly and superiorly
• The proximal fragment is driven anteriorly, threatening the brachial artery

Flexion Type (2-3%)

• Fall directly on a flexed elbow
• Distal fragment displaced anteriorly
• Higher risk of ulnar nerve injury

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4. Classification - Gartland Classification (Modified)

• Campbell's Operative Orthopaedics, Table 38.2
• Tintinalli's Emergency Medicine, p. 3303

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5. Clinical Features

History

• Child aged 5-7 years
• Fall onto outstretched hand
• Immediate pain, refusal to use limb

Examination

• Swelling and bruising around elbow
• Deformity - "S-shaped" elbow on lateral view
• Pucker sign - skin dimpling anteriorly (proximal fragment penetrating brachialis) - indicates difficult reduction

• Tenderness over distal humerus
• Assess 5 Ps of vascular compromise: Pain, Pallor, Pulselessness, Paralysis, Paresthesias
• Palpate radial and ulnar pulses

• Anterior interosseous nerve (AIN) - test by thumb IP joint flexion ("OK sign"); injury causes "pointing index sign"
• Radial nerve - wrist/finger extension
• Median nerve - sensation index finger tip

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6. Radiological Assessment

Views Required

• AP and lateral elbow X-rays
• Oblique views if clinical suspicion high

Key Radiological Signs

• On a true lateral, a line drawn along the anterior cortex of the humerus should intersect the middle third of the capitellum
• In extension-type fracture: line passes through the anterior third or anterior to the capitellum (capitellum displaced posteriorly)

• Posterior fat pad is always pathological on lateral X-ray
• Anterior fat pad "sail sign" = bulging = effusion/occult fracture
• Type I fractures may show ONLY a posterior fat pad sign

• Angle between the growth plate of the capitellum and the long axis of the humerus on AP view
• Normal: 70-75 degrees
• Asymmetric or abnormal Baumann angle suggests fracture/malreduction
• Used to assess adequacy of reduction

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7. Management

Emergency Assessment

1. Full neurovascular examination
2. Splint in position of comfort (avoid hyperflexion if swollen)
3. X-rays

Treatment by Type

TYPE I
  → Long-arm posterior splint / backslab
  → Elbow at 90°, forearm neutral/pronation
  → Immobilize 3 weeks
  → Outpatient orthopaedic follow-up in 1 week

TYPE IIA
  → Closed reduction under GA
  → Above-elbow cast 3-4 weeks

TYPE IIB / TYPE III / TYPE IV
  → Closed Reduction + Percutaneous Pinning (CRPP)
  → Two or three lateral K-wires (avoids ulnar nerve risk)
  → OR crossed pins (lateral + medial) for Type III/IV
  → Above-elbow cast post-op
  → Pins removed at 3-4 weeks

Percutaneous K-Wire Fixation

• Lateral pins only: 2-3 divergent lateral entry pins - preferred to avoid iatrogenic ulnar nerve injury
• Crossed pins: provides more rotational stability but risks ulnar nerve injury with medial pin
• If periosteal hinge is broken (Type III/IV), K-wires are mandatory - cast alone insufficient

Open Reduction Indications

• Failed closed reduction (usually due to soft tissue interposition)
• Open fractures
• Vascular injury requiring exploration
• Irreducible (pucker sign / brachialis interposition)

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8. Neurovascular Management

White Pulseless Hand (= surgical emergency)

• Immediate reduction in operating theatre
• If pulse returns after reduction → observe in 45° flexion, not hyperflexed
• If pulse does not return → explore brachial artery (anterior approach), prepare for vein graft

Pink Pulseless Hand (controversial)

• Good capillary refill, normal colour but no palpable pulse
• Reduce and pin fracture first
• Observe - pulse often returns within 24-48 hours
• If no recovery → brachial artery exploration

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9. Complications

Early Complications

Late Complications

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10. Prognosis

• Type I: Excellent, full recovery expected
• Type II/III with prompt CRPP: Good; most achieve full elbow motion
• Nerve injuries: 90%+ resolve spontaneously within 3-6 months
• Cubitus varus: May require corrective supracondylar osteotomy if severe/symptomatic

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Summary Box (High-Yield for Exam)

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Presentation Contents — 11 Slides

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Developmental Dysplasia of the Hip (DDH)

15-Mark Structured Answer — 2026 MS Orthopaedics Theory Examination

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1. Definition

• Previously called "Congenital Dislocation of the Hip (CDH)" — the term DDH is now preferred as it recognises the developmental and evolving nature of the condition
• Campbell's Operative Orthopaedics, 15th Ed 2026, p. 1402

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2. Incidence and Risk Factors

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3. Pathological Anatomy

• Shallow, oblique roof (increased acetabular index)
• Inverted/hypertrophied limbus (labrum) - may block reduction
• Pulvinar (fatty fibrofatty tissue) fills acetabular floor

• Displaced superolaterally
• Anteversion increases
• Ossification delayed

1. Contracted iliopsoas tendon (hourglass capsule)
2. Hypertrophied ligamentum teres
3. Inverted/hypertrophied acetabular labrum (limbus)
4. Pulvinar in acetabular floor
5. Tight adductor muscles

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4. Clinical Features

Neonatal Assessment (0-3 months)

• Hip flexed to 90°, knee flexed
• Gentle abduction + anterior lift of greater trochanter
• Positive: palpable "clunk" as dislocated femoral head reduces into acetabulum

• Hip adducted + gentle posterior pressure applied
• Positive: femoral head felt to dislocate posteriorly out of acetabulum
• Both tests lose sensitivity after 3 months (soft tissue contracture)

Older Infant / Toddler (3 months - 3 years)

Ambulatory Child (after walking age)

• Trendelenburg gait (waddling) - unilateral
• Bilateral DDH: waddling gait, hyperlordosis, prominent trochanters

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5. Radiological Assessment

A. Plain X-ray (AP Pelvis)

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B. Ultrasound (Graf Classification - <6 months)

• Gold standard for infants under 6 months
• Measures: alpha angle (bony acetabular roof) and beta angle (cartilaginous roof)

C. MRI / Arthrography

• Arthrogram under GA: used before closed reduction to assess medial dye pool, safe zone, obstacles
• Acceptable: medial dye pool ≤5 mm, safe zone ≥20° (ideally ≥45°)
• MRI: gold standard for assessing reduction quality in spica cast

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6. Classification (IHDI - International Hip Dysplasia Institute)

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7. Treatment

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Treatment by Age Group

A. Newborn to 6 Months — Pavlik Harness

• Pavlik harness: dynamic flexion-abduction orthosis
• Maintains hips in flexion 100-110°, abduction 40-50° (Salter position)
• Worn full-time initially; weaned over weeks
• Success rate: 85-95% in first few months of life
• Complications: femoral nerve palsy; avascular necrosis (<1%)
• Failure factors: absent Ortolani sign, bilateral dislocation, acetabular index >36°, age >6 months at start
• If Pavlik harness fails → trial with rigid abduction orthosis (Craig splint / Von Rosen splint)

B. 6 to 18 Months — Closed or Open Reduction

• Assess medial dye pool (acceptable ≤5 mm)
• Assess safe zone (Ramsey): acceptable ≥20°, ideal ≥45°
• Followed by hip spica cast in Salter position (human position)

• Approach: anterolateral (Smith-Petersen) - most common
• Remove all obstacles: iliopsoas tendon, pulvinar, hypertrophied ligamentum teres, inverted limbus
• Capsulorrhaphy (tighten capsule)
• Followed by hip spica cast 6-12 weeks

C. 18 Months to 3 Years — Open Reduction + Femoral Osteotomy

• Open reduction (as above) +
• Derotation (shortening) femoral osteotomy: reduces tension on femoral head; corrects anteversion
• Shortening reduces risk of AVN from pressure during reduction
• Spica cast 6-12 weeks post-op

D. 3 to 8 Years — Open Reduction + Combined Osteotomies

• Open reduction +
• Femoral osteotomy (shortening + derotation) +
• Pelvic osteotomy:

E. Older Child / Adolescent (>8 years)

• Prognosis for full correction worsens significantly
• Salvage procedures: Shelf acetabuloplasty, Chiari osteotomy (medialisation of femoral head)
• Total hip arthroplasty in adults with painful DDH-related arthritis

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8. Complications

Early Complications

Late Complications

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9. Summary (High-Yield Exam Points)

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Legg-Calvé-Perthes Disease (Perthes Disease)

10-Mark Structured Answer — 2026 MS Orthopaedics Theory Examination

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1. Definition

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2. Epidemiology

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3. Aetiology / Pathophysiology

• Coagulation disorder / thrombophilia promoting thrombotic occlusion of the lateral epiphyseal arteries
• Increased intracapsular pressure from synovitis compromising blood supply
• Repetitive micro-trauma
• Elevated venous pressure

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4. Stages (Waldenström's Radiological Stages)

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5. Clinical Features

• Intermittent pain in the hip or referred to the knee (obturator nerve)
• Insidious onset limp
• Symptoms often present for 6 weeks before diagnosis

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6. Investigations

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7. Classification

A. Catterall Classification (Amount of head involvement)

1. Gage sign - V-shaped radiolucency at lateral epiphysis/metaphysis
2. Calcification lateral to epiphysis
3. Lateral subluxation of femoral head
4. Horizontal (oblique) proximal femoral physis
5. Metaphyseal cyst

B. Herring Lateral Pillar Classification (Most widely used - applied in fragmentation stage)

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C. Stulberg Classification (Outcome / healed stage)

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8. Management

Principle of Treatment — CONTAINMENT

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Treatment Decision (Age + Herring Grade)

A. Conservative (Non-Operative) Treatment

• Goal: maintain range of motion, prevent deformity
• Physiotherapy: stretching exercises, maintain abduction and internal rotation
• NSAIDs / analgesics: for pain and synovitis
• Crutches if severe pain (avoid prolonged non-weight-bearing)
• Avoid wheelchairs and prolonged bed rest (promote hip flexion-adduction deformity)
• Bracing (Petrie cast / Atlanta brace): maintains abduction-internal rotation but evidence does not support altering natural history; rarely used now
• Serial X-rays every 3-6 months to monitor stage and Herring grade

B. Surgical Containment

• Redirects femoral head deeper into acetabulum
• Corrects any coxa valga
• Most common surgical procedure for Perthes
• Risk: excessive varus, limb shortening, Trendelenburg gait

• Redirects acetabulum anterolaterally to cover femoral head
• Preferred when femoral head is in good position but acetabular coverage insufficient
• Can be combined with PFVO (triple containment)

C. Salvage Procedures (for healed deformed hip)

• Shelf acetabuloplasty: extends acetabular cover over enlarged femoral head
• Chiari osteotomy: pelvic medialisation osteotomy
• Trochanteric advancement / greater trochanter epiphyseodesis: corrects high riding trochanter
• Hip distraction (arthrodiastasis): Ilizarov frame; used in late onset severe disease
• Total hip arthroplasty: in adults with painful end-stage deformity

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9. Prognosis

• Young age at onset (<6 years) — more remodelling time
• Male sex (greater remodelling potential)
• Herring Group A (or B at young age)
• Spherical femoral head at healing

• Age >9 years at onset
• Herring Group B/C or C
• Head-at-risk signs present
• Lateral subluxation of femoral head
• Stulberg Class III-V at skeletal maturity → premature osteoarthritis

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10. Complications

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Summary — High-Yield Exam Points

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