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(Created page with "==Mechanism of Injury== * Extension-type fractures * 95% of suprcondylar fractures * Due to FOOSH * Flexion-type fractures * 5% of supracondylar fractures * Due to direct traum...")
 
 
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==Mechanism of Injury==
''This page is for <u>pediatric</u> patients; for adult patients see [[distal humerus fracture]]''
==Background==
*Most common elbow fracture in patients age <8yr
*95% are extension type (FOOSH mechanism)


==Clinical Features==
''Do not encourage active/passive elbow movement until displaced fracture has been ruled-out''
*Pain, swelling, very limited range of motion
*Non-displaced fracture may have limited swelling, but child will refuse to move arm
*TTP of posterior, distal humerus
*If evidence of S-shape configuration or skin dimpling, splint before xray


* Extension-type fractures
==Differential Diagnosis==
* 95% of suprcondylar fractures
{{Proximal arm fracture DDX}}
* Due to FOOSH
{{Elbow DDX}}
* Flexion-type fractures
* 5% of supracondylar fractures
* Due to direct trauma to posterior aspect of flexed elbow 


==Physical Findings==
==Evaluation==
[[File:Elbowalignment.png|thumb|Normal pediatric elbow alignment]]
[[File:Elbow ant fat pad.jpg|thumb|Anterior "Sail sign"]]
*Lateral and AP radiographs are usually sufficient, and in many instances demonstrate an obvious fracture. Often, however, no fracture line can be identified. In such cases assessing for indirect signs is essential:
**'''Anterior fat pad sign''' (sail sign): the anterior fat pad is elevated by a joint effusion and appears as a lucent triangle on the lateral projection
**'''Posterior fat pad sign'''
**'''Anterior humeral line''' should intersect the middle third of the capitellum in most children although, in children under 4, the anterior humeral line may pass through the anterior third without injury


===Imaging===
*[[Elbow X-ray (Peds)|True lateral elbow]]
[[File:Supracondylar09.jpg|thumb|Supracondylar fracture]]
**Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
***If not, consider supracondylar fracture (or lateral condyle fracture)
*Forearm/wrist views
**Co-injuries are common with elbow fracture


* Do not encourage active/passive elbow movement until displaced fx has been ruled-out!
===Gartland Classification===
* Pain, swelling, very limited to no range of motion at the elbow
*Type I
* Nondisplaced fx may have limited swelling, but child will refuse to move arm
**Nondisplaced with evidence of elbow effusion (ant sail sign and/or posterior fat pad)
* Posterior distal humerus TTP usually found in these patients
*Type II
* If evidence of S-shape configuration or skin dimpling, spint before xray
**Displaced with intact posterior periosteum
* Forearm/wrist injuries
**Anterior humeral line is displaced anteriorly relative to capitellum
* Occur frequently enough with supracondylar fx that imaging should be performed
*Type III
**Displaced with disruption of anterior and posterior periosteum
***If distal fragment is posteromedially displaced: radial nerve injury
***If distal fragment is posterolaterally displaced: median nerve, brachial artery injury
*Type IV
**Complete periosteal disruption with instability in flexion and extension


==Gartland Classification==
==Management==
{{General Fracture Management}}


===Specific Management===
*Immobilize using double sugar tong or long-arm posterior splint
**Elbow at 90 degrees, forearm in pronation or neutral rotation
*Types II & III should have orthopedic consult in the ED


Type I: Nondisplaced with evidence of elbow effusion (ant. sail and/or post. fat pad)
==Disposition==
 
*Type I fractures may be discharged with ortho follow-up in 48 hours
Type II: Displaced w/ intact posterior periosteum (ant. humeral line is displaced anteriorly rel. to capitellum)
*Type II and III fractures generally require admission
 
Type III: Displaced w/ disruption of anterior and posterior periosteum
 
* No continuity between the proximal and distal fracture fragments
* Direction of displacement is important in predicting neurovascular injury
 
==Treatment==
 
 
* Type I
* Immobilize using a posterior splint and sling (extend from wrist to axilla)
* Refer to ortho within 1 week
* Type II & III  
* Orthopedic consultation regarding closed versus open reduction w/ percutaneous pinning
* Admit


==Complications==
==Complications==
===Vascular===
*Volkmann Ischemic Contracture ([[Compartment syndrome|Compartment Syndrome]] of forearm)
**Occurs more commonly when forearm is also fractured
**Mere lack of a radial pulse does not indicate ischemia unless accompanied by: refusal to open hand, pain with passive extension of fingers, or forearm tendernes
*Brachial artery injury - suggested by ecchymosis over anteromedial aspect of forearm
**Strong collaterals might mask vascular injury


 
===Neurologic===
- Vascular
*Majority of nerve injuries are neuropraxias without long-term sequelae
 
*Median nerve injury (typically AIN)
* Absenst radial pulse in 10-20% of cases
**Motor: Weakness of hand flexors (difficulty making "OK" sign), abduction of thumb
* Need to rule-out compartment syndrome
**Sensory: Altered two-point sensation on palmar surface of thumb, IF, MF
* Occurs more commonly when forearm is also fractured
*Radial nerve injury
* Ecchymosis over anteromedial aspect of forearm suggests brachial artery injury
**Motor: Weakness of wrist extension, thumb extension (thumbs up)
* Rare with type I fx
**Sensory: Altered sensation in dorsal thumb-index web space
- Neurologic
*Ulnar nerve injury
 
**Motor: Weakness of index finger abduction
* Median nerve injury
**Sensory: Altered two-point discrimination over tip of little finger
* Weakness of hand flexors
* Loss of two-point sensation on palmar surface of thumb, IF, MF
* Anterior interosseous nerve is branch of median nerve most often affected
* Forearm pain + difficulty making "ok" sign
* Radial nerve injury
* Weakness of wrist extension, hand supination, and thumb extension (thumbs up)  
* Altered sensation in dorsal web space between thumb and index finger
* Ulnar nerve injury
* May occur with flexion type fractures
* Weakness of wrist flexion and adduction, finger spread, flexion of pinky DIP
* Altered sensation of ulnar side of ring/pinky 
* Majority of nerve injuries are neurpraxias without long-term sequelae


==See Also==
==See Also==
*[[Elbow diagnoses]]
*[[Elbow Fracture (Peds)]]
*[[Elbow Xray Peds]]


==External Links==
*[http://pemplaybook.org/podcast/pediatric-elbow-injuries/ Pediatric Emergency Playbook Podcast: Pediatric Elbow Injuries]


Ortho: Elbow (Fracture)
==References==
 
<references/>
Ortho: Elbow (Minor)
 
Peds: Elbow Fracture (Peds)
 
Rads: Elbow Xray Peds
 
 
Source: UpToDate
 
 
 


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Orthopedics]]

Revisión actual - 17:36 10 may 2023

This page is for pediatric patients; for adult patients see distal humerus fracture

Background

  • Most common elbow fracture in patients age <8yr
  • 95% are extension type (FOOSH mechanism)

Clinical Features

Do not encourage active/passive elbow movement until displaced fracture has been ruled-out

  • Pain, swelling, very limited range of motion
  • Non-displaced fracture may have limited swelling, but child will refuse to move arm
  • TTP of posterior, distal humerus
  • If evidence of S-shape configuration or skin dimpling, splint before xray

Differential Diagnosis

Humerus Fracture Types

Humeral anatomy

Elbow Diagnoses

Radiograph-Positive

Radiograph-Negative

Pediatric

Evaluation

Normal pediatric elbow alignment
Anterior "Sail sign"
  • Lateral and AP radiographs are usually sufficient, and in many instances demonstrate an obvious fracture. Often, however, no fracture line can be identified. In such cases assessing for indirect signs is essential:
    • Anterior fat pad sign (sail sign): the anterior fat pad is elevated by a joint effusion and appears as a lucent triangle on the lateral projection
    • Posterior fat pad sign
    • Anterior humeral line should intersect the middle third of the capitellum in most children although, in children under 4, the anterior humeral line may pass through the anterior third without injury

Imaging

Supracondylar fracture
    • Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
      • If not, consider supracondylar fracture (or lateral condyle fracture)
  • Forearm/wrist views
    • Co-injuries are common with elbow fracture

Gartland Classification

  • Type I
    • Nondisplaced with evidence of elbow effusion (ant sail sign and/or posterior fat pad)
  • Type II
    • Displaced with intact posterior periosteum
    • Anterior humeral line is displaced anteriorly relative to capitellum
  • Type III
    • Displaced with disruption of anterior and posterior periosteum
      • If distal fragment is posteromedially displaced: radial nerve injury
      • If distal fragment is posterolaterally displaced: median nerve, brachial artery injury
  • Type IV
    • Complete periosteal disruption with instability in flexion and extension

Management

General Fracture Management

Specific Management

  • Immobilize using double sugar tong or long-arm posterior splint
    • Elbow at 90 degrees, forearm in pronation or neutral rotation
  • Types II & III should have orthopedic consult in the ED

Disposition

  • Type I fractures may be discharged with ortho follow-up in 48 hours
  • Type II and III fractures generally require admission

Complications

Vascular

  • Volkmann Ischemic Contracture (Compartment Syndrome of forearm)
    • Occurs more commonly when forearm is also fractured
    • Mere lack of a radial pulse does not indicate ischemia unless accompanied by: refusal to open hand, pain with passive extension of fingers, or forearm tendernes
  • Brachial artery injury - suggested by ecchymosis over anteromedial aspect of forearm
    • Strong collaterals might mask vascular injury

Neurologic

  • Majority of nerve injuries are neuropraxias without long-term sequelae
  • Median nerve injury (typically AIN)
    • Motor: Weakness of hand flexors (difficulty making "OK" sign), abduction of thumb
    • Sensory: Altered two-point sensation on palmar surface of thumb, IF, MF
  • Radial nerve injury
    • Motor: Weakness of wrist extension, thumb extension (thumbs up)
    • Sensory: Altered sensation in dorsal thumb-index web space
  • Ulnar nerve injury
    • Motor: Weakness of index finger abduction
    • Sensory: Altered two-point discrimination over tip of little finger

See Also

External Links

References

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