Supracondylar fracture

Background

• Most common fx in age <8yr
• 95% due to FOOSH

Diagnosis

Physical Findings

• Do not encourage active/passive elbow movement until displaced fx has been ruled-out
• Pain, swelling, very limited range of motion
• Nondisplaced fx may have limited swelling, but child will refuse to move arm
• Posterior distal humerus TTP usually found in these patients
• If evidence of S-shape configuration or skin dimpling, splint before xray

Imaging

• True lateral elbow
  • Anterior humeral line should intersect with middle third of capitellum
    • If not, consider supracondylar fx or lateral condyle fx
  • Line drawn along axis of radial head and neck should pass through middle of capitellum
    • If not, consider fx of lateral condyle, radial neck, Monteggia, or elbow dislocation
  • Fat Pads
    • Anterior may be normal or if large may be abnormal ("sail sign")
    • Posterior is always abnormal
• Forearm/wrist views
  • Co-injuries are common w/ elbow fx

Gartland Classification

• Type I: Nondisplaced with evidence of elbow effusion (ant. sail and/or post. fat pad)
• Type II: Displaced w/ intact posterior periosteum (ant. humeral line is displaced anteriorly rel. to capitellum)
• Type III: Displaced w/ disruption of anterior and posterior periosteum
  • If distal fragment is posteromedially displaced: radial nerve injury
  • If distal fragment is posterolaterally displaced: brachial artery, median nerve injury
    • Compartment syndrome may develop

Treatment

• Type I
  • Immobilize using double sugar tong or long-arm posterior splint x3wk
    • Elbow at 90degrees
    • Forearm in pronation or neutral rotation
  • Refer to ortho w/in 48hr
• Type II & III
  • Orthopedic consult in the ED
  • Admit

Complications

Vascular

• Absenst radial pulse in 10-20% of cases
• Need to rule-out compartment syndrome
• Occurs more commonly when forearm is also fractured
• Ecchymosis over anteromedial aspect of forearm suggests brachial artery injury
• Rare with type I fx

Neurologic

• Median nerve injury
  • 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

Elbow (Fracture)

Elbow (Minor)

Elbow Fracture (Peds)

Elbow Xray Peds

Source

UpToDate