slip and fall…

The Case.

A young boy is bought to your ED with an obviously swollen painful left arm after a slip and fall…

These are his xrays…

Swollen&Painful (lat)             Swollen&Painful (AP)

Type III Supracondylar Fracture, with posteromedial displacement.

Supracondylar Fracture

  • The most common paediatric elbow fracture.
  • Typically occurs in kids < 8 years of age.
    • This is a result of the ligament/joint capsule tensile strength being greater than that of the bone itself.
  • Extension vs Flexion:
    • Extension:
      • >95% of all supracondylar fractures are extension related.
      • Olecranon forcefully driven into olecranon fossa.
      • Results in failure of anterior cortex & displacement of distal fragment posteriorly.
      • Can be further defined by the Gartland Classification.
    • Flexion:
      • Energy transferred from posterior aspect of proximal ulna to distal humerus.
      • Anterior displacement of the distal fragment and failure of cortex posteriorly.

The Gartland Classification.

  • Type 1: Non-displaced.
  • Type 2: Displaced fracture with intact posterior cortex.
  • Type 3: Displaced fracture with no cortical contact.
    • A: Posteromedial rotation of the distal fragment.
    • B: Posterolateral rotation of the distal fragment.

Firstly, we should recall the ossification centres of the elbow & the helpful mneumonic “CRITOE”.

Critoe Table

CRITOE

taken from *http://www.wikem.org/wiki/Elbow_X-ray_(Peds)

The Anterior Humeral Line.

  • On a normal lateral elbow x-ray, a line drawn along the anterior surface of the humerus should pass through the middle third of the capitellum.
  • If the capitellum falls posteriorly to this line, an extension-type supracondylar fracture is likely…

anterior humeral line

taken from *http://www.radiologytutorials.com

Abnormal Anterior Humeral Line

An abnormal anterior humeral line – taken from *http://www.radiologyassistant.nl/en/p4214416a75d87

The Radiocapitellar Line.

Fat Pads.

  • An anterior fat pad protrudes from the Coronoid fossa.
    • It is normal unless bulging or shaped ‘like a sail’.
  • posterior fat pad is always pathological.
Ant&Post Fat Pads
Adapted from wikimedia.org

Baumann’s Angle.

  • An additional aid for diagnosing subtle supracondylar fractures.
  • Angle is formed by a line drawn along the growth plate of the capitellum that transects a line running along the axis of the humerus.
  • It should be ~ 75 degrees.

Baumanns Angle

Left is normal. Right is obviously not...

Neurovascular compromise occurs in up to 49% of all Type III injuries.

    • Median nerve:
      • Involved in 50% of cases.
      • Associated with posterolateral displacement.
    • Radial nerve:
      • Involved in 1/3 of cases.
      • Associated with posteromedial displacement.
    • Brachial artery:
      • Includes entrapment, laceration, intimal tear or compression (compartment syndrome).
      • Approximately 40% of cases.
      • Found in either medial or lateral displacement.

Be on the lookout for Compartment Syndrome.

    • Pain on flexion or extension of fingers
    • Forearm tenderness on palpation.
    • Disproportionate pain to injury.
    • Important as unrecognised ischaemic injury can result in Volkmann’s Ischaemic Contracture.

  • Obviously, a limb with neurovascular compromise mandates immediate reduction.
    • Delay to the operating theatres may require a reduction attempt in the ED. Rosen’s demonstrates this manoeuvre quite well.
  • Type I injuries;
    • Splint in ED (aim for 90 degrees of elbow flexion, with neutral rotation).
    • Outpatient referral to Orthopaedics is appropriate.
  • Type II injuries;
    • No current consensus with regards to surgical management.
    • Closed reduction & plaster vs ORIF.
    • Referral to Orthopaedics at let them decide.
  • Type III injuries.
    • Urgent Orthopaedic consultation –> OT for closed reduction, pinning or ORIF.
    • Splinting for comfort.
    • Thorough and repeated neurovascular examination.

  1. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  3. The Royal Children’s Hospital Melbourne; Clinical Practice Guideline on Supracondylar Fractures.

About Chris Partyka

Emergency Doc; interested in ultrasound, retrieval & medical education - #FOAMed

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