A young boy is bought to your ED with an obviously swollen painful left arm after a slip and fall…
These are his xrays…
Type III Supracondylar Fracture, with posteromedial displacement.
- 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:
- >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.
- 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”.
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…
taken from *http://www.radiologytutorials.com
An abnormal anterior humeral line – taken from *http://www.radiologyassistant.nl/en/p4214416a75d87
The Radiocapitellar Line.
- A line drawn along the radial neck should intersect the capitellum.
- Failure to do so, suggests a radial head dislocation.
- For great examples see RadiologySigns – Three children with elbow pain… or Radial Head Dislocation @ Youtube.com
- An anterior fat pad protrudes from the Coronoid fossa.
- It is normal unless bulging or shaped ‘like a sail’.
- A posterior fat pad is always pathological.
Adapted from wikimedia.org
- 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.
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.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- The Royal Children’s Hospital Melbourne; Clinical Practice Guideline on Supracondylar Fractures.