Supracondylar fracture

Background

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

Clinical Features

• Do not encourage active/passive elbow movement until displaced fx has been ruled-out
• Pain, swelling, very limited range of motion
• Non-displaced fx 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

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 sign and/or posterior fat pad)
• Type II
  • Displaced w/ intact posterior periosteum
  • Anterior humeral line is displaced anteriorly relative 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: median nerve, brachial artery injury

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
• Types II & III
  • Orthopedic consult in the ED
  • Admit

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 w/ passive extension of fingers
    • Forearm tendernes
• Brachial artery injury
  • Suggested by ecchymosis over anteromedial aspect of forearm

Neurologic

• Majority of nerve injuries are neurpraxias without long-term sequelae
• Median nerve injury
  • 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

• Elbow (Fracture)
• Elbow Fracture (Peds)
• Elbow Xray Peds
• Elbow (Minor)

Source

• UpToDate