Supracondylar fracture: Difference between revisions

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==Mechanism of Injury==
''This page is for <u>pediatric</u> patients; for adult patients see [[distal humerus fracture]]''
* Extension-type fractures
==Background==
** 95% of suprcondylar fractures
*Most common elbow fracture in patients age <8yr
** Due to FOOSH
*95% are extension type (FOOSH mechanism)
* Flexion-type fractures
 
** 5% of supracondylar fractures
==Clinical Features==
** Due to direct trauma to posterior aspect of flexed elbow 
''Do not encourage active/passive elbow movement until displaced fracture has been ruled-out''
==Diagnosis==
===Physical Findings===
*Do not encourage active/passive elbow movement until displaced fx has been ruled-out
*Pain, swelling, very limited range of motion
*Pain, swelling, very limited range of motion
*Nondisplaced fx may have limited swelling, but child will refuse to move arm
*Non-displaced fracture may have limited swelling, but child will refuse to move arm
*Posterior distal humerus TTP usually found in these patients
*TTP of posterior, distal humerus
*If evidence of S-shape configuration or skin dimpling, splint before xray  
*If evidence of S-shape configuration or skin dimpling, splint before xray  
==Differential Diagnosis==
{{Proximal arm fracture DDX}}
{{Elbow DDX}}
==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===
===Imaging===
*True lateral elbow
*[[Elbow X-ray (Peds)|True lateral elbow]]
**Anterior humeral line should intersect with middle third of capitellum
[[File:Supracondylar09.jpg|thumb|Supracondylar fracture]]
***If not, consider supracondylar fx or lateral condyle fx
**Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
**Line drawn along axis of radial head and neck should pass through middle of capitellum
***If not, consider supracondylar fracture (or lateral condyle fracture)
***If not, consider fx of lateral condyle, radial neck, Monteggia, or elbow dislocation 
*Forearm/wrist views
**Fat Pads
**Co-injuries are common with elbow fracture
***Anterior may be normal or if large may be abnormal ("sail sign")
 
***Posterior is always abnormal
===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


*Forearm/wrist views
==Management==
**Co-injuries are common w/ elbow fx
{{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


==Gartland Classification==
==Disposition==
*Type I: Nondisplaced with evidence of elbow effusion (ant. sail and/or post. fat pad)
*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===
===Vascular===
*Absenst radial pulse in 10-20% of cases
*Volkmann Ischemic Contracture ([[Compartment syndrome|Compartment Syndrome]] of forearm)
*Need to rule-out compartment syndrome
**Occurs more commonly when forearm is also fractured  
*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
*Ecchymosis over anteromedial aspect of forearm suggests brachial artery injury
*Brachial artery injury - suggested by ecchymosis over anteromedial aspect of forearm
*Rare with type I fx
**Strong collaterals might mask vascular injury


===Neurologic===
===Neurologic===
*Median nerve injury
*Majority of nerve injuries are neuropraxias without long-term sequelae
**Weakness of hand flexors
*Median nerve injury (typically AIN)
**Loss of two-point sensation on palmar surface of thumb, IF, MF
**Motor: Weakness of hand flexors (difficulty making "OK" sign), abduction of thumb
**Anterior interosseous nerve is branch of median nerve most often affected
**Sensory: Altered two-point sensation on palmar surface of thumb, IF, MF
**Forearm pain + difficulty making "ok" sign
*Radial nerve injury
*Radial nerve injury
**Weakness of wrist extension, hand supination, and thumb extension (thumbs up)  
**Motor: Weakness of wrist extension, thumb extension (thumbs up)
**Altered sensation in dorsal web space between thumb and index finger
**Sensory: Altered sensation in dorsal thumb-index web space
*Ulnar nerve injury
*Ulnar nerve injury
**May occur with flexion type fractures
**Motor: Weakness of index finger abduction
**Weakness of wrist flexion and adduction, finger spread, flexion of pinky DIP
**Sensory: Altered two-point discrimination over tip of little finger
**Altered sensation of ulnar side of ring/pinky 
**Majority of nerve injuries are neurpraxias without long-term sequelae


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


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


[[Elbow Xray Peds]]
==References==
<references/>
==Source==
UpToDate


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

Latest revision as of 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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