Supracondylar fracture: Difference between revisions
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**Complete periosteal disruption with instability in flexion and extension | **Complete periosteal disruption with instability in flexion and extension | ||
==Management | ==Management== | ||
*Immobilize using double sugar tong or long-arm posterior splint | |||
**Elbow at 90degrees, forearm in pronation or neutral rotation | |||
*Types II & III should have orthopedic consult in the ED | |||
*Types II & III | ==Disposition== | ||
*Type I fractures may be discharged with ortho follow-up in 48 hours | |||
** | *Type II and III fractures generally require admission | ||
==Complications== | ==Complications== | ||
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*Volkmann Ischemic Contracture ([[Compartment syndrome|Compartment Syndrome]] of forearm) | *Volkmann Ischemic Contracture ([[Compartment syndrome|Compartment Syndrome]] of forearm) | ||
**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: | **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 | |||
*Brachial artery injury | |||
**Strong collaterals might mask vascular injury | **Strong collaterals might mask vascular injury | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:Orthopedics]] | [[Category:Orthopedics]] | ||
Revision as of 06:20, 17 June 2018
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
Elbow Diagnoses
Radiograph-Positive
- Distal humerus fracture
- Radial head fracture
- Capitellum fracture
- Olecranon fracture
- Elbow dislocation
Radiograph-Negative
- Biceps tendon rupture/dislocation
- Lateral epicondylitis
- Medial epicondylitis
- Olecranon bursitis (nonseptic)
- Pronator teres syndrome
- Septic bursitis
Pediatric
- Nursemaid's elbow
- Supracondylar fracture
- Lateral epicondyle fracture
- Medial epicondyle fracture
- Olecranon fracture
- Radial head fracture
- Salter-Harris fractures
Evaluation
Imaging
- True lateral elbow
- Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
- If not, consider supracondylar fracture (or lateral condyle fracture)
- Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
- 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
- Displaced with disruption of anterior and posterior periosteum
- Type IV
- Complete periosteal disruption with instability in flexion and extension
Management
- Immobilize using double sugar tong or long-arm posterior splint
- Elbow at 90degrees, 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