Supracondylar fracture: Difference between revisions
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**Nondisplaced with evidence of elbow effusion (ant sail sign and/or posterior fat pad) | **Nondisplaced with evidence of elbow effusion (ant sail sign and/or posterior fat pad) | ||
*Type II | *Type II | ||
**Displaced | **Displaced with intact posterior periosteum | ||
**Anterior humeral line is displaced anteriorly relative to capitellum | **Anterior humeral line is displaced anteriorly relative to capitellum | ||
*Type III | *Type III | ||
**Displaced | **Displaced with disruption of anterior and posterior periosteum | ||
***If distal fragment is posteromedially displaced: radial nerve injury | ***If distal fragment is posteromedially displaced: radial nerve injury | ||
***If distal fragment is posterolaterally displaced: median nerve, brachial artery injury | ***If distal fragment is posterolaterally displaced: median nerve, brachial artery injury | ||
| Line 34: | Line 34: | ||
***Posterior is always abnormal | ***Posterior is always abnormal | ||
*Forearm/wrist views | *Forearm/wrist views | ||
**Co-injuries are common | **Co-injuries are common with elbow fracture | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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**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 | ***Refusal to open hand | ||
***Pain | ***Pain with passive extension of fingers | ||
***Forearm tendernes | ***Forearm tendernes | ||
*Brachial artery injury | *Brachial artery injury | ||
Revision as of 23:54, 12 July 2016
Background
- Most common elbow fracture in patients age <8yr
- 95% are extension type (FOOSH mechanism)
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
Diagnosis
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
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
- Line drawn along axis of radial head and neck should pass through middle of capitellum
- If not, consider fracture 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
- Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
- Forearm/wrist views
- Co-injuries are common with elbow fracture
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
Management
- 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
- Immobilize using double sugar tong or long-arm posterior splint x3wk
- 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 with passive extension of fingers
- 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 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
References
- Orthobullets