Supracondylar fracture: Difference between revisions

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==Background==
==Background==
*Most common elbow fx in pts age <8yr
*Most common elbow fracture in patients age <8yr
*95% are extension type (FOOSH mechanism)
*95% are extension type (FOOSH mechanism)
 
==Clinical Features==
==Clinical Features==
*Do not encourage active/passive elbow movement until displaced fx has been ruled-out
''Do not encourage active/passive elbow movement until displaced fracture has been ruled-out''
*Pain, swelling, very limited range of motion
*Pain, swelling, very limited range of motion
*Non-displaced 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
*TTP of posterior, distal humerus
*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  


==Imaging==
==Differential Diagnosis==
*True lateral elbow
{{Proximal arm fracture DDX}}
**Anterior humeral line should intersect with middle third of capitellum (Image 1)
{{Elbow DDX}}
***If not, consider supracondylar fx or lateral condyle fx
 
**Line drawn along axis of radial head and neck should pass through middle of capitellum
==Evaluation==
***If not, consider fx of lateral condyle, radial neck, Monteggia, or elbow dislocation 
[[File:Elbowalignment.png|thumb|Normal pediatric elbow alignment]]
**Fat Pads
[[File:Elbow ant fat pad.jpg|thumb|Anterior "Sail sign"]]
***Anterior may be normal or if large may be abnormal ("sail sign")
 
***Posterior is always abnormal
===Imaging===
*[[Elbow X-ray (Peds)|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)
*Forearm/wrist views
*Forearm/wrist views
**Co-injuries are common w/ elbow fx
**Co-injuries are common with elbow fracture
[[File:Elbowalignment.png|center|frame|50px|Image 1]]
[[File:Elbow ant fat pad.jpg|center|frame|500px|"Sail sign"]]


==Gartland Classification==
===Gartland Classification===
*Type I
*Type I
**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 w/ intact posterior periosteum
**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 w/ disruption of anterior and posterior periosteum
**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
*Type IV
**Complete periosteal disruption with instability in flexion and extension


==Treatment==
==Management==
*Type I
*Immobilize using double sugar tong or long-arm posterior splint
**Immobilize using double sugar tong or long-arm posterior splint x3wk
**Elbow at 90degrees, forearm in pronation or neutral rotation
***Elbow at 90degrees, forearm in pronation or neutral rotation
*Types II & III should have orthopedic consult in the ED
**Refer to ortho w/in 48hr
 
*Types II & III  
==Disposition==
**Orthopedic consult in the ED
*Type I fractures may be discharged with ortho follow-up in 48 hours
**Admit
*Type II and III fractures generally require admission


==Complications==
==Complications==
===Vascular===
===Vascular===
*Volkmann Ischemic Contracture (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
***Refusal to open hand
*Brachial artery injury - suggested by ecchymosis over anteromedial aspect of forearm
***Pain w/ passive extension of fingers
**Strong collaterals might mask vascular injury
***Forearm tendernes
*Brachial artery injury
**Suggested by ecchymosis over anteromedial aspect of forearm


===Neurologic===
===Neurologic===
*Majority of nerve injuries are neurpraxias without long-term sequelae
*Majority of nerve injuries are neuropraxias without long-term sequelae
*Median nerve injury
*Median nerve injury (typically AIN)
**Motor: Weakness of hand flexors (difficulty making "OK" sign), abduction of thumb
**Motor: Weakness of hand flexors (difficulty making "OK" sign), abduction of thumb
**Sensory: Altered two-point sensation on palmar surface of thumb, IF, MF
**Sensory: Altered two-point sensation on palmar surface of thumb, IF, MF
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==See Also==
==See Also==
*[[Elbow (Fracture)]]
*[[Elbow diagnoses]]
*[[Elbow Fracture (Peds)]]
*[[Elbow Fracture (Peds)]]
*[[Elbow Xray Peds]]
*[[Elbow Xray Peds]]
*[[Elbow (Minor)]]
==Source==
*UpToDate
*Image by Robert Heng
*Drawing provided by Dr Yuranga Weerakkody & Dr Abhijit Datir et al; CC SA NC BY licence
**Available at http://radiopaedia.org/articles/supracondylar-fracture


[[Category:Peds]]
==External Links==
[[Category:Ortho]]
*[http://pemplaybook.org/podcast/pediatric-elbow-injuries/ Pediatric Emergency Playbook Podcast: Pediatric Elbow Injuries]
 
==References==
<references/>
 
[[Category:Pediatrics]]
[[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

Humeral anatomy

Elbow Diagnoses

Radiograph-Positive

Radiograph-Negative

Pediatric

Evaluation

Normal pediatric elbow alignment
Anterior "Sail sign"

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)
  • 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

  • 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

See Also

External Links

References