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)


===Gartland Classification===
==Clinical Features==
*Type I
''Do not encourage active/passive elbow movement until displaced fracture has been ruled-out''
**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
 
==Diagnosis==
===Clinical Features===
*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
*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  
==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===
[[File:Elbowalignment.png|center|frame|thumb|Normal pediatric elbow alignment]]
[[File:Elbow ant fat pad.jpg|center|frame|thumb|"Sail sign"]]
*[[Elbow X-ray (Peds)|True lateral elbow]]
*[[Elbow X-ray (Peds)|True lateral elbow]]
**Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
**Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
***If not, consider supracondylar fx or lateral condyle fx
***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 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
*Forearm/wrist views
**Co-injuries are common w/ elbow fx
**Co-injuries are common with elbow fracture


==Differential Diagnosis==
===Gartland Classification===
{{Proximal arm fracture DDX}}
*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


{{Elbow DDX}}
==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


==Treatment==
==Disposition==
*Type I
*Type I fractures may be discharged with ortho follow-up in 48 hours
**Immobilize using double sugar tong or long-arm posterior splint x3wk
*Type II and III fractures generally require admission
***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==
==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 diagnoses]]


==Source==
==External Links==
*UpToDate
*[http://pemplaybook.org/podcast/pediatric-elbow-injuries/ Pediatric Emergency Playbook Podcast: Pediatric Elbow Injuries]
*Image by Robert Heng
 
*Illustration provided by Dr Yuranga Weerakkody & Dr Abhijit Datir et al; CC SA NC BY licence
==References==
**Available at http://radiopaedia.org/articles/supracondylar-fracture
<references/>


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

Revision as of 18:21, 29 May 2019

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

  • 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