Supracondylar fracture: Difference between revisions
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==Background== | ==Background== | ||
*Most common elbow | *Most common elbow fracture in patients age <8yr | ||
*95% are extension type (FOOSH mechanism) | *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 | *Pain, swelling, very limited range of motion | ||
*Non-displaced | *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=== | ||
*[[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 | ***If not, consider supracondylar fracture (or lateral condyle fracture) | ||
*Forearm/wrist views | *Forearm/wrist views | ||
**Co-injuries are common | **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 | *Type I fractures may be discharged with ortho follow-up in 48 hours | ||
*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 | ||
*Brachial artery injury - suggested by ecchymosis over anteromedial aspect of forearm | |||
**Strong collaterals might mask vascular injury | |||
*Brachial artery injury | |||
===Neurologic=== | ===Neurologic=== | ||
*Majority of nerve injuries are | *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 | ||
Line 74: | Line 72: | ||
==See Also== | ==See Also== | ||
*[[Elbow | *[[Elbow diagnoses]] | ||
*[[Elbow Fracture (Peds)]] | *[[Elbow Fracture (Peds)]] | ||
*[[Elbow Xray Peds]] | *[[Elbow Xray Peds]] | ||
== | ==External Links== | ||
* | *[http://pemplaybook.org/podcast/pediatric-elbow-injuries/ Pediatric Emergency Playbook Podcast: Pediatric Elbow Injuries] | ||
==References== | |||
<references/> | |||
[[Category: | [[Category:Pediatrics]] | ||
[[Category: | [[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
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
- 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)
- 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