Supracondylar fracture
Background
- Most common elbow fx in pts 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 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
- Displaced w/ disruption of anterior and posterior periosteum
Diagnosis
Clinical Features
- Do not encourage active/passive elbow movement until displaced fx has been ruled-out
- Pain, swelling, very limited range of motion
- Non-displaced fx 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 fx or lateral condyle fx
- 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
- Anterior humeral line should intersect with middle third of capitellum (see pediatric elbow alignment)
- Forearm/wrist views
- Co-injuries are common w/ elbow fx
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
Treatment
- 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 w/ passive extension of fingers
- Forearm tendernes
- Brachial artery injury
- Suggested by ecchymosis over anteromedial aspect of forearm
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
Source
- UpToDate
- Image by Robert Heng
- Illustration provided by Dr Yuranga Weerakkody & Dr Abhijit Datir et al; CC SA NC BY licence