- A 2-year-old boy fell from a 1 meter high chair and injured his right elbow. He was brought to the emergency room with pain and deformity of the right elbow. - X-rays showed a Gartland type 3 right supracondylar fracture. The patient underwent closed reduction and percutaneous pinning of the fracture in the operating room. - Supracondylar fractures are common in children aged 5-7 and usually result from a fall onto an outstretched hand. Treatment depends on the fracture type and stability, ranging from splinting to closed or open reduction and pinning. Complications can include nerve palsies, malunion, and compartment syndrome.

1. NOON CONFERENCE
Extern Thanawarath Songchitsomboon 5402059
Ramathibodi hospital

2. Case
•Patient profile : ผู้ป่วยเด็กชาย อายุ 2 ขวบ
•Chief complain : เจ็บบริเวณข้อศอกขวา 1 ชม ก่อน
มาโรงพยาบาล

3. HISTORY
&
PHYSICAL EXAMINATION

4. •Present illness :
1 ชม ก่อนมาโรงพยาบาล ขณะเล่นอยู่บนเก้าอี้ ตกจากเก้าอี้สูงประมาณ 1เมตร
เอาแขนขวาลงกระแทกพื้น ไม่มีศีรษะกระแทกพื้น ร้องตลอดเวลา ปวดบริเวณเหนือ
ข้อศอกขวา ไม่ยอมขยับแขนขวา มีแขนขวาผิดรูป แขนซ้ายขยับได้ปกติดี
•No underlying disease
•No drug allergy

5. Primary survey
•A : can talk, can move neck, not tender along c‐spine
•B : CCT neg, equal breath sound both lungs
•C : BP 112/74, PR 115
•D : E4V5M6, pupils 3 mm RTLBE
•E : Right arm deformity, limit ROM of Right elbow and
shoulder due to pain, can flex and extend wrists and
fingers, radial pulse 2+ both, skin pinprick sensation
normal

6. Secondary survey
•A : no allergy
•M : no medication
•P : no U/D
•L : last meal 19.00 น. (1 hr PTA)
•E : ตกจากเก้าอี้สูง 1 เมตร

7. Physical examination
• V/S : T 36.5 c, BP 112/74 mmHg, PR 115 bpm
• GA : Thai boy, good consciousness
• Head & maxillofacial : no external wound, no stepping, not
tender
• C‐spine & neck : not tender along c‐spine, can move neck
• Respiratory : equal breath sound both lungs
• CVS : normal s1 s2, no murmur, pulse full regular all extremities
• Abdomen : soft, not tender, no guarding

8. •Extremities: Right arm tender, deformity and swelling,
limit ROM of Right elbow and shoulder due to pain, can
flex and extend wrists and fingers, radial pulse 2+ both,
skin pinprick sensation normal

9. Investigation
•Film right elbow AP, LAT

12. •Diagnosis :
Right supracondylar fracture (Gartland type 3)
•Treatment :
•At ER : on posterior long arm splint
•At OR : close reduction + percutaneous pinning

14. SUPRACONDYLAR
FRACTURE

15. •Epidemiology
•incidence
• extension type most common
(95‐98%)
• flexion type less common (<5%)
•demographics
• occur most commonly in
children aged 5 to 7
• M = F
• Mechanism of injury
• fall on outstretched hand

16. •Associated injuries
• neuropraxia
• anterior interosseous nerve (branch of median n.)
• the most common nerve palsy
• radial nerve
• second most common
• ulnar nerve palsy
• seen with flexion‐type injury patterns
• resolve spontaneously
• vascular injury (1%)
• ipsilateral distal radius
fractures

17. Presentation
• Symptoms
• refusal to move the elbow
• pain
• Physical exam
• inspection
• gross deformity
• Bruising, swelling
• S‐shape deformity
• Pucker sign
• motion
• limited active elbow motion (pseudoparalysis)

18. •neurovascular
•nerve exam
• AIN neurapraxia
• unable to flex the interphalangeal joint of his thumb and the distal
interphalangeal joint of his index finger (can't make A‐OK sign)
• radial nerve neurapraxia
• inability to extend wrist or digits may be present due to radial nerve injury
neurapraxia
•vascular exam
• vascular insufficiency at presentation is present in 5 ‐17%
• defined as cold, pale, and pulseless hand
• a warm, pink, pulseless hand does not qualify as vascular insufficiency
• treat with immediate reduction and pinning in OR. Attempted closed
reduction in ER first (see treatment below)

19. Imaging
•Film x‐ray elbow AP and Lateral
•posterior fat pad sign
•displacement of the anterior humeral line
•alteration of Baumann angle

20. Posterior fat pad sign
•lucency along the posterior
distal humerus and
olecranon fossa is highly
suggestive of occult
fracture around the elbow

21. Displacement of the anterior humeral line
• anterior humeral line should intersect the middle third of
the capitellum
• capitellum moves posteriorly to this reference line in
extension type fracture

22. Alteration of Baumann angle
• Baumann's angle is created by drawing a line parallel to
the longitudinal axis of the humeral shaft and a line along
the lateral condylar physis as viewed on the AP image
• normal is 70‐75°, but best judge is a comparison of the
contralateral side
• deviation of >5° indicates coronal plane deformity and
should not be accepted

24. Gartland 1

25. Gartland 2

26. Gartland 3

27. Treatment
• Nonoperative
• long arm posterior splint then long arm casting with less than 90°
of elbow flexion technique typically used for 3‐4 weeks and maybe
followed for additional time in removable long arm posterior splint
• Indications :
• Type I (non‐displaced) fractures
• Type II fractures that meet the following criteria
• anterior humeral line intersects the anterior half of capitellum
• minimal swelling present
• no medial comminution

28. • Operative
• splint in 30‐40° elbow flexion, admit overnight for observation, operate
when surgical team available (surgical "urgency" rather than
"emergency")
• closed reduction and percutanous pinning (CRPP)
• indications : Type II and III supracondylar fractures, flexion type
• open reduction with percutaneous pinning
• indications
• unacceptable closed reduction
• more frequently required with flexion type fractures (than extension type)
• when vascular exploration needed
• open fracture

29. • immediate closed reduction and percutanous pinning
• indications ("red flag" warning signs)
• dysvascular hand (e.g, diminished radial pulse or pale, cool hand)
• severe elbow swelling
• "brachialis sign"
• ecchymosis, dimpling/puckering, palpable subcutaneous bone fragment
• indicates proximal fragment buttonholed through brachialis
• implies more serious injury, higher likelihood of arterial injury, significant swelling, more
difficult closed redution
• neurological defect
• "floating elbow"
• ipsilateral supracondylar humerus and forearm /wrist fractures necessitate immediate
pinning of both fractures to decrease risk of compartment syndrome

30. Complications
• Pin migration
• most common complication (~2%)
• Infection
• occurs in 1‐2.4%
• typically superficial and treated with oral
antibiotics
• Cubitus valgus
• caused by fracture malunion
• can lead to tardy ulnar nerve palsy
• Cubitus varus (gunstock deformity)
• caused by fracture malunion

31. Complications
• Nerve palsy from injury ( most common is AIN injury)
• Volkmann ischemic contracture
• rare, but dreaded complication
• result of brachial artery compression with treatment utilizing elbow hyperflexion casting
than true arterial injury
• increase in deep volar forearm compartment pressures and loss of radial pulse with elbow
flexed >90°
• rarely seen with CRPP and postoperative immobilization in less than 90°
• Postoperative stiffness
• rare after casting or after pinning procedures
• remove pins and allow gentle ROM at 3 weeks postop
• resolves by 6 months
• literature does not support the use of physical therapy

32. Reference
• http://www.orthobullets.com/pediatrics/4007/supracondylar‐fracture‐‐pediatric