Supracondylar Fracture

Posterior Fat Pad

It is August… a few weeks left before school starts… and football season is almost upon us! I love football season, but it is such a double-edged sword – inevitably all of the Peds EDs will be inundated with skeletally immature gladiators having injured themselves. So prepare yourself for the onslaught of supracondylar fractures!

Supracondylar Fractures

  • The supracondylar area is composed of thin, weak bone.
  • Supracondylar fx’s account for >50% of all pediatric fx’s.
  • Peak incidence is 5-7 years.

 

  • Two main types based on mechanism
    • Extension-type (FOOSH)
      • Most common (~95%)
      • Leads to posterior displacement of the fracture
    • Flexion-type
      • From a direct blow to the posterior aspect of the elbow while it is flexed
      • Leads to anterior displacement of the fracture

 

  • Three main classifications
    • Type I – non-displaced, limited radiographic evidence of fx
    • Type II – angulated and displaced, but still partially attached
    • Type III – complete displacement without any connection

Evaluation

  • Evaluation (and Documentation!!) of the Vascular and Neurologic status of the affected arm is imperative!
  • Supracondylar Fx have a great potential for nerve and/or vascular compromise.
  • Vascular
    • Brachial artery may be injured with posteriorly displaced fxs.
    • Documenting radial and ulnar pulses is good… BUT
      • Absence of brisk cap refill is the best indicator of long-term vascular injury.
      • The patient with diminished pulses who has brisk cap refill will likely do well after reduction that is done in an urgent fashion.
      • The patient with diminished pulses and who has poor distal perfusion needs emergent intervention!
      • Using pulse oximetry can also help document peripheral perfusion in the affected arm, if it there is a good waveform and oxygen saturation.
  • Motor Nerve
    • Often getting the child with a deformed arm to cooperate for examination is difficult… give them Pain Meds!!
    • Quick and Dirty nerve exam of the arm
      • Thumb’s up = Radial Nerve
      • Spread fingers out (“like Michael Jordan palming a basketball”) = Ulnar Nerve
      • Abduction of the Thumb (“OK sign”) = Median Nerve
  • Sensory Nerve
    • Dorsal aspect of 1st web space = Radial Nerve
    • Palmer aspect of pinky = Ulnar Nerve
    • Palmar aspect of pointer finger = Median Nerve

 

Consider Complications

  • Always consider Compartment Syndrome
  • Supracondylar Fx are at high risk for it
  • Assess, reassess, and reassess again
  • Look for Pain, Pallor, Pulselessness, Paralysis, and Paresthias
  • Pain with passive range of motion of distal fingers is very concerning!!

 

Subtle radiographic findings

  • The Type II and Type III fractures are often no-brainers… bone looks broke!
  • Type I can be very subtle… so look for:
  • Displaced Anterior Fat Pad (Sail Sign)
  • Any Posterior Fat Pad
  • Anterior Humeral Line not intersecting the middle third of the capitellum.
  • Radiocapitellar line not interesting the middle third of the capitellum.

Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin N Am. 2008; 39:163-171.

Sarraff LM, Haines CJ. Common orthopedic injuries in the pediatric ED. Pediatric Emergency Medicine Reports. 2010; 15 (7): 77-92.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

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