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.