Supracondylar 2

Scenario

7 Year old male who fell onto his left outstretched arm from monkey bars. His parents have brought him in with a swollen left elbow.

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This is a lateral and anterior posterior plane film radiograph of a skeletally immature patient. There are no patient identifiers present. In addition, it is not dated. The most obvious abnormality is there is an anterior and posterior fat pad on the lateral film in addition to a supracondylar fracture. There is a minimally displaced supracondylar fracture. It would be classified as a Gartland’s 1 fracture.

Anterior Humeral Line is a line drawn along the anterior border of the humerus on a lateral plane film radiograph. It should intersect the middle third of the capitellum.

Baumann’s Angle is the Humeral-Capitellar Angle it is measured on a frontal radiograph with the elbow in extension. A difference of >5degrees between the two sides is considered abnormal. Normal angle is 64-81 degrees.

I would approach this patient according to ATLS principles and BOAST guidelines. I would stabilise the patients C-Spine, assess and treat the patients airway, breathing, circulation and disability. Following this I would look for signs of other injury.

Regarding the limb in question I would assess and document the capillary refill time, radial and ulnar pulses and median (including AIN), radial and ulnar nerve function.

I would take a full hx including hand dominance and mechanism of injury.

Furthermore, I would take orthogonal view plane film radiographs.

I would apply a back slab with the arm in less than 90 degrees of elbow flexion.

I would re-check and document neurovascular status post application of back slab.

I would perform a check X-Ray

The back slab would typically be left for 3 weeks. X-Rays would be repeated at 1 week to assess for displacement.

 

Gartland 1

Non displaced

Gartland 2

Intact posterior cortex, hinged in extension.

Gartland 3

Complete displacement

Gartland 4

Complete displacement with no contact between fragments. Unstable in all planes.

 

Ossification Centre

Years

Capitellum

1

Radial head

4

Medial epicondyle

6

Trochlea

8

Olecranon

10

Lateral epicondyle

12

AIN

Median

Radial

Ulnar least common – would most likely be iatrogenic injury

Sensation 1st web space dorsal surface

Sensation volar surface of index finger

Sensation ulnar border of hand

 

Motor

Median – Form a fist/rock

Ulnar – make scissor action with fingers

Radial – Paper

PIN – Thumbs up

 

Temperature of the hand warm/cold

Cap refill time in seconds

Feel radial pulse

Document hand colour

According to BOAST guidelines surgical management should be provided urgently. Note there is controversy regarding management if the patient has an absent radial pulse and a pink hand, some bosses would argue this could be left. However, you should do/say the safest thing which is to take the patient to theatre.

Proximal fragment has buttonholed through the brachioradialis. To achieve reduction you must apply traction and milk the brachioradialis muscle.

Traction – extend the elbow (20 degrees)

Correction of translation coronal plane

Check if pronation/supination improves position further (most commonly pronation)

Flexion of the elbow

Insertion of the lateral wire

Placement of medial wire under direct vision in elbow extension

Screen to ensure stable construct

Cut and bend wire and re-xray

Above elbow backslab

Complete cast in 1 week

Removal of pins at 4 weeks

Pinning technique

Spread of wires

Bicolumnar fixation

Fracture obliquity in the sagittal plane

Ulnar nerve subluxation in flexion

Fracture displacement

I would assess the patient urgently. As part of the assessment I would split the backslab and extend the patients arm.

A decision to explore the patient’s nerve is a consultant decision.