DiagnosticsOrthopedic pitfalls in the ED: Pediatric supracondylar humerus fractures*,**,★
Section snippets
Case 1
An 8-year-old girl fell while riding a roller scooter, landing on her extended left arm. She presented to the emergency department complaining of left arm pain. On examination, she was crying and appeared anxious and upset. Physical examination of the left arm revealed a markedly swollen and ecchymotic elbow with exquisite tenderness over the distal humerus. Except for some minor abrasions to her palm, the rest of the examination was normal. The vascular examination showed a pink, warm hand,
Epidemiology
The majority of supracondylar fractures occur in children from 3 to 10 years of age with the peak incidence occurring between ages 5 and 7.3, 4 Supracondylar fractures are the most common type of elbow fractures in children, accounting for approximately 60% of cases.5, 6 This frequency is a sharp contrast to the relatively uncommon incidence of supracondylar fracture in the adult patient population. Over 90% of pediatric cases are the result of a fall onto an extended arm.7 The complications
Pathophysiology and biomechanics
The bones of children tend to be more porous and pliable than adult bone, whereas their ligaments and tendons have significant tensile strength. As a result, when subjected to deformation stress, the weaker bone tends to yield to the stronger ligament complex around a joint.1, 2, 5 Consequently, a joint sprain in a child is far less common than a fracture. The pediatric elbow is no exception. With the FOOSH mechanism, the extended elbow is placed under extreme compression. Furthermore, in the
Clinical presentation and diagnosis
The typical history for a supracondylar fracture is a fall in which the hand is outstretched in an attempt to break the fall. The child will likely present to the emergency department holding the arm straight in pronation and refuse to use the arm or flex the elbow secondary to pain.3 This is similar in presentation to another commonly encountered pediatric elbow injury—radial head subluxation, better known as nursemaid's elbow. However, the history of a compression mechanism with supracondylar
Radiographic findings
Evaluation of the radiography of the pediatric elbow is complicated by the various stages of development of the ossification centers. A frequently used mnemonic for remembering the radiographic order of secondary ossification center appearance around the elbow is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, external [lateral] epicondyle) (Table 1).Ossification Center Age of Appearance Capitellum 1 year Radial head 3 years
Treatment
Treatment of pediatric, humeral, supracondylar fractures is dictated by the level of displacement and the prereduction physical examination. The most likely pitfall associated with type I fractures is missing the diagnosis. Once the diagnosis is made, the goal of therapy is comfort and immobilization because type I fractures are inherently stable.10 The arm is placed in a long-arm posterior splint with the elbow flexed to 90° and the forearm in neutral rotation for 3 weeks. A circumferential
Complications
Nerve injury or impairment can be associated with long-term morbidity, but the majority of nerve deficits associated with supracondylar fractures are neuropraxias and will resolve with time.13, 26, 27 Motor deficits may be expected to return within 7 to 12 weeks, whereas sensory deficits may be present for longer, often taking over 6 months to recover.11
Vascular injury and outflow impairment are perhaps the most important injuries leading to the most feared complication—compartment syndrome.
Summary
Supracondylar fractures are the most common type of elbow fracture in children. Therefore, the clinician should maintain a high index of suspicion when presented with a child complaining of elbow or arm pain and the appropriate mechanism. Because these fractures have the potential to cause disfigurement and functional morbidity, prompt diagnosis and appropriate treatment can significantly improve outcome. The role of the emergency clinician in these cases is to provide immediate therapeutic
Key points
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Careful examination of radiographs and identification of subtle clues (eg, the anterior and posterior fat pads and the anterior humeral line) can help make the diagnosis in occult fractures.
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Do not forget to assess the anterior interosseous nerve when performing the neurovascular examination. A simple way to do this is have the patient make an ok sign and test it for strength.
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Displaced fractures (types II and III) require prompt reduction and frequent neurovascular examinations.
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Because
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No reprints are available.
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Address correspondence to Andrew D. Perron, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Box 800699, University of Virginia Health System, Charlottesville, VA 22908. E-mail: [email protected]
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