You are a SPR in Orthopaedics. A 12 year old boy presents after falling from monkey bars. X-Rays have been taken by the acident and emergency department and are shown below.
This is a Lateral and AP plane film radiograph of a skeletally immature unkown patients left elbow. The most obvious abnormality is that there is a completely displaced supracondylar fracture.
Gartland’s classification first described in 1959 in Surgical Gynaecological and obstetrics journal by Gartland.
Intact posterior cortex, hinged in extension.
Complete displacement with no contact between fragments
Supracondylars can also be classified as either Extension type or Flexion type. Extension types account for 95-98% of all fractures.
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 reduce the fracture and apply a back slab and reassess the patients limb.
If the patients arm is still pale and pulseless I would contact the consultant on call. Prepare the patient for theatre. Inform the theatre co-ordinator and anaesthetist. In addition, I would consent the patient for theatre.
Ipsilateral supracondylar fracture and forearm/wrist fracture.
It has a high risk of compartment syndrome.
- Pin migration 2/100
- Infection 1/100 patients typically superficial
- Deformity (cubitus varus, cubitus valgus, recurvatum)
- Nerve palsy (AIN most common injury from fracture and may not recover, ulnar nerve at risk intraoperatively).
- Vascular injury (radial pulse)
- Volkmann ischaemic contracture
- Post-operative stiffness (allow gentle ROM at 3-4 weeks post op, resolves by 6 months)
Anterior interosseous nerve (A branch of the median nerve). It supplies the Flexor digitorum profundus, flexor pollicis longus and pronator quadratus.
I would test function of this nerve by asking the patient to make an “OK” sign.
Radial nerve. I would test wrist extension/thumb extension by asking the patient to do a thumbs up.
Ulnar nerve. I would ask the patient to cross his fingers. This tests the dorsal interossei muscles of the hand and deep branch of the ulnar nerve (a terminal branch of the ulnar nerve).
Triceps + Brachialis leading to shortening.
Traction – 10 degrees flexion longitudinal traction with assistant placing counter-traction. Milking manoeuvre may help over the biceps and brachialis starting proximally if difficulty reducing.
Correction of displacement in the medial to lateral plane.
>120 degrees flexion implies that reduction has been achieved.
Fully pronate the forearm in full flexion.
Lateral pin placement (2mm wires utilised as per boast guidelines).
Can use divergent (2 lateral) or crossed pins. If using crossed pin a mini open approach should be used.
- Delayed presentation
- Inconsistent history
- Multiple previous admissions/injuries/attendances
- Hx of child protection concerns
- Sharply defined bruising
- Bite marks
- Genitourinary injury
- Multiple injuries of varying ages
- Subconjunctival haemorrhage
- Fractures inconsistent with age/development of child
- Skull fracture
- Multiple rib fractures
- Old fractures esp if not reported