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.
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.
Intact posterior cortex, hinged in extension.
Complete displacement with no contact between fragments. Unstable in all planes.
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
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
Spread of wires
Fracture obliquity in the sagittal plane
Ulnar nerve subluxation in flexion
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.