SNAP! A pediatric fall onto an outstretched hand!
“Supracondylar fractures are one of the most common pediatric traumatic orthopedic injuries… Most frequently, the mechanism of injury is a fall on an outstretched hand…”
Case
A 21-month-old male presented to the emergency department with right upper extremity pain after a fall from a chair. He was initially discharged after unrevealing x-rays of the right upper extremity. However, after being discharged, the patient and his mother were called back in to the emergency department after an attending pediatric radiologist overread the xrays and identified a posterior fat pad, thereby indicating a supracondylar fracture. In the emergency department, the patient’s vitals were within normal limits for age. His right upper extremity was swollen, but he was able to spontaneously move his shoulder, elbow, and wrist. His perfusion and sensation were intact distally. He was seen by the orthopedics team and was placed in a long arm cast. He was discharged home with orthopedics outpatient follow-up.
Diagnosis
Supracondylar elbow fracture
Discussion
Supracondylar fractures are one of the most common pediatric traumatic orthopedic injuries. They usually occur in children ages five to seven years old, and there is an equal incidence between males and females. [1] Most frequently, the mechanism of injury is a fall on an outstretched hand. [1] Patients usually present with pain in the effected extremity. In the pediatric population, this may translate to refusal to move the joint, as pediatric patients may not able to effectively verbalize the location of the injury.
As with all orthopedic injuries, the clinician should begin by obtaining a detailed history and ensuring that the story provided matches the expected mechanism of injury to ensure that non-accidental trauma is not on the differential. A physical exam must thoroughly assess for neurovascular status, as the elbow contains important nerves and vessels. Specifically, the clinican should assess for anterior interosseous nerve damage (cannot make an “OK sign”), median nerve damage (loss of sensation over the index finger), and radial nerve damage (inability to extend wrist and joints of hand). In fact, nerve damage can occur in as high as 20% of cases. [2] In addition distal perfusion should be assessed, and compartment syndrome should be excluded.
Next, the team should obtain x-rays of the elbow (in both the AP and lateral orientations) as well as multiple views of the radius/ulna. If an occult fracture is present, a posterior fat pad sign may appear on the imaging (Figure 1). [1] If the fracture is more obvious, the Gartland system can be utilized to assess the degree of displacement and grade the fracture. This system helps providers determine if operative or non-operative intervention is the best course of management for the injury (Figures 2 and 3). [1] In general, Type 1 (non-displaced) fractures are treated non-operatively. These injuries are casted for several weeks with plan for outpatient orthopedics follow up. However, there is also evidence to suggest that a posterior arm splint can lead to decreased pain and faster return to normal activity compared to a cast. [3]
Figure 1: A dark lucency present on the posterior aspect of the distal humerus indicative of a “fat pad sign”1.
Figure 2: Gartland Classification and Management of Pediatric Supracondylar Fractures1.
Figure 3: Visual Representation of Gartland Classification1.
As illustrated in Figure 2, any degree of displacement is a potential indication for operative intervention. These decisions are often guided by orthopedics, and many patients may undergo non-emergent surgery either inpatient or outpatient. For example, most fractures that are Type 2 or above are treated with closed reduction and percutaneous pinning (CRPP), which is a minimally invasive surgical procedure where the bones are realigned under fluoroscopy. On the other hand, for some of the Type 3 or above fracture patterns, open surgery is also an option.
Because some fracture patterns require emergent surgery, the initial physical exam is vital. If there is concern for vascular injury or compartment syndrome, orthopedics should be emergently consulted. If there is an obvious deformity with evidence of vascular compromise, patients should undergo closed reduction, possibly under sedation. Angiography can also be considered if this will not delay the intervention. [3] Ultimately, most patients who are treated for a supracondylar fracture operatively tend to recover well. [4]
Take Home Points
A thorough physical exam, especially checking for neurovascular status and compartment syndrome, is paramount in children with elbow injuries.
If there are no red flags on the physical exam, radiographs and consultation with orthopedics often guide the decision for operative versus nonoperative management.
Patients who are managed nonoperatively need arm immobilization and close outpatient orthopedics follow up.
Patients with negative elbow x-rays and failure to clinically improve after a few days need PCP follow up for consideration of repeat imaging.
Author: Prassana Kumar, MD, is a third-year emergency medicine resident at Brown Emergency Medicine Residency.
Faculty Reviewer: Meghan Beucher, MD, is an attending physician at Hasboro Children’s Hospital and faculty with Brown Pediatric Emergency Medicine
References
1. Woon C. Supracondylar Fracture - Pediatric - Pediatrics - Orthobullets. Orthobullets.com. Published 2019. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric
2. Park MJ, Ho CA, Larson AN. AAOS Appropriate Use Criteria. Journal of the American Academy of Orthopaedic Surgeons. 2015; 23 (10): e52-e55. doi: 10.5435/JAAOS-D-15-00408.
3. Hubbard EW, Riccio AI. Pediatric Orthopedic Trauma: An Evidence-Based Approach. Orthop Clin North Am. 2018;49(2):195-210. doi:10.1016/j.ocl.2017.11.008
4. Baratz M, Micucci C, Sangimino M. Pediatric supracondylar humerus fractures. Hand Clin. 2006;22(1):69-75. doi:10.1016/j.hcl.2005.11.002