True AP and Lateral Xrays of Ella’s elbow are below, please describe them and how you would approach an elbow Xray:
Lateral view: demonstrates an obvious fracture line on the anterior supracondylar region of the humerus, less than 1/3 of the capitellum is anterior to the anterior humeral line. There is also raised posterior and anterior fat bad and surrounding soft tissue swelling.
AP view: There is a visible supracondylar fracture line over the medial aspect of the humerus, no apparent intra-articular involvement, rotation, angulation or displacement in this view.
Visible fracture line
- Location and especially presence of articular involvement
- Angulation (use the Anterior humeral line: passes through middle 1/3 of capitellum - see image below on left. If there is a displaced supracondylar fracture this line will pass in front of capitellum, right image below )
- Alignment of the radius and ulnar with the distal humerus (use Radio-capitellar line: line drawn down neck of radius on AP film, should pass through the center of the capitellum. Assesses for radial dislocation)
NOTE: anterior fat pad may be normal, unless assumes ‘ship sail’ shape. Posterior fat pad may be normal if arm in extension. If uncertain immobalise and recommend re-imaging in 7-10 days)
Remember to consider other elbow trauma: radial head dislocation, epicondylar fractures can mimic an undisplaced supracondylar fracture
Remember ossification centres, CRITOE
- Internal/Medial Epicondyle
- External/Lateral Epicondyle
Ella has a Type 1 Gartland's fracture.
Type 1: Non displaced
Type 2: Displaced, posterior cortex in tact. The anterior humeral line does not intersect the capitellum. This can be further subdivided into
- 2a: minimally displaced no rotation
- 2b rotational deformity
Type 3: Completely displaced
Type 4: (not in original Gartland’s classification): complete periosteal disruption with instability in flexion and extension
The elbow has two functionally independent articulations that share a synovial compartment. They are:
1. ulnotrochlear articulation directs flexion and extension
2. radiocapitellar joint governs forearm rotation
Approximately 7 % of supracondylar fractures are associated with nerve injury, what nerves would most likely be effected and how would you test these?
- Anterior interosseus nerve (branch of median nerve): Ella would be unable to make A-OK sign (cannot flex interphalangeal joint of this thumb and DIPJ of her index finger.
- Radial nerve: Ella would be unable extend her wrist or digits
How would you manage Ella’s supracondylar fracture?
Always ensure patient is neurovascularly intact
Ella was managed with a closed reduction, which involved traction followed by flexion of elbow with slight anterior pressure of the posterior displaced segment and placed in a long arm posterior splint (or collar and cuff) at > 90 degrees of flexion for three to four weeks.
Repeat radiographs were taken to ensure adequate reduction and she was referred to fracture clinic in 5-7 days with repeat X-ray.
Note: Without support, the weight of the cast applies an extension torque to the distal humerus and can lead to posterior fracture displacement
How would you manage other supracondylar fractures?
Non-Operative Long arm posterior splint then long arm casting with up to 90 degrees of elbow flexion:
- Indication: Type 1, Type 2a fractures that has no medial comminution, minimal swelling and anterior humeral line intersects the anterior half of the capitellum
- Repeat radiographs at 3-7 days and immobalisation for 3-4 weeks +/- additional time with removal posterior long arm posterior splint.
Immediate closed reduction and percutaneous pinning (K-wires)
- Indications: vascular compromise (pale, cool hand), floating elbow
- Technique: check vascular status after reduction
Closed reduction and percutaneous pinning
- Indications: Type 2b (not meeting the above criteria) and Type 3
Open reduction with percutaneous pinning
- Indication: when closed reduction was not successful, more likely if a flexion type fracture
Kids Health WA. Supracondylar Fractures (2015).Available from: http://kidshealthwa.com/wp-content/uploads/2013/12/Supracondylar.jpg
Radiology Masterclass. Trauma Xrays Upper Limb. (2015). Available from: http://www.radiologymasterclass.co.uk/gallery/trauma
Sheth, U. Taylor, B. (2015) Supracondylar Fractures -Pediatric. Orthobullets. Available from: http://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric Accessed: 1/8/15