This document describes the case of a 5 year 5 month old female patient who presented to the emergency room after falling from a vehicle and injuring her left elbow. She was diagnosed with a left supracondylar fracture (Gartland Type 3) based on physical exam findings of swelling, deformity and limited range of motion of the left elbow as well as x-ray findings. She underwent closed reduction with K-wire fixation of the fracture. Her injury was managed according to standard protocols for supracondylar fractures.

2. PATIENT PROFILE
ผู้ป่วยเด็กหญิง อายุ 5 ปี 5 เดือน ภูมิลาเนา จังหวัดนครราชสีมา

3. CHIEF COMPLAINT
ปวดแขนซ้าย 4 ชั่วโมงก่อนมาโรงพยาบาล

4. PRESENT ILLNESS
4 ชั่วโมงก่อนมาโรงพยาบาล ตกจากยางรถยนต์ สูงประมาณ 50 ซม. แขนซ้าย
กระแทกพื้น ในท่าเหยียด ปวดข้อศอกซ้าย ขยับข้อศอกซ้ายไม่ได้ ไม่ชา ไม่อ่อนแรง
มีแขนผิดรูป ยังขยับข้อมือได้ กามือเหยียดมือได้สุด ไม่มีศีรษะกระแทกพื้น ไม่สลบ
รู้ตัวดี

5. PRIMARY SURVEY
• AIRWAY
• BREATHING
• CIRCULATION
• DISABILITY
• EXPOSURE
Can speak no hoarseness can flex neck not tender along posterior midline of c-spine
Clear equal breath sound both lungs
BP 103/60 mmHg PR102 bpm no external bleeding seen
E4V5M6 pupil 3 mm react to light both eyes
Left elbow swelling and deformity Limit ROM of elbow joint due to pain Neurovascular
intact(Radial pulse 2+ ulnar pulse 2+ intact median ulnar and radial nerve) No open wound seen
CR<2 sec

6. SECONDARY SURVEY
ALLERGY
MEDICATION
PAST HISTORY
LAST MEAL
EVENT
No food or drug allergy
No current medication
None
NPO time at 11.00 am 29/06/2560
Fall from height 50 cm

7. PHYSICAL EXAMINATION
•V/S
•HEENT
•LUNGS
•HEART
•ABDOMEN
•EXTREMITIES
•NEUROLOGICAL
BP 103/60 mmHg PR102 bpm T 36c RR 22/min
No head scar Not pale conjunctiva Anicteric sclera No discharge per ears or nose Tonsils
and pharynx not injected
Normal equal breath sound both lungs No adventitious sound
Normal S1S2 No murmur
Flat shape abdomen Normoactive bowel sound Soft Not tender
Left elbow swelling and deformity Limit ROM of elbow joint Radial pulse 2+ ulnar pulse 2+
No open wound seen CR<2 sec
E4V5M6 pupil 3 mm RTLBE Motor grade V except Lt elbow joint Full ROM of Lt shoulder
and Lt wrist joint Sensory grossly intact

8. INVESTIGATION
• FILM LEFT ELBOW AP, LAT

9. DIAGNOSIS
•LEFT SUPRACONDYLAR FRACTURE
GARTLAND TYPE 3

10. INITIAL MX AT EMERGENCY ROOM
• TEMPORARY SPLINT / IMMOBILIZATION
THIS PATIENT -> WOODEN SPLINT

11. SUPRACONDYLAR FRACTURE
• EXTENSION TYPE MOST COMMON (95-98%)
>>> GARTLAND CLASSIFICATION
• FLEXION TYPE LESS COMMON (<5%)
most commonly in children aged 5 to 7

12. MECHANISM OF INJURY

13. CLINICAL PRESENTATION
• PAIN, REFUSAL TO MOVE THE ELBOW
• S-SHAPED DEFORMITY (III),SWELLING, BRUISING
• LIMITED ACTIVE AND PASSIVE ELBOW MOTION / PSEUDOPARALYSIS
• NEUROVASCULAR
• NERVE EXAM
• AIN NEURAPRAXIA : CAN'T MAKE A-OK SIGN
• RADIAL NERVE NEURAPRAXIA : INABILITY TO EXTEND WRIST OR DIGITS
• VASCULAR EXAM
• COLD, PALE AND PULSELESS HAND

14. RADIOGRAPHIC FINDING

15. CORONAL TILT

16. BAUMANN’S ANGLE
n
is the angle between the lateral condylar physis and the long axis
of the humerus shaft
After reduction and fixation, Baumann’s angle should be equal to
that of the uninjured side (usually 70–75°)
deviation of >5° indicates coronal plane
deformity and should not be accepted

17. HORIZONTAL ROTATION

18. POSTERIOR DISPLACEMENT OF DISTAL FRAGMENT

19. GARTLAND CLASSIFICATION

20. Gartland Classificaiton
(may be extension or flexion type)
Type I
Nondisplaced
Treated with cast immobilization x 3-4wks, with radiographs at 1 wk
Type II
Displaced intact posterior cortex
Treated with Close reduction and long arm cast/locking slab +/-pinning
Type III
Completely displaced but intact posterior periosteal hinge
Treated with Close reduction +pinning and long arm cast/locking slab , pull pins at 3 wks
Type IV*
Complete periosteal disruption with instability in flexion and extension
Treated with Close reduction with percutaneous pinning
Flexion type
Shear mechanism, oblique orientation, inherently unstable
Treated with Close reduction with percutaneous pinning
*not a part of original Gartland classification

21. CLOSE REDUCTION WITH K- WIRE FIXATION
Description of operation
Wound clean
Position supine
No tourniquet
Fluoroscope yes
Finding
Close fracture Lt supracondylar fracture (Gardland III)
Close reduction under GA
K-wire 062 was apply x II
Posterior long arm slab was apply
Blood loss 1 ml
Lateral pinning decrease incidence of ulnar nerve injury compared with cross pinning

22. INDICATION FOR OPEN REDUCTION
• INADEQUATE REDUCTION WITH CLOSED METHOD
• VASCULAR INJURY
• OPEN FRACTURE

23. POST OP CARE
• ELEVATE / SWELLING CONTROL
• PAIN CONTROL
• OBSERVE COMPARTMENT SYNDROME
• REMOVE PINS AND CAST AT 3-4 WK / UNION