This document describes a case of a left elbow injury in a child. On physical examination, the child had swelling, bruising, tenderness, and limited range of motion of the left elbow. X-rays revealed a totally displaced supracondylar fracture of the left humerus. The child was referred for closed reduction and internal fixation using K-wires. Post-operatively, the child was placed in a splint and instructed on pain control and follow-up for pin removal after clinical union.

1. Interesting caseInteresting case
Ext. 5402161

2. Patient profilePatient profile
 เเเเเเเเเเ เเเเเเเเเเเเเเ เเเเ 66 เเเเ

3. Chief ComplaintChief Complaint
 11 ..

4. Intial managementIntial management
 Airway with c spine protectionAirway with c spine protection
 BreathingBreathing
 CirculationCirculation
 DisabilityDisability
 Exposure and environment controlExposure and environment control

5. Secondary surveySecondary survey



 NPO time 8NPO time 8 ..

6. EventEvent
 11..

7. Physical Examination (Physical Examination ())
 V/SV/S- BT 37.4 C, BP 139/55 mmHg, PR 106/min, RR- BT 37.4 C, BP 139/55 mmHg, PR 106/min, RR
20/min O2 sat 97% room air20/min O2 sat 97% room air
 GAGA- alert- alert
 SkinSkin:no rash:no rash
 HEENT no wound at face and scalpHEENT no wound at face and scalp
 HeartHeart-normal s1 s2-normal s1 s2
 LungsLungs-symmetrical chest wall movement, no use-symmetrical chest wall movement, no use
accessory muscle,good air entry,no adventicious soundaccessory muscle,good air entry,no adventicious sound
 AbdomenAbdomen-no distension, soft,not tender-no distension, soft,not tender

8. extremitiesextremities
S shape deformities,swelling,ecchymosis 3S shape deformities,swelling,ecchymosis 3
cm,marked tenderness at distal humerus of left arcm,marked tenderness at distal humerus of left ar
m,loss of isosceles triangle,range of motion limitedm,loss of isosceles triangle,range of motion limited
due to pain,no wound, no fat globuedue to pain,no wound, no fat globue

9. S shape deformitiesS shape deformities

10. S shape deformitiesS shape deformities

11. S shape deformitiesS shape deformities

12. neurovascularneurovascular
 Radial pulse 2+Radial pulse 2+
 Ulnar pulse 2+Ulnar pulse 2+
 Capillary refill < 2 secCapillary refill < 2 sec
 OK sign intactOK sign intact
 Great sign intactGreat sign intact
 Bye-bye sign intactBye-bye sign intact

13. Problem listProblem list
 Acute left elbow pain and deformitiesAcute left elbow pain and deformities
 History of trauma at left elbowHistory of trauma at left elbow

14. DDxDDx
 Closed Supracondylar fracture of left theClosed Supracondylar fracture of left the
humerushumerus
 Closed Lateral condyla fracture of left theClosed Lateral condyla fracture of left the
humerushumerus
 Subluxation of the radial head of left elbowSubluxation of the radial head of left elbow

15. ImmobilizationImmobilization
 Temporary splint(woody splint) or LongTemporary splint(woody splint) or Long
posterior arm slapposterior arm slap
 Go to x-rayGo to x-ray

16. investigationinvestigation
 Flim elbow true AP,LatFlim elbow true AP,Lat

19. Preoperative DiagnosisPreoperative Diagnosis
 Closed Totally displace Supracondylar fractureClosed Totally displace Supracondylar fracture
of left the humerus (GARTLAND 3)of left the humerus (GARTLAND 3)

20. ReferRefer
 Definitive treatmentDefinitive treatment
 Close reduction in OR with internal fixation byClose reduction in OR with internal fixation by
K-wire percutaneous crossed pinningK-wire percutaneous crossed pinning
 Apply posterior long arm slab in slightly flexionApply posterior long arm slab in slightly flexion
and arm slingand arm sling

21. Postoperative DiagnosisPostoperative Diagnosis
 Closed Totally displace Supracondylar fractureClosed Totally displace Supracondylar fracture
of left the humerus (GARTLAND 4 )of left the humerus (GARTLAND 4 )

24. Post op carePost op care
 Elevation/swelling controlElevation/swelling control
 Pain controlPain control
 Observe compartment syndrome andObserve compartment syndrome and
neurovascular complicationneurovascular complication
 Remove pin and slab at 4 week/clinical unionRemove pin and slab at 4 week/clinical union

25. SUPRACONDYLARSUPRACONDYLAR
FRACTURES OFFRACTURES OF
HUMERUSHUMERUS

26. Distal Humerus AnatomyDistal Humerus Anatomy
 Medial epicondyleMedial epicondyle
proximal to trochleaproximal to trochlea ––
 Lateral epicondyleLateral epicondyle
proximal to capitellumproximal to capitellum
––
 Radial fossaRadial fossa ––
accommodates margin ofaccommodates margin of
radial head during flexionradial head during flexion
 Coronoid fossaCoronoid fossa ––
accepts coronoid process ofaccepts coronoid process of
ulna during flexionulna during flexion

27. Supracondylar Fractures of HumerusSupracondylar Fractures of Humerus
 It is # whichIt is # which involves the lower end of the humerusinvolves the lower end of the humerus usuallyusually
involving the thin portion of the humerus throughinvolving the thin portion of the humerus through
Olecranon fossa orOlecranon fossa or
Just above the fossa orJust above the fossa or
MetaphysisMetaphysis
 Most common elbow injuries in children.Most common elbow injuries in children.
 Makes up approximately 60% of elbow injuries.Makes up approximately 60% of elbow injuries.
 Becomes uncommon as the age increases.Becomes uncommon as the age increases.

28. General considerationsGeneral considerations
 Incidence of supracondylar #:Incidence of supracondylar #:
a) Agea) Age : peak age : 5-7 yrs: peak age : 5-7 yrs
Average age : 6.7 yrsAverage age : 6.7 yrs
b) Sexb) Sex : Boys > Girls (Earlier): Boys > Girls (Earlier)
Boys = Girls (Latest Trends)Boys = Girls (Latest Trends)
c) Sidec) Side : Left > Right: Left > Right
( Non dominant > dominant )( Non dominant > dominant )
d) Nerve injuriesd) Nerve injuries : 7% - Median> Radial > Ulnar: 7% - Median> Radial > Ulnar
e) Vascular injuriese) Vascular injuries : 1%: 1%
f) Open injuriesf) Open injuries : < 1%: < 1%

29. g) Cause of #g) Cause of #
Fall from height 70% ----- children > 3 yrsFall from height 70% ----- children > 3 yrs
Fall from bed children < 3 yrsFall from bed children < 3 yrs
Non accidental injury ( Child abuse) children < 15 monthsNon accidental injury ( Child abuse) children < 15 months
h) Associated #sh) Associated #s
Distal radius > Scaphoid > Proximal humerus >Distal radius > Scaphoid > Proximal humerus >
MonteggiaMonteggia
i) Clinical typesi) Clinical types
Extension type: 98%Extension type: 98%
Flexion type : 2%Flexion type : 2%

30. Mechanism of injuryMechanism of injury
 ForFor Extension typeExtension type ofof
SC # humerusSC # humerus
Fall on outstretched handFall on outstretched hand
ElbowElbow hyper extendedhyper extended
Fore arm –Fore arm – pronated orpronated or
supinatedsupinated

31. Mechanism of injuryMechanism of injury
 ForFor Flexion typeFlexion type
of SC # humerusof SC # humerus
Fall directly on theFall directly on the
elbowelbow rather thanrather than
out stretched handout stretched hand

32. Radiographic anatomy of distalRadiographic anatomy of distal
HumerusHumerus
 What are the radiographic views:What are the radiographic views:
Antero posteriorAntero posterior
LateralLateral
ObliqueOblique
Axial ( jones view )Axial ( jones view )

33.  What to look for inWhat to look for in
AP View-AP View----- Baumann`s angle---- Baumann`s angle

34. Radiographic AnatomyRadiographic Anatomy
 Baumann’s angleBaumann’s angle is formed by a lineis formed by a line
perpendicular to the axis of the humerus, and aperpendicular to the axis of the humerus, and a
line that goes through the superior part ofline that goes through the superior part of
physis of the capitellum.physis of the capitellum.
 There is a wide range of normal for this value,There is a wide range of normal for this value,
and it can vary with rotation of the radiograph.and it can vary with rotation of the radiograph.
 The Baumann angleThe Baumann angle is good measurement ofis good measurement of
any deviation of distal humerus`s angulationany deviation of distal humerus`s angulation
 In this case, the medial impaction and varusIn this case, the medial impaction and varus
position alters the Bauman’s angle.position alters the Bauman’s angle.

35. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
 Anterior HumeralAnterior Humeral
Line:Line:
This is drawn alongThis is drawn along
the anterior humeralthe anterior humeral
cortex.cortex.
It should passIt should pass
through the junctionthrough the junction
of anterior &of anterior &
middle 3middle 3rdrd
of theof the
capitellum.capitellum.

36. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
 The capitellum isThe capitellum is
angulated anteriorlyangulated anteriorly
about 30 degrees.about 30 degrees.
 The appearance of theThe appearance of the
distal humerus is similardistal humerus is similar
to a hockey stick.to a hockey stick.
30

37. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
 The physis of theThe physis of the
capitellum is usuallycapitellum is usually
wider posteriorly,wider posteriorly,
compared to thecompared to the
anterior portion ofanterior portion of
the physisthe physis
Wider

38. Anatomical classification of SC #Anatomical classification of SC #

39. Radiographic Classification of SC #sRadiographic Classification of SC #s
 Based on X- Ray appreance # displacementBased on X- Ray appreance # displacement GartlandGartland
described 3 types:described 3 types:
 Type – IType – I : Undisplaced: Undisplaced
 Type – IIType – II : Displaced (posterior cortex intact): Displaced (posterior cortex intact)
 Type –IIIType –III : Displaced ( no cortical contact): Displaced ( no cortical contact)
PosteromedialPosteromedial
PosterolateralPosterolateral

40. Type 1: Non-displacedType 1: Non-displaced
 Note the non-Note the non-
displaced fracturedisplaced fracture
(Red Arrow)(Red Arrow)
 Note the posterior fatNote the posterior fat
pad (Yellow Arrows)pad (Yellow Arrows)

41. Type 2: Angulated/Displaced FractureType 2: Angulated/Displaced Fracture
with Intact Posterior Cortexwith Intact Posterior Cortex

42. Type 3: Complete Displacement, withType 3: Complete Displacement, with
No Contact between FragmentsNo Contact between Fragments

43. Clinical signs & SymptomsClinical signs & Symptoms
 In most cases, children willIn most cases, children will not move the elbownot move the elbow if a fracture is present,if a fracture is present,
although this may not be the case for non-displaced fractures.although this may not be the case for non-displaced fractures.
 SwellingSwelling about elbow is aabout elbow is a constantconstant feature, develop within first few hrs.feature, develop within first few hrs.
 S shaped deformityS shaped deformity
 Distal humeral tendernessDistal humeral tenderness
 Anterior plucker sign +veAnterior plucker sign +ve

44. S-shaped configuration of ULS-shaped configuration of UL

45. Physical ExaminationPhysical Examination
 Neurologic exam is essential,Neurologic exam is essential, as nerve injuries are common. In mostas nerve injuries are common. In most
cases, full recovery can be expectedcases, full recovery can be expected
 Neuro-motor exam may be limited by the childs ability toNeuro-motor exam may be limited by the childs ability to
cooperate because of age, pain, or fear.cooperate because of age, pain, or fear.
 Thumb extension– EPL (radial – PIN branch)Thumb extension– EPL (radial – PIN branch)
 Thumb flexion – FPL (median – AIN branch)Thumb flexion – FPL (median – AIN branch)
 Cross fingers - Adductors (ulnar)Cross fingers - Adductors (ulnar)

46.  Nerve injury incidence is high, between 7 and 16 %Nerve injury incidence is high, between 7 and 16 %
(median, radial and ulnar nerve)(median, radial and ulnar nerve)
 Anterior interosseous nerve is most commonly injured nerveAnterior interosseous nerve is most commonly injured nerve
 In many cases, assessment of nerve integrity is limited , because childrenIn many cases, assessment of nerve integrity is limited , because children
can not always cooperate with the examcan not always cooperate with the exam
 Carefully document pre manipulation exam, as post manipulationCarefully document pre manipulation exam, as post manipulation
neurologic deficits can alter decision makingneurologic deficits can alter decision making
Physical ExaminationPhysical Examination

47.  Vascular injuriesVascular injuries are rare, but pulses should always beare rare, but pulses should always be
assessed before and after reductionassessed before and after reduction
 In the absence of a radial and/or ulnar pulse,In the absence of a radial and/or ulnar pulse,
the fingers may still be well-perfused, because of thethe fingers may still be well-perfused, because of the
excellent collateral circulation about the elbowexcellent collateral circulation about the elbow
 Doppler device can be used for assessmentDoppler device can be used for assessment
Physical ExaminationPhysical Examination

48. Physical ExaminationPhysical Examination
 Thorough documentation of all findings is important. AThorough documentation of all findings is important. A
simple record of “neurovascular status is intact” issimple record of “neurovascular status is intact” is
unacceptable.unacceptable.
 Individual assessment and recording of motor, sensory, andIndividual assessment and recording of motor, sensory, and
vascular function is essentialvascular function is essential
 Always palpate the arm and forearm forAlways palpate the arm and forearm for signs of compartmentsigns of compartment
syndrome.syndrome.

49. TreatmentTreatment
 General principlesGeneral principles::
Splinting elbow in comfortable positionSplinting elbow in comfortable position
20-30degrees of flexion of elbow, pending20-30degrees of flexion of elbow, pending
Careful physical examination & X-ray evaluation.Careful physical examination & X-ray evaluation.
Tight bandaging/ excessive flexion or excessiveTight bandaging/ excessive flexion or excessive
extension should be avoidedextension should be avoided
Associated life threatening complications ( if any)Associated life threatening complications ( if any)
to be attended first.to be attended first.

50.  Simple posterior long arm splint for 3-7days.Simple posterior long arm splint for 3-7days.
 Elbow 60-90Elbow 60-90oo
flexion & Forearm neutral position.flexion & Forearm neutral position.
 Check X-ray after 3-7 days to document any displacementCheck X-ray after 3-7 days to document any displacement
or lack of it.or lack of it.
 Splint converted to long arm cast if no displacement.Splint converted to long arm cast if no displacement.
 If displacement noticed # reduction done & cast applied orIf displacement noticed # reduction done & cast applied or
pinning done.pinning done.
Treatment of type – I #Treatment of type – I #

52.  Duration of immobilisation 3-4wks.Duration of immobilisation 3-4wks.
 No need for any physiotheraphy ( Generally )No need for any physiotheraphy ( Generally )
 Outcome:Outcome: Predictablly excellent if alignment isPredictablly excellent if alignment is
maintained during early healing.maintained during early healing.
Hence type – I #s requires carefulHence type – I #s requires careful
treatment &treatment &
follow up.follow up.

53. Treatment of type – II #Treatment of type – II #
 Good stability obtained after closed reduction.Good stability obtained after closed reduction.
 Once satisfactory reduction achieved further management isOnce satisfactory reduction achieved further management is
same as type – I.same as type – I.
 If medial column collapse present then skeletal stabilisationIf medial column collapse present then skeletal stabilisation
with 2 lateral pins is advocated.with 2 lateral pins is advocated.
 Recent trends led toRecent trends led to SELECTIVE PINNINGSELECTIVE PINNING for type – II #sfor type – II #s

54. SELECTIVE PINNINGSELECTIVE PINNING
Closed reduction is doneClosed reduction is done
Splinting in flexionSplinting in flexion
Non movable cuff & collar slingNon movable cuff & collar sling
Early careful X-ray follow upEarly careful X-ray follow up
If # displacement /angulation noticedIf # displacement /angulation noticed
pin stabilisation is done .pin stabilisation is done .

55. Treatment of type – III #Treatment of type – III #
 Treatment involves management of skeletalTreatment involves management of skeletal
injuries & associated soft tissue injuries (if any).injuries & associated soft tissue injuries (if any).
 Treatment of skeletal injury:Treatment of skeletal injury:
ReductionReduction either closed or openeither closed or open
StabilisationStabilisation either with pins or casteither with pins or cast

56. Technique of reduction (closed)Technique of reduction (closed)
 Traction – to restore length & alignment.Traction – to restore length & alignment.
 Milking maneuver -- if length & alignmentMilking maneuver -- if length & alignment
not restored by tractionnot restored by traction
 Correction of medial/ lateral displacements.Correction of medial/ lateral displacements.
 Correction of rotational deformities.Correction of rotational deformities.
 Correction of posterior displacement by --Correction of posterior displacement by --
flexion reduction maneuverflexion reduction maneuver
 Elbow held in hyper flexion.Elbow held in hyper flexion.
 Fore arm held in pronation – if distal fragment isFore arm held in pronation – if distal fragment is
postero medially displaced,postero medially displaced,
 Fore arm held in supination -- if distal fragment isFore arm held in supination -- if distal fragment is
postero laterally displaced.postero laterally displaced.

58. Indications for open reductionIndications for open reduction
 Open reduction is indicated to obtain alignment ifOpen reduction is indicated to obtain alignment if
closed reduction is unsuccessful as with the following,closed reduction is unsuccessful as with the following,
 Button holingButton holing of the proximal fragment throughof the proximal fragment through
the anterior soft tissues ,the anterior soft tissues ,
 Interposition of the biceps ,Interposition of the biceps ,
 Interposition of the neurovascular structures .Interposition of the neurovascular structures .
An open reduction is also indicated if there is anAn open reduction is also indicated if there is an openopen
fracture ,fracture ,that requires irrigation and debridement .that requires irrigation and debridement .

59. ComplicationsComplications
 Immediate :Immediate :
a) neurologicala) neurological
b) vascularb) vascular
 Early :Early :
a) compartment syndromea) compartment syndrome
b) volkmann`s ischemiab) volkmann`s ischemia
 Late :Late :
a) mal union : cubitus varus / cubitus valgusa) mal union : cubitus varus / cubitus valgus
b) volkmann`s ischemic contractureb) volkmann`s ischemic contracture
c) myositis ossificansc) myositis ossificans
d) elbow stiffnessd) elbow stiffness