This document summarizes the case of a 3-year-old Thai boy who was brought to the emergency room after falling from a motorcycle. On physical examination, he was found to have a deformity and limited range of motion of his left elbow. X-rays revealed a Gartland Type III supracondylar fracture of the left humerus. The patient's management included admission, IV fluids, pain control, antibiotics, and being taken to the operating room for closed reduction with pinning and application of a long arm cast.

1. EXTERN CONFERENCE

2. PATIENT PROFILE
Case เด็กชายไทยอายุ 3 ปี no U/D BW 9.6 kg
CC : ปวดบวมข้อศอกซ้าย 6 ชั7วโมงก่อนมารพ.
PI : 6 ชั7วโมงก่อนมารพ. นั7งซ้อนรถมอเตอร์ไซด์ป้า เกิดอุบัติเหตุล้มเอง เด็กเอาแขน
ซ้ายลงยันพืFน หลังจากนัFนมีอาการข้อศอกปวด บวม ไม่ยอมขยับแขนเอง ป้า
สังเกตเห็นว่าข้อศอกมีอาการผิดรูปจึงรีบพารพ.

3. PRIMARY SURVEY
A: can speak, can flex neck, no tender along c-spine
B: symmetrical chest movement, trachea in midline, no subcutaneous emphysema, clear
and equal both lungs, CCT negative
C: cap refill < 2 sec, BP 137/90 mmHg, PR 115 bpm, BT 37.7 c
D: E4V5M6 pupils 3 mm RTLBE, no lateralization sign
E: Lt. elbow deformity , Abrasion wound along radial side of hand from wrist to
thumb size around 1x1cm. , 2x3 cm. , 2x5 cm. , on woody splint Lt. arm

4. LT. ELBOW DEFORMITY AND AW LT. HAND

5. SECONDARY SURVEY
A: no Hx of drug/food allergy
M: no current medication
P: no underlying disease
L: NPO time 18.00 (5 hr)
E: as present illness

6. PHYSICAL EXAMINATION
Airway and Breathing: spontaneous breathing
Vital signs: BP 137/90 mmHg, PR 115 bpm, RR 20 /min, T 37.7 c
HEENT: not pale conjunctiva, anicteric sclera, no external wound
C-spine: no posterior midline neck pain, no soft tissue contusion or swelling around the
neck
Chest: clear and equal both lungs
CVS: normal S1 S2, no murmur
Abdomen: soft, not tender

7. PHYSICAL EXAMINATION
Extremities: Lt. elbow deformity with limit ROM due to pain , Abrasion wound along
radial side of hand from wrist to thumb size around 1x1cm. , 2x3 cm. , 2x5 cm. ,
Capillary refill Lt. hand <2s.
Neuro: E4V5M6 pupils 3 mm RTLBE, motor Gr V all
­ Special Test :
­ Medial nerve : OK sign – negative , can thumb opposition
­ Radial nerve : can extend wrist or MCP joints can flex finger
­ Ulnar nerve : Froment’s sign - negative
­ Sensory : no loss of any sensory around the hand and arm

8. INVESTIGATION: FILM LT. ELBOW AP LAT

9. DIAGNOSIS
CFX Supracondylar LT. Humerus Gartland III

10. MANAGEMENT
Initial management:
- admit ortho
- NPO
- IV Fluid : 5% DN/3 1000 ml IV rate 50 ml/hr
- Lab Pre-op : CBC , AntiHIV
- Pain Control : Pethidine 15 mg IV q 6 hr.
- ATB : cefazolin 1 g to OR
Definite treatment: Set OR for Close reduction with pinning and Long arm cast

12. SUPRACONDYLAR FRACTURE

13. EPIDEMIOLOGY
- occur most commonly in children age 5-7 years.
- occur in Male = Female

14. MECHANISM OF INJURY
- Fall on out stretching hand.

15. TYPES
- extension type (97.7%)
- flexion type (2.3%)

16. CLINICAL PRESENTATION
- Pain and swelling
- S-Shaped deformity
- Loss of passive and active motions

17. ASSOCIATED INJURY
- Neuropraxia
­ Anterior interosseous nerve (branch of median n.)
­ Radial nerve palsy
­ ulnar nerve palsy
- Vascular compromise (Brachial Artery : Radial and Ulnar artery)
- Ipsilateral distal radius fractures

18. MEDIAN NERVE EXAMINATION
- OK sign (Flexor Pollicis Longus and radial half of Flexor digitorum profundus)
- Thump opposition (opponens pollicis)
- loss of sensation over volar index finger

19. RADIAL NERVE EXAMINAION
- inability to extend wrist or MCP joints

20. ULNAR NERVE EXAMINATION
- Intrinsic muscle “finger crossed” index and middle finger
- Froment’s Sign (Test Adductor pollicis)

21. ELBOW ANATOMY IN PEDIATRICS
- Ossification center “CRITOE”

22. OSSIFICATION CENTER
-

24. GARTLAND CLASSIFICATION
- Type 1 : Nondisplaced Treat by Long arm cast 3-4 wks.
- Type 2 : Displaced with posterior cortex and posterior periosteal hinge intact or
,Deformity is in the sagittal plane only Treat by CR with Long arm cast +/-
pinning
- Type 3 : Complete displaced, often in 2 or 3 planes Treat by CR with long arm cast
with pinning

26. GARTLAND CLASSIFICATION
- Type 4 : Complete periosteal disruption with instability in flexion and extension,
Diagnosed with examination under anesthesia during surgery , Treated most
commonly with CRPP or open reduction if needed
- Medial comminution : Collapse of medial column, loss of Baumann angle, Treated
with CRPP, often requires significant valgus force to reduce
- Flexion type : Mechanism of injury is usually a fall on the olecranon , Treated with
CRPP

27. IMAGING
- Film Elbow AP LAT
- Finding : Posterior Fat pad sign

28. IMAGING (CONT.)
- measurement
­ Displacement of the anterior humeral line
­ anterior humeral line should intersect the middle third of the capitellum in children > 5
years old, and touches the capitellum in children in children <5.
­ capitellum moves posteriorly to this reference line in extension type fractures, and
anteriorly in flexion type fractures
­ Alteration of Baumann angle
­ Baumann's angle is created by drawing a line parallel to the longitudinal axis of the
humeral shaft and a line along the lateral condylar physis as viewed on the AP image
­ normal is 64-81°, but best judge is a comparison of the contralateral side
­ deviation of >5-10° indicates coronal plane deformity and should not be accepted

30. IN THIS CASE

31. IN THIS CASE

32. FINDING FROM RADIOGRAPH

33. MEASUREMENT

34. WHAT ABOUT OPEN REDUCTION WITH PINNING ?
- indication
­ unacceptable closed reduction
­ more frequently required with flexion type fractures (than extension type)
­ when vascular exploration needed
­ open fracture

35. PULSELESS HAND

36. COMPLICATION
- Pin migration
- Infection
- Cubital valgus : cause by fx malunion
- Cubital varus : caused by fracture varus malunion, especially in medial comminution pattern
- Recurvatum : common with non-operative treatment of Type II and Type III fractures
- Nerve Palsy from injury : mechanism = tenting of nerve on fracture, or entrapment in fracture site
M/C anterior interosseous nerve
- Vascular Injury
- Volkmann ischemic contracture (hyperflexion of elbow cause deep volar forearm compartment pressure
and loss of radial pulses
- Postoperative stiffness can be resolve in 6 months

37. THANK YOU