A 5-year-old Thai girl presented with left elbow pain after falling from 60 cm height while playing. On examination, she had swelling of the left elbow with limited range of motion due to pain. X-rays showed a left supracondylar fracture (Gartland Type II). She underwent closed reduction with percutaneous pinning to treat the fracture. Supracondylar fractures most commonly occur in children aged 5-7 years old from falling on an outstretched hand, with extension-type fractures being most common. Treatment depends on fracture classification and displacement.

1. EXT. CONFERENCE
E X T . ว ส วั ต ต์ อ นั น ต์ ณั ฐ ศิ ริ

2. PATIENT PROFILE
• ดญ. ไทย อายุ 5ปี6เดือน ภูมิลาเนา อ.ครบุรี จ.นครราชสีมา
• วัคซีนครบมีสมุด พัฒนาการสมวัย

3. CHIEF COMPLAINT
• เจ็บต้นแขนซ้าย 15ชม ก่อนมารพ.

4. PRESENT ILLNESS
• 15ชม ก่อนมารพ. ขณะเล่นชิงช้า พลัดตกลงมาสูง ประมาณ60ซม. ศอกซ้ายกระแทกพื้น เจ็บมาก ขยับข้อศอกซ้ายไม่ได้
ปวด กามือได้ขยับข้อมือได้ไม่ชา ไม่มีแขนสีซีดลง ไม่มีแขนอ่อนแรง ไม่มีข้อมือตก อาการปวดไม่ดีข้้น จ้งพามารพ.

5. PRIMARY SURVEY
• A: patent airway, can speak, no post C-spine injury, can flex neck
• B: normal breathing pattern, no dyspnea
• C: BP 107/60 ,CR <2secs, no external wound seen
• D: pupil3mm RTLBE, E4V5M6
• E: no external wound, events as mentioned

6. SECONDARY SURVEY
• A : no known allergy
• M : no current meds
• P : no known sx or any underlying disease
• L : last meal 12.00
• E : events as mentioned

7. PHYSICAL EXAMINATION
• GA: A Thai girl conscious, not pale, no jaundice
• HEENT: no pale conjunctiva, anicteric sclera
• Heart : no active precordium, no cyanosis, CR<2secs, no heaving, no thrills, normal
S1S2, mo murmur
• Lungs: no retraction, normal breathing pattern, clear sounds both lungs
• Abdomen: not distend, normoactive bowel sound,soft, not tender, no
hepatospleenomegaly

8. PHYSICAL EXAMINATION
• EXT: Lt Elbow : swelling, no external wound, no bruising, limit ROM Lt. elbow joint due
to pain, radial pulses 2+,AIN intact(can do OK sign), Radial n. intact (no wrist drop)

9. INVESTIGATION

10. DIAGNOSIS
• Lt. supracondylar fracture Gartland II

11. TREATMENTS
• At ER : on Posterior long arm splint
• Operative : Closed reduction with percutaneous pinning

12. S U P R A C O N D Y L A R F R A C T U R E S

13. EPIDEMIOLOGY
• Epidemiology
– incidence
• extension type most common (95-98%)
– demographics
• occur most commonly in children aged 5 to 7
• M = F
• Pathophysiology
– mechanism of injury
• fall on outstretched hand

14. PRESENTATION
• Symptoms
– pain
– refusal to move the elbow
• Physical exam
– inspection
• gross deformity
• swelling
• bruising
– motion
• limited active elbow motion

15. ASSOCIATED INJURY
• vascular injury (1%)
– rich collateral circulation can maintain circulation despite vascular injury
• neuropraxia
• anterior interosseous nerve neurapraxia (branch of median n.)
• the most common nerve palsy seen with supracondylar humerus fractures
• radial nerve palsysecond most common neurapraxia (close second)
• ulnar nerve palsyseen with flexion-type injury patterns
• nearly all cases of neurapraxia following supracondylar humerus fractures
resolve spontaneously, and therefore, further diagnostic studies are not
indicated in the acute setting
• ipsilateral distal radius fractures

16. IMAGING FILM AP,LAT ELBOW
• posterior fat pad sign

17. MEASUREMENT
• displacement of the anterior humeral line
– anterior humeral line should intersect
the middle third of the capitellum
– capitellum moves posteriorly to this
reference line in extension type fracture

18. ALTERATION OF BAUMANN ANGLE
• normal is 70-75 degrees, but best judge is a
comparison of the contralateral side
• deviation of more than 5 degrees indicates
coronal plane deformity and should
not be accepted

19. CLASSIFICATION
GARTLAND CLASSIFICATION
TYPE I Nondisplaced, beware of subtle medial comminution leading to cubitus varus
TYPE II Displaced, posterior cortex intact
TYPE III Completely displaced
TYPE IV Complete periosteal disruption with instability in flexion and extension

20. GARTLAND I

21. GARTLAND II

22. GARTLAND III

23. GARTLAND IV

24. TREATMENT
• Nonoperative
– long arm posterior splint then long arm casting with less than 90° of elbow
flexion techniquetypically used for 3-4 weeks and maybe followed for additional
time in removable long arm posterior splint
– Indications :
• Type I (non-displaced) fractures
• Type II fractures that meet the following criteria
– anterior humeral line intersects the anterior half of capitellum
– minimal swelling present
– no medial comminution
• Operative
– closed reduction and percutanous pinning
• indications : Type II and III supracondylar fractures

25. COMPLICATION
• Pin migration
– most common complication (~2%)
• Infection
– occurs in 1-2.4%
– typically superficial and treated with oral antibiotics
• Cubitus valgus
– caused by fracture malunion
– can lead to tardy ulnar nerve palsy
• Cubitus varus (gunstock deformity)
– caused by fracture malunion

26. REFERENCE
• http://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric