The Case

An intrepid child presents to the Emergency Department after falling from the monkey bars. He has significant pain and swelling about the elbow, along with very limited voluntary range of motion, but his neurovascular status is intact. The X-Rays show the following:

Image courtesy Ortho Bullets https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric
Image courtesy Ortho Bullets https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric

The Diagnosis

This is a Type II Supracondylar Fracture of the Humerus. These injuries are generally seen after a fall onto an outstretched extremity. The monkey bars are the “classic” playground apparatus in which they occur – just far enough to fall to allow one time to stick their arm out towards the ground. The most important X-Ray view is the 90-degree true lateral, but you will also need an AP view. That will allow you to assess for characteristic X-Ray findings such as:

  • Posterior fat pad sign: Lucency on the lateral view along the posterior distal humerus and olecranon fossa. This is highly suggestive of occult fracture around the elbow even if there is not an obvious fracture.
  • Displacement of the anterior humeral line: The anterior humeral line should intersect the middle third of the capitellum in children > 5 years old, and touch the capitellum in children in children <5.

Here is the annotated version of our patient’s X-Ray demonstrating the findings:

Management

If you see a Type II and above splint for comfort (posterior long arm angled at a position tolerable to the child 30-90 degrees) and give pain medicine! There are four types of Supracondylar Fractures of the Humerus. Their management differs by type of course.

Nonoperative treatment for supracondylar fractures of the humerus involves long arm casting with less than 90° of elbow flexion. Indications for this method include a warm perfused hand without neuro deficits and Type I (non-displaced) fractures, as well as Type II fractures that meet specific criteria such as the anterior humeral line intersecting the capitellum, minimal swelling, and no medial comminution. Casting lasts for three weeks with repeat radiographs at one week to check for displacement.

Operative treatment options include closed reduction and percutaneous pinning (CRPP) and open reduction. Indications for CRPP include Type II and III supracondylar fractures. Timing of CRPP is dictated by neurovascular status. Non-urgent cases, which can wait overnight, include a warm perfused hand without neuro deficits.

Urgent cases, requiring same-day treatment, include open fractures, a pulseless limb, non-perfused hand, sensory nerve deficits, excessive swelling, and signs like the “brachialis sign” which indicates a more serious injury with a higher likelihood of arterial injury. “Floating elbow” injuries also require timely pinning to reduce the risk of compartment syndrome.

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References

Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev. 2018 Oct 1;3(10):526-540. doi: 10.1302/2058-5241.3.170049. PMID: 30662761; PMCID: PMC6335593.

Saeed W, Waseem M. Elbow Fractures Overview. 2023 Aug 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28723005.

Woon, C. Supracondylar Fracture – Pediatric: Ortho Bullets. Accessed 7/17/2024. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric