Clinical practice update – PaediatricsPaediatric elbow injuries. Part 2: Assessment of paediatric elbow X-rays, identification and management of supracondylar fractures
Section snippets
Case study
Sophie is a four year old girl who presents to the emergency department (ED) with reluctance to use her right arm since yesterday afternoon. She fell off the bottom of a slide after her brother slid down knocking her off. Sophie has been unsettled overnight and is not using her affected arm. She is holding her arm with her elbow flexed against her body. She has mild swelling to her elbow but there are no bruises or grazes. She complains that her arm is sore and has generalised tenderness on
Background
The differences of the child's skeleton from that of the adult lead to different mechanisms of injury, fracture patterns, healing and treatment and are essential for the clinician to understand.1 Children's bones have structural properties allowing them to withstand greater force and to heal more quickly1 along with remarkable remodelling potential.2 In contrast the ligamentous system is relatively stronger than that of the adult rendering the skeletal system at greater risk of injury. In other
History
Sophie presents following a fall from a slide. Her mother witnessed the fall but is unclear how she landed. Over 90% of supracondylar fractures in children are the result of a fall onto an outstretched arm,3 which is usually an attempt to protect themselves as they fall.7 A fall on the outstretched hand with the elbow hyperextended most commonly causes an extension type of fracture where the force applied to the distal humerus may push it posteriorly.6 If the injury occurs from a fall on the
Examination
Sophie presents carrying her arm with her elbow flexed and the unaffected arm supporting the injured arm. She is complaining of a sore elbow and becomes distressed with attempts to examine or move her arm. She has tenderness over the distal humerus and slight swelling around her elbow.
Presentation of supracondylar fractures in the ED can range from obvious, with visible elbow deformity, to the occult, with only subtle clues present on X-ray.3 Presentation of supracondylar fractures can be
Investigation
Imaging of the elbow to identify injury will include an anteroposterior (AP) view with the elbow extended and a lateral view with the elbow flexed to 90° and the forearm neutral.5, 7 The majority of treatment decisions are made from assessment of the lateral view, making it essential to obtain a true lateral view.5 However, this can be a difficult view to obtain in an uncooperative child who is in significant discomfort.
The distal humerus presents a teardrop or hourglass like shadow above the
Diagnosis
Supracondylar humeral fractures are initially classified as either extension or flexion injuries.6 They are then most commonly classified according to the amount of radiographic displacement of the distal fragment. Extension fractures are described using nomenclature first proposed by Gartland (1959) and modified to include a Type IV injury.2 Type I is an undisplaced fracture with no angulation. The fracture line may be easily visible or indistinguishable. The presence of a posterior fat pad
Management
Supracondylar fracture management commences with the provision of first aid which includes; adequate analgesia and temporary splinting for comfort until a definitive treatment is implemented.7 There are a number of factors which influence definitive management, which is the focus of the following section, such as injury classification, stability and neurovascular status.4
Sophie was treated as a Type I fracture and was therefore placed in an above elbow backslab and a broad-arm sling. She was
Conclusion
Elbow injuries and in particular supracondylar fractures are common presentations to the paediatric ED. While many of these injuries are obvious, Sophie served as an example of an elbow injury where bony injury may be easily overlooked without careful examination and an understanding of the normal variants of the growing elbow that affect interpretation of X-rays. This paper has highlighted some of these normal variants and has briefly outlined management of the supracondylar fracture. This has
Provenance and conflict of interest
Jemma Bates-Smith has not conflicts of interest to declare. Dianne Crellin is an Associate Editor (Paediatrics) but had no role in the peer-review or editorial decision-making relating for this paper. This paper was not commissioned.
Funding
None.
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