Edited by Nattaly Greene, David Evans - 7/1/2021
Descriptors
- One of the most common pediatric fracture patterns
- Usually happens in the setting of a fall onto an outstretched hand
Exam Pearls
Start on well hand and move to injured extremity. A good neurovascular exam is essential - only report what you see
Inspection: Assess skin for open fractures. In some instances, there is gross deformity and swelling about the elbow with ecchymosis in antecubital fossa. Assess for pucker sign.
Vascular: Assess for adequate perfusion of hand and digits. Feel for radial pulse whether present or absent by palpation and compare to contralateral side to evaluate for symmetry. If not palpable, doppler. Assess for perfusion by temperature and color of digits. A well perfused hand is warm and pink; a poorly perfused hand will feel cool and appear pale with sluggish capillary refill.
Neurologic: Assess for common neuropraxias which include anterior interosseous nerve (AIN), radial nerve, ulnar nerve palsies in that order.
AIN: The motor innervation for AIN includes the radial half of FDP, FPL, and PQ. The easiest way to evaluate function is to have the patient make an OK sign. Sometimes it is easier to simply ask to trigger/flex thumb.
Radial nerve: Provides innervation to the extensors including deep extensors such as APL, EPB, EPL, and EIP. One easy way to evaluate function is to have patient give a ‘thumbs up’ and resist abduction of thumb.
Ulnar nerve: Provides innervation at the level of the finger to the dorsal and palmar interossei and 3rd and 4th lumbricals. Have the patient cross index and long finger to evaluate function or make scissor/alligator mouth motion.
Workup
Radiographs: AP, oblique, and lateral Xrays of the elbow - examine anterior humeral line and Baumann angle
Other imaging: If concern for ipsilateral forearm/wrist fractures, obtain AP/Lateral of respective areas or concern. Important not to miss floating elbow.
Labs: Not usually necessary
Management
Need for acute intervention: Yes, immobilization. Urgency and operative vs non-operative depends on fracture pattern and, most importantly, on vascular status.
Non operative:
- Hand warm and well perfused with no neurological deficits
- Based on Garland classification- Type I (non displaced) fractures; type II with minimal swelling - no medial comminution and anterior humeral line intersects the capitellum
Weight-bearing and range of motion: Nonweightbearing and no range of motion at elbow
Type of immobilization: Bivalved long arm cast
If operative (Type III) may splint in 30-40 degrees of flexion
Admission or discharge status: Operative injuries - admit and consent for closed vs. open treatment; non operative may discharge and follow up in a week
Anticoagulation: None
Antibiotics: None for closed fractures. Open fractures will require operative irrigation and debridement and perioperative antibiotics.
Surgical Indications
Absolute: Open fractures; pulseless, poorly perfused hand, and/or neurological deficits.
Emergent operative supracondylars (within hours) - Pulseless, poorly perfused hand (white hand, pale, cool and no doppler)
Urgent operative supracondylars (same day; don't wait overnight)
- Pulseless, well perfused hand
- Sensory nerve deficits
- Floating elbow: ipsilateral forearm/wrist fractures to reduce risk of compartment syndrome
Non urgent (can wait overnight)
- Warm and perfused hand
- Splint in 30-40 degrees of elbow flexion; elevate and admit for observation and elective surgery