# CIM Case: Paediatric Supracondylar Fracture ## Clinical Scenario **Patient:** 6-year-old girl **Presentation:** Fall from monkey bars at school, landed on outstretched right arm, immediate elbow pain and deformity **Relevant history:** Previously healthy, no prior fractures, right-hand dominant, no other injuries **Examination findings:** - Distressed child, holding right arm in supported position - Obvious swelling and deformity at elbow - Anterior dimpling of skin (puckering sign) - **Radial pulse ABSENT** - Hand appears **pale and cool** compared to left - Capillary refill 4 seconds in fingers - Weak finger flexion (cannot flex DIP of index finger or IP of thumb) - Sensation intact to light touch - Unable to extend elbow from flexed position - No other injuries on secondary survey --- ## Investigations Provided ### Imaging **Image 1: AP and Lateral Radiographs of Right Elbow** **Radiological features:** - Extension-type supracondylar fracture - Complete displacement with no cortical contact - Proximal fragment displaced anteriorly (penetrating brachialis) - **Gartland Type IIIB** (posteromedial displacement of distal fragment) - Loss of anterior humeral line through capitellum - Loss of normal carrying angle - Sail sign (posterior fat pad) and elevated anterior fat pad - No associated fractures (radial head, medial epicondyle) --- ## Questions & Model Answers **Gartland Classification (Modified by Wilkins):** | Type | Description | Stability | |------|-------------|-----------| | **I** | Undisplaced, fat pad sign only | Stable | | **II** | Displaced, posterior cortex intact (hinge) | Unstable in extension | | **IIA** | Angulated only | - | | **IIB** | Angulated with rotation | - | | **III** | Completely displaced, no cortical contact | Unstable | | **IIIA** | Posteromedial displacement | - | | **IIIB** | Posterolateral displacement | - | | **IV** | Multidirectional instability (unstable in flexion and extension) | Very unstable | **This Fracture: Gartland Type IIIB** - Complete displacement - Posterolateral displacement of distal fragment (or posteromedial - opposite direction determines neurovascular risk) **This is an ORTHOPAEDIC EMERGENCY Because:** 1. **Absent radial pulse** - brachial artery involvement 2. **Pale, cool hand** - suggests true vascular compromise (not just spasm) 3. **Weak finger flexion** - anterior interosseous nerve (AIN) palsy 4. **"White pulseless hand"** - requires IMMEDIATE intervention **Vascular Status Classification:** | Hand Status | Description | Management | |-------------|-------------|------------| | Pink, pulsed | Normal perfusion | Routine CRPP | | **Pink, pulseless** | Good collateral supply | Urgent CRPP, observe | | **White, pulseless** | Vascular emergency | Immediate reduction + exploration | > **Consultant Tip:** A WHITE pulseless hand is an emergency - immediate reduction is required. A PINK pulseless hand usually improves with reduction and can be observed. **Nerve Injuries in Supracondylar Fractures:** | Nerve | Fracture Pattern | Clinical Test | Incidence | |-------|------------------|---------------|-----------| | **AIN** (branch of median) | Extension type (IIIB) | "OK" sign - FPL (thumb IP), FDP to index | 10-15% | | Median nerve (main trunk) | Extension type | Sensation web space thumb-index, thenar function | 5% | | Radial nerve | Posterolateral displacement | Wrist/finger extension, sensation dorsal web space | 5-10% | | Ulnar nerve | Flexion type, medial K-wire | Finger abduction, sensation little finger | Rare | **Anterior Interosseous Nerve (AIN) Assessment:** - Motor only branch (no sensory) - Test: "OK" sign or "pinch" test - Flex IP joint of thumb (FPL) - Flex DIP of index finger (FDP to index) - If weak/absent: AIN palsy likely **This Patient's Findings:** - Weak finger flexion suggests AIN palsy - Most common nerve injury with extension-type fractures - Usually neurapraxia - recovers spontaneously (90%) **Pre-reduction Documentation (Essential):** - Document ALL nerves before any manipulation - Repeat after reduction - Difficult in distressed child - simple tests: - "Thumbs up" (radial) - "Cross fingers" (ulnar) - "OK sign" (AIN/median) - Sensation to light touch in each nerve territory > **Consultant Tip:** Always document neurovascular status BEFORE and AFTER manipulation. A new deficit post-reduction may need exploration. **Immediate Management (ED):** **Step 1: Assess and Document** - ABC assessment - Complete neurovascular examination - Look for other injuries - Document pulse status, perfusion, motor function **Step 2: If White Pulseless Hand** - **DO NOT wait for theatre** if significant delay - Attempt gentle reduction in ED under sedation - Goal: restore gross alignment to improve perfusion **Reduction Technique:** - Adequate sedation (ketamine or propofol with analgesia) - Longitudinal traction with elbow slightly flexed - Correct rotation (usually medial rotation of distal fragment) - Flex elbow while maintaining traction - Check pulse after reduction **Step 3: Outcomes After Reduction** | Scenario | Next Step | |----------|-----------| | Pulse returns, hand pink | Splint carefully, urgent theatre for CRPP | | Pink pulseless (perfused) | Urgent theatre for CRPP, observe closely | | White pulseless persists | IMMEDIATE theatre - reduction + exploration | **Step 4: Splint Application** - Above elbow backslab - Elbow at 60-90° flexion (not hyperflexed if vascular compromise) - Forearm neutral or slight pronation - Elevate in Bradford sling **Step 5: Analgesia** - IV morphine titrated - Intranasal fentanyl if no IV access - Regional block contraindicated (masks compartment syndrome) > **Consultant Tip:** In a white pulseless hand, don't delay for X-rays or theatre. Reduce immediately in ED if necessary to restore perfusion. **Closed Reduction and Percutaneous Pinning (CRPP)** **Setup:** - General anaesthesia - Supine on radiolucent table - Arm on radiolucent arm board or across chest - Mini C-arm positioned for AP and lateral views - Sterile prep entire arm **Reduction Technique:** | Step | Manoeuvre | |------|-----------| | 1 | Longitudinal traction with elbow extended | | 2 | Correct coronal plane (varus/valgus) | | 3 | Correct rotation (medial rotation common) | | 4 | Milk distal fragment anteriorly while flexing elbow | | 5 | Final flexion to lock reduction | **Verification of Reduction:** - **AP view:** Medial and lateral columns aligned, symmetric columns - **Lateral view:** Anterior humeral line through middle third of capitellum - **Baumann angle:** 9-26° (compare to contralateral if unsure) **Pin Configuration Options:** | Configuration | Technique | Pros/Cons | |---------------|-----------|-----------| | **Lateral entry only** | 2-3 divergent lateral pins | Safe for ulnar nerve, may be less rotationally stable | | **Crossed pins** | Lateral + medial entry | Maximum stability, ulnar nerve at risk with medial pin | **Lateral Entry Pin Technique:** - Two or three 1.6-2.0mm K-wires - Enter through lateral column - Diverge at 30-40° angle - Cross at fracture site - Engage opposite medial cortex - Check on both views **Medial Pin Technique (if used):** - Flex wrist to protect ulnar nerve - Extend elbow to 90° - Palpate medial epicondyle - Small incision to identify nerve - Insert pin anterior to epicondyle - Engage lateral cortex **Post-fixation:** - Confirm pin position on fluoroscopy - Test stability - Bend pins, cut outside skin - Above-elbow backslab at 60-70° flexion - Recheck pulse > **Consultant Tip:** Lateral-only pinning is now preferred by many surgeons. If using medial pin, make a small incision and visualise/protect the ulnar nerve. **Management Algorithm for Persistent Pulselessness:** **Pink Pulseless Hand (Well Perfused):** - Good capillary refill (<2 seconds) - Warm hand - Doppler signal present - **Management:** Close observation, no exploration needed - Monitor pulse oximetry on fingers - Serial neurovascular checks every 1-2 hours **Pale/White Pulseless Hand (Poorly Perfused):** - Capillary refill >3 seconds - Cool hand - No Doppler signal - **Management:** Brachial artery exploration **Surgical Exploration:** - Anterior approach to distal humerus and brachial artery - Incision: Anteromedial, along medial border of biceps - Release bicipital aponeurosis (lacertus fibrosus) - Identify brachial artery proximal and distal to fracture **Findings at Exploration:** | Finding | Management | |---------|------------| | Artery in spasm | Topical papaverine, warm saline, wait | | Artery kinked/tethered | Release from fracture spike | | Artery contused (intimal damage) | May need repair or bypass | | Artery transected | Vascular repair (end-to-end or vein graft) | | Thrombosis | Thrombectomy, repair | **Post-exploration:** - Confirm flow (Doppler, visual pulsation) - Fasciotomy if >6 hours ischaemia - Close loosely or leave wound open if swollen **Compartment Syndrome Watch:** - High index of suspicion - Pain out of proportion - Pain with passive stretch - Tense compartments - Perform fasciotomy if any concern > **Consultant Tip:** Pink pulseless hands almost always do well. White pulseless hands after reduction need exploration. Don't hesitate to call vascular surgery if needed. **Complications:** **Vascular Complications:** - Brachial artery injury (as discussed) - Volkmann ischaemic contracture (late - missed compartment syndrome) - Most feared complication - preventable with vigilance **Neurological Complications:** | Timing | Nerve Involvement | Prognosis | |--------|-------------------|-----------| | At injury | AIN most common | 90% recover spontaneously | | Iatrogenic (medial pin) | Ulnar nerve | Usually neurapraxia, recovers | | Delayed | Cubitus varus → tardy ulnar palsy | May need transposition | **Malunion:** | Deformity | Cause | Consequence | |-----------|-------|-------------| | **Cubitus varus** (gunstock) | Most common, internal rotation/varus malreduction | Cosmetic, tardy ulnar palsy | | **Cubitus valgus** | Rare, lateral collapse | Tardy ulnar palsy | | **Hyperextension** | Anterior angulation | Cosmetic, functional | **Cubitus Varus:** - Most common malunion - Causes: Malreduction, loss of reduction, medial column comminution - Treatment: Lateral closing wedge osteotomy (if significant) **Stiffness:** - Usually temporary - Full ROM expected within 6-12 months - No aggressive physiotherapy needed in children - Avoid passive stretching **Pin Site Infection:** - Superficial: Oral antibiotics, early pin removal - Deep: IV antibiotics, may need washout **Myositis Ossificans:** - Rare - Associated with aggressive physiotherapy - Avoid passive stretching > **Consultant Tip:** Cubitus varus is the most common malunion. It's primarily cosmetic but can cause delayed ulnar nerve problems. Prevention through accurate reduction is better than late osteotomy. --- ## Key Teaching Points ### Pattern Recognition **This pattern suggests Extension-Type Supracondylar Fracture:** - Child 5-8 years old (peak incidence) - Fall onto outstretched hand (FOOSH) - Elbow swelling and S-shaped deformity - Anterior skin puckering (proximal fragment) - May have neurovascular compromise **Gartland Classification Quick Reference:** - **Type I:** Non-displaced (fat pad signs only) - **Type II:** Displaced but hinged (posterior cortex intact) - **Type III:** Completely displaced (no cortical contact) - **Type IV:** Unstable in both flexion and extension **Neurovascular Status Categories:** | Status | Description | Urgency | |--------|-------------|---------| | Normal | Pulse present, warm, normal function | Urgent (within 24h) | | Pink pulseless | Perfused but no radial pulse | Urgent (within 8-12h) | | White pulseless | No perfusion | IMMEDIATE (within 1-2h) | ### Critical Management Points 1. **Document neurovascular status** - before AND after any manipulation 2. **White pulseless hand** - immediate reduction, don't wait for theatre 3. **Pink pulseless hand** - usually does well, but needs urgent fixation 4. **AIN palsy** - most common nerve injury, usually recovers 5. **Lateral-only pinning** - safer for ulnar nerve 6. **Anterior humeral line** - key to confirming reduction on lateral 7. **No aggressive physio** - children regain motion naturally --- ## Common Examiner Follow-ups **Q: "What is the anterior humeral line and how do you use it?"** The anterior humeral line is a line drawn along the anterior cortex of the humerus on a lateral radiograph. **Normal:** Line passes through the middle third of the capitellum **Extension malunion:** Line passes anterior to capitellum (posterior angulation) **Flexion malunion:** Line passes through posterior third Use it to: - Assess adequacy of reduction - Detect subtle extension injuries - Compare to normal side if uncertain --- **Q: "What is Baumann's angle and what is the normal value?"** Baumann's angle is measured on AP radiograph: - Angle between the long axis of humerus and the growth plate of the capitellum - **Normal: 9-26°** (average 16°) - Compare to contralateral side (should be within 5°) - Increased angle suggests varus malunion --- **Q: "When would you consider open reduction?"** Indications for open reduction: - Failed closed reduction (3 attempts) - Vascular injury requiring exploration - Open fracture - Soft tissue interposition (brachialis, nerve) - Severely comminuted fracture Approach: Anterior (for vascular exploration) or lateral (for fixation) --- **Q: "How do you prevent ulnar nerve injury with medial pinning?"** To protect the ulnar nerve: - Make small incision over medial epicondyle - Identify and retract ulnar nerve - Flex wrist (relaxes nerve) - Extend elbow from hyperflexion to ~90° - Direct pin anterior to epicondyle - Engage lateral cortex Many surgeons now avoid medial pins entirely, using 3 lateral pins for equivalent stability. --- ## Related Topics - Lateral Condyle Fractures - Medial Epicondyle Fractures - Paediatric Elbow Fractures - Volkmann Ischaemic Contracture - Cubitus Varus Deformity