Paediatric Supracondylar Fracture
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
Classify this injury and describe the clinical urgency.
What nerves are at risk and how would you assess them?
Describe your initial management of this child.
Describe your operative technique for this fracture.
What if the pulse does not return after reduction and pinning?
What are the potential complications of supracondylar fractures?
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
- Document neurovascular status - before AND after any manipulation
- White pulseless hand - immediate reduction, don't wait for theatre
- Pink pulseless hand - usually does well, but needs urgent fixation
- AIN palsy - most common nerve injury, usually recovers
- Lateral-only pinning - safer for ulnar nerve
- Anterior humeral line - key to confirming reduction on lateral
- 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