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

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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)

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Questions & Model Answers

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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:

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

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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

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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

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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)

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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.

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Related Topics

• Lateral Condyle Fractures
• Medial Epicondyle Fractures
• Paediatric Elbow Fractures
• Volkmann Ischaemic Contracture
• Cubitus Varus Deformity