Pediatric supracondylar fracture of humerus
Causes / typical injury mechanism:
Supracondylar humerus fractures are typically caused by a fall onto an outstretched arm, causing a hyperextension load on the elbow. A more uncommon mechanism of injury is a fall directly onto the olecranon of a flexed elbow. Classic history and presentation:
The classic presentation is a child who sustains a fall and trauma to the extremity, with immediate onset of pain and unwillingness to move the elbow. Prevalence:
This is the most common fracture of the elbow in children.
- Age – Seen most in children aged 3-8 years.
- Sex / gender – Occurs with equal prevalence in both sexes.
The olecranon hyperextends into the olecranon fossa, acting as a fulcrum and leading to anterior tension force and failure of the distal humerus anteriorly.Grade / classification system:
Modified Gartland classification of extension-type fractures
- Type I – Nondisplaced
- Type II – Displaced with intact posterior hinge
- Type III – Completely displaced with no intact cortices
- Type IV – Multidirectional instability (determined by examination under anesthesia)
Classification of vascular status
- Hand well perfused (warm, pink), radial pulse present
- Hand well perfused (warm, pink), radial pulse absent
- Hand poorly perfused (cool, blue, blanched), radial pulse absent
S42.416A – Nondisplaced simple supracondylar fracture without intercondylar fracture of unspecified humerus, initial encounter for closed fracture
263193000 – Supracondylar fracture of humerus
Differential Diagnosis & Pitfalls
- Look for associated fractures in the ipsilateral extremity.
- Do not miss a vascular injury. If the hand is noted to be pulseless, immediate orthopedic referral is recommended. It is not advised to perform ED-based acute reductions as the neurovascular bundle can be entrapped in the fracture, potentially leading to transection or further injury.
- If the hand remains pulseless and poorly perfused after operative reduction, immediate exploration of the brachial artery is indicated as 50% of patients will require vascular surgery and 25% may develop compartment syndrome.
- Do not miss compartment syndrome. Look for tenseness of the volar compartment, swelling at the elbow, and pain with passive finger extension and flexion. Remember the 3 As of pediatric compartment syndrome: anxiety, agitation, and analgesic requirement.