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Diagnose on Sight: 6 year old with elbow pain

2016-12-22T20:05:33+00:00

elbowCase: A previously healthy 6 year old male presents with left elbow pain after wrestling with a friend. What is the diagnosis? Click on image for a larger view.

Poll Results

Answer (Click for explanation)

Type II Supracondylar fracture of the elbow

Explanation

More than half of all pediatric elbow fractures are supracondylar, because this is the weakest part of the elbow joint. They are most commonly caused by a fall on outstretched hand.1

In this case, the anterior humeral line (red) does not intersect the middle third of the capitellum, suggesting a fracture. The arrow points to a disruption of the anterior cortex.

elbow with arrows

Choice of treatment is guided by the Gartland classification. Most orthopedists recommend conservative management for non or minimally displaced fractures, while displaced fractures are treated with operative fixation.2

Gartland classification2

Type Extent of injury Radiographic finding Treatment
I Non-displaced, subtle Intact anterior humeral line (may only have posterior fat pad) Splint, non-operative
II Displaced, posterior cortex intact Anterior humeral line not through middle 1/3 of capitellum Likely operative
III/IV Completely displaced Rotation, comminution Operative

Special attention must be paid to a careful neurovascular exam to evaluate for compartment syndrome. A delay in diagnosis can lead to the devastating complication of Volkmann’s ischemic contracture, which results in severe muscle fibrosis and neuropathy.3

Master Clinician Bedside Pearls

ChrisDoty-298x298 CircleChristopher I. Doty, MD
Program Director & Vice Chair for Education
Associate Professor of Emergency Medicine
University of Kentucky-Chandler Medical Center

1.
Chasm R, Swencki S. Pediatric orthopedic emergencies. Emerg Med Clin North Am. 2010;28(4):907-926. [PubMed]
2.
Ladenhauf H, Schaffert M, Bauer J. The displaced supracondylar humerus fracture: indications for surgery and surgical options: a 2014 update. Curr Opin Pediatr. 2014;26(1):64-69. [PubMed]
3.
Omid R, Choi P, Skaggs D. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90(5):1121-1132. [PubMed]
Jeff Riddell, MD

Jeff Riddell, MD

ALiEM Assistant Editor
Diagnose on Sight series;
Medical Education Research Fellow
University of Washington / Harborview Medical Center
Jeff Riddell, MD

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