What is your diagnosis?

Supracondylar fracture 

• Pearl: Supracondylar fractures are injuries almost exclusive to pediatric patients and occur most commonly between the ages of 5-7 years [1].

• Pearl: Distinguish this injury from a radial head subluxation by clinical history and examination. You don’t want to pull on or manipulate the elbow in a patient with a supracondylar fracture!

What secondary findings on plain films of the elbow can help determine whether a fracture is present?

Anterior humeral line (Image 2), “Sail sign” (Image 3)

Image 2: Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10343

Image 3: Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 59706

What concomitant injuries should you be acutely worried about?

• Other bony injuries on the ipsilateral upper extremity (shoulder, wrist)

• Ulnar Nerve Injury

• Radial Nerve Injury

• Anterior Interosseous Nerve (AIN) injury

• Vascular injury (up to 20% of fractures [2])

• Pearl: Multiple nerves and the brachial artery wrap around the upper extremity just proximal to the elbow. Make sure to assess neurovascular status on the initial evaluation as well as before and after any manipulation performed.

Image 4: Cases courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 55130, rID 55132

What is your management in the ED?

This fracture needs to be urgently reduced and splinted. 

• Pearl: The vast majority of pediatric supracondylar fractures will require surgical repair. Fractures that are neither angulated nor displaced may possibly be successfully managed conservatively without surgery.

Does this patient require orthopedic consultation acutely in the ED?

Yes

• Pearl: As this patient will almost certainly require surgery, it is important to establish a plan for operative intervention prior to ED discharge.