aka Bone and Joint Bamboozler 007
This 5 year old presented to ED with elbow pain and swelling after falling onto his left outstretched arm. The XR is shown.
What is the abnormality?
- Supracondylar fracture
- There is a posterior fat pad.
- Anterior fat pads are normal, although a large anterior fat pad (based on subjective judgement) can be abnormal (sail sign).
- The mantra goes that posterior fat pads are always abnormal – 75% of them have fractures.
- Fat pads generally demonstrate intra-articular disruption.
How do you grade this injury?
Gartland I supracondylar fracture.
- The posterior fat pad and the history indicate a likely supracondylar fracture. These are the most common elbow injuries in kids between 5 and 8 years.
- Some can have anterior displacement of the distal humerus (flexion-type) but most are extension-type injuries.
- The anterior humeral line should go through the middle third of the capitellum. If it doesn’t then this indicates displacement.
- AP views are also helpful but in a Gartland I often there will be no fracture visible on AP.
Gartland I – no displacement
Gartland II – posterior displacement of the distal end of the humerus but with intact cortex (image 3)
Gartland III – complete displacement
How is this managed?
- Gartland I supracondylar fractures can be managed by either a collar and a cuff or a long arm backslab. The healing will be the same but pain management is improved by a backslab (discussion with parents can help decide the most suitable choice). This is usually kept on for three weeks but depending on your hospital there would usually be ortho follow up before this.
- Gartland II can be reduced in ED under sedation (nitrous or ketamine usually). This is done by gently pushing (anteriorly) on the distal end of the humerus as the elbow is flexed to 90 degrees.
- Gartland III will need to go to theatre so call for ortho input
Andrew Dixon from Radiopaedia.org explains the radiological appearance of elbow joint effusions in adults and children in this excellent video tutorial:
Jeremy Jones from Radiopaedia.org explains the radiological appearance of supracondylar fractures children