EXT. CONFERENCEE X T. ว ส ว ตั ต ์ อ น ัน ต ์ณ ัฐ ศ ิริ

PATIENT PROFILE

• ดญ. ไทย อายุ 5ปี6เดือน ภมูลิำาเนา อ.ครบุร ีจ.นครราชสมีา • วคัซนีครบมสีมุด พฒันาการสมวยั

CHIEF COMPLAINT

• เจบ็ต้นแขนซา้ย 15ชม ก่อนมารพ.

PRESENT ILLNESS

• 15ชม ก่อนมารพ. ขณะเล่นชงิชา้ พลัดตกลงมาสงู ประมาณ60ซม. ศอกซา้ยกระแทกพื้น เจบ็มาก ขยบัขอ้ศอกซา้ยไมไ่ด้ ปวด กำามอืได้ ขยบัขอ้มอืได้ ไมช่า ไมม่ีแขนสซีดีลง ไมม่แีขนอ่อนแรง ไมม่ขีอ้มอืตก อาการปวดไมดี่ขึ้น จงึพามารพ.

PRIMARY SURVEY

• A: patent airway, can speak, no post C-spine injury, can flex neck• B: normal breathing pattern, no dyspnea• C: BP 107/60 ,CR <2secs, no external wound seen• D: pupil3mm RTLBE, E4V5M6 • E: no external wound, events as mentioned

SECONDARY SURVEY

• A : no known allergy• M : no current meds• P : no known sx or any underlying disease• L : last meal 12.00• E : events as mentioned

PHYSICAL EXAMINATION

• GA: A Thai girl conscious, not pale, no jaundice• HEENT: no pale conjunctiva, anicteric sclera• Heart : no active precordium, no cyanosis, CR<2secs, no heaving, no thrills,

normal S1S2, mo murmur• Lungs: no retraction, normal breathing pattern, clear sounds both lungs• Abdomen: not distend, normoactive bowel sound,soft, not tender, no

hepatospleenomegaly

PHYSICAL EXAMINATION

• EXT: Lt Elbow : swelling, no external wound, no bruising, limit ROM Lt. elbow joint due to pain, radial pulses 2+,AIN intact(can do OK sign), Radial n. intact (no wrist drop)

INVESTIGATION

DIAGNOSIS

• Lt. supracondylar fracture Gartland II

TREATMENTS

• At ER : on Posterior long arm splint• Operative : Closed reduction with percutaneous pinning

S U PRAC O N DY L A R F RAC T U R ES

EPIDEMIOLOGY• Epidemiology

– incidence• extension type most common (95-98%)

– demographics• occur most commonly in children aged 5 to 7• M = F

• Pathophysiology– mechanism of injury

• fall on outstretched hand

PRESENTATION• Symptoms

– pain– refusal to move the elbow

• Physical exam– inspection

• gross deformity• swelling• bruising

– motion• limited active elbow motion

ASSOCIATED INJURY• vascular injury (1%)

– rich collateral circulation can maintain circulation despite vascular injury• neuropraxia

• anterior interosseous nerve neurapraxia (branch of median n.)• the most common nerve palsy seen with supracondylar humerus

fractures• radial nerve palsysecond most common neurapraxia (close second)• ulnar nerve palsyseen with flexion-type injury patterns • nearly all cases of neurapraxia following supracondylar humerus

fractures resolve spontaneously, and therefore, further diagnostic studies are not indicated in the acute setting

• ipsilateral distal radius fractures

IMAGING FILM AP,LAT ELBOW• posterior fat pad sign

MEASUREMENT

• displacement of the anterior humeral line– anterior humeral line should intersect

the middle third of the capitellum– capitellum moves posteriorly to this

reference line in extension type fracture

ALTERATION OF BAUMANN ANGLE • normal is 70-75 degrees, but best judge is a

comparison of the contralateral side• deviation of more than 5 degrees indicates

coronal plane deformity and should not be accepted

CLASSIFICATION

GARTLAND CLASSIFICATIONTYPE I Nondisplaced, beware of subtle medial comminution leading to

cubitus varusTYPE II Displaced, posterior cortex intactTYPE III Completely displacedTYPE IV Complete periosteal disruption with instability in flexion and

extension

GARTLAND I

GARTLAND II

GARTLAND III

GARTLAND IV

TREATMENT• Nonoperative

– long arm posterior splint then long arm casting with less than 90° of elbow flexion techniquetypically used for 3-4 weeks and maybe followed for additional time in removable long arm posterior splint

– Indications : • Type I (non-displaced) fractures  • Type II fractures that meet the following criteria

– anterior humeral line intersects the anterior half of capitellum– minimal swelling present– no medial comminution

• Operative– closed reduction and percutanous pinning

• indications : Type II and III supracondylar fractures

COMPLICATION• Pin migration

– most common complication (~2%)• Infection

– occurs in 1-2.4%– typically superficial and treated with oral antibiotics

• Cubitus valgus– caused by fracture malunion– can lead to tardy ulnar nerve palsy

• Cubitus varus (gunstock deformity) – caused by fracture malunion

REFERENCE

• http://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric