Slideshow
-
Figure 1. Anteroposterior radiograph of injured right elbow.
-
Figure 2. Lateral view of elbow.
A 6-year-old girl presents to the emergency department (ED) with severe right elbow pain and deformity after a fall from the monkey bars 2 hours earlier. On physical examination, the patient’s skin is intact and she can move her fingers and wrist but cannot move the elbow. Her right hand is pink and warm but no palpable radial or ulnar pulses are present. Radiographs are taken in the ED (Figures 1 and 2).
Submit your diagnosis to see full explanation.
A detailed neurovascular examination is critical after supracondylar humerus fractures. Radial and ulnar artery pulses should be palpated or found with Doppler ultrasonography. A pink warm hand can be present in the absence of a pulse, which may be a sign of a vascular spasm or entrapment. A cold pale hand with capillary refill >2 seconds represents a poorly perfused hand.
Closed reduction and percutaneous fixation in the operating room should be performed urgently in patients with decreased perfusion to avoid an ischemic injury.1 Closed reduction almost always restores vascular perfusion. Angiography is not indicated as closed reduction successfully restores perfusion. Open exploration of the antecubital fossa may be necessary in the case of absent pulses after closed reduction.1,2
The most common nerve injured with pediatric supracondylar humerus fractures is the anterior interosseous nerve (AIN).3 Patients with AIN injuries will not be able to flex the thumb IP joint or the DIP of the index finger (can’t make an “OK” sign). Anterior interosseous nerve (AIN) injuries almost always recover over time (>90%) with an average of 49 days to complete resolution.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
References
1. Howard A, Mupuri K, Abel MF, et al. The treatment of pediatric supracondylar humerus fractures J Am Acad Orthop Surg. 2012;20(5):320-327. doi:10.5435/JAAOS-20-05-320
2. Barrett KK, Skaggs DL, Sawyer JR, et al. Supracondylar humeral fractures with isolated anterior interosseous nerve injuries: is urgent treatment necessary? J Bone Joint Surg Am. 2014;96(21):1793-1797. doi:10.2106/JBJS.N.00136
3. Woon C, Souder C, Skaggs DL. Supracondylar fracture — pediatric. OrthoBullets. Updated June 2, 2022. Accessed July 11, 2022. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric
QUESTION
