Ortho Case of the Week – Peds Upper Extremity ANSWERS
Case 1: A 5-year-old female presents with her parents to the emergency department after a fall onto her outstretched hand with a chief complaint of right elbow pain. She refuses to move it and cries when you try to examine it.
1. Describe your read of the x-rays above.
Her elbow xrays depicted a displaced olecranon fracture (white arrow) with a posterior fat pad sign (blue arrow).
Knowledge of the timing and order of ossification sites in the pediatric elbow is critical to making this diagnosis.
The mnemonic CRITOE is frequently used as a memory aid for the pediatric elbow ossification sites.
The exact age of the formation of the ossification sites is variable both between sexes, with males forming the ossification sites approximately 1 year delayed from females, and at the individual patient level. However, the sequence of development of ossification centers remains the same.
For comparison, normal elbow xrays of a 5-year-old female are shown below.
2. Describe your management of this patient. What type of splint or other assistive device (sling, brace, etc.) would you place this patient in (if any) for this pathology?
This patient needs reduction with immobilization in a posterior long arm split (video) and close orthopedics follow-up.
Management of olecranon fractures:
- Stress fractures and apophysitis:
- NSAIDS, rest, avoidance of elbow resistance exercises
- Convert to cast if not improving clinically
- Non-displaced/minimally displaced fractures with intact extensor mechanism:
- Long arm splint/cast
- 3-4 weeks of immobilization
- Repeat x-rays at 7 days to assess for new displacement
- Displaced, unstable or comminuted fractures, or loss of extensor mechanism:
- ORIF
Case 2: An 8-year-old female presents with right elbow pain after she lost her grip on the monkey bars and fell onto her outstretched hand.
1. What is your read of the x-ray above?
Anteriorly displaced supracondylar fracture, Gartland classification type III.
- Gartland classification of supracondylar fractures (based on the degree and direction of displacement, and the presence of an intact cortex)
- Type 1: Minimal displacement – fat pad elevation on radiographs
- Type 2: Posterior hinge – anterior humeral line anterior to capitellum
- Type 3: Displaced – no cortices intact
- Type 4: Periosteal disruption with instability in both flexion and extension
Gartland classification:
2. What nerve is most commonly injured with this type of injury and how would you test for it?
Anterior interosseous nerve, a branch of the median nerve. The patient will be unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can’t make an OK sign).
3. How would you manage this patient if you did not have orthopedics available?
Evaluate for neurovascular compromise, compartment syndrome, open fracture. If orthopedics is not available, this patient would need reduction and immobilization with a posterior long arm splint, followed by transfer for orthopedics.
- Gartland type 1 fractures:
- Long arm posterior splint (video)
- Elbow in 90 degrees of flexion
- Forearm in neutral position
- Orthopedic follow-up in one week for likely operative management
- Long arm posterior splint (video)
- Gartland type 2 and type 3 fractures
- Immediate orthopedic consultation in order to determine appropriate intervention (closed versus open reduction with percutaneous pin placement)
- Gartland 2/3 fractures have higher likelihoods of occult neurovascular injury and thus residual deformity
- Likely closed reduction and percutaneous pinning
Resources and additional reading:
https://www.orthobullets.com/pediatrics/4010/olecranon-fractures–pediatric