Ortho Case of the Week – Elbow and Humerus ANSWERS
Case 1: A 6-year-old male is BIB his mother right elbow pain after falling off the monkey bars.
Source: Radiopaedia
1. Describe the pathology on the x-rays above.
Supracondylar fracture with posterior angulation.
A line drawn along the anterior humerus should should intersect the middle third of the capitellum in patients 5 years or older and touch the capitellum in patients < 5 years old (see below). In this case, the anterior humeral line does not transect the middle third of the capitellum.
Normal elbow xrays of a patient 5 or older (left) and less than five (right):
2. How would you manage this patient?
Long arm posterior splint with less than 90° of elbow flexion. The patient should be seen in the ER by orthopedics for closed reduction and pinning.
Patients should be splinted in long arm splints with less than 90 degrees of elbow flexion and referred to orthopedics as an outpatient if:
Type I (non-displaced) fractures OR
Type II (posteriorly-displaced) fractures where the anterior humeral line intersects the capitellum, minimal swelling is present, and there is no medial comminution.
AND
The patient’s hand is warm and well-perfused without neuro deficits.
Otherwise, the patient needs to be seen by orthopedics in the ER for more urgent closed vs open fixation.
3. What nerve is most commonly injured with this type of fracture? How would you test it?
Anterior interosseous nerve, a branch of the median nerve. Damaged if the patient cannot flex the IP joint of the thumb and the DIP joint of the index finger (can’t make OK sign).
The radial nerve is also commonly injured. Damaged if the patient cannot extend the wrist, MCP joints and thumb IP joint.
In most cases, these are only neuropraxia and resolve spontaneously.
Case 2: A 37-year-old male presents with right elbow pain after a FOOSH injury while playing basketball with his son.
Source: Radiopaedia
4. Describe the pathology on the x-ray above.
This xray shows an occult, non-displaced (Type I) radial head fracture as evidenced by posterior fat pad and anterior sail signs.
5. How would you manage this patient?
Sling immobilization for several days followed by active mobilization. Criteria for short period of immobilization followed by active mobilization exercises include: minimal displacement, no mechanical block, and intra-articular displacement <2mm. Longer periods of immobilization tend to have more associated elbow stiffness. Higher grade fractures will likely require ORIF.
Follow up timeline:
- Nondisplaced without mobility restrictions: ortho follow up within 1 week
- Displaced or mobility restrictions: ortho follow up within 24 hours for possible ORIF
Case 3: An 85-year-old female is brought in from her memory care facility for right shoulder pain after a mechanical fall.
Source: Radiopaedia
6. Describe the pathology on the x-ray above.
Closed, displaced, transverse fracture of proximal meta-diaphyseal region of humerus.
7. What nerve is most commonly injured with this pathology? How would you test it?
Axillary nerve. Test sensation over the lateral shoulder in the “military patch” distribution.
Case 4: A 77-year-old female presents with left arm pain and swelling after a syncopal fall.
8. Describe the pathology on the x-ray above.
Spiral fracture of the mid humeral diaphysis with posterior displacement and angulation of the distal segment.
9. What nerve is most commonly injured with this pathology? How would you test it?
Radial nerve. Test wrist and finger extension and sensation to digits 1-3 and radial half of fourth digit.
