Orthopaedic Emergencies 283
Injuries to the Elbow and Forearm
Supracondylar fracture of the humerus
DIAGNOSIS
1 This fracture occurs most commonly in children from a fall on to the
outstretched hand, although it is also seen in adults following a direct blow
to the elbow.
2 There is tenderness and swelling over the distal humerus, but the olecranon
and two epicondyles remain in their usual ‘equilateral triangle’ relationship
(which is lost in dislocation of the elbow).
3 Test for median nerve damage and look for any signs of arterial occlusion,
such as pain, pallor, paralysis, paraesthesiae, and pulselessness.
4 Complications include:
(i) Brachial artery damage – compression, intimal damage or
division may be caused by posterior displacement of the lower
end of the proximal humeral fragment.
(ii) Median nerve damage – associated with sensory loss over the
radial three-and-a-half fingers and weakness of abductor pollicis.
(iii) Local tissue swelling – tense and rapidly progressive swelling may
cause vascular compromise to the distal forearm.
(iv) Volkmann’s ischaemic contracture – a late but devastating
complication resulting from tissue necrosis secondary to distal
forearm arterial compromise.
5 X-ray will show any displacement, although one-third of fractures are un-
displaced, some merely greenstick.
(i) An occult, undisplaced fracture may be inferred by the presence
of a haemarthrosis causing a posterior or anterior fat pad sign on
X-ray (see p. 284).
(ii) Request comparison views of the other normal elbow if there is
difficulty in interpreting the radiographs, especially in children
with epiphyseal growth plates.
MANAGEMENT
1 Refer the patient immediately to the orthopaedic team if arterial occlusion is
suspected, for manipulation under general anaesthesia.
2 Refer displaced, comminuted, or severely angulated fractures also to the
orthopaedic team, even if there is no arterial damage.
3 Manage undisplaced and greenstick fractures conservatively with analgesia,
and a collar and cuff with the forearm f lexed to at least 80° or more from
extension, allowing the triceps to help splint the fracture.
(i) Arrange review in the next fracture clinic.
