Supracondylar fracture Flashcards
You are the CT1 on Orthopaedics. You are called to A&E to see a 6-year-old girl who has fallen off a trampoline. She has a deformed right arm, which is pale and pulseless distally. What would you do before A-E assessment?
- put out paediatric trauma call
- move pt to resus
- make sure senior support is aware
- give kid analgesia asap
A+B
Airway
- Begin by triple immobilising C-spine. The fracture in the arm is a distracting injury, and there may be other life-threatening injuries. Ensure airway patency.
Breathing
- 15L high flow oxygen
- Oxygen saturation, respiratory rate
- Inspect, palpate, percuss, auscultate chest
- Adjuncts: CXR, ABG
C + D
Circulation
- Gather observations: heart rate, capillary refill time, blood pressure
- Gain venous access –ideally two wide bore cannulae, and take bloods at the same time (FBC, U&E, LFT, Clotting, G&S and x-match)
- Examine for sources of bleeding: (chest, abdomen, long bones pelvis) – consider adjuncts such as Fast scanning
–If evidence of pelvis fractures/ bleeding – use pelvic binders
- Start IV fluids. Consider major haemorrhage protocol
- Examine limbs distal perfusion status – particularly examining right upper limb for vascular compromise which is a surgical emergency. Get help ASAP if suspected.
Disability
GCS, temperature, capillary blood glucose.
E + everything else
Exposure
- Completely exposure the patient and assess for other fractures.
Adjuncts to the primary survey
- C-spine X-ray, CXR, Pelvic X-ray, X-ray of displaced limb and joint above / below
What are the most likely explanations for the distal limb ischaemia in this context?
- brachial artery compression, contusion, or transection due to fracture displacement
- compartment syndrome
How can you assess the distal neurovascular status in the context of a supracondylar humeral fracture?
Vascular
- Inspect for pallor
- Palpate for temperature
- Pulses: brachial, radial and ulnar (consider handheld doppler if available)
- Capillary refill
Neurological
Motor
- Median (AIN branch): Ask the patient to make the OK sign – opposing thumb and flexed index finger (AIN most common neuropraxia in this injury).
- Ulnar: Ask the patient to cross index and middle finger
- Radial: Ask the patient to extend the wrist
Sensory (autonomous areas)
- Median: Distal volar index finger
- Ulnar: Distal volar little finger
- Radial: 1st dorsal webspace
What are the complications of supracondylar fracture?
Early:
- Damage to local structures (brachial artery, radial/ median nerve, brachial vein),
- infection,
- haemorrhage
Intermediate:
- Compartment syndrome,
- infection,
- secondary bleeding
Late:
- Volkman ischaemic contracture,
- Sudek’s atrophy,
- mal-union (cubitus valgus/varus deformity)
- non-union (make sure you can explain these briefly – see below).
Operative complications:
- Early: Bleeding, infection, damage to local structures
- Late: Failure of repair, Repeat procedure, Scarring, CRPS
What is malunion / non-union?
Malunion: Healing of fracture in an abnormal/ deformed position, leading to deformity or shortening of the limb.
Non-union: Arrest in fracture repair process.
What is the classification for supracondylar fractures?
probs not important to know
Gartland classification
Type 1 may be managed conservatively
Type 2 and 3 require MUA +/- external fixation
Your registrar reviews the child and attempted manipulation with analgesia was not tolerated in A&E. The registrar is concerned about brachial artery injury as a result of the supracondylar fracture. How would you manage the patient in this case?
Surgical emergency with devascularised limb
complex case needs senior ortho and vascular input
Inform
- senior ortho
- vascular and/or plastics
- theatre coordinator
- on-call anaesthetics
Presurgical
- reassess ABCDE and cont resus
- book on theatre - 1B CEPOD (limb saving)
- prepare consent and mark with parental consent
- chase bloods and ensure crossmatch
- peripheral neurovascular monitoring
- immobilise arm
- analgesia
Whats the CEPOD classification of devascularised limb?
1B
