Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: - Supracondylar Fracture Type I - Supracondylar Fracture Type II - Supracondylar Fracture Type III - Supracondylar Fracture Type IV

1. Pediatric Orthopedic Imaging Case Studies
Kelsey Lena, MD1, Danielle Sutton, MD1, Virginia Casey, MD2
Department of Emergency Medicine1 & OrthoCarolina2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Pediatric Orthopedic Imaging Mastery Project
August 2021

2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. It’s All About The Anatomy!

4. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that is to be
penetrated
• If there is no tissue, the color of the x-ray will be black
• The greater the density, the lighter the color

5. Reading Systematically
• Identify you are reviewing the correct patients imaging
(name, date of birth, date of imaging)
• Review both AP and lateral views, as this can help you
describe the fracture/deformity in both planes
• X-rays of two adjacent joints must be taken or a joint
injury could potentially be missed
• Identify which bone and what fractured part of the bone is
injured
Diaphysis
Metaphysis
Epiphysis

6. CASE #1:
A 6-year-old boy presents
to the emergency
department with elbow pain
after falling during a soccer
game. On physical exam
the patient keeps his arm
adducted and in flexion.
Diagnosis?
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum

7. CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
Subtle fracture with non-displacement
CASE #1:
A 6-year-old boy presents
to the emergency
department with elbow pain
after falling during a soccer
game. On physical exam
the patient keeps his arm
adducted and in flexion.
Diagnosis?
Supracondylar Fracture
Type I
Treatment:
Cast immobilization for 3-4
weeks

8. Posterior fat pad
Subtle anterior
displacement
Another example of a
Type I Supracondylar Fracture.
Assess the anterior humeral line (black
line). If it does not pass through the
middle of the capitellum, there is
concern for posterior
displacement/angulation.

9. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
CASE #2:
A 7-year-old girl presents to
the emergency department
complaining of arm pain
after falling off a swing and
attempting to catch herself
with her left arm. Physical
exam reveals edema of the
left elbow.
Diagnosis?

10. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
CASE #2:
A 7-year-old girl presents to
the emergency department
with a edematous left elbow
after falling off a swing and
attempting to catch herself
with her left arm.
Diagnosis?
Supracondylar Fracture
Type II
Treatment:
Closed reduction and
percutaneous pinning
(secondary to angulated
fracture)
Angulated with an
intact posterior cortex
and posterior
periosteal hinge

11. Another Type II
Supracondylar
Fracture. Note the
angulated fracture, but
intact posterior cortex

12. Another Type II Supracondylar Fracture

13. CASE #3: A 9-year-old male presents to the emergency department
following a bicycle accident. Physical examination reveals an
apparent deformity of the elbow with decreased sensation to the
forearm and hand.
Diagnosis?

14. Completely displaced
often in 2-3 planes
Treatment: Often closed
reduction and
percutaneous pinning
Lack of attachment to the
posterior hinge
CASE #3: A 9-year-old male presents to the emergency department
following a bicycle accident. Physical examination reveals an
apparent deformity of the elbow with decreased sensation to the
forearm and hand.
Diagnosis? Supracondylar Fracture Type III

15. Another example of
Type III Supracondylar
Fracture

16. Type III Supracondylar
Fracture. Note better
visualization of the
displaced fracture in the
lateral view versus the
AP view

17. Type III Supracondylar Fracture.
Note the complete displacement
with no contact between bone
fragments

18. CASE #4:
A 12-year-old female
presents to the
emergency department
following a motor
vehicle collision. She is
tearful and tachycardic
with heart rate in the
140’s. Physical
examination reveals a
cold and pulseless right
hand with significant
edema and ecchymosis
of the elbow. There is
significant pain on
palpation, and she is
unable to flex or extend
the forearm.
Diagnosis?

19. CASE #4:
A 12-year-old female
presents to the
emergency department
following a motor
vehicle collision.
Physical examination
reveals a cold and
pulseless right hand
with significant edema
and ecchymosis of the
elbow. The patient is
unable to flex or extend
the forearm.
Diagnosis?
Supracondylar Fracture
Type IV
*Typically diagnosed
intra-operatively
Treatment: Emergent open
reduction and external
fixation
Complete dislocation
and periosteal
disruption, making
the elbow highly
unstable*

20. Another example of a Type IV
Supracondylar Fracture. Note
the complete dislocation

21. Type IV Supracondylar Fracture
Complete periosteal
disruption

22. Another example of a Type IV
Supracondylar Fracture and
how it may appear in the ED
when considered an open
fracture.
An open supracondylar fracture
requires emergent fixation,
given poor perfusion that
accompanies injury.

23. Supracondylar Humeral Fractures
• Most common traumatic fractures seen in children less than 10 years
old, with peak age around 5-7 years old
• Mechanism of injury typically secondary to extension-type injuries due
to a fall onto the outstretched hand while the elbow is extended
• Occurs equally in both males and females
• Incidence:
-Extension type (95-98%)
-Flexion type (< 5%)

24. Classification
System of
Supracondylar
Fractures
• Numerous classification systems lead to difficulty in accurately classifying
supracondylar fractures and thus, developing a single care standard
• The Gartland classification is the most commonly used in the U.S.
• AO Classification and Bahk’s pattern:
-Commonly used in France
-Shortcomings include classifying rotated fractures less operative than
displaced fractures, when in fact, they can be even more difficult to reduce
• Lagrange and Rigault Classification:
-Less reliable based on current data

25. Gartland Classification System
• Based upon the degree of displacement, direction of displacement, and whether
the boney cortex is intact or disrupted.
• Used as a tool to determine if a fracture determines operative intervention
Type I Non-displaced or minimally displaced
Type II Displaced with an intact posterior cortex
Type III Completely displaced:
III a: Complete posterior displacement with no cortical contact
III b: Complete displacement with soft tissue gap
Type IV Diagnosed intra-operatively with displacement, periosteal
disruption, and instability in flexion and extension

26. Gartland Classification System

27. Anatomy of the Elbow
orthobullets.com

28. Ossification: 1 yr
Fusion: 12 yrs
Ossification:12 yrs
Fusion: 12 yrs
Ossification: 4 yrs
Fusion: 15 yrs
Ossification: 10 yrs
Fusion: 15 yrs
Ossification: 6 yrs
Fusion: 17 yrs
Ossification: 8 yrs
Fusion: 12 yrs
orthobullets.com

29. Clinical Presentation
• Physical exam:
-Ranges from edema and ecchymosis at the site of injury to gross
deformity with limited range of motion of the elbow
• Neuro exam:
-Assess for sensation discrepancy
-Radial arterial injury, radial nerve neurapraxia (inability to extend
wrist, MCP joint, and thumb IP joints), median nerve injury
(absent sensation over dorsum index finger), spread fingers (ulnar nerve),
AIN neuropraxia (unable to perform “A-OK” sign)
• Vascular exam:
-Assess for warm and pink skin with capillary refill < 2 seconds
-Ensure radial pulse present with palpation or doppler pulse

30. Inability to perform “A-OK” Sign
• Important examination finding in the Emergency Department
• The physician will be assessing for an anterior interosseous nerve deficit
• Patient will be unable to flex the DIP joint of the index finger and IP joint of the thumb
on the affected hand

31. Complications of Supracondylar Fracture
• “Floating elbow”
-Evidence of supracondylar fracture + forearm or wrist fracture
-Patient at increased risk for compartment syndrome and will require
urgent operative intervention
• “Brachialis Sign”
-Ecchymosis + palpable bone fragment + antecubital skin dimpling
-Patient at increased risk for arterial injury
• Volkmann Contracture – Rare Occurrence
-Ischemic contracture due to damage to the brachial artery
• Malunion
• Damage to the ulnar, radial, or median nerves

32. Complications of Supracondylar Fracture
Floating Elbow
Brachialis Sign
Note the dimpling of
the skin

33. Treatment
Non-operative:
-Supracondylar Fractures Type I/II
-Well perfused hand without neurological deficits
-Long arm casting with elbow flexion < 90º
-Cast should remain in place for at least 3-4 weeks
Operative:
-Supracondylar Fractures Type III/IV OR Supracondylar Fracture
Type II with inadequate perfusion, neurological deficits, or significant angulation
-Closed reduction and percutaneous pinning or open reduction and
internal fixation
Type I Type II Type III Type IV

34. The modified Gartland
Classification validates non-
operative treatment for
Supracondylar Type I Fractures
and operative repair of
Supracondylar Type III
Fractures
• Definitive treatment for Supracondylar Type
IIa vs. IIb Fracture difficult to validate,
given one needs to assess if rotational
deformity is present
• Regarding Supracondylar Type II Fractures,
the terminology of the fracture (whether
displacement or rotational deformity is
present), is more clinically useful in
determining treatment plan

35. Operative Intervention
• Time to closed reduction with percutaneous pinning dependent upon patient’s neurovascular
presentation
• Non-urgent:
-Patient appropriate for operating room the next day
-Perfused hand without neurological deficits
-Reduce and splint arm with elbow flexion 30º- 40º
• Urgent:
-Plan for operating room the same day of presentation
-Pulselessness or neurological deficits with improvement following reduction and
splinting of supracondylar fracture
• Emergent:
-Plan for operating room within the next few hours
-Pulseless hand with minimal to no perfusion following reduction of supracondylar
fracture

36. Summary of This
Month’s Diagnosis
• Supracondylar Fracture Type I
• Supracondylar Fracture Type II
• Supracondylar Fracture Type III
• Supracondylar Fracture Type IV

37. Resources
• Abzug J, Herman M. Management of Supracondylar Humerus Fractures in Children: Current
Concepts. J Am Acad Orthop Surg. 2012, 20:69-77.
• Agashe M. Classifications of Supracondylar Humerus Fractures: Are they Relevant? Are we Missing
Something? International Journal of Paediatric Orthopaedics. Volume 1. Issue 1. July-Sept 2015.
Page 6-10.
• Leung S. Paryavi E. Does the Modified Gartland Classification Clarify Decision Making? J Pediatr
Orthop. Volume 38, Number 1. January 2018.
• Wendling-Keim D. Binder M. Prognostic Factors for the Outcome of Supracondylar Humeral
Fractures in Children. Orthopedic Surgery. Volume 11, Number 4. August, 2019.
• https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric