Case Report

Presented by : Andi Ratih Radiah Iskandar

Resident : dr. Iswahyudi / dr. Harry
Supervisor : dr. Ira Nong, M.Kes, Sp.OT
Name : MF

Age : 7 years old

Gender : Boy

Admission : April 10th 2019

Registration : 879745
Chief Complain : pain at the right arm
¡ Suffered since 12 hours before admitted to Wahidin
Sudirohusodo General Hospital.
¡ Patient felt the pain right after fell down while playing alone
in front of his house without parental supervision. No one saw
the patient’s position when he fell. After being found, patient’s
right arm was unable to move because of pain and swelling.
Patient was referred from Bantaeng Hospital.
¡ There is no history of decreased level of consciousness.
¡ There is no history of projectile vomiting.
¡ Compos mentis / well nourished
¡ BP : 100/70 mmHg
¡ RR : 24x/min, symmetric, spontaneous, abdominothoracal type
¡ HR : 110x/min, regular, strong
¡ T : 36.8oC (axillary)
Right Arm Region
Look : Deformity (+) (Angulation, Shortening), swelling (+),
hematom (+), wound (-)
Feel : Tenderness (+)
Move : Active and passive movement of right elbow joint
cannot be evaluated due to pain
NVD : Sensibility is good. Pulsation of radial artery and
ulnar artery are palpable. Capillary refill time < 2
seconds.
Special : OK sign (+), extend thumb (+), finger abduction (+)
test
¡ WBC : 11,2 x 103/mm3
¡ HGB : 10.9 g/dL
¡ HCT : 34 %
¡ PLT : 359 x 103/mm3
¡ HBsAg : Non- Reactive
¡ BT : 3’00”
¡ CT : 8’00”
 April 10th 2019

• Right Humerus (AP) &

Right Elbow (Lateral)
• 1/3 distal right
humerus fracture with
distal fragment
displaced to
cranioposterolateral
 April 11th 2019

Right Elbow AP/Lat

Right Humerus AP/Lat

¡ Closed fracture supracondylar right
humerus (Gartland classification type III)
¡ IVFD Ringer Laktat 18dpm
¡ Paracetamol 250mg/8h/IV
¡ Planning : CRPP Alternative ORIF
 SUPRACONDYLAR
HUMERUS FRACTURE
¡ Fracture at the
thinnest portion of
distal humerus
¡ Between distal
humeral fossae
(above the level of
the growth plate)

-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer.
¡ Incidence
§ Commonest fractures in children
§ Most common fracture requiring surgery in children
§ Extension type most common (95-98%)
§ Flexion type less common (<5%)

¡ Demographics
§ Occur most commonly in children aged 5 to 7
§ Male > Female

-Solomon, L., Warwick, D. J., & Nayagam, S. (2014). Apley and Solomon's Concise System of Orthopaedics and Trauma, Fourth Edition.
Hoboken: CRC Press.
-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer.
¡ Extension type :
§ Fall on outstretched hand
§ Elbow hyperextended
§ Forearm pronated or
supinated

-Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer
 ¡ Flexion type :
The cause is
direct trauma or
a fall onto a
flexed elbow.

-Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer
-Netter, F. H. (2010). Netter concise atlas of orthopaedic anatomy (2nd ed.). Philadelphia: Elsevier.
¡ The medial and lateral
columns of the distal
humerus are connected
by a thin segment of bone
¡ Between the olecranon
fossa posteriorly and
coronoid fossa anteriorly
where the fracture line
extends transversely

Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
• Posteriorly, the olecranon is forced
into the depths of the olecranon
fossa.
• As the bending force continues,
the distal humerus fails anteriorly
in the thin supracondylar area.
• When the fracture is complete, the
proximal fragment can continue
moving anteriorly and distally,
potentially harming adjacent soft
tissue structures such as the
brachialis muscle, brachial artery,
and median nerve.

-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer
-Netter, F. H. (2010). Netter concise atlas of orthopaedic anatomy (2nd ed.). Philadelphia: Elsevier.
-Orthobullets. (2017). Retrieved April, 2019, from http://www.orthobullets.com/
-Netter, F. H. (2010). Netter concise atlas of orthopaedic anatomy (2nd ed.). Philadelphia: Elsevier.
-Orthobullets. (2017). Retrieved April, 2019, from http://www.orthobullets.com/
 ¡ Presenting complaints: The child is brought
to the hospital with a history of fall, followed
by pain, swelling, deformity and inability to
move the affected elbow.

Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
¡ Inspection
§ Gross deformity (S-deformity)
§ Swelling
§ Bruising
¡ Motion
§ Limited active elbow motion
¡ Neurovascular
§ Median nerve neurapraxia
§ Radial nerve neurapraxia
§ Vascular injury : brachial artery

Netter, F. H. (2010). Netter concise atlas of orthopaedic anatomy (2nd ed.). Philadelphia: Elsevier.
• S-shaped Deformity

Created by the anterior

prominence of the
proximal fragment’s spike
and extension of the distal
fragment (2 points of
angulation)

-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer.
• Pucker sign

May be present if the

proximal fragment has
penetrated the brachialis
muscle and the fascia of
the elbow until engaging
the deep dermis.

This is a sign of
considerable soft tissue
damage.

-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer.
¡ Findings :
§ Posterior fat pad sign
¡ Measurement :
§ Displacement of the anterior humeral line
§ Alteration of Baumann angle

Orthobullets. (2017). Retrieved April, 2019, from http://www.orthobullets.com/

¡ Fat pad sign
§ Lucency along the posterior distal humerus and olecranon
fossa is highly suggestive of occult fracture around the
elbow
¡ Anterior Humeral Line
§ A line drawn on a lateral view along the anterior surface of
the humerus should pass through the middle third of the
capitellum
§ Capitellum moves posteriorly to this reference line in
extension type fracture

Normal Abnormal
 ¡ Baumann’s angle Anteroposterior x-rays
§ Drawing a line parallel to the longitudinal axis of the humeral shaft and a line along
the lateral condylar physis
§ Normally this angle is less than 80 degrees.

Solomon, L., Warwick, D. J., & Nayagam, S. (2014). Apley and Solomon's Concise System of Orthopaedics and Trauma, Fourth Edition.
Hoboken: CRC Press.
 ¡ Type I : Immobilization in a long arm cast or splint at
60 to 90 degrees of flexion for 2 to 3 weeks.
¡ Type II : This is usually reducible by closed methods
followed by casting; it may require pinning if unstable
(crossed pins versus two lateral pins) or if reduction
cannot be maintained without excessive flexion and
risk of damage to neurovascular structures.
¡ Type III : Attempt closed reduction and pinning;
traction (olecranon skeletal traction) may be needed
for comminuted fractures with marked soft tissue
swelling or damage.
-Solomon, L., Warwick, D. J., & Nayagam, S. (2014). Apley and Solomon's Concise System of Orthopaedics and Trauma, Fourth Edition.
Hoboken: CRC Press.
-Orthobullets. (2017). Retrieved April, 2019, from http://www.orthobullets.com/
Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
§ Immediate
§ Injury to the brachial artery, radial pulse absent
§ Injury to nerves (radial nerve, median nerve, ulnar nerve)

¡ Early
§ Volkmann’s ischemia

¡ Late
§ Malunion (cubitus valgus, cubitus
varus/gunstock deformity >>)
§ Myositis ossificans
§ Volkmann’s ischemic contracture (VIC)

Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
-Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical
-Waters, P. M., Skaggs, D. L., & Flynn, J. M. (2015). Rockwood and Wilkins Fractures in Children(8th ed.). Philadelphia: Wolters Kluwer.
¡ The distal fragment may be displaced and/ or
tilted either posteriorly or anteriorly, medially or
laterally; sometimes it is also rotated.
¡ Posterior displacement and tilt is the commonest
(95% of all cases), suggesting a hyperextension
injury, usually due to a fall on the outstretched
hand.
¡ The jagged end of the proximal fragment pokes
into the soft tissues anteriorly, sometimes
injuring the brachial artery or median nerve.
¡ On examination:
§ When presented early, before significant swelling
: Unusual posterior prominence of the point of the
elbow (tip of olecranon) because of the backward
tilt of the distal fragment.
§ When presented late, gross swelling : clinical
diagnosis difficult. Must look for the possibility of
brachial artery, radial nerve, and median nerve
injury.
¡ Needs immediate care
§ Nerve injury: Median N, Radial N
§ Vascular injury: Brachial artery (tenting)
§ Swelling: compartment syndrome
¡ Supracondylar fractures X-rays showing supracondylar fractures of
increasing severity.
(a) Undisplaced. (b) Distal fragment posteriorly angulated but in
contact. (c) Distal fragment completely separated and displaced
posteriorly. (d) A rarer variety with anterior angulation.
¡ Closed reduction and percutaneous K-wire
fixation:
¡ Open reduction and K-wire fixation:
¡ Continuous traction:
 ¡ High ulnar nerve palsy
§ (injury proximal to the elbow) This will cause
paralysis of all the muscles supplied by the ulnar
nerve in the forearm and hand. In addition, there
will be a sensory deficit in the skin of the hand.
¡ Low ulnar nerve palsy
§ (injury in distal-third of forearm) There will be
sparing of forearm muscles but the muscles of the
hand will be paralysed. Sensory deficit will be
same as in high ulnar nerve palsy.

Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
 ¡ Low lesions may be caused by pressure (e.g. from a deep ganglion)
or a laceration at the wrist. There is hypothenar wasting and the
hand is clawed due to paralysis of the intrinsic muscles. Finger
abduction is weak, and the loss of thumb adduction makes pinch
difficult (see Figure 11.9(c) for Froment’s test). Sensation is lost
over the ulnar one and a half fingers.
¡ High lesions occur with elbow fractures; they are also seen (much
later) if malunion produces marked cubitus valgus with tension on
the nerve where it skirts the medial epicondyle. Remember that
ulnar nerve symptoms can also be caused by nerve entrapment in
the cubital tunnel, especially in patients lying for long periods with
the elbows flexed and pressing on the bed. Curiously, the visible
deformity is not marked, because the ulnar half of flexor digitorum
profundus is paralysed and the fingers are therefore less ‘clawed’.
Otherwise motor and sensory loss are the same as in low lesions.

Solomon, L., Warwick, D. J., & Nayagam, S. (2014). Apley and Solomon's Concise System of Orthopaedics and Trauma, Fourth Edition.
Hoboken: CRC Press.
¡ High radial nerve palsy
§ This occurs if the nerve is injured in the radial groove. In
this type, all the muscles supplied by radial nerve except
the triceps and anconeus are paralysed. Occasionally,
the radial nerve may be injured still higher up, in which
case even the triceps may be paralysed. This is called
very high radial nerve palsy.
¡ Low radial nerve palsy
§ This occurs if the nerve is injured around the elbow so
that the muscles supplied by the radial nerve in the
distal arm (brachioradialis, extensor carpi radialis
longus and brevis) are spared.
Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
¡ Low lesions are usually due to fractures or dislocations
at the elbow, or an open wound or surgical accident.
The patient cannot extend the metacarpophalangeal
joints.
¡ High lesions occur with fractures of the humerus or after
prolonged tourniquet pressure. They are also seen in
patients who fall asleep with the arm dangling over the
back of a chair (Saturday night palsy). There is an
obvious wrist-drop due to weakness of the wrist
extensors and a small patch of sensory loss on the back
of the hand at the base of the thumb.
¡ Very high lesions are usually due to pressure in the axilla
(‘crutch palsy’). The triceps muscle is wasted and
paralysed.
Solomon, L., Warwick, D. J., & Nayagam, S. (2014). Apley and Solomon's Concise System of Orthopaedics and Trauma, Fourth Edition.
Hoboken: CRC Press.
¡ The proximal
metaphyseal spike
penetrates laterally with
posteromedially
displaced fractures and
places the radial nerve
at risk; with
posterolaterally
displaced fractures, the
spike penetrates
medially and places the
median nerve and
brachial artery at risk.
Maheshwari, J., & Mhaskar, V. A. (2015). Essential orthopaedics (including clinical methods)(5th ed.). New Delhi: Jaypee Brothers Medical.
¡ Posterior fat pad sign