CASE

PRESENTATI
ON
John Vincent A. Pagaddu
JUNIOR INTERN
ORTHOPEDICS DEPARTMENT

HISTORY
DATE AND TIME: June 1, 2015 (2:00
PM)
Source of History: The Patient and
his father
Reliability: 90%

General Data
- Patient DT
- 9 y/o
- Male
- Filipino
- Roman Catholic
- Resident of Cataggaman Nuevo,
Tug City

CHIEF COMPLAINT

PAIN AT THE LEFT

ELBOW

HPI
NOI: FALL
TOI: 5:30pm
POI: Cataggaman Nuevo,
Tuguegarao City
DOI: May 23, 2015

HPI
1 hour PTA
Patient fell from a height of approximately 5 feet.
Directly onto the ground with flexed elbow.
Elbow was noted to be painful, deformed, with
limited ROM
Also associated with hematoma and abrasions
No LOC, seizure and headache
No other associated Ssx
No medications were given
Patient was brought by his uncle to CVMC for further
observation
and
management;
hence,
the

PAST MEDICAL HISTORY

No allergies
Has not undergone any surgical
operations
(+) hospitalization for 3 days
(January 2006):
due to dyspnea

IMMUNIZATION HISTORY
COMPLETE

G and D
- Normal growth
- No developmental delay

Family History
Father denied any heredofamilial
disease
such
as
cancer,
hypertension, DM, GI diseases,
Pulmonary diseases and renal
diseases.

Personal-Social History
Patient is a 9year-old grade 4 pupil
Fund of doing outdoor activities
Living with his parents and two other
siblings
Both parents are non-smoker; though
father is an occasional drinker.

ROS
Integumentary: No rashes, sores, itchiness, and dryness
of skin
HEENT: No headache, blurring of vision, dizziness
Neck: No lymphadenopathy and stiffness of neck
Respiratory: No cough and dyspnea
Cardiovascular: No palpitations and easy fatigability
Gastrointestinal: No nausea and vomiting
Urinary: No hematuria and dysuria
Musculoskeletal: No myalgia, and backache
Neurologic: No seizures, numbness, paresthesia
Hematologic: No easy bruisability and bleeding

Physical Examination
General Survey:
- awake
- well-nourished
- not in respiratory distress
Vital Signs:
Temperature: 36.3 degrees Celsius
HR:

80 bpm

RR :

20 cpm

Physical Examination
Anthropometric Measurement
Weight: 20.5 kg
Height: 124 cm
Skin
Inspection: fair complexion, no palmar pallor, skin
rashes, and jaundice
Abrasions were noted at the left elbow, about 3 cm in
length

Palpation: poor skin turgor

Physical Examination
Head

Normocephalic, With normal hair

distribution, No head trauma

Eyes

Anicteric sclera, Pinkish palpebral

conjunctiva
No conjunctival injection

Ears

Pinnae are normal in shape

Clear external auditory canals
Tympanic membranes are shiny and
pearly white

Nose

No nasal flaring
Pinkish mucosa
Midline septum

Orophary Moist mucous membrane

nx
Tonsils are not inflamed
Midline uvula

Neck

No cervical lymphadenopathy
No tracheal deviation

Chest and Lungs Symmetrical chest expansion

No chest retraction
Resonant on Percussion
No adventitious sounds at both lungs
Cardiovascular

Adynamic precordium
PMI at left mid-clavicular line in 5th ICS
Normal rate and regular rhythm
No murmurs

Abdomen

Flat, No lesions, Normoactive bowel sounds at a

rate of 6bs/min
No tenderness, No hepatosplenomegaly noted

Genitalia

Grossly male

Extremities Deformed left elbow, with limited ROM.

Neurologi
c

Mental Status:
Alert and conscious
Cerebellar:
Negative for Nystagmus

Neurolo Cranial Nerves:

IIntact olfaction
gic
II-

Visual fields are full to

confrontation. Pupils

are 2-4

mm and briskly reactive to light.

III, IV,VI- At primary gaze, no eye
deviation. Able to follow objects
at different directions
V-

Facial sensation is intact to

prinprick
VII-

Symmetric facial expression

with niral eye closure and smile

VIII-

Hearing is normal to

rubbing fingers
IX, X-

Palate elevates

Motor: Good Motor Strength and able to move both lower

extremities and the right upper extremity. Left extremity
has limited ROM due to pain and deformity.
Muscle bulk and tone are normal. Strength is full
Biceps
Triceps
Hip
Hip
Knee
Knee
bilaterally.
Flexion

Extensio Extensio Flexion

n
n

NA

NA

NA

NA

nsory:
Grade- 100%.
Pain sensation is intact at both upper and lower extrem

Reflexes:

DTRs:
Brachioradi Biceps Triceps Patella planta
alis
r
r
Left
2+
NA
NA
2+
2+
Righ
2+
NA
NA
2+
2+
t

Babinski Reflex: Absent

Menigeal signs:
Negative Brudzinskis and Kernigs signs

IMPRESSION
FRACTURE, CLOSE, COMPLETE,
TRANSVERSE, DISPLACED, DISTAL
HUMERUS, LEFT

(SUPRACONDYLAR FRACTURE)

General Consideration
Incidence of Supracondylar Fracture:
Age: PEAK AGE: 5-6 year old
Average Age: 6.7 y/o
Sex: Boys > Girls (Earlier)
Boys = Girls (Latest trends)
Side:Left> Right (Non-dominant > Dominant)
Nerve injuries (7.7%): Median>Radial> Ulnar
Vascular injuries (1%)
Open injuries (1%)

MECHANISM OF INJURY
Extension
Type
of
Supracondylar
Fracture
(98%)
- the most common
- a fall onto the outstretched
hand with the elbow in full
extension
- Forearm
supinated

pronated

or

MECHANISM OF INJURY

MECHANISM OF INJURY
Flexion
Type
of
Supracondylar
Fracture
(2%)
- Fall directly on the elbow
rather than an outstretched
hand

Radiographic Anatomy
of Distal Humerus
Radiographic Views:
o Antero posterior
o Lateral
o Oblique
o Axial (jones view)

Radiographic Anatomy
of Distal Humerus
Baumanns Angle
- humeral capitellar angle
-between
the
line
perpendicular to the long
axis of the humeral shaft
and the physeal line of the
lateral condyle.
- a good measurement of
any deviation of distal
humerus angulation
- at least 10 degrees

Radiographic Anatomy
of Distal Humerus
Anterior Humeral Line
along
the
humeral cortex

anterior

- it should pass through the

junction of anterior and
middle 3rd of the capitellum

ANATOMICAL CLASSIFICATION OF
SUPRACONDYLAR FRACTURE

The pucker sign

TREATMENT
GENERAL PRINCIPLES:
- Splinting elbow in comfortable position (20-30O
of flexion of elbow)
- pending careful physical examination and Xray evaluation
- Tight bandaging/excessive flexion or excessive
extension should be avoided
- associated life threatening complications (if
any) to be attended)

TREATMENT OF TYPE I
FRACTURE
- Simple posterior long arm splint for 3-7 days
- Elbow 60-90 degrees flexion and Forearm
neutral position
- Check X-ray after 3-7 days to document any
displacement
- Splint converted to long arm cast if no
displacement
- if displacement is noticed: fracture reduction
and cast applied or pinning is done.

TREATMENT OF TYPE I
FRACTURE
Duration of immobilization: 3-4 weeks
No need for any physiotherapy
Outcome:
Predictably
excellent
if
alignment is maintained during healing.
TYPE I requires careful treatment and
follow-up

TREATMENT OF TYPE I
FRACTURE
- the treatment of choice for type II fractures is
operative stabilization rather than cast immobilization.
- initial treatment of type II fractures: closed reduction
and casting.
- Good stability obtained after closed reduction.
-If medial column collapse is present, then skeletal
stabilization with 2 lateral pins is advocated.
-Pinning
avoids immobilization with the elbow markedly flexed
for any fracture that would require elbow flexion of more than 90
degrees to hold reduction, pins should be used to hold the
reduction, and the elbow should be immobilized in less flexion
(usually about 45 to 70 degrees).

TREATMENT OF TYPE III

FRACTURE
- Treatment involves management of skeletal
injuries and associated soft tissue injuries (if any).
- Treatment of Skeletal injury:
Reduction either closed or open
Stabilisation either with pins or cast

Because type III fractures are inherently unstable,

the elbow must be held in extreme flexion to
prevent the distal fragment from rotating.