Approximately 5 y/o male presents with right elbow pain and refusal to move the right arm after falling from a chair on an outstretched arm.
Gross deformity present on the distal humerus, just proximal to the elbow with mild skin tenting and tenderness. Refusal to move the elbow joint. Unable to extend the wrist and digits. Remainder of exam normal.
Obtain AP and lateral elbow views
Normal Elbow: anterior humerus line intersects the middle third of the capitellum
Garland Type 1: Non-displaced
Garland Type II: Displaced with posterior cortex intact
Garland Type III: Completely displaced
- Posterior long arm splint with less than 90 degrees of flexion
- Type I and some Type II fractures.
- Consult Ortho for Type II fractures to determine if operative management is needed
- All Type III fractures, some Type II fractures
- “floating elbow” : ipsilateral supracondylar and forearm fractures
- Immediate operative management if vascular compromise is present
- Reduce in ER if any vascular compromise is present
- Most are admissions with next day operative fixation
- Incredibly common in 5-7 year olds with a fall on an outstretched arm.
- Radial, ulnar, anterior interosseous nerve neurapraxia all very common and resolve with reduction without long term effects but require expedited management
- Very easy to miss a type I fracture, use the anterior humerus line and fat pad sign
- Garland classification above, determines management
- Can be associated with vascular injury (~1%), this requires immediate reduction
- Use the anterior humerus line and fat pad sign to help find subtle fractures
- High suspicion in any fall on an outstretched arm
- Remember the Garland Classifications
- Most Type II and all Type III will require operative management and admission
- A posterior long arm splint for Type I fractures
- Always assess for neurovascular compromise
By Dr. Mohamed El-Kara
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