fracture displacement Notably, a spiral fracture in a child less than years old may be suspicious for nonaccidental trauma unless the mechanism is consistent with this pattern of injury ( Fig 111.14 ) Vascular injuries are uncommon, but there is risk of radial nerve injury in up to 5% of fractures, particularly for fractures involving the middle and distal thirds of the humeral shaft Fortunately, most injuries of the radial nerve represent neuropraxias, and full return of function may be expected within to months Nonoperative management is standard for uncomplicated diaphyseal fractures, using the same techniques described above for proximal humerus fractures Alternatively, the application of a sugar-tong splint to the upper arm with a sling to support the forearm is recommended for displaced fractures Some orthopedic surgeons advise reducing the angulation to less than 10 degrees before proceeding with nonoperative treatment, but this recommendation is not universal as gravity will help align the fracture over time Indications for surgical stabilization and/or urgent orthopedic consultation for isolated humeral shaft fractures include open fractures, neurovascular compromise after reduction, completely displaced fractures, or fractures angulated more than 20 degrees in children and 10 degrees in adolescents Children should follow up with orthopedic surgery within week of injury, and healing generally takes to weeks, depending upon the age of the child FIGURE 111.14 Spiral fracture (arrows) of the right humerus in an 18-month-old girl Although in this case the injury was accidental, spiral humeral fractures in children younger than years must always evoke concerns about physical abuse Injuries of the Elbow Supracondylar Fractures Goals of Treatment Children with a mechanism and examination concerning for supracondylar fractures should have early assessment of neurovascular status to assess for neurologic or vascular compromise Fractures associated with neurovascular compromise should have early involvement of orthopedic surgery Management of supracondylar fractures is also aimed at preventing long-term complications including poor functional outcomes from failure to achieve anatomic alignment during reduction and immobilization CLINICAL PEARLS AND PITFALLS A radiograph with a true lateral view of the elbow is imperative for proper visualization of the anterior and posterior fat pads, and the anterior humeral line (Figs 111.15 and 111.16 ) The presence of abnormalities of the fat pads or displacement of the anterior humeral line on lateral view strongly suggests presence of fracture (Fig 111.17 ) In patients with extensive soft tissue edema, elevation of the fat pads may be obscured; therefore, relying on the clinical examination and identifying the anterior humeral line on the lateral elbow radiograph are important Fractures may be complicated by vascular injury to the brachial artery, compartment syndrome, or neurologic injury to the median, radial, or ulnar nerves Supracondylar fractures associated with ipsilateral forearm fractures are particularly high risk for the development of ischemic injury even when pulses and capillary refill are normal on examination Children whose distal humeral epiphyses have not yet ossified may require arthrogram, ultrasound, or MRI to assess for possible transphyseal or low supracondylar humerus fracture Current Evidence Elbow fractures account for approximately 18% of all pediatric fractures and are among the most problematic pediatric fractures in terms of diagnosis, treatment, and complications The most common mechanism of injury resulting in a supracondylar fracture is FOOSH with resulting hyperextension load on the elbow The extension supracondylar fracture accounts for 95% of these injuries and is often described using the Gartland classification system ( Table 111.5 ) Less commonly, a direct fall onto the flexed elbow results in an anterior displacement of the distal fragment The FOOSH mechanism causes the ulna and triceps muscles to exert an unopposed force on the distal humerus, causing failure of the anterior periosteum and, in more severe injuries, extending to and through the posterior cortex This progression results in a posterior displacement of the condylar complex Displacement of the fracture increases the risk of injury to the brachial artery and the median, radial, and ulnar nerves as the neurovascular bundles are stretched and/or disrupted Obesity in childhood and adolescence reduces bone mineral density with an increased propensity for fractures This can be associated with more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications FIGURE 111.15 A: Anteroposterior radiograph of a normal elbow of a child B: Normal lateral radiograph Clinical Considerations Clinical recognition A child with a supracondylar fracture often presents to the ED holding the arm straight in pronation and refusing to use the arm or flex at the elbow Supracondylar fractures occur most commonly between and 10 years ... Current Evidence Elbow fractures account for approximately 18% of all pediatric fractures and are among the most problematic pediatric fractures in terms of diagnosis, treatment, and complications