TABLE 111.6 GUIDE TO THE NEUROLOGIC EXAMINATION OF THE DISTAL UPPER EXTREMITY A Motor function Nerve Muscles innervated Radial Extensor carpi radialis longus Ulnar Flexor carpi ulnaris Interosseous Median Flexor carpi radialis Flexor digitorum superficialis Opponens pollicis Anterior Interosseous B Sensory function Nerve Radial Ulnar Median Anterior Interosseous Motor examination Wrist extension Wrist flexion and adduction Finger spread Wrist flexion and abduction Flexion fingers at proximal interphalangeal joint Opposition thumb to base of little finger Flexor digitorum profundus Flexion distal phalanx of I and II index finger Flexor pollicis longus Flexion distal phalanx of thumb (test the strength when patient is making an “ok” sign) Sensory innervation Dorsal web space between thumb and index finger Ulnar aspect palm and dorsum of hand Little finger and ulnar aspect of ring finger Radial aspect palm of hand Thumb, index, middle, radial aspect ring finger None FIGURE 111.18 Common elbow fractures in children: lateral condylar fracture (A ), medial epicondylar fracture (B ), and radial neck fracture (C ) The treatment of acute, nondisplaced fractures (e.g., Gartland type I) or when only the posterior fat pad sign is present is generally nonsurgical immobilization These injuries should be splinted in a long arm posterior splint/back slab, with the arm in pronation or neutral rotation and at 90 degrees of flexion at the elbow Children should be referred to orthopedics for casting within week if not casted at the initial encounter in the ED Immobilization for a total of to weeks is often sufficient Supracondylar injuries have minimal potential for remodeling; therefore, displaced fractures (Gartland type II and III) without neurovascular injury should have urgent orthopedic consultation for reduction ( Fig 111.19 ) Reduction is performed to decrease the risk of cosmetic deformity or poor functional outcomes (e.g., Volkmann contracture or cubitus varus) Current American Academy of Orthopedic Surgeons consensus recommends reduction and operative repair of all type II fractures, however it may be acceptable for minimally displaced type II to be treated nonoperatively Whether or not surgery is indicated, some type II injuries may be considered for outpatient referral for definitive treatment For injuries without neurovascular compromise, existing data not provide clear guidance on a time threshold to reduction of displaced injuries In the setting of limited access to definitive care, all patients should be splinted in a position of comfort and have close monitoring of neurovascular status while awaiting reduction Type III fractures and any patient with significant pain or swelling should be monitored in hospital for worsening neurologic, vascular, or pain symptoms until taken to the operating room FIGURE 111.19 Displaced and rotated type III supracondylar fracture in an 8-year-old girl The distal pulses were absent on examination, but returned with fracture reduction