Updated: 6/2/2022

Supracondylar Fracture - Pediatric

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  • summary
    • Supracondylar Fractures are one of the most common traumatic fractures seen in children and most commonly occur in children 5-7 years of age from a fall on an outstretched hand.
    • Diagnosis can be made with plain radiographs.
    • Treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on presence or absence of hand perfusion.
  • Epidemiology
    • Incidence
      • extension type most common (95-98%)
      • flexion type less common (<5%)
    • Demographics
      • occur most commonly in children aged 5-7years
      • M = F
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • fall on outstretched extremity
    • Associated injuries
      • neuropraxia
        • anterior interosseous nerve (AIN) neurapraxia (branch of median n.)
          • the most common nerve palsy seen with supracondylar humerus fractures
        • radial nerve palsy
          • second most common neurapraxia (close second)
        • ulnar nerve palsy
          • seen with flexion-type injury patterns
        • nearly all cases of neurapraxia following supracondylar humerus fractures resolve spontaneously
          • further diagnostic studies are not indicated in the acute setting
      • vascular compromise (5-17%)
        • rich collateral circulation can maintain circulation despite vascular injury
      • ipsilateral distal radius fractures
  • Anatomy
    • Ossification centers of elbow
      • age of ossification/appearance and age of fusion are two independent events that must be differentiated
        • e.g., internal (medial epicondyle) apophysis
          • ossifies/appears at age 6 years (table below)
          • fuses at age ~ 17 years (is the last to fuse)
        • +/- one year, varies between boys and girl
        • Ossification Centers of the Elbow
        • Ossification Center
        • Years at ossification
        • (appear on xray)
        • Years at fusion
        • (appear on xray) 
        • Capitellum
        • 1
        • 12
        • Radial Head
        • 4
        • 15
        • Medial epicondyle
        • 6
        • 17
        • Trochlea
        • 8
        • 12
        • Olecranon
        • 10
        • 15
        • Lateral epicondyle
        • 12
        • 12
  • Classification
      • Gartland Classification
      • (may be extension or flexion type)
      • Characteristics 
      • Treatment
      • Type I
      • Nondisplaced
      • Beware of subtle medial comminution leading to cubitus varus which technically means it is not a Type I Fracture
      • Treated with cast immobilization x 3-4wks, with radiographs at 1 week
      • Type II
      • Displaced, in 1 plane
      • Posterior cortex and posterior periosteal hinge intact
      • Deformity is in the sagittal plane only
      • Typically treated with CRPP
      • Type III
      • Displaced, in 2 or 3 planes
      • Treated most commonly with CRPP or open reduction if needed
      • Type IV
      • Complete periosteal disruption with instability in flexion and extension
      • Diagnosed with examination under anesthesia during surgery
      • Treated most commonly with CRPP or open reduction if needed
      • Medial comminution*
      • Collapse of medial column, loss of Baumann angle
      • Leads to varus malunion/classic gunstock deformity
      • May or may not be
      • associated with a sagittal plane deformity
      • Treated with CRPP, often requires significant valgus force to reduce
      • Flexion type
      • Mechanism of injury is usually a fall on the olecranon
      • Treated with CRPP
      • More likely to require open reduction
  • Presentation
    • Symptoms
      • pain
      • refusal to move the elbow
    • Physical exam
      • inspection
        • gross deformity
        • swelling
        • ecchymosis in antecubital fossa
      • motion
        • limited active elbow motion
      • neuro exam
        • neurovascular exam must be done before any reduction maneuver to be certain nerve or vascular injury is not iatrogenic (stuck in fracture site)
        • Evaluate for
          • AIN neurapraxia
            • unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can't make A-OK sign)
          • median nerve injury
            • loss of sensation over volar index finger
          • radial nerve neurapraxia
            • inability to extend wrist, MCP joints, thumb IP joint
              • PIP and DIP can still be extended via intrinsic function (ulnar n.)
      • vascular exam
        • assess pulse
          • present or absent by palpation
          • present or absent by biphasic doppler pulse
        • assess vascular perfusion
          • well perfused
            • warm
            • pink
          • poorly perfused
            • cold
            • pale
            • arterial capillary refill > 2 seconds
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral x-ray of the elbow (really of the distal humerus)
      • findings
        • posterior fat pad sign
          • lucency on a lateral view along the posterior distal humerus and olecranon fossa is highly suggestive of occult fracture around the elbow
      • measurement
        • displacement of the anterior humeral line
          • anterior humeral line should intersect the middle third of the capitellum in children > 5 years old, and touches the capitellum in children in children <5.
          • capitellum moves posteriorly to this reference line in extension type fractures and anteriorly in flexion type fractures
        • alteration of Baumann angle
          • Baumann's angle is created by drawing a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image
          • normal is 70-75°, but best judge is a comparison of the contralateral side
          • deviation of >5-10° indicates coronal plane deformity and should not be accepted
    • Angiography
      • is typically not indicated
  • Treatment
    • Nonoperative
      • long arm casting with less than 90° of elbow flexion
        • indications
          • warm perfused hand without neuro deficits and
            • Type I (non-displaced) fractures
            • Type II fractures that meet the following criteria
              • anterior humeral line intersects the capitellum
              • minimal swelling present
              • no medial comminution
        • technique
          • typically used for 3 weeks
          • repeat radiographs at 1 week to assess for interval displacement
    • Operative
      • closed reduction and percutanous pinning (CRPP)
        • indications
          • fracture pattern
            • type II and III supracondylar fractures
            • flexion type
            • medial column collapse
        • time to CRPP dictated by neurovascular status
          • non-urgent (can wait overnight)
            • indications
              • warm perfused hand without neuro deficits
                • some argue can treat an isolated AIN injury in non-urgent fashion
            • technique
              • splint in 30-40° elbow flexion, admit overnight for observation and elevation for elective surgery
          • urgent (same day - do not wait overnight)
            • indications
              • pulseless, well-perfused hand
              • sensory nerve deficits
              • excessive swelling
              • "brachialis sign"
                • ecchymosis, dimpling/puckering antecubital fossa, palpable subcutaneous bone fragment
                  • indicates proximal fragment buttonholed through brachialis
                • implies more serious injury, higher likelihood of arterial injury, significant swelling, more difficult closed reduction
              • "floating elbow"
                • ipsilateral supracondylar humerus and forearm/wrist fractures warrant timely pinning of both fractures to decrease the risk of compartment syndrome
            • technique
              • check vascular status after reduction
                • if evidence of good distal perfusion admit for 48 hours of observation
                • if not well perfused perform vascular exploration
          • emergent (within hours)
            • indications
            • technique
              • check vascular status after reduction
                • if well perfused admit and observe for 48 hours
                • if not well perfused perform vascular exploration
      • emergent vascular exploration and CRPP
        • indications
          • pulseless white hand (pale, cool, no doppler) following CRPP
          • pulsatile and perfused hand that loses pulse following CRPP
        • technique
          • remove K-wires and reassess vascular status
          • open exploration and reduction if vascular status does not improve
      • open reduction, percutaneous pinning, +/- vascular exploration
        • indications
          • open fracture
          • failed closed reduction
            • more frequently required with flexion type fractures (compared to extension type)
          • pulseless white OR pink hand that is unable to be reduced or there remains a gap
            • gap might represent entrapped vascular structure
  • Techniques
    • Closed reduction and percutaneous pinning (CRPP)
      • fixation
        • closed reduction (extension-type)
          • posteromedial displacement: forearm pronated with hyperflexion
          • posterolateral displacement: forearm supinated with hyperflexion
          • if pronation or supination does not work, try the opposite
        • 2 lateral pins
          • usually sufficient in type II fractures
          • test stability under fluoroscopy
          • technical pearls
            • maximize separation of pins at fracture site
            • engage both medial & lateral columns proximal to fracture
            • engage sufficient bone in proximal & distal segments
            • low threshold for 3rd lateral pin if concern about stability with first 2 pins
            • pins should be inserted with elbow in flexion for extension-type injury and elbow in extension for flexion-type injury
        • 3 lateral pins
          • biomechanically stronger in bending and torsion than 2-pin constructs
          • indications (where 2 lateral pins are insufficient)
            • comminution
            • type III and type IV (free floating distal fragment)
          • no significant difference in stability between three lateral pins and crossed pins
            • risk of iatrogenic nerve injury from a medial pin makes three lateral pins the construct of choice
        • crossed pins
          • biomechanically strongest to torsional stress
          • higher risk of ulnar nerve injury (3-8%)
            • highest risk if placed with elbow in hyperflexion as ulnar nerve subluxates anteriorly over medial epicondyle in some children
          • reduce the risk of ulnar nerve injury by
            • placing medial pin with elbow in extension
            • use small medial incision (rather than percutaneous pinning)
        • remove pins postop at 3 weeks
    • Open Reduction with Percutaneous Pinning
      • approach
        • anterior approach if pulseless or median nerve injury
        • a lateral or medial approach where periosteum is torn
        • never posterior as posterior dissection can --> AVN
      • soft tissue
        • identify median nerve and brachial artery
      • bone work
        • confirm reduction with C-arm
      • instrumentation
        • 2 or 3 K-wires depending on the degree of stability
  • Complications
    • Pin migration
      • most common complication (~2%)
    • Infection
      • occurs in 1-2.4%
      • increased risk in age <4.5 years
      • typically superficial and treated with oral antibiotics
    • Cubitus valgus
      • caused by fracture malunion
      • can lead to tardy ulnar nerve palsy
    • Cubitus varus (gunstock deformity)
      • caused by fracture varus malunion, especially in medial comminution pattern
      • is NOT caused by growth disturbance
      • may represent a cosmetic issue with little functional limitations, however has been associated with posterolateral elbow instability
      • can lead to tardy ulnar nerve palsy
        • anterior nerve subluxation is most common cause
        • nerve entrapment by scar tissue and fibrous bands of FCU second most common cause
    • Recurvatum
      • common with non-operative treatment of Type II and Type III fractures
    • Nerve palsy from injury
      • usually resolve, nerves rarely torn
      • extension type fractures
        • neuropraxia in 11%
        • most commonly AIN
        • mechanism = tenting of nerve on fracture, or entrapment in the fracture site
      • flexion type fractures
        • neuropraxia in 17%
        • most commonly cause ulnar neuropraxia
    • Vascular Injury
      • radial pulse absent on initial presentation in 7-12%
      • pulseless hand after closed reduction and pinning (3-4%)
        • if perfusion is lost following reduction and pinning, pins should be removed immediately
      • decision to explore is based on quality of extremity perfusion rather than absence of pulse
      • arteriography is NOT indicated in isolated injuries
      • role of doppler is unclear and does not change treatment
    • Volkmann ischemic contracture
      • rare, but dreaded complication
      • may result from elbow hyperflexion casting
        • increase in deep volar forearm compartment pressures and loss of radial pulse with elbow flexed >90°
      • rarely seen with CRPP and postoperative immobilization in less than 90°
    • Postoperative stiffness
      • rare after casting or after pinning procedures
        • remove pins and allow gentle ROM at 3-4 weeks postop
      • resolves by 6 months
      • literature does not support the use of physical therapy

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Questions (60)
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(OBQ19.195) A 5-year-old boy presents to the ER at 9 pm with the injury shown in Figure A after falling off the monkey bars. Examination reveals the ability to make an a-ok sign, cross his fingers, and give a thumbs up. He has no radial pulse and his hand is cold. The decision is made to proceed with closed reduction and percutaneous pinning. When should the procedure be performed?

QID: 214097
FIGURES:

Urgently, within 6-8 hours

4%

(55/1310)

First case the following morning (~6 am)

1%

(9/1310)

8 hours after his last meal

0%

(6/1310)

Emergently, as soon as the operating room allows

94%

(1234/1310)

As a scheduled procedure the following day with a vascular surgeon present

0%

(2/1310)

L 1 A

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(OBQ18.13) For which of the following injuries should lateral pins be placed with the elbow in an extended position?

QID: 212909

Fracture with the anterior humeral line intersecting the middle third of the capitellum

1%

(16/1859)

Fracture with the supracondylar region of the humerus displaced anteriorly to the humeral shaft

76%

(1405/1859)

Fracture with the supracondylar region of the humerus displaced posteriorly to the humeral shaft with an intact posterior periosteal hinge

7%

(126/1859)

Fracture with the supracondylar region of the humerus with complete periosteal disruption and instability in flexion and extension

7%

(135/1859)

Fracture with the supracondylar region of the humerus displaced posteriorly to the humeral shaft with a disrupted posterior periosteal hinge

9%

(167/1859)

L 2 A

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(OBQ18.20) An 8-year-old sustains the injury shown in Figure A after falling downstairs. He is able to cross his fingers, flex and extend the IP joint of his thumb, and has intact sensation. His fingers have a brisk capillary refill but there is no palpable or dopplerable pulse. Injury films are shown in Figure A. This patient should undergo:

QID: 212916
FIGURES:

Emergent vascular exploration

3%

(77/2238)

Open reduction and internal fixation

11%

(251/2238)

Close monitoring for compartment syndrome perioperatively and urgent surgery

60%

(1342/2238)

Closed reduction and casting

24%

(542/2238)

Delayed surgical intervention to allow for soft tissue rest

0%

(3/2238)

L 3 A

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(OBQ18.44) Aaron and Randy are twin 8-year-old brothers who fall off a trampoline and sustain supracondylar humerus fractures that undergo closed reduction and percutaneous pinning. 6 weeks postoperatively Randy is placed into physical therapy for elbow range of motion while Aaron is not. In long-term follow up how will Randy's outcome compare to Aaron's?

QID: 212940

Randy will have a decreased rate of heterotopic ossification

1%

(16/2255)

Aaron will be less likely to have a cubitus varus deformity

1%

(14/2255)

Randy will have superior functional an motion recovery compared to Aaron

4%

(96/2255)

Randy will have improved motion but the functional recovery will be similar

6%

(133/2255)

There will be no difference in functional and motion recovery

88%

(1984/2255)

L 1 A

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(OBQ18.66) A 7-year-old patient presents with right elbow swelling and deformity after falling off of a trampoline. Figures A and B demonstrate the injury radiographs. In the emergency department, the patient has a warm pink hand with a strong radial pulse and intact AIN motor function. The patient is taken to the OR the next morning for closed reduction and percutaneous pinning. After the fracture is reduced and the pins are placed, the patient's hand appears pale and cool with absent radial pulses. What is the next appropriate step?

QID: 212962
FIGURES:

Apply a splint and reassess pulses in the PACU

1%

(17/1940)

Warm the extremity and reassess pulses

2%

(38/1940)

Perform a doppler examination

4%

(73/1940)

Remove the pins, re-displacement of the fracture, and reassess pulses

85%

(1653/1940)

Perform an anterior exploration

7%

(138/1940)

L 2 A

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(OBQ18.219) A 7-year-old girl falls in the park and sustains the injury depicted in Figure A and B. The most commonly observed nerve injury would result in deficits in which of the following muscles?

QID: 213115
FIGURES:

Dorsal interossei

1%

(28/1939)

Extensor digitorum communis

1%

(28/1939)

Extensor pollicis longus

4%

(72/1939)

Flexor pollicis longus

91%

(1760/1939)

Palmar interossei

2%

(32/1939)

N/A A

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(OBQ18.14) An 8-year-old male sustained the injury shown in Figures A-B. On physical examination, he is found to have a nerve deficit. Which of the following is the most likely nerve deficit and how should the nerve injury be managed after the fracture has been reduced and stabilized?

QID: 212910
FIGURES:

Anterior interosseous nerve (AIN); observation

90%

(2023/2236)

AIN; neurolysis

1%

(14/2236)

Median nerve; observation

6%

(126/2236)

Median nerve; neurolysis

0%

(10/2236)

Ulnar nerve; observation

2%

(47/2236)

L 1 A

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(OBQ17.41) A 7-year-old girl presents to the emergency room after a fall with right arm pain. She has full motor and sensory function. Her fingers are warm and pink with a capillary refill <3 seconds, and she is noted to have ecchymosis in her antecubital fossa. Radiographs are seen in Figures A and B. What is the most appropriate management plan?

QID: 210128
FIGURES:

Closed reduction, long arm casting, and discharge home

8%

(149/1870)

Closed reduction, long arm casting, and admission for a 24-hour observation

13%

(251/1870)

Closed reduction, percutaneous pin fixation, and discharge home

74%

(1387/1870)

Closed reduction, percutaneous pin fixation, and admission for arteriography

3%

(51/1870)

Open reduction with brachial artery exploration and admission for observation

1%

(23/1870)

L 2 A

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(OBQ16.86) A young child falls during gymnastics practice and sustains the isolated injury shown in Figure A. She is admitted to hospital for surgery. The prevalence of which complication is increased with this injury pattern?

QID: 8848
FIGURES:

Compartment syndrome

73%

(1371/1871)

Infection rates

0%

(2/1871)

Open fracture

1%

(22/1871)

Triceps avulsion

0%

(5/1871)

Vascular injury

25%

(461/1871)

L 4 A

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(OBQ13.172) A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

QID: 4807
FIGURES:

Intrinsics of the hand

5%

(122/2665)

Wrist extensor

3%

(83/2665)

Thumb extensor

2%

(51/2665)

Thumb IP flexor

89%

(2366/2665)

Digital extensor

1%

(18/2665)

L 1 A

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(OBQ13.163) A 7-year-old sustains the isolated injury shown in Figures A and B. On physical examination there is no evidence of soft tissue compromise and he is able to make an okay sign, give a thumbs up sign and cross his fingers. Which treatment will minimize complications?

QID: 4798
FIGURES:

Observation alone

0%

(5/2120)

Closed reduction with casting in > 90 degrees of flexion

0%

(10/2120)

Closed reduction with casting at 90 degrees of flexion

1%

(11/2120)

Closed reduction and a percutaneous pinning construct using laterally based pins

91%

(1920/2120)

Closed reduction and a percutaneous pinning construct using crossed pins

8%

(159/2120)

L 1 C

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(OBQ13.74) A 6-year-old presents with an elbow deformity after falling from the monkey bars. The skin is intact and no evidence of puckering is seen. The patient is neurovascularly intact. Representative radiographs of the injury are shown in Figures A and B. What is the optimal initial treatment for this injury based on the AAOS guidelines?

QID: 4709
FIGURES:

Observation alone

0%

(3/2205)

Closed reduction and casting

1%

(25/2205)

Primary open reduction and internal fixation

2%

(44/2205)

Closed reduction with medial and lateral crossed pins

11%

(238/2205)

Closed reduction with two or three lateral pins

85%

(1877/2205)

L 2 B

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(OBQ13.239) Figures A through E are injury radiographs of elbow injuries in children. A child complains of decreased sensation over the small finger acutely after an elbow injury. Which of the following radiographs is consistent with his injury?

QID: 4874
FIGURES:

Figure A

85%

(3703/4348)

Figure B

3%

(142/4348)

Figure C

4%

(188/4348)

Figure D

4%

(156/4348)

Figure E

3%

(130/4348)

L 2 A

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(OBQ12.54) Following successful operative treatment, routine removal of hardware is recommended at 3-4 weeks for which of the following procedures?

QID: 4414
FIGURES:

Figure A

1%

(25/4861)

Figure B

2%

(105/4861)

Figure C

3%

(127/4861)

Figure D

94%

(4564/4861)

Figure E

0%

(17/4861)

L 1 B

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(OBQ12.112) A 7-year-old patient presents with a fracture of her left supracondylar humerus and distal radius as evidenced in Figure A. She is neurovascularly intact and the skin shows no evidence of open wounds. Radiographs of the elbow show a displaced supracondylar fracture. Radiographs of the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation. This injury is most appropriately treated with which of the following?

QID: 4472
FIGURES:

Closed reduction and casting of the supracondylar humerus fracture and distal radius fracture

1%

(51/4722)

Closed reduction and pinning of both the supracondylar humerus fracture and distal radius fracture

52%

(2461/4722)

Closed reduction and casting of the supracondylar humerus fracture and pinning of distal radius fracture

1%

(62/4722)

Open reduction and pinning of both the supracondylar humerus and the distal radius fracture

6%

(285/4722)

Closed reduction and pinning of the supracondylar humerus fracture and closed reduction and casting of distal radius fracture

39%

(1838/4722)

L 4 B

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(OBQ11.228) A 9-year-old-female presents with her parents who have concerns regarding the appearance of her elbow (Figure A). Her past medical history is significant for a supracondylar fracture treated in a cast when as a younger child. She has no pain with motion and has 0 to 120 degrees range of motion. She does not have functional limitations but her parents would like to improve the appearance of her elbow. Which of the following procedures will correct the cubitus varus but may result in a lateral prominence?

QID: 3651
FIGURES:

Reverse V Osteotomy

1%

(63/4204)

Medial opening-wedge osteotomy with medialization of the distal fragment

28%

(1168/4204)

Step-cut osteotomy

6%

(236/4204)

Dome Osteotomy

8%

(332/4204)

Lateral closing-wedge osteotomy

56%

(2374/4204)

L 4 C

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(OBQ11.67) Which of the following elbow apophyses is the last to fuse during growth?

QID: 3490

Capitellum

3%

(114/4131)

External (lateral) epicondyle

45%

(1873/4131)

Radial head

2%

(75/4131)

Internal (medial) epicondyle

48%

(1969/4131)

Trochlea

2%

(87/4131)

L 4 B

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(SBQ08OS.142.1) A 22-year-old male presents with worsening right-hand pain and numbness. He localizes his symptoms to the ring and small finger with the involvement of the dorsoulnar aspect of the hand. He does have a distant history of a supracondylar humerus fracture that was treated with closed reduction percutaneous pinning when he was 5 years of age. A radiograph of the right elbow is depicted in figure A. What is the most likely cause of nerve irritation in this patient?

QID: 216308
FIGURES:

Compression by Osborne's ligament

32%

(286/898)

Traction irritation

35%

(312/898)

Anterior nerve subluxation

19%

(168/898)

Compression by the ligament of Struthers

9%

(85/898)

Compression in Guyon canal

5%

(41/898)

L 4 E

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(OBQ08.248) A child falls off of the monkey bars at school and sustains the left elbow injury shown in Figure A. What is a disadvantage of the fixation construct shown in Figure B compared to Figure C for this injury pattern?

QID: 634
FIGURES:

Less biomechanical stability

4%

(59/1527)

Higher incidence of compartment syndrome

0%

(6/1527)

Higher chance of osteomyelitis

1%

(14/1527)

Higher risk of iatrogenic injury to the ulnar nerve

93%

(1420/1527)

Higher risk of iatrogenic injury to the anterior interosseous nerve

2%

(26/1527)

L 1 C

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(SAE07PE.16) A 5-year-old boy sustained an elbow injury. Examination in the emergency department reveals that he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. The radial pulse is palpable at the wrist, and sensation is normal throughout the hand. Radiographs are shown in Figures 6a and 6b. In addition to reduction and pinning of the fracture, initial treatment should include

QID: 6076
FIGURES:

repair of the posterior interosseous nerve.

1%

(7/727)

repair of the median nerve at the elbow.

0%

(3/727)

neurolysis of the anterior interosseous nerve.

1%

(10/727)

observation of the nerve palsy.

96%

(695/727)

immediate electromyography and nerve conduction velocity studies.

1%

(5/727)

L 1 E

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(OBQ07.179) A 7-year-old boy falls off the playground and sustains the injury shown in figure A. What motor deficit is associated with the nerve most commonly injured in this fracture pattern?

QID: 840
FIGURES:

Weakness of the flexor digitorum profundus to the index finger

14%

(395/2816)

Weakness of the extensor pollicis longus

6%

(159/2816)

Wrist drop

6%

(166/2816)

Weakness of the flexor pollicis longus

13%

(371/2816)

Hand intrinsic weakness

61%

(1705/2816)

L 3 A

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(OBQ07.132) What is the advantage of medial and lateral crossed pins compared to two lateral pins in the treatment of supracondylar humerus fractures?

QID: 793

Greater ultimate clinical arc of elbow motion

0%

(9/1805)

Lower revision rate

1%

(14/1805)

Lower incidence of ulnar nerve injury

2%

(38/1805)

Greater experimental biomechanical stability

93%

(1687/1805)

More anatomic fracture reduction

3%

(51/1805)

L 1 C

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(OBQ06.227) What is the etiology of cubitus varus following a supracondylar humerus fracture in a child?

QID: 238

Overgrowth of the lateral physis

10%

(261/2523)

Malreduction of the fracture

68%

(1725/2523)

Growth arrest of medial physis

21%

(520/2523)

Injury to the ulnar nerve

0%

(6/2523)

Radial head dislocation

0%

(4/2523)

L 1 C

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(OBQ05.90) A 10-year-old boy sustained the injury shown in figure A while jumping off a trampoline. His hand is pulseless and cold. What is the next step in management?

QID: 976
FIGURES:

Loose-fitting splint application and reassess in 1 hour

1%

(8/1404)

Emergent closed reduction and pin fixation

90%

(1263/1404)

Angiogram

1%

(17/1404)

Open vascular exploration

8%

(111/1404)

Forearm skeletal traction pin

0%

(0/1404)

L 1 D

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(OBQ04.140) The most common nerve injured in the fracture shown in Figure A innervates all of the following muscles EXCEPT?

QID: 1245
FIGURES:

flexor digitorum profundus index finger

2%

(32/1690)

flexor digitorum profundus middle finger

2%

(27/1690)

flexor pollicis longus

3%

(46/1690)

extensor pollicis longus

92%

(1549/1690)

pronator quadratus

2%

(31/1690)

L 1 C

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(OBQ04.12) A 5-year-old boy sustains a type II (Gartland classification) supracondylar fracture which is treated with cast immobilization. Healing results in a mild gunstock deformity. Surgical treatment of this will most likely result in:

QID: 123

improved functional outcome

7%

(100/1457)

improved cosmesis

83%

(1207/1457)

improved pain relief

1%

(11/1457)

improved range of motion

8%

(112/1457)

reduce non-union rates

1%

(15/1457)

L 1 D

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(OBQ04.225) A 8-year-old boy has a cubitus varus deformity of his left elbow after a supracondylar humerus fracture was treated in a splint. What is the most common cause of this deformity?

QID: 1330

Malreduction causing malunion

72%

(937/1310)

Medial epicondyle growth arrest

18%

(238/1310)

Lateral condyle overgrowth

8%

(108/1310)

Medial epicondyle avascular necrosis

1%

(13/1310)

Unrecognized compartment syndrome

0%

(3/1310)

L 2 D

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