01Approach to the Critical Patient/attcp38

Immediate priorities

›Initial stabilization

›Airway and breathing compromise uncommon

›Escalate for altered mental status from multisystem trauma

›Circulation threats

›Major hemorrhage rare unless open fracture or associated injury

›Pain and distress

›Early analgesia before repeated exams and imaging (ACEP Level C)

›Neurovascular risk

›Immediate reassessment after any manipulation or splinting (ACEP Level C)

Limb threat screening

›Limb threat triggers

›Pulseless extremity

›If pale cool hand, emergent orthopaedics and reduction pathway (Class I)

›If pink warm hand, urgent orthopaedics and frequent reassessment (Class I)

›Compartment syndrome concern

›Disproportionate pain

›Pain with passive finger extension

›Increasing analgesic requirement

›Skin tenting or threatened open fracture

›Immediate orthopaedics notification (Class I)

Initial immobilization

›Temporary immobilization

›Posterior long arm splint

›Elbow flexion target 60-90 degrees if perfusion intact

›Avoid flexion > 90 degrees if swelling or vascular concern

›Sling and elevation

›Hand at or above heart level

02History/hx32

Injury context

›Mechanism and timing

›Fall on outstretched hand

›Extension-type most common

›Direct blow or fall onto flexed elbow

›Flexion-type less common

›Time since injury

›Progression of swelling and pain

Symptoms and risk signals

›Neurovascular symptoms

›Numbness or tingling

›Median distribution thumb index middle

›Ulnar distribution ring small

›Radial dorsal thumb web space

›Weakness

›Pinch weakness

›Finger extension weakness

›Hand color temperature change

›Pallor

›Coolness

›Pain pattern

›Severe pain out of proportion

›Compartment syndrome concern

›Pain with finger movement

›Compartment syndrome concern

Past and baseline

›Dominant hand

›Functional impact planning

03Physical Exam/exam50

Neurovascular exam

›Vascular status

›Radial pulse

›Palpable

›Doppler-only

›Absent

›Capillary refill

›Delayed

›Hand perfusion

›Color pink or pale

›Temperature warm or cool

›Median nerve and AIN

›Sensation palmar thumb index

›Decreased

›AIN motor

›OK sign thumb IP and index DIP flexion

›Radial nerve and PIN

›Sensation dorsal thumb web space

›Decreased

›PIN motor

›Thumb extension

›MCP extension

›Ulnar nerve

›Sensation small finger

›Decreased

›Motor

›Finger abduction

›Froment sign if cooperative

04Differential Diagnosis/ddx25

Elbow trauma differential

›Mimics and associated injuries

›Lateral condyle fracture of humerus

›ICD-10 S42.45

›Medial epicondyle fracture

›Often with elbow dislocation

›Radial head or neck fracture

›Pain with pronation supination

›Olecranon fracture

›Posterior tenderness

›Elbow dislocation

›Prominent olecranon

›Monteggia injury

›Proximal ulna fracture with radial head dislocation

›Forearm both-bone fracture

›Deformity away from elbow

Limb-threatening differential

›Vascular and compartment complications

›Brachial artery injury

›Pulseless or Doppler-only

›Volkmann ischemic contracture risk state

›Prolonged ischemia

›Acute compartment syndrome of forearm

›Pain out of proportion

Coding concepts

›Supracondylar fracture, pediatric

›ICD-10 S42.41

›SNOMED CT Supracondylar fracture of humerus

05Laboratory Tests/lt19

Perioperative and complication labs

›Baseline labs for operative pathway

›Complete blood count for operative planning

›Anemia or leukocytosis context

›Electrolytes and creatinine for anesthesia planning

›Dehydration from poor intake

›Coagulation studies if bleeding disorder history

›INR and aPTT abnormalities

›Open fracture labs and infection risk

›Wound culture not routine in ED

›Culture at debridement if indicated

›Serum lactate not routine

›Consider if shock or polytrauma

Point-of-care testing

›Bedside glucose if altered mental status

›Hypoglycemia alternative cause for symptoms

›Hemoglobin point-of-care if concerning bleeding

›Rare in isolated closed supracondylar fracture

Interpretation pitfalls

›Lab limitations

›Normal labs do not exclude vascular injury

›Diagnosis clinical plus imaging

06Diagnostic Tests/dt42

Scoring Systems

›Classification systems

›Gartland classification for extension-type

›Type I nondisplaced

›Anterior humeral line intersects capitellum

›Type II displaced with posterior hinge

›Posterior cortex intact

›Type III completely displaced

›No cortical contact

›Type IV multidirectional instability

›Instability in flexion and extension

›Perfusion status categories

›Pulseless pink hand

›Adequate perfusion despite absent pulse

›Pulseless pale hand

›Ischemic limb until proven otherwise

MRI

›MRI role limited

›Occult physeal or ligament injury suspicion

›Persistent pain with normal radiographs

›Neurovascular structure evaluation rarely first-line

›Time and sedation limits in ED

CT

›CT indications uncommon

›Complex intra-articular distal humerus fracture concern

›Surgical planning in atypical patterns

›Polytrauma with unclear anatomy

›When radiographs inadequate

07Disposition/dispo31

Ortho consultation and level of care

›Consultation triggers

›Gartland type II to IV

›Urgent orthopaedics (Class I)

›Any neurovascular deficit

›Urgent orthopaedics (Class I)

›Pulseless extremity

›Emergent orthopaedics (Class I)

›Open fracture or skin tenting

›Emergent orthopaedics (Class I)

›Compartment syndrome concern

›Emergent orthopaedics (Class I)

Admission and transfer criteria

›Admission indications

›Planned operative fixation

›NPO status

›Frequent neurovascular checks needed

›Q1 hour checks initially if vascular concern

›Uncontrolled pain or sedation recovery needs

›Monitoring for airway and analgesia

›Transfer indications

›No pediatric orthopaedics or OR capability

›Time-sensitive transfer for type III or pulseless hand

›Vascular surgery support needed

›Suspected brachial artery injury with ischemia

Discharge criteria

›Discharge eligibility

›Gartland type I

08Treatment/t82

Analgesia and antiemesis

›Symptom control

›Acetaminophen

›15 mg/kg PO

›Maximum single dose 1000 mg

›Maximum 60 mg/kg/day

›Ibuprofen

›10 mg/kg PO

›Maximum single dose 600 mg

›Avoid if dehydration or renal disease

›Opioid for severe pain

›Morphine

›0.05-0.1 mg/kg IV

›Repeat every 10-20 minutes as needed

›Monitor for respiratory depression

›Fentanyl

›1-2 mcg/kg IV or IN

›Repeat every 10 minutes as needed

›Short duration useful for imaging and splinting

›Antiemetic if needed

›Ondansetron

›0.15 mg/kg PO or IV

›Maximum 8 mg

Immobilization and edema control

›Nonoperative initial management

›Posterior long arm splint

›Elbow flexion 60-90 degrees if perfusion intact

›Neutral forearm rotation

09Special Populations/sp23

Pregnancy

›Pregnancy considerations

›Pediatric supracondylar fracture rare in pregnancy context

›Consider pregnancy status in adolescent patients

›Imaging

›Plain radiographs acceptable with shielding when feasible

›Analgesia

›Prefer acetaminophen first line

›NSAID avoidance in later pregnancy if applicable

Geriatric

›Geriatric considerations

›Pediatric supracondylar fracture not a geriatric diagnosis

›If adult distal humerus fracture, management differs

›Alternative adult patterns

›Osteoporotic distal humerus fractures

Pediatrics

›Pediatric specifics

›Weight-based dosing for analgesia and sedation

›Use kg-based calculations and maximum dose caps

›Non-accidental trauma screen in atypical history

›Inconsistent mechanism or delayed presentation

›Immobilization tolerance

›Extra padding for swelling

›Cast and splint pressure point checks

›Follow-up timing

›Early ortho follow-up due to displacement risk in swelling phase

10Background/b29

Epidemiology

›Population patterns

›Common pediatric elbow fracture type

›Peak school-age children

›Extension-type majority

›Fall on outstretched hand mechanism

›Associated neurovascular injury risk

›Higher in displaced fractures

Pathophysiology

›Injury mechanics

›Distal humerus supracondylar region failure

›Thin cortical bone and olecranon fossa area

›Extension-type

›Distal fragment displaced posteriorly

›Flexion-type

›Distal fragment displaced anteriorly

›Neurovascular structures at risk

›Brachial artery in antecubital fossa

›Median nerve and AIN

›Radial nerve

›Ulnar nerve in flexion-type and medial pinning

Therapeutic Considerations

›Management goals

›Restore alignment

›Prevent malunion and cubitus varus

›Protect perfusion and nerve function

›Time-sensitive limb salvage in ischemia

›Minimize swelling complications

11Patient Discharge Instructions/pdi21

copy discharge instructions

›Discharge instructions

›Splint care

›Keep splint clean and dry

›Do not insert objects inside splint

›Elevation and swelling control

›Keep hand elevated above heart level for 48 hours

›Ice over splint intermittently if comfortable

›Pain control

›Acetaminophen and ibuprofen per weight-based plan

›Avoid duplicate acetaminophen in combination products

›Activity limits

›No sports climbing or rough play until cleared

›Follow-up

›Orthopaedics appointment within 5-7 days or sooner as directed

›Return to ED now if

›Increasing pain not controlled by medication

›Fingers numb tingling or weak

›Fingers turning pale blue or cold

›Increasing swelling with tight splint sensation

›Inability to move fingers

›Fever or drainage from wound if open injury

12References/r10

Clinical guidelines and evidence sources

›Core references

›Pediatric supracondylar humerus fracture management summaries in orthopedic texts

›Gartland classification standard usage

›Emergency medicine procedural sedation guidance

›Ketamine pediatric dosing standards

Professional society and consensus

›Consensus and society materials

›Pediatric orthopedic society educational resources on supracondylar fractures

›Operative indications for displaced fractures

›Emergency department neurovascular documentation standards

›Limb-threatening injury escalation pathways

Evidence & Review

Evidence & Review