Cutting edge Orthopedics

12 • CUTTING EDGE - ORTHOPEDICS anterior cortex of the humerus on a true lateral view of the elbow, intersects the middle third of the capitellum in children over 4 years of age (Fig. 11) and the middle or anterior third of the capitellum in children under 4 years of age [46]. If the anterior humeral line does not intersect the capitellum, the distal fragment is displaced posteriorly. This is consistent with an extension-type fracture (Fig. 3). Additionally, the AP radiograph can be used to determine if there is angulation in the coronal plane by measuring Baumann’s angle or the humeral-capitellar angle. Baumann’s angle is the angle between the physeal line of the lateral condyle and a line perpendicular to the long axis of the humeral shaft. A normal Baumann’s angle is 9°–26°. A Baumann’s angle less than 9° indicates varus angulation. Management Initial Management In the emergency department, the injured extremity should be splinted in 20°–40° of flexion at the elbow. An unnecessarily tight wrap should be avoided [19, 25], and too much flexion may compromise vascular status of the limb and increase compartment pressures [38, 47]. The limb should also be elevated [5, 19, 25]. A thorough physical exam and radiographic evaluation should be performed. Generalized definitive treatment strategies for supracondylar humerus fractures can be found in Table 1. Non-sedating analgesics, such as acetaminophen, ibuprofen, ketorolac, or low-dose morphine, should be ordered to avoid masking a developing compartment syndrome [14]. Regular neurovascular exams should be performed. Fig. 11: Image depicting the anterior humeral line (AHL) intersecting the middle third of the capitellum (Courtesy of Joshua M. Abzug, MD). sion, which can occur with bleeding from th fracture site in the setting of trauma. A previous study investigating the final diagnosis for pediat- ric elbow radiographs that were negative except for a posterior fat pad sign determined that 76% had an occult fracture about the elbow. Of the 76% that had a fracture, 53% were a supracondy- lar humerus frac ure [ 44 ]. Notably, the anterior fat pad can be visualized on normal elbow radio- graphs [ 45 ] and is not a reliable predictor of frac- ture [ 9 ]. There are several radiographic parameters that should be evaluated when a supracondylar hum rus fracture is present. In a typi al elbow, the anterior hum ral line, a line following the anterior cortex of the hu erus on a true lateral view of the elbow, intersects the middle third of the capitellum in children over 4 years of age (Fig. 4.11 ) and the middle or anterior third of between the physeal line of the lat an a line per endicular to the lon humeral shaft. A normal Bauman 9°–26°. A Baumann’s angle less t cates varus angulation. Management Initial Management In the emergency department, the inj ity should be splinted in 20°–40° of elbow. An unnecessarily tight wra avoided [ 19 , 25 ], and too much flexi promise vascular status of the limb compartment pressures [ 38 , 47 ]. The also be elevated [ 5 , 19 , 25 ]. A thoro exam and radiographic evaluation sh form d. Generalized definitive treat gi s for supracondylar humerus frac found in Table 4.1 . Non-sedating such as acetaminophen, ibuprofen, low-dose morphine, should be orde masking a developing compartme [ 14 ]. Regular neurovascular exam performed. Non-operative Management Indications for nonsurgical man supracondylar humerus fractur Gartland Ty e I fractures without n injury or ins abilit [ 5 , 8 , 48 , 49 ]. radiograph needs to be carefully asse placement. If the anterior humeral li the capitellum ossification center, th considered nondisplaced or minimal Fig. 4.11 Image depicting the anterior humeral line (AHL) intersecting t e middle third of the capitellum (Courtesy of Joshua M. Abzug, MD) 4 Supracondylar Humerus Fractures