History of fall, swelling present at elbow

Reading File

Finding Sources

Reading File

Based on the X-ray image and the clinical history, here is a detailed analysis:

X-Ray Interpretation - Elbow

Image Findings

This is a lateral view X-ray of the elbow showing:

Posterior displacement of the distal humeral fragment - the distal humerus/condylar region is displaced posteriorly relative to the humeral shaft
Disruption of the normal anterior humeral line - the anterior humeral line (drawn along the anterior cortex of the humerus) normally bisects or passes through the middle third of the capitellum; here it appears to pass anterior to the capitellum, indicating posterior displacement
Prominent olecranon - visible posteriorly
Joint effusion/soft tissue swelling - consistent with the clinical finding of elbow swelling
Fat pad signs - a posterior fat pad sign (sail sign on the anterior side) would be expected with the degree of injury visible

Most Likely Diagnosis

Supracondylar fracture of the humerus - Extension type (Gartland classification)

This is the most common elbow fracture in children (peak age 5-10 years). The classic mechanism is a fall on outstretched hand (FOOSH) with elbow in full extension, causing the distal fragment to displace posteriorly - exactly matching this patient's history.

The appearance can mimic posterior elbow dislocation; distinguishing features:

In supracondylar fracture: fracture line is proximal to the condyles; the relationship of radius-to-capitellum is maintained
In posterior dislocation: the olecranon and radius displace posteriorly together, losing the normal radial head-capitellum relationship

Gartland Classification (Extension Type)

Type	Description	Management
Type I	Nondisplaced	Long arm cast/splint in 90° flexion
Type II	Posterior cortex intact, angulated	Closed reduction + casting; consider pinning
Type III	Complete displacement, no cortical contact	Closed reduction + percutaneous K-wire fixation (ORIF if needed)

This X-ray shows features consistent with Gartland Type II-III given the degree of posterior displacement visible.

Critical Neurovascular Checks (MANDATORY)

Before any intervention, assess:

Anterior interosseous nerve (AIN) - most commonly injured; test by "OK sign" (thumb-index pinch)
Radial nerve - test wrist/finger extension
Brachial artery - check radial pulse, capillary refill, hand color ("pulseless pink hand" vs. "pulseless white hand")
Median nerve - test thumb opposition and sensation

Immediate Management

Immobilize with a long arm posterior splint at 90° of elbow flexion, forearm in neutral rotation - do not flex beyond 90° if vascular compromise present
Ice, elevation, analgesia
Urgent orthopedic consultation - displaced fractures require reduction
Admit for neurovascular monitoring if displaced or significant soft tissue swelling
Emergent consultation indicated if: vascular insufficiency, nerve injury, open fracture, or irreducible fracture

Based on the trend in current practice, delayed reduction and fixation (up to 24 hours after injury) is now accepted without increased complication - reducing the need for true emergent OR intervention unless neurovascular compromise is present.

Tintinalli's Emergency Medicine, p. 1858

Differential to consider: Posterior elbow dislocation - if the radial head-capitellum alignment is disrupted on this film, dislocation should be considered. A true AP view would help confirm.

Next step: AP view of the elbow + urgent orthopedic review.

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