The pediatric elbow has six ossification centers (CRITOE) appearing predictably with age — knowing them prevents missed fractures. Supracondylar fractures are the most common pediatric elbow fracture and carry significant neurovascular risk.
🚩 Red-flag clues (must not miss)
- •Cool/pale hand, absent radial pulse, pain with passive finger extension = vascular injury / compartment syndrome
- •Anterior interosseous nerve injury (can't make 'OK' sign) = displaced supracondylar fx
- •Posterior fat pad sign on lateral elbow XR = occult fracture (usually supracondylar or radial neck)
- •Significant displacement, open fx, floating elbow = emergent ortho
History
- Mechanism — FOOSH (extension supracondylar), fall on flexed elbow (olecranon), axial pull (nursemaid's)
- Age (nursemaid's typical 1–4 y; supracondylar peak 5–7 y)
- Hand/finger numbness, color change
Exam
- Inspection — swelling, deformity, ecchymosis (anterior = supracondylar)
- Neurovascular: radial pulse, cap refill, median (OK sign — AIN), AIN, ulnar, radial nerve function
- Palpation — medial/lateral epicondyles, olecranon, radial head
- Compartment check — pain with passive finger extension is the earliest sign
Labs
- Generally not needed; CBC/CRP if atraumatic or septic concern
Imaging
- Elbow XR — AP + true lateral; assess anterior humeral line (should bisect capitellum) and radiocapitellar line
- Posterior fat pad = occult fracture; anterior 'sail sign' = effusion
- CRITOE order (Capitellum 1y, Radial head 3y, Internal/medial epicondyle 5y, Trochlea 7y, Olecranon 9y, External/lateral epicondyle 11y)
- Comparison views or MRI if occult injury suspected
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Supracondylar humerus fracture | FOOSH 5–7 y, posterior fat pad, anterior humeral line off | Long-arm splint at 60–90° (NOT > 90° — vascular), urgent ortho; emergent if pulseless |
| Lateral condyle fracture | Lateral elbow tenderness, intra-articular, often needs ORIF | Splint, ortho — high non-union risk if missed |
| Medial epicondyle avulsion | Throwing injury, valgus stress, ulnar n. symptoms | Splint, ortho — ORIF if displaced > 5 mm or in joint |
| Radial head/neck fracture | Lateral pain, ↓ supination/pronation | Long-arm splint, ortho; angulation > 30° may need reduction |
| Olecranon fracture | Fall on flexed elbow, posterior tenderness | Splint in extension, ortho |
| Nursemaid's elbow (radial head subluxation) | 1–4 y/o, axial pull, arm held pronated, refuses to use | Reduction (supination + flexion OR hyperpronation); no XR if classic |
| Elbow dislocation | Obvious deformity, posterior most common | Reduction, post-reduction films, ortho |
| Little Leaguer's elbow (medial epicondyle apophysitis) | Repetitive throwing, medial pain, no acute trauma | Rest 4–6 wk, no throwing, PT |
| Panner disease / OCD of capitellum | Lateral pain, throwers/gymnasts, capitellar lucency | Rest, ortho, MRI |
| Septic elbow / osteomyelitis | Fever, atraumatic swelling, ↑ CRP | Aspiration, IV abx, MRI |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g) | |
| Morphine | 0.1 mg/kg IV (max 5 mg) | For displaced fx awaiting reduction |
Management / next steps
- Splint supracondylar at 60–90° flexion — NEVER > 90° (vascular compromise)
- Document and reassess neurovascular exam frequently; a pulseless pink hand may be observed but pulseless white = OR
- Nursemaid's: if classic and reduction successful (click + use within 15 min), no XR needed
- Posterior fat pad without obvious fracture → splint and ortho follow-up — assume occult fx
Pearls
- Always check the anterior humeral line on lateral elbow XR — should pass through middle third of capitellum.
- AIN is the most commonly injured nerve in supracondylar fractures — test 'OK' sign.
- Lateral condyle fractures look minor on XR but have high non-union — always refer.