A 12-year-old boy is brought to the emergency department by his parents due to left arm pain. He was competing in a basketball tournament and fell on his left arm while his left hand was outstretched and immediately experienced severe pain. The patient has seasonal allergies for which he takes loratadine daily. Immunizations are up to date. Physical examination reveals a tearful and anxious boy in moderate distress. There is significant swelling over the left elbow, and the patient has limited range of motion at the elbow secondary to pain. He can fully extend and flex all 5 digits. Radial pulse is palpable, and there is brisk capillary refill. There is no tenderness to palpation over the wrist or forearm. Radiograph of the elbow is shown below and reveals a displaced posterior fat pad in the olecranon fossa. In addition to administration of pain medication, which of the following is the most appropriate next step in management of this patient?

Question

A 12-year-old boy is brought to the emergency department by his parents due to left arm pain.  He was competing in a basketball tournament and fell on his left arm while his left hand was outstretched and immediately experienced severe pain.  The patient has seasonal allergies for which he takes loratadine daily.  Immunizations are up to date.  Physical examination reveals a tearful and anxious boy in moderate distress.  There is significant swelling over the left elbow, and the patient has limited range of motion at the elbow secondary to pain.  He can fully extend and flex all 5 digits.  Radial pulse is palpable, and there is brisk capillary refill.  There is no tenderness to palpation over the wrist or forearm.  Radiograph of the elbow is shown below and reveals a displaced posterior fat pad in the olecranon fossa.  In addition to administration of pain medication, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0cd_4043_8f63_91ee60e13e32_MD0005_00 This patient's presentation is suggestive of an occult supracondylar fracture, a common childhood fracture involving the distal humerus. The typical history is immediate, severe pain after falling on an outstretched hand (FOOSH). Examination findings include elbow pain, swelling, and limited range of motion. Due to proximity of blood vessels (ie, brachial artery) and nerves (eg, median nerve), distal perfusion and neurologic function may be compromised as shown by poor capillary refill or weakness in hand flexion. distal perfusion Radiographic findings may show definitive signs of fracture (eg, fracture line, displacement) or a posterior fat pad, which suggests an occult fracture. As seen in this patient, a fat pad (red arrow) is an abnormal radiolucency posterior to the humerus that represents displaced fat due to a traumatic elbow effusion. Treatment of an occult or nondisplaced supracondylar fracture includes splint placement for immobilization. Displaced fractures require reduction (closed or open) with percutaneous pinning (Choice C). fat pad Displaced fractures (Choice A) Manual reduction by flexion and supination is the treatment for nursemaid's elbow, or radial head subluxation. This injury occurs in young children after axial traction of an extended arm; x-ray is typically normal. (Choice B) Compartment syndrome, a rare complication of a supracondylar fracture, presents with excessive swelling, increasing pain, and poor distal perfusion, none of which is present in this patient. Treatment is emergent fasciotomy to prevent limb ischemia. (Choice E) Conservative measures (eg, rest, application of ice, elevation) are appropriate for sprains or strains of an extremity. An occult fracture should be suspected in this patient with severe pain, a classic FOOSH mechanism, and a posterior fat pad visible on x-ray. Educational objective: Supracondylar fractures usually occur after a fall on an outstretched hand and typically present with elbow pain and swelling as well as limited range of motion. An occult, nondisplaced fracture may be presumed if there is fat-pad displacement on radiograph and should be treated with immobilization. References: Fracture supracondylar humerus: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28208961) Supracondylar humeral fractures in children: current concepts for management and prognosis. (http://www.ncbi.nlm.nih.gov/pubmed/26311512)

A 12-Year-Old Boy Is Brought to the Emergency Department by His