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Physical Exam for Supracondylar Frx

- Dicussion:
    - assess for swelling and tenseness of the forearm compartments;
    - assess carrying angles of the affected and non affected arms;
    - r/o neurologic deficits
          - median nerve injuries are more often associated w/ posteromedial displacement;
          - AIN injuries are most common and occur w/ postero-lateral displacement;
          - w/ posteromedial displacement, lateral spike of proximal fragment may tether the radial nerve;
    - r/o vascular injuries:
          - vascular injuries are more often associatted w/ posterolateral displacement;
          - medial spike may tether brachial artery;
          - it is essential to check and recheck not only the presence of a radial pulse but also its quality;
                - remember that an intimal arterial injury can occur slowly over several hours;
    - skin changes:
          - "dimple sign" occurs when a spike of bone penetrates brachialis muscle and anterior subQ tissues causing subQ hemorrage;
          - if the brachialis is buttonholed by the distal humeral spike, then the muscle can be milked off the spike by grasping the proximal arm and squeezing sequentially from proximal to distal;
                 - avoid excessive medial squeezing (to avoid N/V injury);


          - reference:
                 - Closed Reduction and Percutaneous Pinning of Displaced Supracondylar Humerus Fractures in Children: Description of a New Closed Reduction Technique for Fractures with Brachialis Muscle Entrapment.

    - r/o compartment syndrome;
          - note that median nerve injury can mask the symptoms of a compartment syndrome;
    - olecranon & 2 epicondyles form a straight line in extended positition;
          - when elbow is flexed to 90 deg, they form corners of triangle;
          - shape of this triangle is unaltered in supracondylar frx of humerus but  is distorted by posterolateral dislocation of elbow;
    - associated injury:
          - palpate distal radius for frx

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