Endgames Picture Quiz

An injury in a child’s elbow

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6279 (Published 22 November 2011) Cite this as: BMJ 2011;343:d6279
  1. Nawfal Al-Hadithy, core trainee year 1, trauma and orthopaedics,
  2. Simon C Mordecai, core trainee year 1, trauma and orthopaedics,
  3. Madhavan C Papanna, specialty trainee, trauma and orthopaedics
  1. 1Luton and Dunstable Hospital, Luton LU4 0DZ, UK
  1. Correspondence to: N Al-Hadithy Nawfal{at}yahoo.com

An 8 year old, right hand dominant schoolgirl was playing on the climbing frame at school and had a fall from a height of 2 m. She fell on her outstretched left hand and immediately complained of pain in her left elbow. She was unable to move her elbow and was brought to hospital for further assessment. On examination, there was a swelling of her elbow, and she was unable to flex or extend her elbow. However, she was able to supinate and pronate her hand but this was limited, owing to pain in her elbow. Her radial pulse was thready, but the hand was warm and well perfused with a capillary refill of less than 2 seconds. Sensory deficit was not reliably established. We obtained an anterior-posterior and lateral radiograph of her elbow (figs 1 and 2).


  • 1 What is the diagnosis, and what sign should you look for if in doubt?

  • 2 What features of the paediatric elbow make radiological interpretation difficult?

  • 3 What are the classification and mechanism of this type of injury?

  • 4 What would you be looking for on examination?

  • 5 How would you manage this injury, and what specific complications would you expect?


1 What is the diagnosis, and what sign should you look for if in doubt?

Short answer

Displaced supracondylar fracture; a visible fat pad (posterior) (fig 3) indicates an undisplaced fracture.

Fig 3 A visible posterior fat pad

Long answer

Supracondylar fractures are among the commonest fractures in children and occur in the distal humerus just above the epicondyles. It typically remains extra-articular.

In a displaced fracture, the diagnosis is usually obvious on plane radiographs. If, however, the fracture is undisplaced, the diagnosis is often more difficult, and the “posterior fat pad” may be of diagnostic value. The fat pads are small masses of fat within the fibres of the joint capsule and are therefore intracapsular …

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