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Clinical introduction
An 8-year-old girl was brought to the emergency room complaining of severe pain and a deformity in her left elbow after falling off a trampoline with her hand outstretched. A cursory examination revealed a dimple and subcutaneous haematoma on the anterior portion of the distal arm but no apparent neurovascular defects (figure 1).
Photograph of the right elbow on arrival showing puckering skin with subcutaneous haematoma.
Question
What is the most likely diagnosis of the injury?
A supracondylar humeral fracture without any displacement
A supracondylar humeral fracture with a severe displacement
An olecranon fracture
A dislocation of the elbow joint
For the answer see page 166
From the question on page 90
Answer: B
Puckering skin with a subcutaneous haematoma in an injured elbow is known as the ‘pucker sign’. In cases of severe supracondylar humeral fractures, the anterior portion of the distal arm frequently presents with subcutaneous haematoma.1 The pucker sign indicates that the proximal fragment of a fractured and displaced humerus has penetrated the brachialis muscle and dermal layer.2 In the present case, the patient's X-ray (figure 2) showed a supracondylar humeral fracture with a completely displaced fragment (Gartland type 3).
Anteroposterior (A) and lateral (B) X-rays taken shortly after arrival.
Patients with a supracondylar humeral fracture with no displacement do not present skin puckering owing to the absence of fragmentation or a displaced fracture. Patients with olecranon fractures do not present puckering on the anterior portion of the distal arm even if the fractures involve severe displacement. Because of the absence of fractures, patients with only elbow dislocations also do not present puckering.
As soon as the X-ray was taken, orthopaedic surgeons were consulted and the patient underwent an emergency open reduction and internal fixation operation (figure 3).
Postoperation anteroposterior (A) and lateral (B) X-rays.
Emergency physicians should consider the pucker sign as a red flag in assessing paediatric elbow injuries because it constitutes evidence of a ‘near’ open fracture, which may be difficult to reduce by simple manipulation alone and often requires surgical intervention.3
Acknowledgments
We would like to thank James Valera for proofreading and editing this manuscript.
Footnotes
Contributors All authors looked after the patients, wrote the manuscript and approved the submission of the current manuscript.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.