A 7-year-old boy presents to the emergency department following a fall on an outstretched hand while playing. Clinical examination reveals swelling over the anterior aspect of the elbow, severe pain, and loss of elbow extension. Neurovascular examination is intact. Which investigation is most appropriate to confirm the diagnosis and assess fracture displacement?

Explanation

## Investigation of Choice for Supracondylar Fracture ### Why Plain Radiographs Are First-Line **Key Point:** Plain radiographs (AP, lateral, and oblique views) are the gold standard investigation for diagnosis and classification of supracondylar fractures of the humerus. **High-Yield:** Supracondylar fractures account for 50–60% of all pediatric elbow fractures. The lateral view is most sensitive for detecting displacement and angulation, while the AP view helps assess medial or lateral shift. ### Radiographic Assessment | View | Primary Information | |------|---------------------| | **Lateral** | Fracture line, anterior/posterior displacement, angulation | | **AP** | Medial/lateral displacement, rotation | | **Oblique** | Additional detail of fracture pattern and comminution | ### Classification on Plain Films The **Gartland classification** (most widely used) is determined entirely from plain radiographs: 1. **Type I:** Undisplaced or minimally displaced (intact cortices) 2. **Type II:** Displaced with intact posterior cortex (angulation without translation) 3. **Type III:** Completely displaced (no cortical contact) **Clinical Pearl:** Type II and III fractures typically require reduction and percutaneous pinning. Plain radiographs provide all information needed for this decision. ### Why Other Investigations Are Not First-Line - **MRI:** Not required for diagnosis; reserved for soft tissue injury assessment (rare in acute setting) - **CT with 3D reconstruction:** Unnecessary for routine cases; adds radiation and cost; reserved for complex/comminuted patterns - **Ultrasound:** Operator-dependent; not standard for fracture diagnosis in pediatric trauma **Tip:** Always obtain lateral view first—it is the most informative single view for supracondylar fractures.