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The epidural space surrounds the dura and contains fat, lymphatics, blood vessels, connective tissue, and nerve roots (primary site of action for local anesthetics). When compared to the dense motor and sensory blockade of a spinal injection, epidural catheters provide controlled segmental analgesia spanning 2–3 spinal cord levels above and below level of insertion, with minimal motor blockade. Achieving desired sensory blockade level depends on the type, concentration, and volume of local anesthetic solution. Advantages of neuraxial analgesia include (1) minimizing parenteral opioids and their associated complications, (2) decrease rate of nosocomial pneumonia, and (3) shorter duration of mechanical ventilation in patients with rib fractures. Spinal and/or epidural hematoma, as a result of catheter insertion or removal, is a rare but potentially devastating complication in the context of coagulopathy or patients taking anticoagulant medication. Any patient with relative contraindications or complications should receive prompt consultation with an anesthesiologist or a member of the acute pain management team. Epidural catheter placement should only be performed by those with the technical expertise and a substantial amount of experience in the placement of this regional anesthesia technique. Paravertebral blockade has become more prevalent in the ICU, especially for pain associated with unilateral rib fractures, breast surgery, and thoracic surgery. The success rate and analgesic efficacy of paravertebral blocks are similar when compared to thoracic epidural catheter placement. Compared to epidural analgesia, paravertebral blockade is safer to perform and results in less hypotension and urinary retention.

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children’s elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann’s angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann’s angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.

Background: Temporary elbow stiffness after the treatment of a supracondylar humeral fracture in a child is often a concern of parents. However, little attention has been devoted to documenting, longitudinally, the time required for motion recovery. The purpose of the present study was to provide a prospective, longitudinal evaluation of elbow motion in a large population of pediatric patients undergoing treatment of a supracondylar humeral fracture. Methods: We prospectively examined 373 patients (375 fractures) who presented to our urgent care center between March 1, 2007, and September 30, 2008. On the basis of a standard protocol, patients were managed with either casting or surgery, depending on the severity of the injury, and then were followed for a minimum of seven weeks. Values of elbow flexion and extension were recorded, and the relative arc of motion was calculated as a percentage of the motion of the contralateral elbow. Results: In general, following a supracondylar humeral fracture, the greatest increases in flexion, extension, and the absolute and relative arcs of motion are observed within the first month after cast removal, with a progressive improvement for up to forty-eight weeks after the injury. Age had a significant effect on the recovery of elbow motion, with patients older than five years of age demonstrating a 3% to 9% lower relative arc of motion at the follow-up points in comparison with younger patients. Similarly, patients with more-severe fractures requiring surgical treatment demonstrated a decrease in relative elbow motion of 10% (with respect to the contralateral side) at the time of cast removal in comparison with those who were managed nonoperatively. Conclusions: The present study demonstrates that an initial rapid recovery in elbow motion can be expected after a supracondylar humeral fracture in a child, followed by a progressive improvement for up to one year after the injury. This motion recovery is slower in older patients and in those with more severe injuries. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.