Nobel’s Paradox: Dynamite can be fun, and dangerous!!

An 8-year-old male presents to the ED following a small explosion in his backyard. He has a known history of pyromania and has been getting a bit creative with his projects. This time, left unsupervised, he ignited his experiment which exploded sending him flying backward about 2 meters to land primarily on his buttocks and elbows. Miraculously, he sustained no life-threatening injuries and he is hemodynamically stable in the ED; vitals are HR 110, BP 100/70, and RR 16. His physician father ran out to the back yard and was about to spank him (still legal in about 35 states) when he noticed the pained and stunned expression on his son’s face and the child is trying to point to his mangled limb. The boy describes 8 out of 10 pain in his right elbow that began immediately after he made contact with the ground (see film). On physical exam, the child holds the elbow flexed and his forearm close to his trunk. There is a notable deformity of the elbow and the child resists passive motion due to pain. On neurological examination, he is unable to effectively adduct and abduct his fingers, but he retains his ability to oppose the thumb. He also notes some weakness of finger flexion at the 4th and 5th digits. Distal pulses are palpable bilaterally and cap refill is <2 sec. What is the most likely etiology for our pyromaniac’s deficits?

A. Cervical spine injury

B. Median nerve entrapment

C. Radial head subluxation

D. Supracondylar fracture

E. Ulnar Fracture

Thanks to Emilio Feijoo, M’ 24 for contributing to this  question.