Diagnose

Supracondylar fractures may be inherently obvious or almost impossible to diagnose.

The clinical findings in severely displaced fractures are generally so obvious that the most
difficult part of the diagnosis is remembering to perform a thorough examination to assess for
other injuries, as well as possible neurologic injury. This is particularly important given that
neurologic injury is present in 10% to 15% of cases and ipsilateral fractures occur in 5%
(usually the distal radius).
A complete and thorough assessment of the neurologic function of the hand is often
difficult in a very young child with an acute elbow fracture. However, if a gentle and deliberate
effort is made, most children by the age of 3 or 4 years will cooperate with a two-point sensory
and directed motor examination. For uncooperative children, it is important to forewarn the
parents that when a thorough examination is possible, there is a 10% to 15% chance that a
neurologic injury will be discovered. Fortunately, these injuries almost always do well.
Although a complete neurologic examination is not always possible, it is always
possible to assess the vascular status of patients with displaced supracondylar humeral
fractures. It is also of paramount importance to be vigilant for clinical signs of a developing
compartment syndrome. The earliest sign of compartment syndrome is pain out of proportion
to the physical findings. Obviously, in the emergency department, all patients with severely
displaced supracondylar fractures have significant pain. However, the pain associated with
compartment syndrome is usually of greater intensity and more persistent than that associated
with routine injury. Also, patients in whom compartment syndrome is developing may
experience pain on passive extension of the fingers. Other than pain, the most reliable early
sign of compartment syndrome is a full or tense compartment. Unfortunately, by the time that
the classic symptoms of pallor, paresthesia, and paralysis develop, there has typically been
irreversible damage to the neuromuscular tissue.
The differential diagnosis of severely displaced supracondylar humeral fractures
includes elbow dislocations and all conditions that mimic them, such as transphyseal distal
humeral fractures and unstable lateral condylar fractures (Milch type II). True elbow
dislocations are relatively uncommon. When elbow dislocations do occur, they are generally
seen in older children and may be associated with medial epicondylar fractures. Transphyseal
distal humeral fractures are more common than supracondylar fractures in children younger
than 2 years but are uncommon in children older than 2 years. Transphyseal fractures have
been reported to be associated with child abuse in as many as 50% of cases. Unstable lateral
condylar fractures can be differentiated from supracondylar fractures most readily on the lateral
radiograph. Supracondylar fractures usually originate at the olecranon fossa and are transverse
or, less commonly, short oblique. Lateral condylar fractures originate more distally, often with
only a small metaphyseal fragment visible on the lateral radiograph. On the AP view, an
unstable lateral condyle fracture (Milch type II) may have a normal-appearing radial-capitellar
joint but will demonstrate subluxation of the ulnar-trochlear joint. Conversely, a Milch type I
lateral condyle fracture will have a disrupted radial-capitellar joint.
The diagnosis of a minimally displaced supracondylar humeral fracture may be difficult
to make. If seen soon after the injury, nondisplaced supracondylar fractures may have minimal
swelling and can be difficult to differentiate from minimally displaced lateral condylar, medial
epicondylar, or radial neck fractures. The most notable findings may be mild swelling and
tenderness over the supracondylar region of the humerus. Careful clinical examination will
reveal tenderness medially and laterally over the supracondylar ridges, whereas with lateral
condylar fractures the tenderness is lateral and with medial epicondylar fractures it is medial.
In radial neck fractures the tenderness is over the radial neck posterolaterally. However, a small
child with a painful elbow does not always cooperate with such a careful examination. In these
cases the definitive diagnosis may not be evident until the cast is removed several weeks later.
When the fracture cannot be seen clearly on radiographs, it is important to obtain a
thorough history to ensure that there was indeed a witnessed fall and that the symptoms began
immediately after the injury because patients with osteoarticular sepsis often have a swollen,
painful elbow and a history of trauma. If the elbow pain did not begin immediately after a
witnessed traumatic event, consideration should be given to the assessment of laboratory
indices (e.g., complete blood cell count, differential, erythrocyte sedimentation rate, and C-
reactive protein level) to ensure that the symptoms are not a result of occult infection.

Radiographic Findings
The diagnosis of a supracondylar humeral fracture is confirmed radiographically.
Obtaining good-quality radiographs is complicated by the fact that the elbow is painful and
difficult to move. Because of rotational displacement, it may be impossible to obtain true
orthogonal views of severely displaced fractures. However, with proper instruction to the
radiographer, true AP and lateral radiographs of fractures with moderate or minimal
displacement can be obtained. Obtaining a true AP view of the elbow requires full elbow
extension and is therefore seldom possible. Consequently, we obtain an AP view of the distal
humerus, which can be achieved with any degree of elbow extension . The importance of
obtaining a true lateral radiograph of the distal humerus cannot be overstated because most
treatment decisions are made from assessment of the lateral radiograph. Although repeating
radiographs is slow, tedious, and frustrating, it is worth the effort because, too often, “bad x-
rays lead to bad decisions.” If a nondisplaced or minimally displaced fracture is suspected but
the AP and lateral views do not show a fracture, oblique views may be useful.
Several radiographic parameters are helpful for managing patients with supracondylar
humeral fractures. One is Baumann’s angle, determined from an AP radiograph of the distal
humerus. It is the angle between the physeal line of the lateral condyle of the humerus and a
line drawn perpendicular to the long axis of the humeral shaft. A number of studies have
assessed the use of Baumann’s angle in the management of supracondylar humeral fractures.
These studies have shown that although the normal angle varies from 8 to 28 degrees,
depending on the patient, there is little side to side variance in any one individual. It has also
been shown that relatively small changes in elbow position, rotation or flexion, may alter
Baumann’s angle significantly. More reproducible Baumann’s angles may be achieved by
using a line drawn along the lateral or medial humeral cortex. A small angle should alert the
clinician to the possibility of significant varus. Also, obtaining a comparison view to calculate
Baumann’s angle on the uninjured extremity may be a useful adjuvant in the decision making
process for minimally displaced fractures. The AP radiograph should also be assessed for
comminution of the medial or lateral columns, and for translation. Occasionally a completely
displaced fracture will look relatively well aligned on the lateral radiograph but will show
translation on the AP film. This translation cannot occur without complete disruption of the
anterior and posterior cortices. Therefore, if present, it always represents an unstable fracture.
 There are also several important radiographic parameters on the lateral radiograph. A
fat pad sign may alert the physician to the presence of an effusion within the elbow. The anterior
fat pad is a triangular radiolucency anterior to the distal humeral diaphysis; it is seen clearly
and, in the presence of elbow effusion, it is displaced anteriorly. The posterior fat pad is not
normally visible when the elbow is flexed at right angles; however, if an effusion is present, it
will also be visible posteriorly
There are several additional radiographic parameters to assess on the lateral radiograph
(Fig. 33-46). First, the distal humerus should project as a teardrop or hourglass. The distal part
of the teardrop or hourglass is formed by the ossific center of the capitellum (see Fig. 33-46,
A). It should appear as an almost perfect circle. An imperfect circle or obscured teardrop or
hourglass implies an oblique orientation of the distal portion of the humerus from an inadequate
radiographic technique or fracture displacement. Second, the angle formed by the long axis of
the humerus and the long axis of the capitellum should be approximately 40 degrees.In
supracondylar fractures with posterior tilting of the distal fragment (seen with extension
fractures), the humerocapitellar angle will diminish, whereas with anterior tilting of the distal
fragment (seen with less common flexion injuries) it will increase. Third, the anterior humeral
line—a line drawn through the anterior cortex of the distal humerus—should pass through the
middle third of the ossific nucleus of the capitellum.In children younger than 4 years, the line
may pass more anteriorly through the capitellum than in older children.254 With extension
supracondylar fractures the anterior humeral line will pass anterior to the middle of the
capitellum. Finally, the coronoid line, a line projected superiorly along the anterior border of
the coronoid process, should just touch the anterior border of the lateral condyle of the humerus.
However, with extension supracondylar fractures, the coronoid line will pass anterior to the
anterior border of the lateral condyle.
Bahk and co-workers have noted that obliquity of the fracture line in extension
supracondylar fractures may be predictive of problems with management. Those with more
coronal obliquity were more often associated with comminution and rotational malunion.
Those with greater sagittal obliquity (>20 degrees) were more likely to result in extension
malunion.

Treatment
To quote Mercer Rang again, the goal of treatment of supracondylar humeral fractures
is to “avoid catastrophes” (vascular compromise, compartment syndrome) and “minimize
embarrassments” (cubitus varus, iatrogenic nerve palsies). With this goal in mind, treatment of
supracondylar humeral fractures can be divided into a discussion of their management in the
emergency department, care of nondisplaced fractures, and treatment of displaced fractures.
Treatment of Perfused Hand
 Non Operative
1. Long
 Operative
1. Emergency Treatment
It is important that the child and limb receive proper care while awaiting
definitive treatment. Unless the patient has an ischemic hand or tented skin, the limb
should be immobilized as it lies with a simple splint. If possible, radiographs should be
 obtained before splinting, or radiolucent splint material should be used. If the distal
extremity is initially ischemic, an attempt to align the fracture fragments better should
be made immediately in the emergency department. This can be accomplished by
extending the elbow, correcting any coronal plane deformity, and reducing the fracture
by bringing the proximal fragment posteriorly and the distal fragment anteriorly. Often,
this simple maneuver immediately restores circulation to the hand. In extension-type
fractures, flexion of the elbow should be avoided because it may cause further damage
to the neurovascular structures. The distal circulation should always be checked before
and after the splint is applied. Sensation, motor function, and skin integrity should also
be carefully checked and recorded.26 Patients with open fractures should receive
intravenous antibiotics and appropriate tetanus prophylaxis. All patients should be kept
from having any food or drink by mouth (NPO) until a definitive treatment plan has
been outlined.

2. Treatment of Nondisplaced Fractures

Treatment of nondisplaced fractures is straightforward and noncontroversial. It
consists of long-arm cast immobilization for 3 weeks. We often initially treat the patient
in the emergency department with a posterior splint, with figureeight reinforcement.
The position of the forearm in the long-arm cast has been the subject of a great deal of
speculation. For truly nondisplaced fractures there is no theoretic advantage to
pronation or supination. We generally immobilize nondisplaced fractures with the
forearm in neutral position. The patient returns 5 to 10 days after injury for removal of
the splint. Radiographs are repeated to ensure that no displacement has occurred, and
the patient is placed in a long-arm cast for an additional 2 to 3 weeks, at which time
immobilization is discontinued. After cast removal the parents are forewarned that
normal use of the arm may not resume for 1 to 2 weeks, and that some pain and stiffness
should be expected for the first 2 months. Children return 6 to 8 weeks after cast
removal for review of their ROM. We have found that patients returning for an ROM
check at 3 to 4 weeks may have mild residual deficits in extension or flexion, or both.
This can be disconcerting to the parents, who expect everything to be normal at this
visit. This parental anxiety (and the long discourse of reassurance) can be avoided by
allowing the child to be out of the cast for a longer period before returning for the final
checkup.

There are a few potential pitfalls in the management of nondisplaced

supracondylar humeral fractures that merit further discussion. The first concerns the
diagnosis. Sometimes the only visible radiographic abnormality is the presence of a fat
pad sign. Frequently, after 1 to 3 weeks, the fracture, as well as the periosteal reaction
associated with its healing, will be obvious. Failure to make this diagnosis at the outset
is of little concern because the fracture is stable. Of more concern is the possibility of
misdiagnosing an occult infection or nursemaid’s elbow as a nondisplaced
supracondylar humeral fracture. A thorough history will suggest the correct diagnosis.
At times, undisplaced fractures cause soft tissue swelling and may even result in
compartment syndrome. Thus, we are careful to not immobilize the arm in more than
90 degrees of flexion, and we often use a posterior splint rather than a cast. If a cast is
applied, it is generously split. The parents must be educated on the importance of edema
control and watching for signs of increased swelling and pressure. Too often patients
are discharged from the emergency department with instructions to elevate the arm and
 use a sling. It should not be surprising that a number of these patients return for follow-
up with swollen extremities. Parents, in an effort to follow directions, are dogmatic
about use of the sling. Unfortunately, this keeps the extremity in a dependent position
and promotes swelling. Time should be taken in the emergency department to explain
to the parents (and the nurses giving discharge instructions) that the extremity should
be elevated with the fingers above the elbow and the elbow above the heart for the first
48 hours after the injury. The sling is for comfort after the swelling has subsided.
Parents should be instructed to return immediately to the emergency department if it
appears that the splint or cast is becoming too tight or the pain seems to be increasing
inappropriately.

3. Treatment of Displaced Fractures

Several treatment options are available for the management of displaced

fractures (types II and III). By definition, all these fractures require reduction. Usually,
even for severe type III injuries, reduction can be accomplished in a closed fashion.
Options exist in regard to the method of maintaining the reduction until the fracture has
healed, including cast immobilization, traction, and percutaneous pin fixation. If
adequate closed reduction cannot be achieved, open reduction should be performed;
this is almost universally followed by pin fixation.

Closed Reduction
Reduction of Extension-Type Fracture. Under general anesthesia, the child is
positioned at the edge of the operating table, with the arm over a radiolucent table to
allow assessment of the reduction with an image intensifier. Some surgeons elect to use
the image intensifier itself as the table. An assistant grasps the proximal humerus firmly
to allow traction to be placed on the distal fragment. Traction should be applied with a
steady continuous force, with the elbow in full extension. Once adequate traction has
been applied, the coronal plane (varus-valgus) deformity is corrected while traction is
maintained. Continuing to maintain traction with the nondominant hand, the surgeon
uses the fingers of the dominant hand to apply a posterior force to the proximal
fragment. The thumb of the dominant hand is advanced along the posterior humeral
shaft in an attempt to milk the distal fragment further distally. Once the thumb reaches
the olecranon, it applies an anterior force to the distal fragment while the fingers
continue to pull the proximal fragment posteriorly. Concurrently, the nondominant
hand flexes the elbow and pronates the forearm for posterior medially displaced
fractures and supinates the forearm for posterior lateral fractures. (With the elbow in a
flexed position, the patient’s thumb should point in the direction of the distal fragment’s
initial displacement.) While the elbow is being flexed, the surgeon’s nondominant hand
can continue to exert a distracting force on the distal fragment. With the elbow
hyperflexed, the reduction is then assessed on AP and lateral views. The lateral image
can be obtained by externally rotating the shoulder or rotating the image intensifier.
With very unstable fractures the surgeon may need to rotate the image intensifier to
avoid displacing the fracture. Once the reduction has been confirmed, the fracture can
be immobilized with a cast, traction, or percutaneous pin fixation.
 Several caveats to achieving successful closed reduction need mention. The first
is that every effort should be made to avoid vigorous manipulations and
remanipulations because they only damage soft tissue and elicit more swelling. The
second is the management of extremely unstable fractures, which are often
posterolaterally displaced. Maintenance of reduction is difficult because supination is
not as effective at tightening the intact lateral soft tissue hinge as pronation is at
stabilizing posteromedially displaced fracture. During reduction, as the elbow is placed
into hyperflexion, these fractures occasionally displace into valgus. When valgus
displacement is noted, a different reduction maneuver is required. Traction and the
posteriorly directed force to the proximal fragment remain unchanged. However, as the
elbow is flexed, a varus force is applied, and flexion is stopped at 90 degrees. The
reduction is confirmed and usually stabilized with percutaneous pinning.
 Reduction of Flexion-Type Fractures. Closed reduction is obtained with
longitudinal traction and the elbow in extension; the distal fragment is reduced with a
posteriorly directed force . Any coronal plane deformity is then corrected. Once
adequate reduction has been confirmed, it is usually maintained with percutaneous
pinning. Severely displaced flexion-type injuries are more likely to require open
reduction than the more common extensiontype fractures.
 Percutaneous Pinning. The development of image intensifiers and power pin
drivers has made percutaneous pin fixation of supracondylar humeral fractures a
relatively simple procedure. Because percutaneous pin fixation yields the most
predictable results with the fewest complications, it is our preferred technique for
immobilization of displaced supracondylar humeral fractures.
The technique for percutaneous pinning involves the placement of two or three
0.62-inch smooth K-wires (smaller K-wires may be used in patients younger than 2
years) distally to proximally in a crossed or parallel fashion. The use of a crossed pin
or parallel pin technique has been the subject of considerable debate; see later,
“Controversies in Treatment.” Once closed reduction has been achieved, the extremity
is held in the reduced position by the surgeon’s nondominant hand or an assistant. We
usually place the lateral pin first although occasionally, with an unstable
posterolaterally displaced fracture, the initial pin may have to be placed medially. If
two lateral pins are to be used, the first pin should be placed as close to the midline as
possible (just lateral to the olecranon). If only one lateral pin is to be placed, the starting
point is the center of the lateral condyle. After the first pin is placed, the second pin is
inserted laterally (in the center of the lateral column) or medially. The relationship of
the second pin to the first pin and the fracture is an important aspect of percutaneous
pin fixation. The rotational stability of the fixation is enhanced if the second pin crosses
the fracture line at a significant distance from the first pin. Careful attention must be
given to ensure that the pins do not cross the fracture at the same point. This potential
error can be made with crossed or parallel pins. We avoid this problem by attempting
to divide the fracture into thirds with the pins.

If a medial pin is used, care must be taken to ensure that the ulnar nerve is not
injured. The starting position for a medial pin is the inferiormost aspect of the medial
epicondyle. The pin should be started as far anteriorly as possible. It is often helpful for
the surgeon holding the reduction to milk the soft tissue posteriorly, with the thumb left
immediately posterior to the medial epicondyle to protect the ulnar nerve .If the elbow
is extremely swollen, a small incision can be made to identify and protect the ulnar
nerve. It is important to remember that flexion of the elbow displaces the ulnar nerve
anteriorly. Thus it is safer to place a medial pin with the elbow in extension.447,540,553
Similarly, if the arm is immobilized in flexion, the nerve may be tented around the pin,
thereby leading to ulnar nerve symptoms without direct penetration of the nerve by the
pin.

Placement of K-wires percutaneously through the narrow distal humerus

requires some finesse. As in all percutaneous procedures in orthopaedics, it is facilitated
by knowing the anatomy and by reducing the task into two separate, twodimensional
problems. Appropriate pin placement is made easier by first lining up the pin driver in
the AP plane, locking this angle in, and then lining up the pin driver in the lateral plane
without changing the angle in the AP plane. Positioning the pin driver and subsequently
the pin sequentially in only these two orthogonal planes simplifies a conceptually
difficult task. The use of a pin driver rather than a drill, which requires a chuck key,
also facilitates pin placement because the pin can be advanced more readily in the
power driver.
Once the fracture has been stabilized with at least two pins, the elbow is
extended, and the reduction and pin placement are confirmed on orthogonal
radiographic views. If the reduction and pin placement are acceptable, the pins are bent,
cut (it is best to leave a few centimeters of pin out of the skin to facilitate removal), and
covered with sterile felt to decrease skin motion around the pin. The arm is immobilized
in 30 to 60 degrees of flexion in a posterior splint or widely split or bivalved cast. The
child is observed overnight and discharged with instructions on cast care and elevation.
The child usually returns in 7 to 10 days for examination, and radiographs are generally
taken to check for maintenance of reduction. At 3 weeks the radiographs are repeated,
the pins are removed, and the immobilization is discontinued. The parents are instructed
to expect gradual ROM and to avoid forced manipulation. Final follow-up is at 6 to 8
weeks to evaluate alignment and ROM.
As with all treatment methods, there are potential complications with
percutaneous pinning, including pin tract inflammation or infection, iatrogenic ulnar
nerve injury, and loss of reduction. Pin tract inflammation or infection occurs in 2% to
3% of patients in most large series of supracondylar humeral fractures treated by pin
fixation.96 Fortunately these infections usually respond to removal of the pin and a
short course of oral antibiotics, although osteomyelitis can develop. Ulnar nerve injury
from a medially placed percutaneous pin is another potential complication. The true
incidence of this problem is difficult to determine because not all ulnar nerve injuries
are iatrogenic. However, the ulnar nerve is the least commonly injured nerve in
supracondylar fractures; this type of injury occurs most frequently in the rare flexion
injuries. If an ulnar nerve deficit is noted postoperatively and a medial pin is present,
we recommend removal of the medial pin and observation. Fortunately, in most cases,
the ulnar nerve makes a complete recovery.
Loss of reduction can occur after closed reduction and percutaneous pinning of
supracondylar humeral fractures (Fig. 33-54). This complication is generally the result
of inadequate surgical technique and can be minimized by close attention to detail to
ensure that the pins are maximally separated at the fracture and have adequate purchase
in the proximal fragment.
Cast Immobilization. The advantages of cast immobilization are that a cast is
easy to apply, readily available, and familiar to most orthopaedists. Casting does not
require sophisticated equipment, there is little chance of iatrogenic infection or growth
arrest, and it can yield good results. Therefore some surgeons advocate closed reduction
and cast immobilization as the initial treatment option for all displaced supracondylar
humeral fractures and reserve percutaneous pinning for patients in whom cast
management fails.
After closed reduction is obtained, treatment of displaced fractures with a cast
is similar to treatment of a nondisplaced fracture,68 but with a few differences. First,
the cast should be carefully applied to avoid compression in the antecubital fossa.
Second, patients requiring reduction are admitted to the hospital overnight for
observation. Again, it is imperative that the nursing staff and parents understand the
importance and technique of edema control. The final and perhaps most significant
difference in the management of displaced fractures with a cast is that the cast is not
removed at the initial follow-up visit 7 to 10 days after the reduction; rather, radiographs
are obtained with the arm in the cast. Again, the cast is maintained for 3 to 4 weeks
after the reduction, and the parents are warned to expect a period of pain and stiffness
after cast removal.
Cast immobilization is not without potential problems. Most displaced
supracondylar fractures are stable only if immobilized in more than 90 degrees of
flexion. Casting an injured elbow in hyperflexion may lead to further swelling,
increased compartment pressure, and possibly the development of Volkmann’s
ischemic contracture (compartment syndrome). Although Volkmann’s ischemic
contracture can develop in any patient with a supracondylar humeral fracture,
regardless of the treatment method, cast immobilization requires flexion of the elbow
and a rigid circumferential dressing, both of which may exacerbate the condition. An
A-frame cast that leaves the antecubital fossa free of casting material may reduce cast
complications.
Loss of reduction is the other potential problem with cast immobilization. As
the swelling subsides, a cast inevitably loosens and allows the elbow to extend, which
may result in loss of reduction. Often this will occur after the first follow-up radiograph
shows maintenance of the reduction. In this scenario, it is not until the cast is removed
a few weeks later that the varus hyperextension malunion is discovered. Although good
results can be obtained with cast immobilization, particularly with type II fractures, the
necessity to immobilize the elbow in flexion and the unpredictable problem of loss of
reduction have led us away from the use of cast immobilization of supracondylar
fractures that require reduction.
Traction. Traction also yields good results in the management of displaced
supracondylar humeral fractures. Numerous traction techniques have been described,
including overhead or lateral traction with skin or skeletal traction applied with an
olecranon pin or screw. Traction has been advocated to maintain a closed reduction and
achieve reduction of irreducible fractures. A period of traction preceding an attempt at
closed reduction in a massively swollen arm has also been described. However, the
most effective way to prevent local swelling, or to decrease it if the elbow is already
swollen, is to achieve immediate reduction and stabilize the fracture and soft tissue.
There are several drawbacks to skeletal traction that have led to a steady decline
in its use, including the need for prolonged hospitalization, relative discomfort for the
child until the fracture becomes sticky, pin inflammation and infection, potential for
loss of reduction, and possible development of neurovascular complications, such as
ulnar nerve injury from olecranon pins, compartment syndrome from excessive traction
or circumferential bandages, and circulatory embarrassment from acute hyperflexion of
the elbow while in traction.
We do not use traction in the management of supracondylar humeral fractures.
Its use is only described here for historical completeness. It may have a role in the rare
fracture that cannot be managed routinely because of extenuating circumstances.
Open Reduction. Indications for open reduction of a supracondylar humeral
fracture include an ischemic pale hand that does not revascularize with reduction of the
fracture, open fracture, irreducible fracture, and inability to obtain a satisfactory closed
reduction. If the hand remains ischemic after reduction of the fracture, the brachial
artery should be immediately explored through an anterior approach. Once the arterial
pathology (entrapment, laceration, or compression) has been identified, the fracture
should be reduced and percutaneously pinned. If necessary, the arterial pathology can
then be addressed.
Open fractures require emergency operative débridement. After débridement,
the fracture can be reduced with an open technique and percutaneously pinned. With
appropriate débridement, fracture stabilization, and antibiotic coverage, the
complication rate of open fractures is not significantly different from that of severely
displaced closed fractures.
Supracondylar fractures may be irreducible if the distal aspect of the proximal
fragment buttonholes through the brachialis muscle. This buttonholing often produces
a characteristic puckering of the skin over the displaced proximal fragment. The
presence of this pucker sign is not in itself an indication for open reduction because
 closed reduction may be successful. However, this sign should alert the surgeon to a
potentially refractory fracture that may require open reduction.
The decision that a closed reduction is unacceptable and an open reduction is
indicated must be made on an individual basis. We accept mild angulation in the sagittal
plane and translation in the coronal plane. A mild amount of valgus angulation in the
coronal plane is also acceptable. However, varus angulation in the coronal plane,
particularly if associated with a small amount of hyperextension in the sagittal plane or
a contralateral carrying angle that is neutralor varus, is likely to yield a cosmetically
poor result that will not remodel. If significant varus deformity exists after the best
attempt at closed reduction, we proceed to open reduction. We usually approach the
elbow from the side opposite the displaced distal fragment. This allows any interposed
soft tissue to be removed from the fracture site. Once reduced with an open technique,
the fracture is stabilized with percutaneous pins. Ersan and co-workers compared
anterior to lateral open approaches and concluded that the anterior incision yields better
anatomic access, with a smaller scar.158 Aktekin and associates found poor functional
and cosmetic results when open reduction was performed through a posterior, triceps-
sparing approach.

DIAGNOSE

Supracodylar fracture, these are among the commonest fractures in children. The distal
fragment may be displaced either posteriorly or anteriorly.1

Mechanism of injury Posterior angulation or displacement (95 per cent of all cases) suggests a
hyperextension injury, usually due to a fall on the outstretched hand. The humerus breaks just
above the condyles. The distal fragment is pushed backwards and (because the forearm is
usually in pronation) twisted inwards. The jagged end of the proximal fragment pokes into the
soft tissues anteriorly, sometimes injuring the brachial artery or median nerve. Anterior
displacement is rare; it is thought to be due to direct violence (e.g. a fall on the point of the
elbow) with the joint in flexion.1

Classification Type I is an undisplaced fracture. Type II is an angulated fracture with the

posterior cortex still in continuity. IIA – a less severe injury with the distal fragment merely
angulated. IIB – a severe injury; the fragment is both angulated and malrotated. Type III is a
completely displaced fracture (although the posterior periosteum is usually still preserved,
which will assist surgical reduction).1

Following a fall, the child is in pain and the elbow is swollen; with a posteriorly
displaced fracture the S-deformity of the elbow is usually obvious and the bony landmarks are
abnormal. It is essential to feel the pulse and check the capillary return; passive extension of
the flexor muscles should be pain-free. The wrist and the hand should be examined for evidence
of nerve injury.1

Patients with supracondylar fractures present with pain and swelling about the elbow.
Active elbow motion is limited, and gross deformity of the arm may be present with displaced
fractures. Thorough examination of the limb includes evaluation of the soft tissues for severe
swelling, skin lacerations, or abrasions, and assessment for other fractures in the upper
extremity. Fractures of the distal radius are the most common ipsilateral fractures that occur in
conjunction with supracondylar fractures.6 Children who sustain supracondylar fractures with
diaphyseal forearm fractures are at higher risk of developing compartment syndromes of the
forearm than are those with isolated supracondylar fractures.2

Thorough neurologic assessment may be difficult because of pain, anxiety, or poor

cooperation with the examination, particularly in children aged <3 to 4 years. One recent
analysis of several studies indicated that nerve injuries occur in as many as 11.3% of patients
with supracondylar fractures.8 In patients with extension-type supracondylar fractures, anterior
interosseous nerve injury is most common, followed by median, radial, and ulnar nerve injuries.
The ulnar nerve is most commonly injured in flexion-type fractures.8 It is critical that the
surgeon make the best effort to diagnose nerve deficits in these younger patients through
observation of activities and repeat examinations if necessary. In most patients, neurologic
deficit identified at the time of injury is temporary and resolves within 6 to 12 weeks. A change
in the neurologic examination postoperatively is more concerning and may indicate that the
affected nerve was injured during manipulation and pinning or that it is trapped in the fracture
site. Exploration of the nerve may be required to prevent ongoing nerve injury.2

Accurate determination of the vascular status of the involved limb in the emergency
department is also critical. First, the distal radial pulse is palpated to determine flow. In some
cases, Doppler ultrasonography may be necessary. However, perfusion of the hand is a better
indicator of the vascular status of the limb after supracondylar fracture. In most children,
abundant collateral flow to the forearm and hand originates proximal to the site of the fracture.
Despite absence of a radial pulse resulting from injury or spasm of the brachial artery at the
fracture site, the hand may be well-perfused. Clinical indicators of sufficient distal perfusion
include normal capillary refill, skin temperature, and color (typically described as pink). The
child with an ischemic limb may experience significant forearm pain, loss of motor function,
pain with passive stretch of the digits, and/or paresthesias. The vascular status of the injured
extremity is categorized as normal, pulseless with a pink hand, or dysvascular, which is
sometimes described as pulseless with a white hand. Supracondylar fracture with a dysvascular
hand constitutes a surgical emergency.2

The fracture is seen most clearly in the lateral view. In an undisplaced fracture the ‘fat
pad sign’ should raise suspicions: there is a triangular lucency in front of the distal humerus,
due to the fat pad being pushed forwards by a haematoma. In the common posteriorly displaced
fracture the fracture line runs obliquely downwards and forwards and the distal fragment is
tilted backwards and/or shifted backwards. In the anteriorly displaced fracture the crack runs
downwards and backwards and the distal fragment is tilted forwards. On a normal lateral x-
ray, a line drawn along the anterior cortex of the humerus should cross the middle of the
capitulum. If the line is anterior to the capitulum then a Type II fracture is suspected. An
anteroposterior view is often difficult to obtain without causing pain and may need to be
postponed until the child has been anaesthetized. It may show that the distal fragment is shifted
or tilted sideways, and rotated (usually medially). Measurement of Baumann’s angle is useful
in assessing the degree of medial angulation before and after reduction.1

(a) (b) (c) (d)

X-ray showing supracondylar fractures of increasing severity; (a) undisplaced. (b) distal fragment
posterior angulated but in contact. (c) distal fragment completly separated and displaced
posteriorly. (d) A rarely variety with anterior angulation
 (a) (b) (c)

Anteroposterior x-rays are sometimes difficult to make out, especially ifnth elbow is held flexed
after reduction of the suprocondylar fracture. Measurement of baumann’s angle is helpful. This is
the angle subtended by the longitudinal axis of the humeral shaft and a line through the coronal axis
of the capitellar physis, as shown in (a) the x-ray of a normal elboow and the accompanying diagram
(b) normally this angle is less than 80 degrees. If the distal fragmen is tilted in varus, th icreased
angle is readily detected (c)

Treatment
This is the current concepts management of supracondylar humerus fractures.
Management of extension supracondylar fractures is generally determined by Gartland type.
Type I fractures are managed with 3 to 4 weeks of long arm cast immobilization with the elbow
flexed to 90° and the forearm held in neutral rotation. This treatment is also used when the
initial radiograph is negative for fracture but demonstrates a visible posterior fat pad.
Management of type II supracondylar fractures is controversial. Many patients with type IIA
fractures may be successfully treated with closed reduction and casting; however, close
observation is required to monitor for loss of reduction. All type IIB fractures are best managed
with closed reduction and pinning. For type III fractures, closed reduction and pinning is the
initial management choice. We use the semisterile technique to perform closed reduction and
percutaneous pinning3

This technique does not require drapes or gowns and thus reduces operating room time
and cost. Iobst et all, reported no superficial pin tract or deep infections requiring treatment in
their study of 304 cases managed with this technique. In most cases, 0.062-in Kirschner wires
(K-wires) are used, but larger pins (5/64-in) should be considered for older children. At the
conclusion of the procedure, the arm is splinted in 60° to 80° of flexion. At 1 week
postoperatively, radiographs are obtained to confirm maintenance of reduction. When
reduction is maintained, the splint is overwrapped with fiberglass. The K-wires are removed in
the office 3 to 4 weeks postoperatively, and the arm is kept in a sling for 1 to 2 weeks. Otsuka
and Kasser2 provided a complete detailed description of the technique and aftercare. Type IV
fractures are managed with a modified pinning technique. Rather than rotating the arm to obtain
orthogonal views during pin insertion, the fluoroscopy unit can be rotated or two fluoroscopy
units can be used simultaneously. Leitch et all, suggest preplacement of K-wires into the distal
fragment before reduction. Open reduction and internal fixation is indicated predominantly for
fractures that cannot be adequately reduced with closed methods and for open fractures. The
anterior approach to the elbow provides the best exposure of the neurovascular structures and
the soft-tissue obstacles anteriorly that prevent reduction. This approach is performed through
either a transverse or an oblique incision made across the elbow flexion crease.3

Bashyal et all performed a retrospective review of 622 patients treated for

supracondylar fractures and evaluated the complications associated with management. Overall,
4.2% of patients had complications. The most common complication was pin migration, which
required an unanticipated return to the operating room for pin removal in 1.8% of patients.
Infectious complications related to wire fixation were seen in six patients (1%). Five infections
were superficial, and one additional patient required treatment of pin tract osteomyelitis and
elbow septic arthritis. One patient had malunion; four others were returned to the operating
room for repeat reduction and pinning. Compartment syndrome was present in three patients,
and one patient had postoperative ulnar nerve injury.3

Timing of Surgical Intervention

Traditionally, closed reduction and pinning of type III supracondylar fractures was
performed as an emergent procedure within several hours of admission, regardless of the time
of day or night. This was done because of concerns regarding increasing swelling, the
development of compartment syndrome, and increasing difficulty with achieving an adequate
closed reduction. However, this practice has been challenged in recent studies.3
 Mehlman et al, compared the rates of perioperative complications in fractures managed
≤8 hours after injury with those managed >8 hours after injury (52 versus 146 patients,
respectively). No significant difference was noted with regard to the need for conversion to
open reduction, superficial pin tract infection, or iatrogenic nerve injury. No cases of compartment
syndrome occurred in either group. In a retrospective analysis of 150 patients, Gupta et al18 compared
complication rates in patients who had surgery <12 hours after injury with those who had surgery >12
hours after injury. These authors found no difference in perioperative complications between the
groups. Bales et al, reported similar findings in a prospective study of 145 fractures, showing no
increase either in the number of perioperative complications or in the need for open reduction after
surgical delays as long as 21 hours from injury. These authors emphasize the need for a thorough
evaluation in the emergency department to assess neurovascular status and associated injuries, gentle
positioning and splinting of the limb without attempting fracture reduction, frequent monitoring in the
hours before surgery, and availability of the operating room within a reasonable time frame after
admission.3

Based on this evidence and our own experience, we believe that it is safe to delay
surgical treatment of most type III supracondylar fractures to within 12 to 18 hours of injury.
At our institutions, all patients with type III supracondylar fractures are evaluated in the
emergency department by an orthopaedic surgery resident. The arm is then carefully positioned
with the elbow in 20° to 40° of flexion and placed in a long arm splint. The child is admitted
to the hospital and undergoes neurovascular checks by the nurse at 2-hour intervals. Pain
medication is limited to agents that will not sedate the patient or mask symptoms and signs of
compartment syndrome (eg, acetaminophen, ibuprofen, ketorolac, low-dose morphine). All
patients admitted overnight undergo surgery the next morning, typically within 12 hours after
admission. Injuries treated as emergencies include open supracondylar fractures or those with
tenting or puckering of the skin, fractures with abnormal vascular status, and fractures that are
at particularly high risk of compartment syndrome, such as those associated with severe
forearm swelling or that occur in combination with a forearm fracture (eg, floating elbow).
Children who may not be reliably examined for compartment syndrome because of young age
or cognitive disability are typically treated emergently, as are children with complete motor
and sensory median nerve deficit. (Table 1)3

Type II Fracture

Management of type II supracondylar fractures remains controversial because

published reports support several options as primary treatment, including reduction and
casting, reduction and pinning of all type II fractures, and reduction and pinning of type IIB
fractures only. Parikh et al performed a retrospective review of consecutive type II fractures
managed with initial closed reduction and casting. In seven fractures, reduction was lost by the
time of follow-up. Five of these fractures subsequently were managed successfully with repeat
closed reduction and pinning. The authors concluded that type II fractures are best managed
initially with reduction and casting.3

Others have suggested that all type II fractures be managed with closed reduction and
pinning either because of the potential for displacement or to obtain anatomic reduction.
O’Hara et al reviewed 71 children (29 type IIA fractures, 22 type IIB, 20 type III). None of the
type IIB and III fractures managed with pinning required a repeat operation, and no malunions
were observed. One third of the children treated without pinning, including patients with varus
deformity, required further surgery. The authors concluded that all type IIB and III fractures
should be pinned after reduction.3

At our institutions, most type II fractures are managed primarily with closed reduction
and pin fixation. The main reasons for this management protocol are concern regarding
inability to maintain adequate reduction in a cast or splint, poor patient adherence to follow-up
instructions, and inability to distinguish a type IIA fracture from a type IIB fracture. Closed
reduction and casting is the primary treatment only for those patients with minimal swelling
and posterior displacement without rotation or translation on any radiographic view. For this
limited number of patients, follow-up radiographs are obtained 5 to 7 days after injury. Surgical
reduction and pinning is performed if the reduction is not maintained.3
Pin Configuration

Traditionally, a crossed pin configuration has been used to stabilize supracondylar fractures
after reduction. With the elbow held in flexion, one lateral pin is placed percutaneously just
proximal to the capitellum in the metaphysis, and one pin is placed percutaneously anterior to
the ulnar groove in the medial epicondyle. The pins are configured to cross proximal to the
fracture site in the midline of the distal humerus, and they are advanced through the cortices.
This configuration has been shown in clinical series to be effective for maintaining reduction
and has been shown in biomechanical testing21 to be superior to other pin configurations,
including multiple lateral entry pins. However, ulnar nerve injury occurs in as many as 10% of
patients. Direct nerve penetration or stretching of the nerve around the pin are possible causes
of injury. In addition, because in some children the ulnar nerve subluxates anteriorly out of the
ulnar groove when the elbow is held in maximum flexion, this complication may occur even
when the medial pin is placed correctly in the medial epicondyle.3

To avoid this complication, many surgeons use only lateral entry pins to stabilize
supracondylar fractures. Skaggs et all retrospectively reviewed 345 extension-type
supracondylar fractures and compared the outcomes of displaced fractures managed with
lateral entry pins only or with crossed pins. Maintenance of reduction was the same for both
groups. However, no ulnar nerve injuries occurred in the lateral entry pinning group, whereas
a 7.7% incidence of iatrogenic nerve injury was reported in the crossed-pin group. Gaston et
al23 showed similar findings in another smaller study of the same design. In a prospective,
randomized clinical study, Kocher et al, compared the outcomes of displaced fractures
managed with either lateral entry pins or crossed pins. Neither clinically significant loss of
reduction nor iatrogenic ulnar nerve injury was identified in either group.3

Sankar et al, demonstrated that loss of fracture reduction is possible with lateral entry
pins if proper technique is not applied. In their retrospective review of 279 displaced
supracondylar fractures, 8 (2.9%) lost fixation. Seven of these eight fractures were initially
managed with two lateral entry pins only. The authors identified important technical errors,
including failure to engage both fragments with at least two pins, failure to achieve bicortical
fixation with at least two pins, and failure to achieve ≥2 mm of pin separation at the fracture
site (Figure 2). They recommended critical radiographic evaluation of each pin to avoid these
errors. They also advised checking the stability of fixation by stressing the fracture site under
fluoroscopy at the completion of the procedure.3

At our institutions, most displaced fractures are stabilized with only lateral entry pins.
For type II fractures, at least two bicortical pins are used, whereas type III fractures are typically
stabilized with at least three lateral pins (Figure 3). The pins are configured as far apart as
possible in a divergent manner, ideally not converging or crossing at the fracture site. Ideally,
both the medial and the lateral columns are engaged to im prove stability. If the distal humerus
is comminuted or the fracture reduction is very unstable, a medial pin is placed. Following
placement of the lateral pins, the medial pin is inserted through a small incision over the medial
epicondyle with the elbow in extension. Varus/valgus, flexion/extension, and rotational
stresses are applied to the fracture under live fluoroscopy at the conclusion of surgery to ensure
stability. The arm is then splinted in 80° of flexion and neutral rotation while the patient is still
under anesthesia.

Pink Pulseless Hand The pulseless limb associated with supracondylar fracture is one
of the most distressing injuries that the orthopaedic surgeon encounters. This anxiety is fueled
in part by the rarity of the injury, lack of experience with vascular repair of small vessels, and
lack of consensus regarding the best management of the condition. Most surgeons follow a
similar treatment algorithm for this injury.3

Emergency surgery is indicated for the pink pulseless hand and for the dysvascular limb
in association with a supracondylar fracture. In the operating room, the fracture is reduced
closed if possible and pinned. The vascular status is reassessed and observed for 15 to 20
minutes for signs of improvement. Regardless of the status of the pulse, if the hand is well-
perfused, the arm is splinted in 40° to 60° of flexion and the child is admitted to an intensive
care or stepdown unit for monitoring. If perfusion is not restored within this time frame, the
vessel is immediately explored through an anterior approach. After inspection of the vessel,
the artery is directly repaired; if that is not possible, a vein graft is used to span the defect.
Prophylactic forearm and hand fasciotomies are performed in cases of reperfusion with
prolonged ischemia. Unless the child has sustained multiple injuries or fractures in the same
limb, arteriography is not useful and may in fact delay revascularization or exacerbate vessel
spasm (Figure 4).3

This algorithm has been supported in the literature.3,26,27 The authors of a study
evaluating vascular status following vessel repair noted that the limb remained well-perfused
and functioned normally even if the radial pulse did not return or the vessel repair was not
patent.3

Some recent studies indicate that this strategy underestimates the severity of
neurovascular injury in patients with a pink pulseless hand. In an analysis of 19 published
articles, White et al, identified 98 patients with pink pulseless hands after supracondylar
fractures. Forty-five of these patients underwent vessel exploration. Five vessels were found to
be in spasm, and 40 had vessel injury requiring repair. At follow-up, the patency rate was 90%.
Mangat et al, retrospectively compared patients with pink pulseless hands treated with closed
reduction and pinning to those treated additionally with vessel exploration. Of the 11 patients
initially treated with pinning only, 4 required secondary exploration that identified vessel
tethering or entrapment at the fracture site. Three of these patients had nerve entrapment or
tethering involving the median and/or anterior interosseous nerve. Of the eight patients treated
with early exploration, the vessel was found to be tethered at the fracture site in six patients,
four of whom also had nerve entrapment. All vessels that underwent repair remained patent at
follow-up.3

Blakey et al, reported that 23 of 26 patients referred to their institution

withpinkpulselesshandsfollowingsupracondylar fracture had some evidence of ischemic
contractures of the forearm and hand. Of these, two patients responded to stretching; the
remainderrequiredfurthersurgicalintervention. These authors recommended urgent exploration
of the vessel in a child with a pink pulseless hand following reduction.3

We emergently perform closed reduction and pinning in children who present with pink
pulseless hands after supracondylar fractures. At our institutions, scenarios requiring emergent
vascular exploration include complete median nerve palsy associated with an abnormal
vascular examination; a dysvascular limb; pink pulseless hand and an equivocal or worsening
vascular examination; and signs or symptoms of forearm or hand ischemia. Although some
have recommended exploring all limbs without a palpable radial pulse following closed
reduction, it is our opinion that higher level evidencebased outcome studies are needed to
justify exploration in all of these children.3

For comparation, lets we look how the menagement of supracondylar humrus fracture
in Apley’s system of orthopaedics and fracture ninth edition. If there is even a suspicion of a
fracture, the elbow is gently splinted in 30 degrees of flexion to prevent movement and possible
neurovascular injury during the x-ray examination. 1

TYPE I: UNDISPLACED FRACTURE

The elbow is immobilized at 90 degrees and neutral rotation in a light-weight splint or

cast and the arm is supported by a sling. It is essential to obtain an x-ray 5–7 days later to check
that there has been no displacement. The splint is retained for 3 weeks and supervised
movement is then allowed. The capitulum normally angles forward about 30 degrees; if the
capitulum is in a straight line with the humerus on the lateral x-ray, it will still remodel. Even
with Type I fractures, care must be taken to recognise any medial tilt of the distal fragment on
the anteroposterior x-ray, otherwise cubitus varus can result. Measure Baumann’s angle.1

TYPE II A: POSTERIORLY ANGULATED FRACTURE – MILD

In these cases swelling is usually not severe and the risk of vascular injury is low. If the
posterior cortices are in continuity, the fracture can be reduced under general anaesthesia by
the following step-wise manoeuvre: (1) traction for 2–3 minutes in the length of the arm with
counter-traction above the elbow; (2)correction of any sideways tilt or shift and rotation (in
comparison with the other arm); (3) gradual flexion of the elbow to 120 degrees, and pronation
of the forearm, while maintaining traction and exerting finger pressure behind the distal
fragment to correct posterior tilt. Then feel the pulse and check the capillary return – if the
distal circulation is suspect, immediately relax the amount of elbow flexion until it improves.
X-rays are taken to confirm reduction, checking carefully to see that there is no varus or valgus
angulation and no rotational deformity. The anteroposterior view is confusing and unreliable
with the elbow flexed, but the important features can be inferred by noting Baumann’s angle.
Again, subtle medial tilt and rotation of the distal fragment must be recognised. If the acutely
flexed position cannot be maintained without disturbing the circulation, or if the reduction is
unstable, (and most of these fractures are unstable!) the fracture should be fixed with
percutaneous crossed K-wires (take care not to skewer the ulnar nerve!).1

Following reduction, the arm is held in a collar and cuff; the circulation should be
checked repeatedly during the first 24 hours. An x-ray is obtained after 3– 5 days to confirm
that the fracture has not slipped. The splint is retained for 3 weeks, after which movements are
begun.1

TYPES II B AND III: ANGULATED AND MALROTATED OR POSTERIORLY

DISPLACED

These are usually associated with severe swelling, are difficult to reduce and are often
unstable; moreover, there is a considerable risk of neurovascular injury or circulatory
compromise due to swelling. The fracture should be reduced under general anaesthesia as soon
as possible, by the method described above, and then held with percutaneous crossed K-wires;
this obviates the necessity to hold the elbow acutely flexed. Smooth wires should be used (this
lessens the risk of physeal injury) and great care should be taken not to injure the ulnar, radial
and median nerves. Postoperative management is the same as for Type II A.1

OPEN REDUCTION

This is sometimes necessary for (1) a fracture which simply cannot be reduced closed;
(2) an open fracture; or (3) a fracture associated with vascular damage. The fracture is exposed
(preferably through two incisions, one on each side of the elbow), the haematoma is evacuated
and the fracture is reduced and held by two crossed K-wires.1

CONTINUOUS TRACTION

Traction through a screw in the olecranon, with the arm held overhead, can be used (1)
if the fracture is severely displaced and cannot be reduced by manipulation; (2) if, with the
elbow flexed 100 degrees, the pulse is obliterated and image intensification is not available to
allow pinning and then straightening of the elbow; or (3) for severe open injuries or multiple
injuries of the limb. Once the swelling subsides, a further attempt can be made at closed
reduction.1

TREATMENT OF ANTERIORLY DISPLACED FRACTURES

This is a rare injury (less than 5 per cent of supracondylar fractures). However,
‘posterior’ fractures are sometimes inadvertently converted to ‘anterior’ ones by excessive
traction and manipulation. The fracture is reduced by pulling on the forearm with the elbow
semi-flexed, applying thumb pressure over the front of the distal fragment and then extending
the elbow fully. Crossed percutaneous pins are used if unstable. A posterior slab is bandaged
on and retained for 3 weeks. Thereafter, the child is allowed to regain flexion gradually.1

(a) (b) (c) (d)

(e) (f) (g) (h) (i)

Supracondylar fracturs-treatment (a) the ununjured arm is examined first (b) traction of the fractured
arm (c) correcting lateral shift and tilt (d) correcting rotation (e) correcting backwards shift and tilt (f)
feeling the pulse; the elbow is kept well fixed while x-ray films are taken (h) for the first 3 weeks the
arm is kept under clothes; after this (i) it is outside the clothes

Complications

Vascular Insufficiency Absence of the radial pulse is reported in 6 to 20 percent of all

supracondylar fractures. Vascular injury evident by involvement of brachial artery is most
commonly associated with Type II and III supracondylar fractures, frequently encountered in
postero-laterally displaced fractures. Patients without significant improvement in pulse after
orthopaedic care, warrant emergent vascular exploration, especially if there is intractable pain,
persistence of pain or increasing pain despite of fracture site stabilization which is suggestive
of ischemia. Griffin et al., in a systematic review of 161 children with supracondylar fractures
and a pulseless hand found that closed reduction and percutaneous pinning resulted in return
of the radial pulse in 51% (82 of 161) of cases. A total of 63 of remaining 79 children with
persistent pulseless hand after operative care underwent vascular exploration. Brachial artery
injury or thrombus was found in 61 patients (97%). Mangat et al., in an observational study of
19 children who had a perfused but pulseless hand after Gartland Type III fracture concluded
that in cases where there is vascular deficit along with neurological deficit (due to median/
anterior interosseous nerve involvement), early exploration is recommended, as these appear
to be strongly predictive of nerve and vessel entrapment at the fracture site. Those with isolated
vascular deficit can be managed by closed reduction and could be observed for return of
vascularity and if needed secondary exploration. Blakey et al., in an observational study of 26
children who had a pink pulseless hand, wherein 3 underwent immediate surgical exploration
of vessel with good functional results and remaining 23 who presented late (four days to one
year after injury) and did not have early release of brachial artery obstruction developed
ischemic contractions of hand and/or forearm muscles, and thus recommended urgent
exploration of the vessels and nerves in such cases not relieved by reduction of a supracondylar
fracture of the distal humerus and presenting with persistent and increasing pain suggestive of
a deepening nerve lesion and critical ischemia. In a study of 66 children by Korompilias et al.,
with displaced supracondylar fractures of the humerus, they encountered 4 patients with a pink
yet pulseless hand after fracture reduction. On exploration brachial artery thrombus was found
in 3. Subsequent thrombectomy was performed, which led to the restoration of a palpable radial
pulse. In 1 patient with open fracture, brachial artery contusion and spasm were found, and
treated by removal of adventitia. They concluded that pulselessness even in the presence of
viable pink hand after an attempt at closed reduction is an indication for surgical exploration
of the brachial artery, to check for its patency.3

Neurologic Deficit

The frequency of neurologic deficit reported after supracondylar fractures in children is 10 to

20 percent and increases in some series of children with Type III supracondylar fractures to as
high as 49 percent. Median nerve and its anterior interosseous nerve branch is at risk and gets
most commonly involved in postero-lateral displacement of the distal fracture fragment,
whereas radial nerve is most commonly involved with postero-medial displacement of the
distal fracture fragment. Ulnar nerve injuries are commonly associated with flexion type
supracondylar fractures. Most often associated nerve injuries are neuropraxias that usually
resolve within two to three months. One should consider surgical exploration for nerve deficits
that persist beyond three months. Barret KK et al., in one of the largest retrospective,
multicentric study conducted on 4409 patients with supracondylar fracture of the humerus
presenting with anterior interosseous nerve injury (no sensory involvement) concluded that an
isolated anterior interosseous nerve injury associated with this fracture in itself is not an
indication for surgery. In this huge series they showed complete neurological recovery in a
mean time of 49 days with 90 percent of the patients recovering by 149 days. 3

Forearm Compartment Syndrome Resulting in Volkmann's Ischemic Contracture

Vascular injury and primary swelling from the injury can lead to the development of
compartment syndrome within 12 to 24 hours. If a compartment syndrome is not treated timely,
the associated ischemia may progress to infarction and subsequent development of Volkmann's
ischemic contracture: fixed flexion of the elbow, pronation of the forearm, flexion at the wrist,
and joint extension of the metacarpal-phalangeal joint.3

Malunion

One of the frequent long term complications of supracondylar fracture are angular deformities,
of which cubitus varus or “gunstock” deformity is very common. The distal humerus physis,
in contrast to the proximal humeral physis, contributes only 15 to 20 percent to the overall
longitudinal growth of the humerus. This suggests very limited remodeling in correction of
fracture angulation in children with supracondylar fractures. Modern surgical techniques (e.g.,
closed reduction with percutaneous pinning) have reduced this frequency of cubitus varus from
58 percent to approximately 3 percent in children treated for supracondylar fractures.
Posttraumatic cubitus varus deformity has important problems, which are associated with tardy
ulnar nerve palsy, tardy Postero-Lateral Rotatory Instability (PLRI) [59], and secondary distal
humeral fractures. Therefore, humeral osteotomy is used to correct this deformity and to avoid
such later complications . Eren A et al., conducted a study to evaluate the relationship between
the fracture displacement and cubitus varus deformity in displaced supracondylar humerus
fractures. They observed that the carrying angle loss was more significant in Type III-A
fractures compared with Type III-B and concluded that although anatomic reduction has been
achieved by surgical treatment without loss of reduction, further there is still a risk for cubitus
varus deformity for Type III-A fractures due to the initial compression of the medial column
or, in other words, physical injury. Stiffness elbow-secondary to manipulation with or without
development of myositis. Supracondylar fractures of the humerus are a common pediatric
elbow injury that can be associated with neurovascular complications and skeletal deformity.
The understanding of the anatomy, radiographic findings, complications, as well as the
management options that associated with this fracture, allow physicians to limit the morbidity
associated with this injury.3
DAFTAR PUSTAKA
1. Solomon, Lois. Et. all. 2010. Apley’s System of Orthopaedics and Fractures.
Southampton: University of Southampton.
2. Kumari, Viinet. Et. all. 2016. Supracondylar Humerus: A Review. Journal Of Clinical
and Diagnostic.
3. Abzug, Joshua. Et. all. 2012. Management of supracondylar Humerus Fractures in
Child Current Concept. New York : Journal of the American Academy of
Orthopaedic Surgeons.