The Pediatric Upper Extremity

DOI 10.1007/978-1-4614-8758-6_52-1
# Springer Science+Business Media New York 2014

Supracondylar Humerus Fracture

Afamefuna Nduagubaa* and John Flynnb
a
Childrens Hospital of Philadelphia, Philadelphia, PA, USA
b
Department of Orthopaedic Surgery, Childrens Hospital of Philadelphia, Philadelphia, PA, USA

Abstract
Supracondylar humerus fractures are the most common elbow fractures in children. While
nondisplaced type I supracondylar fractures can be managed nonoperatively with reduction and
casting, operative xation with closed reduction and percutaneous pinning (CRPP) is indicated for
most displaced injuries (Types II, III, and IV). Two or three lateral pins are usually sufcient to
stabilize most fractures; however, in very rare cases of persistent instability after third lateral pin,
a medial pin may be required. Consideration of management of supracondylar humerus injuries
should include a thorough evaluation of limb perfusion as this has consequences for treatment.
Limbs that regain perfusion but remain pulseless after operative xation can be observed for an
additional 48 h. But limbs that remain poorly perfused require urgent open exploration.
Surgicalmanagement of supracondylar humerus fractures has good outcomes and very low
complication rates.

Keywords
Supracondylar humerus fracture; Elbow injuries; Pediatric injuries; FOOSH; Fractures; CRPP;
Cubitus varus; Trauma

Introduction to Supracondylar Humerus Fracture

Supracondylar humerus fractures are the most common elbow fractures in the pediatric population
(Cheng et al. 1999; Otsuka 1997). They account for two-thirds of all elbow injuries in children
(Kasser and Beaty 2006) and represent 16 % of all pediatric fractures (Cheng and Shen 1993).
These fractures may occur in association with ipsilateral diaphyseal forearm fractures, neurovascular
complications, and/or compartment syndrome (Dhoju et al. 2011). Supracondylar fractures of
the humerus occur equally in girls and boys, more commonly between 5 and 7 years of age
(Cheng et al. 2001; Farnsworth et al. 1998; Omid 2008).
Current evidence supports surgical xation for management of Gartland type II and III
supracondylar fractures; (Abzug and Herman 2012; Howard et al. 2012; Skaggs et al. 2004)
however, controversies remain regarding the timing of treatment and management of complications.

*Email: afam@hms.harvard.edu

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Pathoanatomy and Applied Anatomy Relating to Supracondylar Humerus

Fracture
The increased incidence of supracondylar fractures in skeletally immature children compared to
adults is likely due to maximum ligamentous laxity at this age and the thinner cortex surrounding the
supracondylar area (Brubacher and Dodds 2008; Nork et al. 1999; Fig. 1) which makes the distal
humerus more fragile and predisposes it to fracture. The distal humerus is made up of the medial and
lateral columns, which are connected by a thin segment of bone. This segment of bone is even
thinner at the olecranon fossa (posterior humerus) and the radial and coronoid fossa (anterior
humerus), and while allowing for full range of motion at the elbow without neurovascular impinge-
ment, it is especially weak and thus at high risk for fracture.
Depending on the direction of displacement of the distal humerus fragment, supracondylar
fractures can be classied into extension and exion types. Extension-type fractures account for
9799 % of all supracondylar humerus fractures (Mahan et al. 2007) and are usually due to a fall on
an outstretched hand with the elbow in full extension. A typical injury mechanism is a fall from
playground equipment onto the non-dominant hand (usually the left) with the elbow in hyperexten-
sion to brace the fall. In this type of injury, the distal fragment is displaced posteriorly, thus leading to
an extension-type fracture. In contrast, exion-type supracondylar fractures are most commonly
caused by a direct blow to the elbow with the arm in exion. In this scenario, the distal fragment is
displaced anteriorly. Flexion-type supracondylar fractures are rare and therefore have not been as
extensively characterized as extension-type fractures.
In extension-type supracondylar fractures, the elbow is locked in hyperextension, which
engages the olecranon in the olecranon fossa of the posterior humerus. Linear forces transmitted
to the anterior capsule provide bending forces against the olecranon, which now serves as a fulcrum.

Fig. 1 Lateral view of the distal humerus. Note the thin bone separating the coronoid fossa (anterior) from the olecranon
fossa (posterior) (Courtesy of Shriners Hospital for Children, Philadelphia)

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Fig. 2 An anterior pucker sign may be present if proximal fracture segment penetrates the brachialis muscle and other
soft tissues

In this type of supracondylar fracture, the proximal segment is often displaced anteriorly, and the
anterior periosteum is almost always torn (Skaggs and Flynn 2010). The distal fragment can be
either displaced posteromedially (in 75 % of cases) or posterolaterally. This distinction of direction
has implications for whether the arm should be pronated during reduction. In posteromedially
displaced fractures, the medial periosteum remains intact. Applying tension on medial periosteum
with the forearm pronated closes this hinge corrects valgus malalignment and stabilizes the fracture.
In contrast, posterolaterally displaced fractures have a torn medial periosteum. Pronation will
further destabilize these fractures; thus, supination is better at aiding in reduction. The key take home
point is that not all extension-type supracondylar fractures should be reduced with the forearm
pronated.
In Gartland type IV fractures, both the anterior and posterior periosteum are disrupted. These
fractures are unstable in both extension and exion and require a different management.

Assessment of Supracondylar Humerus Fracture

Signs and Symptoms of Supracondylar Humerus Fracture
The child with a supracondylar fracture typically complains of elbow pain, swelling, and restricted
range of motion at the elbow following a traumatic event, most often a fall onto the outstretched arm
(Baratz et al. 2006). When evaluating the patient, the entire upper extremity should be examined
thoroughly and assessed for concomitant fractures, such as forearm fractures, as they can occur in
association with supracondylar fractures and greatly increase the risk of compartment syndrome
(Blakemore et al. 2000). Soft-tissue swelling, ecchymosis and skin puckering (Fig. 2) suggest
a more severe fracture pattern with the associated possibility of a neurovascular injury (Omid 2008).

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A thorough neurologic exam must be performed because of the high prevalence of neurologic
injury in association with supracondylar fractures. Sensation should be tested in children old enough
to comply with the exam, typically 8 years of age or older. The sensory distribution of the radial
nerve (rst dorsal digital space), median nerve (palm of the rst three digits) and ulnar nerve (ulnar
side of little nger) should be assessed. The motor exam should assess function of the radial nerve
(nger metacarpophalangeal (MP) extension and wrist extension), anterior interosseous nerve
(distal interphalangeal (DIP) joint of the index/long nger and thumb interphalangeal joint exion),
median nerve (proximal interphalangeal (PIP) joint nger exion), and ulnar nerve (abduction and
adduction of the digits).
It is essential to assess the vascular status as the prevalence of displaced supracondylar
fractures presenting with vascular compromise has been reported to be as high as 20 %
(Pirone et al. 1988; Campbell et al. 1995). The vascular status is categorized as present pulses
with a warm hand, pulseless with a warm hand, and pulseless with a cold hand (Skaggs and
Flynn 2010).

Supracondylar Humerus Fracture Imaging and Other Diagnostic Studies

Standard radiographs for supracondylar humerus fracture evaluation should include anteroposterior
(AP) of the distal humerus (not an AP of the elbow) and a true lateral of the elbow in anatomic
position. Oblique views are not routinely required but can be obtained for comparison to the
uninvolved elbow in order to detect minimally displaced fractures. Computed tomography
(CT) scan and magnetic resonance imaging (MRI) are not routinely used.
In radiographic evaluation of supracondylar humeral fractures, three key parameters should be
assessed: (a) presence of a posterior fat pad sign (which may be the only sign of a supracondylar
humerus fracture and thus should not be missed) (Skaggs and Mirzayan 1999); (b) location of the
anterior humeral line (AHL) in relation to the capitellum; and (c) measurement of Baumanns angle.
The AHL is drawn down along the anterior humeral cortex (Herman et al. 2009) and should intersect
through the middle third of the capitellum except in children younger than 4 years of age, where it
may intersect the anterior third (Herman et al. 2009; see Figs. 3, 4, 5, and 6).

Fig. 3 A posterior fat pad sign may be the only evidence of a nondisplaced supracondylar fracture

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Fig. 4 The anterior humeral line (AHL) should intersect the capitellum in a normal elbow

Fig. 5 In a displaced supracondylar humerus fracture, the AHL is anterior to the capitellum

In displaced extension-type fractures, the AHL is usually anterior to the capitellum. The
Baumanns angle, which is the angle between the long axis of the humeral shaft and the physeal
line of the lateral condyle, should be 10 . Baumanns angle <9 signies a fracture in varus
angulation.

Supracondylar Humerus Fracture Classification

Several classication systems exist for supracondylar fractures; however, the modied Gartland system
is the most widely used (Omid 2008; Abzug and Herman 2012; Howard et al. 2012; Gartland 1959). The
Gartland system categorizes extension-type supracondylar fractures into three types: Type I is
a nondisplaced or minimally displaced (<2 mm) supracondylar fracture with an intact AHL. In Gartland
type I supracondylar fractures, often a posterior fat pad sign is the only evidence of fracture (Fig. 7).

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Fig. 6 The Baumanns angle is usually >10

Fig. 7 Gartland type I fracture with posterior fat pad sign and subtle cortical irregularity

Gartland type II supracondylar fractures are displaced (>2 mm) with an intact, hinged, posterior
periosteum (Fig. 8). In this fracture type, the AHL is often anterior to the capitellum, but in some
mildly displaced cases, it just abuts it. Modications by Wilkins (1984) further subdivide type II
fractures into subtypes A and B. Type IIA fractures are angulated posteriorly but lack rotational
deformity. These fractures are often stable after exion reduction and in some rare cases can be

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Fig. 8 Gartland type II supracondylar fracture. Note that the capitellum is posterior to the AHL, indicating that closed
reduction and pinning is indicated

Fig. 9 In Gartland type III, there is complete displacement without any meaningful cortical contact

managed with nonoperatively with casting, as long as the fracture is completely stable and remains
reduced while casted at 8090 . Type IIB fractures still retain an intact posterior hinge but have some
degree of rotational displacement. These fractures are generally unstable after reduction and require
xation with Kirschner wires (K-wires). In, Gartland type III, there is complete displacement without
any hinge and there is usually a rotational deformity in the frontal and transverse planes (Fig. 9).

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A fourth type has been recently classied by Leitch et al. for fractures that are unstable in both exion
and extension.

Gartland AHL relationship to Cortex intact?

classication capitellum Stability? Recommended treatment
Type I AHL intersects Cortex intact Long arm cast immobilization 3 weeks
center of capitellum circumferentially
Type IIa AHL anterior to Posterior cortex intact, Generally closed reduction and pinning, but some can be
capitellum stable treated with cast immobilization for 3 weeks
Type IIb AHL anterior to Posterior cortex intact, Closed reduction with pin xation
capitellum rotational instability
Type III AHL anterior to No intact cortex, Closed reduction with pin xation
capitellum unstable in extension
Type IV AHL anterior or No intact cortex Closed reduction with pin xation
posterior to Unstable in extension
capitellum and exion

Supracondylar Humerus Fracture Outcome Tools

No outcome tools exist specically for supracondylar humerus fractures.

Supracondylar Humerus Fracture Treatment Options

Initial management of displaced supracondylar fractures involves elbow splinting at approximately
2040 of exion with avoidance of tight bandaging. This position prevents vascular compromise
that may occur with excessive exion (Mapes and Hennrikus 1998; Battaglia et al. 2002). Upon
arrival in the emergency department, a careful and thorough physical exam should be undertaken,
followed by denitive fracture treatment, most commonly with closed reduction and percutaneous
pin xation. Other treatment options include simple immobilization for nondisplaced/minimally
displaced Gartland type I fractures and open reduction and pin xation in cases of failed closed
reduction and open fractures.

Nonoperative Management of Supracondylar Humerus Fracture

The nonoperative treatment of type I fractures involves short-term simple immobilization followed
by range of motion exercises. The indication for nonoperative treatment of supracondylar fractures
is a Gartland type I (nondisplaced or minimally displaced <2 mm) supracondylar fracture without
evidence of nerve injury or instability. The decision regarding nonoperative treatment is greatly
enhanced by assessment of the AHL. If, on the initial presentation lm, the AHL intersects the
capitellum ossication center, then the fracture is dened as minimally displaced, and cast immo-
bilization alone is the recommended treatment (Skaggs and Flynn 2010). The orthopedic surgeon
should also assure that on the AP x-ray, there is not excessive medial impaction that could cause
cubitus varus. Baumanns angle should be assessed and be in the acceptable range.

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Indications/Contraindications
The indication for nonoperative treatment of supracondylar humerus fractures is a Gartland type
I supracondylar fracture.
Supracondylar humerus fracture
Nonoperative management
Indications Contraindications
Gartland type I fracture AHL transects the capitellum on lateral Displaced fractures in which the AHL is anterior to
radiograph capitellum
The Baumann angle is >10 on affected side Open fractures

Techniques
The patient is initially treated with a long arm cast with the elbow exed 8090 for 3 weeks,
followed by range of motion exercises (Williamson and Cole 1993; Charnley 1961; Cuomo
et al. 2012). At the completion of immobilization, patients can begin active range of motion
exercises and will often not require physical therapy. A return visit for a range of motion check at
46 weeks post immobilization is typically offered.
Supracondylar humerus fracture
Nonoperative management
Elbow is casted for approximately 3 weeks at 8090 of exion followed by an active range of motion program. Return
to all activities is allowed when the patient is asymptomatic

Outcomes
Nondisplaced/minimally displaced supracondylar fractures treated with simple immobilization have
universally excellent outcomes. In a recent study, Cuomo and associates reviewed 53 patients with
Gartland type I fractures and found intact AHL and Baumanns angle >9 at 3 weeks follow-up after
treatment with only splint immobilization (Cuomo et al. 2012). Ballal et al. (2008) also reported
excellent outcomes in all subjects in their series of 40 patients.

Operative Treatment of Supracondylar Humerus Fracture

Operative treatment consists of either closed reduction with pin xation or, in rare circumstances,
open reduction with pin xation.

Closed Reduction and Percutaneous Pinning of Supracondylar Humerus Fracture

Indications/Contraindications
Closed reduction with pin xation (CRPF) is the preferred treatment for Gartland type II, III, and IV
supracondylar fractures. Indications for CRPF are (1) a displaced fragment in which the capitellum
is posterior to the anterior humeral line and (2) minimally displaced fragments with medial column
comminution or any malalignment in the coronal plane, making Baumanns angle in the unaccept-
able range. Contraindications for closed reduction with xation are (1) open fractures, (2) failed
closed reduction, and (3) a limb that remains dysvascular after CRPF. These patients should undergo
an immediate open reduction.

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Fig. 10 Patient is supine on the operating table and uoroscopy unit monitor is on the opposite side of the surgeon

Supracondylar humerus fracture

Closed reduction and pin xation
Indications Contraindications
Displaced (Gartland type IIIV) fractures Nondisplaced or minimally displaced fractures
Fractures with medial column comminution Open fractures requiring debridement
Fractures with coronal plane malalignment

Surgical Procedure: Closed Reduction

Preoperative Planning Reduction and xation of a supracondylar fracture is generally an urgent
issue, with treatment in the rst 24 h after injury. In circumstances when there is either poor
perfusion to the hand or in severe fractures with median nerve injury, these fractures are reduced
and xed emergently (Abzug and Herman 2012).
Closed reduction and percutaneous for supracondylar humerus fracture
Preoperative planning
OR Table: standard
Position/positioning aids: Supine/radiolucent arm board
Fluoroscopy location: On same side as the surgeon; place monitor on opposite side for easy viewing
Equipment: Basic orthopedic set, K-wires, K-wire driver

Positioning Supine with the C arm parallel to the table and on the same side as the injured arm. For
ease of viewing by the surgeon, the uoroscopy unit monitor should be placed on the other side of
the bed, opposite the surgeon (Fig. 10).

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Fig. 11 (a) Jones view of the elbow after closed reduction; (b) to obtain this view, the elbow is maximally exed with
the forearm pronated. The image is obtained by directing the radiographic tube perpendicular to the distal elbow in an
anterior to posterior direction.

In children less than 3 years of age, a radiolucent hand table is valuable because the upper arm is
not long enough to bring the elbow to the center of the image intensier. Additionally, in very
unstable fractures, such as Gartland type IV fractures, the radiolucent hand table is also valuable so
that the image intensier can be rotated to get a lateral x-ray.

Surgical Approach After prophylactic antibiotics and endotracheal intubation, the injured hand,
forearm, elbow, and arm are prepped and draped up to the shoulder. In type II fractures or moderate
type III fractures, reduction is performed by gentle longitudinal realignment and then exion. In
severe type III fractures, gentle massaging of the brachialis and biceps is performed rst, in order to
free the metaphyseal fragment. This brachialis milking technique should be done with patience,
and if done skillfully will avoid many unnecessary open reductions. Next, reduction in the sagittal
plane should be attempted by slowly exing the elbow with the non-dominant hand and at the same
time pushing forward on the olecranon with the thumb of the dominant hand. Satisfactory reduction
can be assessed by exing the childs elbow to see if the ngers can touch the shoulder. If the
reduction is unsuccessful, the patient will be unable to do so.
Fluoroscopy images in AP, lateral, and oblique planes should be obtained, and successful
reduction is conrmed by checking for intersection of the capitellum by the AHL on the lateral
view, Baumanns angle 10 on the AP view and intact medial and lateral columns on oblique
views. Highly unstable fractures may preclude moving the arm to obtain images; instead, the
uoroscopy should be rotated to obtain images in the lateral and oblique views.
The elbow should be held in a exed position to obtain a Jones view as the initial image, (Fig. 11)
and then the entire arm (not the forearm) should be rotated to obtain the lateral image of the elbow.
Once the reduction is deemed satisfactory, pin xation is performed while using the Jones view.

Technique: Percutaneous Pinning Pin xation allows for maintenance of a stable construct
without the need to secure the elbow in excessive exion. Successful xation is achieved by
maintaining sufcient separation of the pins at fracture site (>2 mm) while ensuring bicortical
engagement of both the lateral and medial columns. Typically two smooth Kirschner wires
(K-wires) (Zimmer, Warsaw, IN) are sufcient for Gartland type II fractures, while Gartland type
III fractures usually require three or even four K-wires. The use of 0.062 in. K-wires is typically
adequate but smaller or larger sizes may be used depending on the size of the child.

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Fig. 12 (a) (AP view) A supracondylar fractures imaged 3 weeks after xation, showing good conguration for two
pins. Note the wide pin spread and divergence. (b) (AP view) Intraoperative uoroscopy after placing three divergent
lateral entry pins. (c) Optimal conguration for two pins (lateral view)

Prior to placement of the rst pin, the starting point and trajectory should be assessed. This can be
done easily by holding the free K-wire against the lateral condyle and conrming the path with
uoroscopy.
Once the starting point is conrmed, the wires are advanced with the drill. The rst wire should be
low and somewhat transverse, often coursing through the olecranon fossa, and should engage the
medial cortex. This is referred to as four cortex xation. The second wire is placed in a divergent
trajectory from the rst, also engaging the medial cortex. A third pin is added to type III fractures or
type II fractures that remain unstable even after placement of two lateral pins.
In oblique fracture patterns that prevent a third pin placement or fractures that remain unstable
after reduction, a medial pin is placed. To minimize potential ulnar nerve damage, the elbow is
extended after placement of lateral pins. Then, the medial pin is inserted at the medial epicondyle in
a slight posterior to anterior direction (Fig. 12).
After the wires are placed, a lateral image in full exion is obtained. Subsequent images in 90 ,
60 , and 30 of exion are obtained, carefully studying the capitellum on the lateral view to assure
that it does not displace with progressive extension. Alternatively, the elbow can be brought through
a range of motion while live uoroscopy is performed to ensure no displacement occurs. If the
xation is stable, then the AP view is checked to ensure alignment and stability. Static images or live
uoroscopy should be performed while a varus and valgus stress is applied to assess stability in the
coronal plane.
Following successful pin placement, the k-wires are bent and cut to a length 12 cm above the
skin to prevent migration under skin. The pins are then wrapped in Xeroform, and antimicrobial
Vaseline gauze, which also aids in the prevention of pin migration. The limb is then casted in about
7080 of exion
Closed reduction with percutaneous pinning for supracondylar humerus fracture
Surgical steps
Perform gentle longitudinal realignment of fracture
Reduce fracture in sagittal plane
Conrm successful reduction on Jones and lateral views
Place rst k-wire lower and more transverse in distal humerus, often engaging four cortices, including the olecranon
fossa
(continued)

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Closed reduction with percutaneous pinning for supracondylar humerus fracture

Surgical steps
Place second wire divergent from the rst, engaging the medial cortex more proximally
Assess stability in both the AP and lateral planes
Bend and cut k-wires to 12 cm above the skin. Wrap pins in Xeroform or antimicrobial Vaseline gauze
Cast arm in 7080 of exion

Postoperative Care
The upper limb should be elevated such that the hand is above the heart for the rst day after surgery.
As long as the xation was stable, the rst follow-up can be at three weeks following the surgery. At
this time, AP and lateral radiographs are taken with the cast off but the pins still in position. If the
fracture is healed, and it is universally, except in much older children, the pins are removed and
active range of motion exercises are begun. Typically, the child returns 6 weeks postoperatively for
a range of motion check and can resume normal physical activity afterward. Formal physical therapy
is not routinely recommended for supracondylar fractures, unless the child lacks signicant range of
motion at 68 weeks after injury.
Closed reduction with percutaneous pinning for supracondylar humerus fracture
Postoperative protocol
Elevate upper limb above heart for about 24 h after surgery
Follow up in 3 weeks after surgery remove cast, obtain AP and lateral radiographs to assess reduction; remove pins if
healed
Second postoperative visit at 6 weeks postoperatively for range of motion check. Full activities can be resumed if
asymptomatic

For Type IV Fractures or Flexion-Type Fractures

Type IV and exion-type supracondylar fractures are treated with the protocol described by Leitch
et al. (2006). The fracture is manually manipulated into an anatomic reduction on a radiolucent hand
table. Often, the reduction is assisted by a small towel rolled and placed behind the distal humerus,
just above the fracture line. The rst pin is then placed using tactile sense alone. Then, while holding
the elbow steady, AP and lateral images are obtained. If the reduction is satisfactory, two more pins
are placed in a divergent pattern.
Outcomes of Closed Reduction and Percutaneous Pinning of Supracondylar Humerus Fractures.
Many authors have noted good outcomes after surgical xation of type II and III supracondylar
fractures (Skaggs et al. 2004; Sankar et al. 2007; Skaggs et al. 2008). Albrektson and associates
(Skaggs et al. 2008) reviewed 189 patients with Gartland type II fractures treated with closed
reduction and lateral pinning and reported excellent outcomes, according to Flynn criteria (Flynn
et al. 1974) in 95 % of subjects. Furthermore, none of the 189 patients had any intraoperative
complications, loss of reduction, or neurological injury following fracture reduction. Similarly,
Skaggs et al. (2004) reported excellent outcomes and no loss of reduction at 9 weeks follow-up in
124 children xed with only lateral entry pins. Loss of reduction with pinning is quite uncommon.
Sankar et al. (2007) reviewed 8 of 279 patients with loss of reduction after lateral pin xation and
found all cases to be due to technical errors and the use of only two pins in cases where three was
likely more appropriate. While both lateral entry only pins and cross pinning have been shown to
achieve great fracture xation, (Mahan et al. 2007; Gaston et al. 2010) cross pinning is associated
with increased iatrogenic injury to the ulnar nerve (Skaggs et al. 2001; Babal et al. 2010; Slobogean

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et al. 2010). In a recent meta-analysis, Slobogean et al. reviewed 39 studies including 2,639 patients
and found iatrogenic ulnar nerve injury was present in 3.4 % of patients treated with cross pins and in
just 0.7 % of patients treated with lateral pins alone (Slobogean et al. 2010).

Open Reduction and Percutaneous Pinning of Supracondylar Humerus Fracture

Indications/Contraindications
Indications for open reduction are open fractures requiring debridement and fractures that failed
satisfactory closed reduction due to interposed tissue. Additionally, fractures associated with poor
hand perfusion in which there is concern about brachial artery injury are treated with open reduction
so that the artery can be explored and managed as necessary.
Supracondylar humerus fracture
Open reduction and pin xation
Indications Contraindications
Open fractures requiring debridement
Fractures that failed initial closed reduction
Fractures in which there is concern about brachial artery injury

Surgical Procedure
Preoperative Planning and Positioning Same as in closed reduction and percutaneous pin
placement.

Surgical Approach(es) A transverse anterior approach is utilized for open reduction as it allows for
visualization of the median nerve and the brachial artery. Typically a 45 cm transverse incision
made at the antecubital fossa is both cosmetically ideal and also allows adequate exposure for
fracture manipulation. Following the incision, dissection should proceed through the fascia down to
the bicipital aponeurosis. The brachial artery and median nerve should be identied where they lie
immediately deep to bicipital aponeurosis and medial to the biceps tendon. Next, incise the bicipital
aponeurosis taking care to avoid damage to the brachial artery and median nerve. The artery and
nerve are removed from the fracture site. Now, the fracture can be reduced by applying posterior
force on proximal fragment with concomitant traction to forearm with the elbow exed at 90 . Pin
xation can proceed similarly as described for closed reduction.
Open reduction with percutaneous pinning for supracondylar humerus fracture
Surgical steps
45 cm transverse incision at the antecubital fossa
Dissect through fascia to bicipital aponeurosis. Identify and protect median nerve and brachial artery
Attempt reduction of fracture segments
Secure reduced fracture with three divergent lateral entry pins
Check pin placement and reduction with uoroscopy
Close incision with bioabsorbable suture

Postoperative Care
Postoperative care for supracondylar humerus fractures managed with open reduction and percuta-
neous pin xation proceeds similar to fractures treated with closed reduction.
Outcomes of Open Reduction and Percutaneous Pinning of Supracondylar Humerus Fractures.
Open reduction is similarly associated with low rates of complications. In 52 displaced fractures
treated with an open approach, Weiland et al. (1978) reported excellent outcomes in all patients.

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Reitman and associates (Reitman et al. 2001) reported 75 % of patients with excellent results
according to Flynn criteria (Flynn et al. 1974) and loss of motion in only 4 cases.

Flexion-Type Supracondylar Fracture Management

Similar to extension-type injuries, exion-type supracondylar fractures can be classied using
a modied Gartland system (Wilkins 1990) as types I, II, and III. Like in extension-type injuries,
type I exion-type supracondylar is nondisplaced and can be managed similarly by placing in a long
arm cast with the elbow exed to 90 for comfort. Type II injuries are moderately displaced with an
intact anterior hinge, whereas type III injuries are characterized by severe displacement of both the
anterior and posterior cortices. Stable type II fractures with minimal angulation can be reduced and
held in place with a long arm cast with the elbow in extension; however, unstable type II and type III
fractures usually require closed reduction and pinning.
In exion-type supracondylar fractures, the posterior periosteum is torn precluding exion of the
elbow for reduction. Rather, the elbow is extended so as to place tension on the anterior periosteum.
The elbow is exed to about 30 for reduction. Pin placement is greatly aided by placing a rolled
towel just above the fracture behind the distal humerus. Once anatomic reduction is assured, the
image intensier is rotated around the arm board to obtain AP and lateral radiographs, in order to
conrm the reduction. The rst pin is placed using primarily tactile sensation, penetrating the
cortices as is typical for all supracondylar humerus pinning. If reduction and xation are maintained,
two additional pins are placed as described above.
Open reduction may be indicated for exion-type injuries that fail closed reduction.

Preferred Treatment
Type I Long arm casting with the elbow in 90 of exion for approximately 3 weeks.
Type II Closed reduction and pinning for most type II fractures. Placement of two divergent pins is
usually adequate, but we do not hesitate to place a third pin if there are concerns of instability.
Type III Closed reduction and placement of three lateral entry pins. Given that these fractures are
highly unstable, three lateral pins are placed rather than two.
Type IV Treatment is utilization of the protocol recommended by Leitch et al.

Surgical Pitfalls and Prevention

Supracondylar humerus fracture
Potential pitfalls and preventions
Potential pitfall Pearls for prevention
Iatrogenic ulnar nerve Use lateral entry pins only
injury
If a medial pin is required, insert lateral pins rst, then extend elbow and protect ulnar nerve
during insertion of medial pin
Pin migration Dont insert and back out pins repeatedly during pinning. Bend and cut k-wires leaving at least
12 cm protruding above the skin; cover wires with Xeroform or antimicrobial Vaseline gauze
Loss of reduction Ensure at least 2 mm pin separation at fracture site
Make sure both pins engage the proximal and distal segments
Use two lateral pins for type II fractures and three for type III fractures; if unsure do not hesitate
to insert another pin
Stress fracture after pinning to ensure adequate stability
Compartment Avoid tight bandaging and excessive arm exion; avoid casting in 90 of exion
syndrome
(continued)

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Supracondylar humerus fracture

Potential pitfalls and preventions
Potential pitfall Pearls for prevention
In children, an increasing analgesia requirement is the most sensitive indicator for an evolving
compartment syndrome

Management of Complications
Vascular Injury
Supracondylar fractures presenting with vascular injuries are fairly common (312 %); however,
vascular reconstruction is rarely required. While a pulseless and well-perfused hand can be managed
urgently, a dysvascular limb requires an emergency procedure. In most cases, perfusion is restored
after anatomic reduction and xation. If the hand remains poorly perfused, immediate exploration
and repair is undertaken or consultation with a vascular surgeon should occur.
For a previously well-perfused limb with present radial pulses that subsequently looses perfusion
after reduction, urgent pin removal and arterial exploration should be performed to release a possible
entrapped artery from the fracture site. Treatment for well-perfused hands that remain pulseless after
reduction is still controversial. These patients are admitted for 48 h and monitored closely for any
signs or symptoms of an evolving compartment syndrome.

Compartment Syndrome
Compartment syndrome of the forearm in association with supracondylar humerus fractures is
estimated at 0.10.5 % (Battaglia et al. 2002; Bashyal et al. 2009); however, incident rates increase
to 7 % with concomitant forearm injuries (Blakemore et al. 2000). In children, the classic ve Ps
(pain, pallor, pulseless, paresthesias, and paralysis) are poor indicators for evolving compartment
syndrome; rather increased analgesic requirement is a more sensitive indicator (Bae et al. 2001).
In patients with suspicion of an evolving compartment syndrome, initial management should
include removal of dressings, reduction of exion to several degrees lower than 90 , and immediate
fracture stabilization with K-wires.

Neurologic Injuries
The anterior interosseous nerve (4 %) is the most commonly injured nerve in supracondylar
fractures, followed by the radial nerve (3 %) (Babal et al. 2010). Ulnar nerve injuries are rare and
are usually associated with exion-type supracondylar fractures or an iatrogenic complication of
medial pin placement. In most cases of nerve injury, recovery is spontaneous and management
generally involves observation for 22.5 months (Brown and Zinar 1995). However, iatrogenic
ulnar nerve injuries may require immediate removal of the pin to allow for faster recovery of neural
function. The use of lateral entry pins as opposed to crossed pins is recommended to avoid potential
damage to the ulnar nerve. In the rare cases where medial pins become necessary, lateral pins should
be placed rst, followed by extension of elbow and/or a small incision performed prior to placement
of a medial pin.

Pin Tract Infection

Pin tract infections after operative management of supracondylar fractures are estimated at less than
12.5 % (Skaggs et al. 2004, 2008; Bashyal et al. 2009; Cheng et al. 1995). Standard management is
removal of the pin(s) and oral antibiotics (Skaggs et al. 2008). Typically, the fracture is stable enough
at the time of detection of the infection, to permit pin removal without loss of reduction.

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Pin Migration
Pin migration is estimated at 1.8 % and can be prevented by leaving at least 1 cm of the K-wire above
skin and protecting the skin by bending the wire at a 90 angle or by covering the wire with a felt
cover (Bashyal et al. 2009).

Loss of Reduction
Loss of xation following pinning of supracondylar fractures is rare and is usually associated with
technical errors in xation. This complication can be prevented by engaging both the proximal and
distal fragments with at least two pins and ensuring 2 mm of pin separation at the fracture site
(Sankar et al. 2007).

Cubitus Varus
Cubitus varus occurs with malunions, typically in supracondylar fractures treated with casting only
or fractures pinned in malalignment, or without stable pinning. Pirone and associates reported
cubitus varus in 8 % of patients with fractures held in place with just cast immobilization compared
to 2 % in patients who underwent pin stabilization (Pirone et al. 1988). Traditionally thought to be
just a cosmetic deformity, cubitus varus can be a cause of chronic elbow pain, tardy rotational
instability, and additionally can increase the rate of lateral condyle fractures of the elbow (ODriscoll
et al. 2001; Abe et al. 1997, 1995).
Ensuring an intact Baumanns angle after reduction and during fracture healing can prevent this
complication. In children who develop substantial cubitus varus after supracondylar elbow fractures,
we recommend correctional elbow osteotomy. We prefer lateral closing wedge osteotomy of the
distal humerus and pin xation through a lateral or posterior approach using a modication of the
osteotomy technique described by Wiltse (Skaggs et al. 2011).
Supracondylar humerus fracture
Complication Management
Vascular injury Urgent closed reduction and percutaneous pinning for poorly perfused limbs
Exploration and repair or vascular surgery consult for hands that remain poorly perfused
Compartment syndrome Removal of dressings, reduction of exion, and immediate fracture stabilization with
K-wires
Iatrogenic ulnar nerve Immediate removal of pins
injury

Summary
Supracondylar fractures are common fractures in children. Gartland type I fractures are managed
nonoperatively, but displaced fractures (Gartland type II, III and IV) are treated with closed
reduction and pinning. Surgical management has good outcomes and very low complication rates.

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