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C OPYRIGHT 2008

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Current Concepts Review

Supracondylar Humeral Fractures

in Children
By Reza Omid, MD, Paul D. Choi, MD, and David L. Skaggs, MD
Investigation performed at Childrens Hospital Los Angeles, Los Angeles, California

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion.

Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus
malunion.

Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the
vascular problem.

A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when
there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of
compartment syndrome.

Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they
are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Supracondylar humeral fractures are the most common elbow

fractures seen in children1-3. Modern techniques for their
treatment have dramatically decreased the rates of malunion
and compartment syndrome. There still remain several controversial topics with regard to the treatment of these injuries,
including the urgency of operative treatment, pin placement
configuration, whether type-II supracondylar fractures should
be treated operatively or nonoperatively, and management of
dysvascular limbs.
Epidemiology
Two-thirds of children hospitalized because of an elbow injury
have a supracondylar humeral fracture4. The age range in
which most supracondylar fractures occur is between five and
seven years old. Traditionally, boys have had a higher incidence
of this type of fracture, but the difference in rates between girls
and boys seems to be equalizing, and higher rates in girls have
actually been reported in some series5,6. The injuries have

predominantly involved the left, or nondominant side, in almost all studies5-8.

Mechanism of Injury and Anatomy
Supracondylar fractures are divided into extension and flexion
types. Extension-type fractures, which account for approximately 97% to 99% of supracondylar humeral fractures5,9, are
usually due to a fall onto the outstretched hand with the elbow
in full extension, and they are the focus of this review. The
medial and lateral columns of the distal part of the humerus
are connected by a thin segment of bone between the olecranon fossa posteriorly and the coronoid fossa anteriorly, resulting in a high risk of fracture to this area. With elbow
extension, the olecranon engages the olecranon fossa and acts
as a fulcrum, while the anterior aspect of the capsule simultaneously provides a tensile force on the distal part of the
humerus proximal to its insertion. The resulting injury is an
extension-type supracondylar humeral fracture.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice,
or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

J Bone Joint Surg Am. 2008;90:1121-32

doi:10.2106/JBJS.G.01354

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Classification
The modified Gartland classification of supracondylar humeral
fractures is the most commonly accepted and used system12.
The kappa values for the intraobserver and interobserver variability of this classification were higher than those for previously assessed fracture-classification systems, according to a
report by Barton et al.13.
Type I
A Gartland type-I supracondylar fracture is nondisplaced or
minimally displaced (by <2 mm) and is associated with an
intact anterior humeral line. There may or may not be evidence of osseous injury; the posterior fat-pad sign may be the
only evidence of the fracture (Fig. 2). These fractures are very
stable because the periosteum is intact circumferentially.

Fig. 1

Laterally torn periosteum in association with a

Type II
A Gartland type-II supracondylar fracture is displaced (by >2
mm), and the posterior cortex is presumably intact, but
hinged. On a true lateral radiograph of the elbow, the anterior
humeral line does not go through the middle third of the
capitellum (Fig. 2). Generally, no rotational deformity is seen
on an anteroposterior radiograph because of the intact posterior hinge. With common usage of the classification, any

posteromedially displaced supracondylar humeral fracture. (Reprinted, with permission,

from: Skaggs DL. Closed reduction and pinning
of supracondylar humerus fractures. In: Tolo VT,
Skaggs DL, editors. Master techniques in orthopaedic surgery: pediatrics. Philadelphia:
Lippincott, Williams and Wilkins; 2008.)

With extension-type injuries, the anterior periosteum is

torn. The intact posterior periosteal hinge provides stability to
the fracture and facilitates reduction. Abraham et al. described
the different types of periosteal changes seen with extensiontype supracondylar humeral fractures in immature monkeys10.
They reported that the position of maximum stability for reduction was full flexion and pronation as opposed to supination. Subsequently, many authors have also described using
pronation to assist in reduction, but this should not be automatic. The direction of fracture displacement often indicates
whether the medial or lateral periosteum remains intact. The
most common posteromedially displaced fracture is usually
associated with an intact medial periosteum. Pronation places
the medial periosteum on tension, thus closing the hinge and
correcting varus malalignment (Fig. 1). However, the medial
periosteum is often torn in patients with a posterolaterally
displaced fracture, in which case pronation may be counterproductive. Instead, supination may be better, especially when
the lateral periosteum is intact, which it usually is with this
injury. If the posterior periosteal hinge is also disrupted, the
fracture becomes unstable in both flexion and extension; such
an injury has been recently described as a multidirectionally
unstable, modified Gartland type-IV fracture11.

Fig. 2

Lateral radiograph of an elbow with a supracondylar humeral fracture (black arrows) and an elevated posterior fatpad (white arrows). The anterior humeral line (thin white
line) passes through the capitellum but not through its
middle third, so some posterior angulation is present. This
fracture may be considered type II, although it is on the
border of being type I. (Reproduced with permission of
Childrens Orthopaedic Center, Los Angeles.)

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rotational deformity noted on an anteroposterior radiograph

would qualify the fracture as type III.
Type III
A Gartland type-III fracture is a displaced supracondylar
fracture with no meaningful cortical contact. There is usually
extension in the sagittal plane and rotation in the frontal and/
or transverse planes. The periosteum is extensively torn, and
soft-tissue and neurovascular injuries often accompany this
fracture. A potential pitfall is to underappreciate the extent of
loss of normal alignment in fractures with comminution and
collapse of the medial column. Involvement of the medial
column in this way signifies malrotation in the frontal plane
and thus defines the injury as type III.
Type IV
Leitch et al. retrospectively reviewed the characteristics of 297
displaced extension-type supracondylar fractures and described nine (3%) with multidirectional instability 11. These
fractures are characterized by an incompetent periosteal hinge
circumferentially and are defined by instability in both flexion
and extension. This multidirectional instability is usually determined with the patient under anesthesia at the time of the
operation. The instability pattern may be due to the initial
injury, or it may occur iatrogenically during attempted reduction. Classifying this fracture as a separate type may be
warranted as multidirectional instability has treatment implications; however, time will tell if others find this addition to the
Gartland classification system useful.
Clinical Evaluation
When a child with elbow pain is examined, it is essential that
the entire extremity be evaluated, as forearm fractures can
occur in association with supracondylar fractures and can
substantially increase the risk of compartment syndrome 14.
The examiner must take note of soft-tissue swelling, ecchymosis, and skin puckering. Skin puckering results from the
proximal segment piercing the brachialis muscle and engaging
the deep dermis. This is a sign of considerable soft-tissue damage. Any bleeding from a punctate wound should be considered
to indicate an open fracture. Assessment of the vascular status
is essential. The prevalence of displaced supracondylar humeral fractures presenting with vascular compromise has been
reported to be up to 20% (10% [twenty-three of 230] in the
study by Pirone et al.15, 12% [seventeen of 143] in that by Shaw
et al.16, and 19% [eleven of fifty-nine] in that by Campbell
et al.17). The vascular status may be classified into one of three
categories: class I, which indicates that the hand is well perfused (warm and red) and a radial pulse is present; class II,
which indicates that the hand is well perfused but the radial
pulse is absent; and class III, which indicates that the hand is
poorly perfused (cool and blue or blanched) and the radial
pulse is absent.
The neurologic examination must be performed carefully because of the high prevalence of neurologic injury.
Preoperative assessment of the ulnar nerve in particular may

be challenging, as young children in pain may not be able to

cross their fingers. However, even young children will usually
pinch an examiners finger and allow the examiner to palpate
contraction of the first dorsal interosseous muscle and confirm
ulnar motor function. As a last resort, the hand can be wrapped
in a wet cloth. In this test, any area of skin not exhibiting the
normal wrinkling response is presumed to have an injury to
the nerve innervating that area. During the physical examination, a very high index of suspicion is needed to avoid
missing a developing compartment syndrome; considerable
swelling and/or ecchymosis, anterior skin puckering, and an
absent pulse are indications of this complication.
Radiographic Diagnosis
Radiographic examination begins with a true anteroposterior
view of the distal part of the humerus, rather than an anteroposterior radiograph of the elbow, and a true lateral radiograph of the elbow. Initial radiographs may show no evidence
of a fracture except for a posterior fat-pad sign. In a series of
thirty-four patients with traumatic elbow pain and a posterior
fat-pad sign but no visible fracture, one of us (D.L.S.) and
Mirzayan found that 53% (eighteen) had a supracondylar
humeral fracture, 26% (nine) had a fracture of the proximal
part of the ulna, 12% (four) had a fracture of the lateral
condyle, and 9% (three) had a fracture of the radial neck18.
When an osseous injury is present, two main radiographic
parameters are used to evaluate these fractures. On a true
lateral radiograph of a normal elbow, the anterior humeral line
should cross the capitellum through its middle third (Fig. 3).
In an extension-type supracondylar fracture, the capitellum is
posterior to this line. The Baumann angle, or humeral capitellar angle, is the angle between the long axis of the humeral
shaft and the physeal line of the lateral condyle; the normal
range for this angle is about 9 to 26. A decrease in the
Baumann angle is a sign that a fracture is in varus angulation
and may be seen with subtle comminution of the medial column (Fig. 4).
Treatment
Initial Management
Displaced supracondylar fractures requiring a reduction should
be initially treated with a splint, with the elbow in a comfortable position of approximately 20 to 40 of flexion and
avoidance of tight bandaging or splinting. Excessive flexion or
extension may compromise the limbs vascularity and increase
compartment pressure19,20. The arm should then be gently
elevated.
Treatment with Traction
Traction as definitive treatment for supracondylar fractures in
children is largely of historic interest in modern centers. Rates
of cubitus varus ranging from 9% to 33% have been reported
in some series21,22, whereas excellent results have been reported
in others23-25. Nevertheless, fourteen to twenty-two days of inhospital traction are difficult to justify given the excellent results with closed reduction and pin fixation, which usually

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in the fracture site and one should proceed to an open reduction. A detailed description of this operative technique is
available in the literature26.

Fig. 3

The anterior humeral line should cross the capitellum through the middle third on a true lateral radiograph of a normal elbow. (Reprinted, with permission,
from: Skaggs DL, Flynn JM. Staying out of trouble
in pediatric orthopaedics. Philadelphia: Lippincott,
Williams and Wilkins; 2006.)

requires no more than one night of hospitalization and is associated with a low rate of intraoperative complications.
Closed Reduction and Pin Fixation
This is the most common operative treatment of supracondylar fractures. An initial attempt at closed reduction is indicated for almost all displaced supracondylar fractures that are
not open. With the patient under general anesthesia, the
fracture is first reduced in the frontal plane with fluoroscopic
verification. The elbow is then flexed while the olecranon is
pushed anteriorly to correct the sagittal deformity and reduce
the fracture. Criteria for an acceptable reduction include restoration of the Baumann angle (which is generally >10) on
the anteroposterior radiograph, intact medial and lateral columns as seen on the oblique radiographs, and the anterior
humeral line passing through the middle third of the capitellum on the lateral radiograph. As there is considerable rotation
at the shoulder, a certain amount of rotational malalignment in
the axial plane can be tolerated at the fracture site. Any rotational malalignment is detrimental to fracture stability, so, if it
is present, one must be especially careful in assessing the stability of the reduction and probably use a third fixation pin.
The fracture reduction is held with two or three
Kirschner wires, as will be discussed later in this review. The
elbow is immobilized in 40 to 60 of flexion, depending on
the amount of swelling and the vascular status. If there is a
considerable gap in the fracture site or the fracture is irreducible with a so-called rubbery feeling on attempted reduction, the median nerve and/or brachial artery may be trapped

Open Reduction
Open reduction is indicated in cases of failed closed reduction,
a dysvascular limb, and open fractures. In the past, open reduction led to concerns regarding elbow stiffness, myositis
ossificans, unsightly scarring, and iatrogenic neurovascular
injury. However, several studies have demonstrated a low rate
of complications associated with open reduction. In a study
of fifty-two displaced fractures treated with open reduction
through a lateral approach, Weiland et al. reported a moderate
loss of motion of 10% (five) of the elbows but no cases of
infection, nonunion, or myositis ossificans27. Fleuriau-Chateau
et al. reported that, of thirty-four patients treated with open
reduction through an anterior approach, 6% (two) had an
unsatisfactory loss of motion but none had infection, myositis
ossificans, malunion, or a Volkmann contracture28. Reitman
et al.29 reported that 78% (fifty-one) of sixty-five patients
treated with open reduction (through either a medial or a
lateral approach) had an excellent or good result according to
the criteria of Flynn et al.30. Loss of motion was reported in
four cases. In a prospective, randomized controlled study of
twenty-eight children, Kaewpornsawan31 compared closed reduction and percutaneous pin fixation with open reduction
(through a lateral approach); the patients treated with percutaneous pin fixation showed no differences with regard to

Fig. 4

The Baumann angle is formed by the line perpendicular to the long axis of the humeral shaft and the
physeal line of the lateral condyle. A decrease in the
Baumann angle may indicate medial comminution.
(Reprinted, with permission, from: Skaggs DL, Flynn
JM. Staying out of trouble in pediatric orthopaedics.
Philadelphia: Lippincott, Williams and Wilkins;
2006.)

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cubitus varus, neurovascular injury, the range of motion, the

infection rate, the union rate, or the criteria of Flynn et al.
Although the direct anterior approach to the elbow is
not commonly used by many orthopaedists, it is our preferred
approach, particularly in cases of neurovascular compromise.
The anterior approach has the advantages of allowing direct
visualization of the brachial artery and median nerve as well as
the fracture fragments. When the operation is performed
through a relatively small (5-cm) transverse incision along the
cubital fossa, the resulting scar is much more cosmetic than is
the scar resulting from the lateral approach, and scar contraction limiting elbow extension is not an issue. In a series
of twenty-six patients treated with the anterior approach,
Koudstaal et al.32 found the results to be equivalent to those of
the traditional lateral or combined lateral and medial approach
in terms of malunion, the criteria of Flynn et al.30, and the
range of motion.
The posterior approach is generally not recommended
because of the high rate of loss of motion and, more importantly, the risk of osteonecrosis secondary to disruption of the
posterior end arterial supply to the trochlea of the humerus33,34.
Treatment by Fracture Type
Type-I Fractures
It is generally agreed that these fractures should be managed in
a long arm cast with the elbow in approximately 60 to 90 of
flexion for approximately three weeks. It is recommended that
follow-up radiographs be made at one and two weeks to identify any fracture displacement.
Type-II Fractures
The optimal treatment of type-II fractures has evolved into the
current trend of operative intervention rather than cast immobilization. The distal part of the humerus provides 20% of
the growth of the humerus and thus has little remodeling
potential. The upper limb grows approximately 10 cm during
the first year of life, 6 cm during the second year, 5 cm during
the third year, 3.5 cm during the fourth year, and 3 cm during the
fifth year2. Toddlers (less than three years old) have some remodeling potential so the surgeon may accept nonoperative
treatment of a type-II fracture in which the capitellum abuts
the anterior humeral line but does not cross it. However, a
child who is eight to ten years old has only 10% of growth of
the distal part of the humerus remaining, so an adequate reduction is essential to prevent malunion.
The results of two studies support the initial treatment of
type-II fractures with closed reduction and a cast. Hadlow et al.
made the point that pin fixation of all type-II fractures in their
series would have meant that 77% (thirty-seven) of the fortyeight patients would have undergone an unnecessary operative
procedure35. However, 23% (eleven) of the forty-eight patients
in that series lost reduction following closed reduction and
underwent a delayed operation. Two of fourteen patients who
were followed had a poor outcome on the basis of the criteria
of Flynn et al.30. In a retrospective study of twenty-five elbows
treated with closed reduction and a cast, Parikh et al.36 reported

that 28% (seven) had a loss of reduction, 20% (five) had delayed surgery, and 8% (two) had an unsatisfactory outcome
according to the criteria of Flynn et al.
In contrast, in a consecutive series of sixty-nine children
with a type-II fracture treated with closed reduction and pin
fixation, there was no radiographic or clinical loss of reduction,
no cubitus varus, no hyperextension, no loss of motion, no
iatrogenic nerve palsies, and no need for additional surgery 37.
In a study of 191 consecutive type-II fractures treated with
closed reduction and percutaneous pin fixation, there were
four pin track infections (2%), three of which were treated
successfully with oral antibiotics and pin removal38. In the
fourth case, operative irrigation and de bridement was performed for a wound infection not involving the joint. There
were no nerve or vascular injuries and no loss of reduction,
delayed union, or malunion.
Another reason for advocating operative treatment of
these injuries is that the amount of hyperflexion needed to
maintain reduction of type-II fractures without pin fixation
would predispose these patients to increased compartment
pressures19. In a study by Mapes and Hennrikus, who used
Doppler examination, positions of pronation and increased
flexion were found to decrease flow in the brachial artery 20. The
authors recommended a position of flexion and supination for
vascular safety. Pin fixation of these fractures obviates the
need for immobilization with considerable elbow flexion. The
basic concept is that, in any case requiring elbow flexion of
>90 to hold reduction, the reduction should instead be held
by pins and the arm should be immobilized with the elbow in
less flexion (usually about 45 to 70).
Type-III Fractures
If the child presents to the emergency department with the
extremity in either extreme flexion or extreme extension, the
arm should be carefully placed in 30 of flexion to minimize
vascular insult and compartment pressure. The standard of
care in most centers for the treatment of type-III fractures is
operative reduction and pin fixation.
The Special Case of Comminution of the Medial Column

Fractures with medial comminution may not have the dramatic displacement of most type-III fractures, but they must
be treated with operative reduction because collapse of the
medial column will lead to varus deformity in an arm with an
otherwise minimally displaced supracondylar fracture (Fig. 5).
De Boeck et al.39 recommended closed reduction with percutaneous pin fixation when a fracture has medial comminution,
even if it is otherwise minimally displaced, in order to prevent
cubitus varus. In their retrospective review, cubitus varus did
not develop in any of six patients with medial comminution
who had undergone operative fixation whereas it developed in
four of seven patients who had been treated nonoperatively.
Type-IV Fractures
While this extremely unstable fracture could be treated with
open reduction, Leitch et al. described a treatment protocol

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Fig. 5

Medial comminution is a subtle radiographic finding

and indicates a more unstable fracture variant, which
may collapse into varus if it is not treated appropriately. (Reprinted, with permission, from: Skaggs DL,
Flynn JM. Staying out of trouble in pediatric orthopaedics. Philadelphia: Lippincott, Williams and Wilkins;
2006.)

utilizing closed reduction in nine patients11. Their recommended

technique is to first place two Kirschner wires into the distal
fragment. Next, the fracture is reduced in the anteroposterior
plane, and the reduction is verified by imaging. At this point,
rather than the arm being rotated for a lateral image, as is
commonly done for more stable fracture patterns, the fluoroscopy unit is rotated into the lateral view. The fracture is then
reduced in the sagittal plane, and the Kirschner wires are driven
across the fracture site. All nine fractures treated with this technique united; there were no cases of cubitus varus, malunion,
or loss of motion; and no additional operative treatment was
required. Because of the limited number of these uncommon
yet potentially problematic fractures, the need for open reduction
as well as the true complication rate cannot be predicted.
Complications
Vascular Injury
Approximately 10% to 20% of patients with a type-III supracondylar fracture present with an absent pulse15,16,40,41. An
absent radial pulse is not in itself an emergency, as collateral
circulation may keep the limb well perfused. Urgent, but
nonemergent, reduction with pin fixation in the operating
room is indicated42. An arm that is pulseless with signs of poor
perfusion is an emergency. When a patient with a severely

displaced supracondylar fracture and compromised vascularity

to the limb presents to the emergency department, the arm
should be splinted with the elbow in approximately 20 to 40
of flexion4.
Fracture reduction should not be delayed by waiting for
an angiographic study, as reduction of the fracture usually
restores the pulse43. Several reports have shown angiography to
be an unnecessary test that has no bearing on treatment15,16,41,44.
Shaw et al. reported on a series of 143 type-III supracondylar
fractures, seventeen of which were associated with vascular
compromise16. All underwent reduction and percutaneous pin
fixation without a preoperative angiogram. Blood flow to the
hand was not restored after the reduction in three of the seventeen patients, and open exploration was required. In fourteen of the seventeen patients, blood flow to the hand was
restored without complications. The authors concluded that
prereduction angiography adds nothing to the management of
these injuries. In another study, angiography was utilized for
four of seventeen dysvascular limbs with a supracondylar humeral fracture; the angiogram did not alter the course of
management in any of the cases44.
If anatomic reduction cannot be obtained by closed reduction in the setting of an absent pulse, open reduction
through an anterior approach is indicated in order to allow
evaluation of all vital structures at risk for incarceration between
the fracture fragments28,45. Once the artery has been freed from
the fracture site, arterial spasm may be relieved by application of
lidocaine, warming, and ten to fifteen minutes of observation.
If, following fracture reduction in a pulseless limb, the pulse
does not return and the hand remains poorly perfused, vascular
reconstruction (usually by a vascular surgeon) is indicated.
There is controversy about what constitutes the best
treatment if the pulse does not return but the hand is well
perfused. Our practice is to admit the child to the hospital,
elevate the limb slightly, and observe him or her for at least
forty-eight hours. Loss of perfusion can occur during this time
and necessitate emergent treatment. Alternatively, vascular
reconstruction may be performed. However, Sabharwal et al.
found that early repair of the brachial artery is associated with
a high rate of symptomatic reocclusion and residual stenosis,
and they recommended a period of close observation with
frequent neurovascular checks before more invasive correction
of this problem is contemplated42. If a pulse was present preoperatively but is absent following reduction and pin fixation,
immediate rereduction, which in most cases should be open, is
indicated, as the artery or adjacent tissue is presumed to be
entrapped in the fracture site.
Neurologic Injury
The rate of associated neurologic injury has been reported to
be as high as 49%, but in most modern series it has ranged
between 10% and 20%17. Previously, investigators reported
that the radial nerve is injured most often21,46-49, but, as first
noted by Spinner and Schreiber50, the anterior interosseous
nerve actually appears to be the most commonly injured with
extension-type supracondylar fractures of the humerus40,51-53.

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This condition presents as paralysis of the long flexors of the

thumb and index finger without sensory changes. Complete
median nerve injury, due to contusion or transection of the
nerve at the level of the fracture, has also been described with
these fractures and presents with sensory loss in the median
nerve distribution as well as motor loss of all muscles innervated by the median nerve50,54.
Open reduction of the fracture and exploration of the
injured nerve is not necessarily indicated when a nerve injury
is associated with a closed fracture. Neural recovery, regardless
of which nerve is injured, generally occurs after two to 2.5
months of observation, but it may take up to six months4,55.
Nerve transections are rare and almost exclusively involve the
radial nerve52,56-58.
There is a lack of information in the literature on which
to base treatment of an iatrogenic ulnar nerve injury that occurs following placement of a medial pin. Lyons et al. reported
on seventeen patients with an iatrogenic ulnar nerve injury
that was presumably due to a medial pin59. All seventeen patients had a complete return of function, although many did
not have it until four months later. Only four of the seventeen
patients had removal of the medial pins. This study demonstrates that ulnar nerve function can eventually return without
pin removal.
Rasool demonstrated, with operative exploration, that
the pin rarely directly impales the ulnar nerve but more
commonly constricts the nerve within the cubital tunnel by
tethering adjacent soft tissue60. These findings were later confirmed by an ultrasonographic study by Karakurt et al.61.
Common sense suggests that removal of the causative factor
(the medial pin) earlier rather than later may lead to a quicker
recovery of the nerve. However, routine surgical exploration of
the ulnar nerve is not recommended30,55,60,62.
Compartment Syndrome
The rate of compartment syndrome in the setting of a supracondylar fracture is estimated to be 0.1% to 0.3%19. Blakemore
et al. found the prevalence of forearm compartment syndrome
to be three of thirty-three in association with the combined
injury of a supracondylar fracture and a radial fracture 14.
Battaglia et al. showed that the threshold position for increased
forearm pressures is between 90 and 120 of elbow flexion19.
This highlights the importance of immobilization of the elbow
in a position well below 90 of flexion. In what we believe is the
largest reported retrospective study of compartment syndrome
following supracondylar humeral fractures in children, Skaggs
et al. showed that ecchymosis and severe swelling even in the
presence of an intact radial pulse with good capillary refill
should alert the treating physician to the possibility of a
compartment syndrome63. Special attention must be paid to
supracondylar fractures with median nerve injury, as the patient will not feel pain in the volar compartment64.
Cubitus Varus
Some authors have proposed that unequal growth in the distal
part of the humerus causes cubitus varus deformity 46,65.

However, this is unlikely as there is not enough residual growth

left in this area to cause cubitus varus within the time in which
it is recognized. The most common reason for cubitus varus in
patients with a supracondylar fracture is therefore malunion
rather than growth arrest17,23,27,30,66. Cubitus varus can be prevented by making certain that the Baumann angle is intact at
the time of reduction and remains so during healing. Pirone
et al. reported cubitus varus deformity in eight (8%) of 101
patients treated with cast immobilization compared with two
(2%) of 105 patients treated with pin fixation, with ages ranging from 1.5 to fourteen years (mean, 6.4 years)15.
Treatment for cubitus varus has in the past been considered for cosmetic reasons only. However, there are several
consequences of cubitus varus such as an increased risk of
lateral condyle fractures, pain, and tardy posterolateral rotatory instability, which may be indications for an operative
reconstruction with a supracondylar humeral osteotomy67-72.
Pin Track Infections
The rate of pin track infections in children treated with percutaneous Kirschner wire fixation of a fracture has ranged
from <1% to 21%73. The reported rates of pin track infections
in association with supracondylar humeral fractures range
from <1% to 6.6%8,37,74,75. Battle and Carmichael evaluated a
series of 202 fractures, 92.6% (187) of which involved the
upper extremity, and reported an infection rate of 7.9% (sixteen of 202)73. Twelve of the sixteen infections required oral
antibiotics and local pin care, one required intravenous
antibiotics, and three required an operative incision and
de bridement. One of us (D.L.S.) and colleagues noted only one
pin track infection in a series of 124 supracondylar humeral
fractures treated with percutaneous pin fixation. The single pin
track infection resolved with administration of oral antibiotics
and pin removal37. Gupta et al. reported one pin track infection
in a series of 150 fractures; it also resolved with use of oral
antibiotics and pin removal76. In a larger series, of 198 fractures,
Mehlman et al. identified five pin track infections (2.5%), which
were treated with oral antibiotics and resolved without sequlae75.
Controversies
Crossed Pins Compared with Lateral Entry Pins
The rate of iatrogenic injury of the ulnar nerve associated with
the use of crossed pins has been reported to be as low as 0%,
but the rates were 5% (seventeen of 345) and 6% (nineteen of
331) in what we believe to have been the two largest reported
series of supracondylar fractures8,55,59,60,62,77-79. Others have reported that these injuries occur more commonly79,80. In 1977,
Arino et al. recommended the placement of two lateral pins in
order to avoid injury to the ulnar nerve66. A recent systematic
review81 of thirty-five articles comparing medial and lateral pin
fixation with lateral entry pin fixation revealed that iatrogenic
ulnar nerve injury occurred in forty (3.4%) of 1171 cases involving medial and lateral crossed pins and five (0.7%) of 738
cases in which only lateral entry pins had been used. Iatrogenic
ulnar nerve injuries usually resolve, but there have been several
reports of permanent iatrogenic ulnar nerve injuries53,60,77.

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Fig. 6

Properly placed divergent lateral entry pins. On the anteroposterior radiograph, there should be maximal pin separation at the
fracture site, and the pins should engage both the medial and the lateral column just proximal to the fracture site and should
engage an adequate amount of bone proximal and distal to the fragments. On the lateral radiograph, the pins should incline
slightly in the anterior-to-posterior direction in accordance with normal anatomy. (Reprinted from: Skaggs DL, Cluck MW, Mostofi
A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am.
2004;86:702-7.)

Zaltz et al. reported that, when the elbow was flexed

>90, the ulnar nerve migrated over, or even anterior to, the
medical epicondyle in most (thirty-two) of fifty-two children
less than five years of age62. Wind et al. showed that the location
of the ulnar nerve cannot be adequately determined by palpation to allow blind medial pin placement80. Unfortunately,
even making an incision over the medial epicondyle in an
effort to ensure that the ulnar nerve is not directly injured by a
pin does not guarantee protection of this nerve77. In contrast,
Weiland et al. reported that fifty-two patients treated with
crossed pins and use of a small medial incision had no iatrogenic ulnar nerve injuries27. Green et al. reported that, of sixtyfive patients treated with two lateral and one medial pin by
means of a mini-open technique, one had an iatrogenic nerve
injury82.
In a series in which six iatrogenic ulnar nerve injuries
were treated with early exploration, the nerve was directly
penetrated by the pin in two cases, constriction of the cubital
tunnel occurred in three cases, and the nerve was fixed anterior
to the medial epicondyle in one case60. Thus, even if direct
penetration of the ulnar nerve is avoided, simply placing a
medial epicondyle entry pin adjacent to the nerve may cause
injury, presumably by constriction of the cubital tunnel.
One of us (D.L.S.) and colleagues reported on a series of
345 supracondylar humeral fractures treated with percutane-

ous pin fixation and showed that the use of a medial pin was
associated with a 4% risk of ulnar nerve injury (six of 149)
when the medial pin was placed without elbow hyperflexion
and a 15% risk (eleven of seventy-one) when the medial pin
was placed with the elbow in hyperflexion77. None of the 125
procedures in which the fracture was treated with lateral entry
pins alone resulted in iatrogenic ulnar nerve injury. This observation is consistent with the finding of anterior subluxation
of the ulnar nerve with elbow flexion beyond 90 in the study
by Zaltz et al.62. Thus, one apparently undeniable conclusion is
that, if a medial pin is used, the lateral pin(s) should be placed
first, the elbow should then be extended, and the medial pin
should be placed without hyperflexion of the elbow. Of course,
the simplest way to avoid iatrogenic nerve injuries is to not
place a medial pin. No iatrogenic ulnar nerve injuries were
reported in a series of 124 consecutive fractures stabilized with
lateral entry pins only, regardless of the fracture displacement
or stability 37.
The second issue with regard to pin configuration is
fracture stability. Biomechanical studies of the stability provided by various pin configurations have been somewhat
misleading. In two studies evaluating the torsional strength of
pin configurations, crossed pins were found to be stronger
than two lateral pins83,84. Unfortunately, those studies are of
little relevance, as the two lateral pins were placed immediately

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maximal pin separation at the fracture site with engagement of

the medial and lateral columns, a low threshold for placement
of a third laterally based pin if additional stability is needed,
and the use of three pins for type-III fractures37. Gordon et al.
further validated this point by recommending use of two lateral pins initially for a type-III fracture and then stressing the
fracture under fluoroscopy to determine the need for a third
lateral pin89.
In a study of eight supracondylar humeral fractures that
lost reduction, Sankar et al. reported that the loss of fixation in
all cases was due to technical errors that were identifiable on
the intraoperative fluoroscopic images and could have been
prevented with proper technique85. They identified three types
of pin-fixation errors: (1) failure to engage both fragments
with two pins or more, (2) failure to achieve bicortical fixation
with two pins or more, and (3) failure to achieve adequate pin
separation (>2 mm) at the fracture site. A systematic review of
thirty-five articles showed a loss of reduction of zero of 849
fractures treated with crossed pins and four (0.7%) of 606
fractures treated with lateral entry pins81.
In a prospective, randomized clinical trial comparing
lateral and cross-pin fixation techniques in the treatment of
type-III supracondylar humeral fractures, Kocher et al. found

Fig. 7-A

Intraoperative anteroposterior fluoroscopic

view of two lateral entry pins placed for a type-II
fracture. (Reproduced with permission of Childrens Orthopaedic Center, Los Angeles.)

adjacent to each other and were not separated at the fracture

site as is recommended37,85. A more relevant biomechanical
study by Lee et al. showed that two divergent lateral pins
separated at the fracture site were superior to crossed pins with
loading in extension and varus but were equivalent with
loading in valgus86. The greater strength seen with divergence
of the pins was attributed to the location of the intersection of
the two pins and the fact that the greater amounts of divergence between the two pins allow for some purchase in the
medial column as well as the lateral column (Figs. 6 and 7).
Bloom et al. reported that three lateral divergent pins
were equivalent to cross-pin fixation and both of these constructs were stronger than two lateral divergent pins87. Another
study, in which medial comminution was simulated, showed
that three lateral divergent pins had torsional stability equivalent to that of standard crossed medial and lateral pins88.
Thus, contemporary biomechanical studies support the clinical recommendations for use of three lateral entry pins in the
treatment of type-III fractures37,85.
One of us (D.L.S.) and colleagues demonstrated no
malunions or loss of fixation in a series of 124 consecutive
fractures treated with lateral entry pins. They recommended

Fig. 7-B

Intraoperative anteroposterior fluoroscopic view of three lateral entry pins

placed for a type-III fracture. Ideally, the
lateralmost pin could be more lateral,
running directly up the lateral column.
However, the fracture remained stable
during stress under fluoroscopy, so these
pin locations were accepted. (Reproduced
with permission of Childrens Orthopaedic
Center, Los Angeles.)

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no significant difference between the two treatment groups

with regard to any radiographic or clinical outcome measure90.
However, because of the lack of power in this study, which had
a small sample size of twenty-four patients who had undergone
cross-pin fixation, the absence of iatrogenic ulnar nerve injury
may have been due to chance alone. Another prospective
randomized study, by Blanco et al., showed no significant
difference in the radiographic outcomes between lateral entry
and cross-pin fixation techniques for the management of typeIII supracondylar humeral fractures in children91.
Delayed Treatment
The authors of several studies have concluded that an eight to
twenty-one-hour delay before surgery does not have any deleterious effects on the outcomes for children with a supracondylar fracture75,76,92-94. These studies were all retrospective
and may have demonstrated good results in large part because
of the selection bias resulting from experienced pediatric orthopaedic surgeons choosing which fractures required urgent
treatment. While we are not aware of any published studies to
support our opinion, we believe that, if conditions such as
poor perfusion, an associated forearm fracture, firm compartments, skin puckering, antecubital ecchymosis, or very

considerable swelling are present, operative treatment should

not be delayed.
Overview
The current recommended treatment for Gartland type-II and
III fractures is operative reduction and pin fixation. When
correct technique is used, lateral entry pins alone provide
sufficient fixation stability with avoidance of the possibility of
iatrogenic ulnar nerve injury. A supracondylar fracture in a
pulseless limb should be treated with urgent reduction, which
should not be delayed to await an angiogram as fracture reduction usually restores perfusion. Associated nerve injuries
normally resolve, and immediate nerve exploration in patients
with a closed fracture is generally not indicated. n

Reza Omid, MD
Paul D. Choi, MD
David L. Skaggs, MD
Childrens Orthopaedic Center, Childrens Hospital Los Angeles,
4650 Sunset Boulevard, MS 69, Los Angeles, CA 90027

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