Review Article

Management of Supracondylar
Humerus Fractures in Children:
Current Concepts

Abstract
Joshua M. Abzug, MD Supracondylar humerus fractures are the most common elbow
Martin J. Herman, MD fractures in the pediatric population. Type I fractures are managed
nonsurgically, but most displaced injuries (types II, III, and IV)
require surgical intervention. Closed reduction and percutaneous
pinning remains the mainstay of surgical management. Numerous
studies have reported recent alterations in important aspects of
managing these fractures. Currently, many surgeons wait until 12
to 18 hours after injury to perform surgery provided the child’s
neurovascular and soft-tissue statuses permit. Increasingly, type II
fractures are managed surgically; cast management is reserved for
fractures with extension displacement only. Two to three lateral
pins are adequate for stabilizing most fractures. Evolving
management concepts include those regarding pin placement, the
problems of a pulseless hand, compartment syndrome, and
posterolateral rotatory instability.

From the Department of

Orthopaedics, University of
Maryland School of Medicine,
Baltimore, MD (Dr. Abzug), and The
Orthopedic Center for Children, St.
Christopher’s Hospital for Children,
Philadelphia, PA (Dr. Herman).
Dr. Herman or an immediate family
member serves as a paid consultant
to Lanx and serves as a board
member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons
and the Pediatric Orthopaedic
Society of North America. Neither
Dr. Abzug nor any immediate family
member has received anything of
value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2012;20:
69-77
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
S upracondylar fracture is the most
common type of elbow fracture
in children, accounting for 3% of all
pediatric fractures.1,2 This fracture
type is well studied. Otsuka and
Kasser2 published a thorough review
of the topic in 1997. Several con-
cepts have emerged in the past de-
cade regarding the management of
pediatric supracondylar humerus
fractures.
Supracondylar fractures occur
most commonly in children aged be-
tween 5 and 7 years.3 Most fractures
occur on the left or nondominant side,
and recent studies have suggested a
nearly equal incidence between males
and females.4,5 Extension fractures
account for approximately 98% of
these injuries, and they usually occur
as the result of a fall on an out-
stretched hand with the elbow in full
extension.4
Physical Examination
Patients with supracondylar frac-
tures present with pain and swelling
about the elbow. Active elbow mo-
tion is limited, and gross deformity
of the arm may be present with dis-
placed fractures. Thorough examina-
tion 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 frac-
tures.6 Children who sustain supra-
condylar fractures with diaphyseal
forearm fractures are at higher risk
of developing compartment syn-
dromes of the forearm than are those
with isolated supracondylar frac-
tures.7

February 2012, Vol 20, No 2 69

Management of Supracondylar Humerus Fractures in Children: Current Concepts
Figure 1
Normal lateral radiograph in a
pediatric patient demonstrating
placement of the anterior humeral
line, which lies along the anterior
humeral cortex. A second line is
drawn perpendicular to the first line
at the base of the capitellum ossific
nucleus. This second line is divided
into thirds to determine where the
intersection takes place, if at all.
Thorough neurologic assessment
may be difficult because of pain,
anxiety, or poor cooperation with
the examination, particularly in chil-
dren 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 supracon-
dylar fractures.8 In patients with
extension-type supracondylar frac-
tures, anterior interosseous nerve in-
jury is most common, followed by
median, radial, and ulnar nerve inju-
ries. The ulnar nerve is most com-
monly injured in flexion-type frac-
tures.8 It is critical that the surgeon
make the best effort to diagnose
nerve deficits in these younger pa-
tients through observation of activi-
ties and repeat examinations if neces-
sary. 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
70
is trapped in the fracture site. Explo-
ration of the nerve may be required
to prevent ongoing nerve injury.
Accurate determination of the vas-
cular 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 ultrasonogra-
phy may be necessary. However, per-
fusion of the hand is a better indica-
tor 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 re-
sulting from injury or spasm of the
brachial artery at the fracture site,
the hand may be well-perfused. Clin-
ical indicators of sufficient distal per-
fusion include normal capillary refill,
skin temperature, and color (typi-
cally described as pink). The child
with an ischemic limb may experi-
ence significant forearm pain, loss of
motor function, pain with passive
stretch of the digits, and/or paresthe-
sias. The vascular status of the in-
jured extremity is categorized as nor-
mal, pulseless with a pink hand, or
dysvascular, which is sometimes de-
scribed as pulseless with a white
hand. Supracondylar fracture with a
dysvascular hand constitutes a surgi-
cal emergency.
Radiographic Evaluation
Suspected elbow fracture is best eval-
uated on high-quality AP and lateral
radiographs centered on the elbow.
Radiographs are assessed for evi-
dence of fracture, degree of commi-
nution, and intra-articular extension
of the fracture line. Direction and de-
gree of displacement as well as signs
of rotational or translational mal-
alignment are also noted. Oblique
views of the injured elbow and com-
parison radiographs of the uninjured
Journal of the American Academy of Orthopaedic Surgeons
elbow may be helpful to identify
minimally displaced fractures; how-
ever, these are not routinely required.
When no fracture is visible, the pres-
ence of the posterior fat pad, which
is seen on the lateral radiograph as
lucency along the posterior distal hu-
merus and the olecranon fossa, is
highly suggestive of occult elbow
fracture. In one study, 76% of chil-
dren with a negative initial radio-
graph and a visible posterior fat pad
were shown on repeat radiographs
obtained several weeks later to have
a fracture, as evidenced by periosteal
changes about the distal humerus,
proximal radius, or olecranon.9
The anterior humeral line is a ra-
diographic marker drawn along the
anterior humeral cortex and ex-
tended to the capitellum on the lat-
eral radiograph. This line intersects
the middle third of the capitellum in
most healthy children older than 4
years of age but may lie in the ante-
rior one third of the capitellum in
those aged <4 years10 (Figure 1). Pos-
terior displacement of extension-type
fractures is present if the anterior hu-
meral line does not intersect the capi-
tellar ossific nucleus. Orthogonal
views of the entire humerus and fore-
arm of the injured extremity are rou-
tinely obtained to evaluate for addi-
tional ipsilateral fractures.
Classification
The Gartland classification is the
most commonly used scheme to de-
scribe extension-type supracondylar
fractures. Type I fractures are non-
displaced, type II fractures have an
intact posterior hinge, and type III
fractures involve complete displace-
ment.11 Wilkins12 modified the Gart-
land classification by dividing type II
fractures into subtypes A and B.
Type IIA fractures are extended but
have no rotational abnormality or
fragment translation. These fractures

are frequently stable following a
flexion reduction maneuver and can
be held in a cast. In addition to ex-
tension deformity, type IIB fractures
involve some degree of rotational
displacement or translation. These
fractures are generally unstable after
reduction. Distinguishing between
the subtypes allows the surgeon to
predict which type II fractures may
be successfully managed with reduc-
tion and casting and which require
reduction and fixation.13
Leitch et al14 recently proposed the
addition of a type IV fracture to the
Gartland classification. Type IV frac-
tures are unstable in both flexion
and extension because of complete
loss of a periosteal hinge. These
fractures occur either as result of
trauma or by excessive flexion force
applied during the closed reduction
maneuver.
Management
Management of extension supracon-
dylar fractures is generally deter-
mined by Gartland type. Type I frac-
tures are managed with 3 to 4 weeks
of long arm cast immobilization with
the elbow flexed to 90° and the fore-
arm held in neutral rotation. This
treatment is also used when the ini-
tial radiograph is negative for frac-
ture but demonstrates a visible poste-
rior fat pad.
Management of type II supracondy-
lar fractures is controversial. Many pa-
tients with type IIA fractures may be
successfully treated with closed reduc-
tion and casting; however, close obser-
vation 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 reduc-
tion and pinning is the initial man-
agement choice. We use the semister-
ile technique to perform closed
reduction and percutaneous pinning.
February 2012, Vol 20, No 2
Joshua M. Abzug, MD, and Martin J. Herman, MD
This technique does not require
drapes or gowns and thus reduces
operating room time and cost. Iobst
et al15 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 ob-
tained to confirm maintenance of re-
duction. When reduction is main-
tained, the splint is overwrapped
with fiberglass. The K-wires are re-
moved 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 de-
tailed description of the technique
and aftercare.
Type IV fractures are managed
with a modified pinning technique.
Rather than rotating the arm to ob-
tain orthogonal views during pin in-
sertion, the fluoroscopy unit can be
rotated or two fluoroscopy units can
be used simultaneously. Leitch et al14
suggest preplacement of K-wires into
the distal fragment before reduction.
Open reduction and internal fixa-
tion is indicated predominantly for
fractures that cannot be adequately
reduced with closed methods and for
open fractures. The anterior ap-
proach to the elbow provides the
best exposure of the neurovascular
structures and the soft-tissue obsta-
cles anteriorly that prevent reduc-
tion. This approach is performed
through either a transverse or an
oblique incision made across the el-
bow flexion crease.
Surgical Complications
Complications are common even
with ideal management. Recently,
Bashyal et al16 performed a retro-
spective review of 622 patients
treated for supracondylar fractures
and evaluated the complications as-
sociated with management. Overall,
4.2% of patients had complications.
The most common complication was
pin migration, which required an un-
anticipated return to the operating
room for pin removal in 1.8% of pa-
tients. Infectious complications re-
lated 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 op-
erating room for repeat reduction
and pinning. Compartment syn-
drome was present in three patients,
and one patient had postoperative
ulnar nerve injury.
Evolving Management
Concepts
Timing of Surgical
Intervention
Traditionally, closed reduction and
pinning of type III supracondylar
fractures was performed as an emer-
gent procedure within several hours
of admission, regardless of the time
of day or night. This was done be-
cause of concerns regarding increas-
ing swelling, the development of
compartment syndrome, and increas-
ing difficulty with achieving an ade-
quate closed reduction.2 However,
this practice has been challenged in
recent studies.
Mehlman et al17 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 differ-
ence was noted with regard to the
need for conversion to open reduc-
tion, superficial pin tract infection,
71
Management of Supracondylar Humerus Fractures in Children: Current Concepts
Table 1
Factors Used to Determine
Emergent Management of
Supracondylar Humerus Fracture
in Pediatric Patients
Open fracture
Dysvascular limb
Skin puckering
Floating elbow
Median nerve palsy
Evolving compartment syndrome
Young age
Cognitive disability
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 al19 reported
similar findings in a prospective
study of 145 fractures, showing no
increase either in the number of peri-
operative complications or in the
need for open reduction after surgi-
cal delays as long as 21 hours from
injury. These authors emphasize the
need for a thorough evaluation in the
emergency department to assess neu-
rovascular status and associated in-
juries, gentle positioning and splint-
ing of the limb without attempting
fracture reduction, frequent monitor-
ing in the hours before surgery, and
availability of the operating room
within a reasonable time frame after
admission.
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 depart-
72
ment by an orthopaedic surgery resi-
dent. The arm is then carefully posi-
tioned 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 neurovascu-
lar checks by the nurse at 2-hour in-
tervals. Pain medication is limited to
agents that will not sedate the pa-
tient or mask symptoms and signs of
compartment syndrome (eg, acet-
aminophen, ibuprofen, ketorolac,
low-dose morphine). All patients ad-
mitted 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 sta-
tus, and fractures that are at particu-
larly high risk of compartment syn-
drome, such as those associated with
severe forearm swelling or that occur
in combination with a forearm frac-
ture (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).
Type II Fracture
Management of type II supracondy-
lar fractures remains controversial
because published reports support
several options as primary treatment,
including reduction and casting,20 re-
duction and pinning of all type II
fractures,3 and reduction and pinning
of type IIB fractures only.13 Parikh et
al20 performed a retrospective review
of 25 consecutive type II fractures
managed with initial closed reduc-
tion and casting. In seven fractures,
reduction was lost by the time of
follow-up. Five of these fractures
subsequently were managed success-
fully with repeat closed reduction
Journal of the American Academy of Orthopaedic Surgeons
and pinning. The authors concluded
that type II fractures are best man-
aged initially with reduction and
casting.
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.3
O’Hara et al13 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 pin-
ning, including patients with varus
deformity, required further surgery.
The authors concluded that all type
IIB and III fractures should be
pinned after reduction.
At our institutions, most type II
fractures are managed primarily with
closed reduction and pin fixation.
The main reasons for this manage-
ment protocol are concern regarding
inability to maintain adequate reduc-
tion 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 radio-
graphic view. For this limited num-
ber of patients, follow-up radio-
graphs are obtained 5 to 7 days after
injury. Surgical reduction and pin-
ning is performed if the reduction is
not maintained.
Pin Configuration
Traditionally, a crossed pin configu-
ration has been used to stabilize su-
pracondylar fractures after reduc-
tion. With the elbow held in flexion,
one lateral pin is placed percutane-
ously just proximal to the capitellum
in the metaphysis, and one pin is
 Joshua M. Abzug, MD, and Martin J. Herman, MD

Figure 2

Illustrations demonstrating potential technical errors in closed reduction and percutaneous pinning of supracondylar
humerus fractures in children. In each panel, the left image is an AP view and the right image is a lateral view.
A, Failure to obtain bicortical fixation across the fracture secondary to the pin exiting anteriorly through the fracture site
(arrow). B, Failure to obtain bicortical fixation across the fracture site secondary to intramedullary pin placement
(arrow). C, The pins cross the fracture site with a spread <2 mm (arrow). (Redrawn with permission from Sankar WN,
Hebela NM, Skaggs DL, Flynn JM: Loss of pin fixation in displaced supracondylar humeral fractures in children:
Causes and prevention. J Bone Joint Surg Am 2007;89[4]:713-717.)

placed percutaneously anterior to the
ulnar groove in the medial epicon-
dyle. 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.2 This configuration has
been shown in clinical series to be ef-
fective 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.22 Direct nerve pene-
tration 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.
To avoid this complication, many
surgeons use only lateral entry pins
to stabilize supracondylar fractures.
Skaggs et al22 retrospectively re-
viewed 345 extension-type supracon-
dylar fractures and compared the
outcomes of displaced fractures man-
aged with lateral entry pins only or
with crossed pins. Maintenance of
reduction was the same for both
groups. However, no ulnar nerve in-
juries occurred in the lateral entry
pinning group, whereas a 7.7% inci-
dence of iatrogenic nerve injury was
reported in the crossed-pin group.
Gaston et al23 showed similar find-
ings in another smaller study of the
same design. In a prospective, ran-
domized clinical study, Kocher et al24
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.
Sankar et al25 demonstrated that
loss of fracture reduction is possible
with lateral entry pins if proper tech-
nique is not applied. In their retro-
spective review of 279 displaced su-
pracondylar fractures, 8 (2.9%) lost
fixation. Seven of these eight frac-
tures were initially managed with
two lateral entry pins only. The au-
thors identified important technical
errors, including failure to engage
both fragments with at least two
pins, failure to achieve bicortical fix-
ation with at least two pins, and fail-
ure to achieve ≥2 mm of pin separa-
tion at the fracture site (Figure 2).
They recommended critical radio-
graphic evaluation of each pin to
avoid these errors. They also advised
checking the stability of fixation by
stressing the fracture site under fluo-
roscopy at the completion of the pro-
cedure.
At our institutions, most displaced
fractures are stabilized with only lat-
eral entry pins. For type II fractures,
at least two bicortical pins are used,
whereas type III fractures are typi-
cally stabilized with at least three lat-
eral pins (Figure 3). The pins are
configured as far apart as possible in
a divergent manner, ideally not con-
verging or crossing at the fracture
site. Ideally, both the medial and the
lateral columns are engaged to im-

February 2012, Vol 20, No 2 73

Management of Supracondylar Humerus Fractures in Children: Current Concepts

Figure 3

Fluoroscopic images of a pediatric patient managed with lateral-only percutaneous pinning for a type III supracondylar
humerus fracture. A, Preoperative lateral view demonstrating complete displacement. B, AP view following pin
placement demonstrating the spread of the pins through the medial and lateral columns. C, Lateral view demonstrating
the spread of the pins in the AP plane.

prove stability. If the distal humerus
is comminuted or the fracture reduc-
tion 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 me-
dial epicondyle with the elbow in ex-
tension. Varus/valgus, flexion/exten-
sion, and rotational stresses are
applied to the fracture under live flu-
oroscopy at the conclusion of sur-
gery 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 or-
thopaedic 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.2
Emergency surgery is indicated for
the pink pulseless hand and for the
dysvascular limb in association with
a supracondylar fracture. In the op-
erating room, the fracture is reduced
closed if possible and pinned. The
vascular status is reassessed and ob-
served 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 step-
down unit for monitoring. If perfu-
sion is not restored within this time
frame, the vessel is immediately ex-
plored through an anterior ap-
proach. After inspection of the ves-
sel, 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, arte-
riography is not useful and may in
fact delay revascularization or exac-
erbate vessel spasm (Figure 4).
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 ra-
dial pulse did not return or the vessel
repair was not patent.28
Some recent studies indicate that
this strategy underestimates the se-
verity of neurovascular injury in pa-
tients with a pink pulseless hand. In
an analysis of 19 published articles,
White et al29 identified 98 patients
with pink pulseless hands after su-
pracondylar fractures. Forty-five of
these patients underwent vessel ex-
ploration. 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 al28 retrospectively compared pa-
tients 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

74 Journal of the American Academy of Orthopaedic Surgeons


Figure 4
Treatment algorithm for managing the pulseless hand in pediatric patients
with supracondylar humerus fracture.
a
The surgeon consulted should be one with expertise in small vessel
reconstruction.
only, 4 required secondary explora-
tion that identified vessel tethering or
entrapment at the fracture site. Three
of these patients had nerve entrap-
ment or tethering involving the me-
dian and/or anterior interosseous
nerve. Of the eight patients treated
with early exploration, the vessel
was found to be tethered at the frac-
ture site in six patients, four of
whom also had nerve entrapment.
All vessels that underwent repair re-
mained patent at follow-up.
Blakey et al30 reported that 23 of 26
patients referred to their institution
with pink pulseless hands following su-
pracondylar fracture had some evi-
dence of ischemic contractures of the
forearm and hand. Of these, two pa-
tients responded to stretching; the re-
mainder required further surgical inter-
vention. These authors recommended
urgent exploration of the vessel in a
child with a pink pulseless hand fol-
lowing reduction.
We emergently perform closed re-
duction and pinning in children who
present with pink pulseless hands
after supracondylar fractures. At
February 2012, Vol 20, No 2
Joshua M. Abzug, MD, and Martin J. Herman, MD
our institutions, scenarios requiring
emergent vascular exploration in-
clude complete median nerve palsy
associated with an abnormal vascu-
lar 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 fol-
lowing closed reduction, it is our
opinion that higher level evidence-
based outcome studies are needed to
justify exploration in all of these
children.
Cubitus Varus
Cubitus varus is one of the most com-
mon complications of supracondylar
fractures managed with either casting
or pinning. This deformity typically is
painless and does not affect elbow mo-
tion. Traditionally, surgeons believed it
to be primarily a cosmetic deformity.
However, O’Driscoll et al31 identified
22 adult patients who presented with
pain as well as signs and symptoms
of elbow instability 20 to 30 years
after sustaining supracondylar frac-
tures in childhood; all had healed in
cubitus varus. The authors hypothe-
sized that this “tardy posterolateral
elbow instability” causes medial dis-
placement of the elbow mechanical
axis, resulting in asymmetric triceps
forces that cause slow attenuation of
the lateral collateral ligament. Valgus
osteotomy and ligament reconstruc-
tion yields satisfactory results.
We recommend correctional os-
teotomy in children with substantial
residual cubitus varus following su-
pracondylar elbow fractures. The
cosmetic deformity and the potential
for posterolateral rotatory instability
should be discussed with the parents.
Ideally, the surgery is done ≥1 year
after injury, when elbow range of
motion has stopped improving and
when the child is old enough to co-
operate with postoperative instruc-
tions (eg, age 4 to 5 years). Many
different procedures may be used.
We prefer to perform lateral closing
wedge osteotomy and pin fixation
through a lateral or posterior ap-
proach (Figure 5). Technique modifi-
cation (eg, dome osteotomy, step-cut
osteotomy) may be required in chil-
dren with severe sagittal plane or ro-
tational deformities.
Compartment Syndrome
Compartment syndrome is a rare
complication of supracondylar frac-
ture, but it may result in devastating
complications. Traditional signs and
symptoms associated with compart-
ment syndrome in adults are unreli-
able indicators of the evolution of
the condition in children. In children,
an increasing need for narcotic medi-
cation to control pain is the best in-
dicator of compartment syndrome.32
Anxiety, discomfort, and inability to
understand commands or verbalize
responses to questions make it diffi-
cult for the surgeon to evaluate chil-
75
Management of Supracondylar Humerus Fractures in Children: Current Concepts
Figure 5
A, AP elbow radiograph in a pediatric patient demonstrating cubitus varus
deformity after treatment of a supracondylar humerus fracture. No sagittal
plane deformity was present. B, AP elbow radiograph following lateral closing
wedge osteotomy and pin placement.
dren effectively. A recent report indi-
cates that children who undergo
vascular repair for a dysvascular
limb after supracondylar fractures
are also at increased risk of develop-
ing compartment syndrome, even af-
ter successful vascular repair.33
At our institutions, children with
type III supracondylar fractures are
observed in the hospital for 12 to 24
hours postoperatively to allow for
early detection of impending com-
partment syndrome. Neurovascular
checks and surveillance for signs and
symptoms of increasing pain are
done at 2- to 4-hour intervals until
discharge. To prevent excessive seda-
tion or pain control that may mask
subtle signs of the condition, nonnar-
cotic analgesics or low doses of nar-
cotics are used for pain control. Pa-
tients with suspected compartment
syndrome are typically returned to
the operating room for measurement
of compartment pressures. Manage-
ment involves volar forearm fasciot-
omy performed through an extensile
approach from the elbow to the
wrist. Excellent results have been re-
76
contents. In this article, reference 24 is
a level I study. References 19 and 23
are level II studies. References 9, 13,
16-18, 22, 25, and 28 are level III
studies. References 4, 5, 7, 8, 14, 15,
20, 27, and 29-33 are level IV studies.
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77