Pediatric Supracondylar Humerus Fractures 

Updated: Aug 27, 2018
Author: Jiun-Lih Jerry Lin, MBBS, MS(Orth); Chief Editor: Jeffrey D Thomson, MD 

Overview

Practice Essentials

Pediatric supracondylar humerus fractures (SCHFs) are common and significant injuries. They are distinctly different from adult SCHFs and thus are approached differently. Complications include neurovascular injury, compartment syndrome, malunion, and Volkmann contracture.

Timely diagnosis and proper management can prevent postinjury complications. These injuries are diagnosed by means of anteroposterior (AP) and true lateral radiographs. Lateral condyle fractures are a differential for supracondylar humerus fractures (SCHFs).

Type 1 and type 2A fractures may safely be treated nonoperatively if patients and parents are compliant. Type 2B, type 3, and flexion-type fractures require closed or open reduction and pin fixation. Pulseless and ischemic limbs require emergency reduction and fixation with or without vascular exploration by a vascular surgeon. The duration of immobilization varies, depending on injury severity, patient age, and local hospital protocols.

Background

Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children, accounting for approximately 12-17% of all pediatric fractures.[1, 2] The vast majority of SCHFs are seen in children younger than 10 years, with a peak incidence between 5 and 7 years.[2] The most common mechanism of injury is falling onto an outstretched hand with a hyperextended elbow.[3, 2] Rarely (< 5% of cases), SCHFs are seen with falls onto a flexed elbow, in which case they are referred to as flexion-type SCHFs.[4]

SCHFs have been associated with morbidity due to malunion, neurovascular complications, and compartment syndrome. Nonunion of an SCHF is rarely an issue, but if it does develop, it can result in long-term deformity and functional deficits.

Historically, the majority of SCHFs were treated by means of closed reduction and long arm casting with the elbow hyperflexed to greater than 100º. Although the hyperflexed position helped in maintaining reduction, it also led to problems associated with vascular compromise and subsequent Volkmann contracture.

Currently, management and follow-up of these fractures are determined on the basis of the Gartland classification (see Classification).[5]  Type 1 and type 2A fractures may safely be treated nonoperatively, provided that patients and parents are compliant with therapy. Type 2B, type 3, and flexion-type fractures require closed or open reduction and pin fixation. There is no clear international evidence on the proportion of pediatric SCHFs that are treated operatively as opposed to nonoperatively.

SCHFs may also be seen in the elderly population, where they commonly result from low-energy trauma (eg, falling from a flat surface and landing directly on the elbow). These fractures represent completely different injury entities and should be worked up, assessed, and managed as such. In the geriatric setting, fracture comminution and nonunion are major concerns, and the choices of fixation method and therapeutic approach are drastically different from those seen in the pediatric setting.[6]  For more detail on adult SCHFs, see Supracondylar Humerus Fractures.

Anatomy

The elbow is a synovial hinge joint between the distal humerus and the proximal radius and ulna. Radiographic evaluation of the pediatric elbow requires knowledge and understanding of the secondary ossification centers in the elbow so that normal anatomy can be distinguished from pathologic anatomy. The sequence of ossification follows a predictable pattern, as expressed in the acronym CRITOE (see Table 1 below).[7]

Table 1. Order of Ossification and Fusion of Elbow Ossification Centers (Open Table in a new window)

Ossification Center

Age at Ossification Appearance (y)

Age at Fusion (y)

Capitellum

1

12

Radius

3

15

Internal (medial)

epicondyle

5

17

Trochlea

7

12

Olecranon

9

15

External (lateral) epicondyle

11

12

It should be noted that the ages of ossification and fusion can vary between individuals and are generally earlier in females than in males.[8] The capitellum is the first ossification center to be noted, appearing around the age of 1 year in both males and females. It should also be noted that the elbow is primarily cartilaginous in patients younger than 2.5 years and that structural injuries may be difficult to assess on plain radiography alone.[9]

Etiology

Pediatric SCHFs most commonly occur in children aged between 5 and 7 years, and their prevalence is similar in males and females.[2]  They are usually a result of falling from a height. In children older than 4 years, falls are commonly from play equipment, such as monkey bars, trampolines, and climbing frames, whereas younger children often fall from household furniture, such as beds and lounges.[1, 3]

Prognosis

If pediatric SCHFs are promptly diagnosed and treated, no long-term complications or functional deficits are expected.

 

Presentation

History

In most instances, pediatric supracondylar humerus fractures (SCHFs) result from a fall on outstretched hand with the elbow hyperextended.[3, 2]  As in the assessment of any case of pediatric trauma, it is always necessary to consider the possibility of a nonaccidental injury, neglect, or both; however, these are rare with this fracture type.

Physical Examination

In supracondylar elbow fractures, the olecranon is driven into the olecranon fossa, and the anterior humeral cortex fails in tension. The muscle action of the triceps brachii displaces the distal fragment posteriorly and proximally.[6]  Upon examination, the child is often distressed, the elbow may appear angulated, and the upper extremity may be shortened.

Neurovascular status must be carefully evaluated and monitored. Owing to the close proximity of the neurovascular structures in this region, injury to these structures is common.[10, 11]  It is worth noting that nearly all neurapraxia after an SCHF resolves spontaneously, and for this reason, further diagnostic studies and exploration are not indicated in the acute setting.[12]  In addition, clinicians must be aware that neurovascular status is dynamic and that repeat examination and documentation are therefore important.

Associated nerve injuries

Nerve injuries that may be associated with pediatric SCHFs include the following[12] :

  • Anterior interosseous nerve palsy - The most common nerve palsy seen with extension-type SCHFs
  • Radial nerve palsy - The second most common neurapraxia in extension-type SCHFs
  • Ulnar nerve palsy - The most common nerve palsy in flexion-type SCHFs

Associated vascular injuries

Displaced SCHFs can result in compromised distal circulation. The clinician must establish the vascularity of the injured limb by assessing the radial pulse as well as the perfusion of the fingers. A nonperfused hand is an orthopedic emergency that warrants reduction and fixation of the injury within 2 hours (see Approach to Pulseless Limb). However, because of the rich collateral circulation at the elbow, the incidence of true limb ischemia in this injury is low (~1%).[12, 13]

Clinical signs that mandate urgent orthopedic review include the following:

  • Compound fracture
  • Severe swelling
  • Neurologic injury
  • Absence of radial pulse
  • Ischemia of the hand

The patient should be kept on NPO (nil per os) status until a decision about surgical management has been made by the orthopedic team.[7]

Classification

The Gartland classification system is used to categorize SCHFs on the basis of the degree and direction of displacement.[7, 5, 13]  [14]

Gartland type 1 SCHFs are characterized as follows:       

  • Undisplaced or minimally displaced fracture
  • Recommended treatment - Cast immobilization for 4-6 weeks; check radiograph at 1 week and 2 weeks post injury

Gartland type 2 SCHFs are characterized as follows:

  • Type 2A - Displaced fracture with posterior cortex and posterior periosteal hinge intact, with no rotational deformity or fragment translation (see the first image below)
  • Type 2B - Rotational deformity or fragment translation (see the second image below)
  • Recommended treatment - Closed reduction and collar and cuff in elbow hyperflexion (simple type 2A); closed reduction and percutaneous pinning (type 2A or 2B); check radiograph at 1 week and 2 weeks post injury; remove pins at 3-4 weeks
(A, B) Anteroposterior (AP) and lateral elbow radi (A, B) Anteroposterior (AP) and lateral elbow radiographs of 6-year-old girl with type 2A supracondylar humerus fracture with no rotational deformity on AP view. Anterior humeral line is crossing anterior to capitellum. (C, D) AP and lateral elbow radiographs of same patient after treatment with collar-and-cuff in elbow hyperflexion. Fracture is now reduced, and anterior humeral line now transects capitellum.
(A, B) Elbow radiographs of 5-year-old boy with ty (A, B) Elbow radiographs of 5-year-old boy with type 2B supracondylar humerus fracture (SCHF). Type 2B fracture differs from type 2A in that it has additional rotational component. (C, D) Postoperative radiographs of same patient showing cross Kirschner wire (K-wire) configuration in stabilization of SCHF. Intramedullary medial wire placement was done deliberately so as to provide valgus force and counteract any risk of fracture drifting into varus, leading to potential gunstock deformity. Lateral wire was placed to engage medial cortex as shown, for same reason.

Gartland type 3 SCHFs (see the image below) are characterized as follows:      

  • Completely displaced fracture, with no or minimal cortical contact; higher incidence of neurovascular injury
  • Recommended treatment -  Closed reduction and percutaneous pinning; check radiographs at 1 week and 2 weeks post injury; remove pins at 4 weeks and start elbow range of motion
(A, B) Elbow radiographs of 10-year-old girl showi (A, B) Elbow radiographs of 10-year-old girl showing type 3 supracondylar humerus fracture. (C, D) Intraoperative radiographs of same patient demonstrating reduction and fixation of fracture. Two Kirschner wires (K-wires) were used to stabilize lateral column, and one K-wire was used to stabilize medial column.

In 2006, Leitch et al proposed a modification to the original Gartland classification that added a fourth type.[14]  In this modification, Gartland type 4 SCHFs were described as multidirectionally unstable fractures that can displace into both flexion and extension. The management recommended by the authors consisted of closed reduction and percutaneous pinning. Complication rates associated with these unstable fractures were no higher than those associated with other, more stable fractures. 

 

DDx

Diagnostic Considerations

Pediatric lateral condyle fracture is an injury in the elbow that is often missed or mistaken for a supracondylar humerus fracture (SCHF). Clinically, it is important to differentiate between an SCHF (extra-articular) and a lateral condyle fracture (intra-articular). The management of lateral condyle fractures is much more aggressive than that of SCHFs, and there is a very low tolerance for fracture displacement.[7, 15]  (See the image below.)

(A, B) Anteroposterior (AP) and lateral radiograph (A, B) Anteroposterior (AP) and lateral radiographs of 4-year-old boy showing lateral condyle fracture. This common fracture can be difficult to discern on AP radiographs and thus may be missed. Lateral condyle fracture is intra-articular and often requires more aggressive treatment, more intensive monitoring, or longer immobilization as compared with supracondylar humerus fracture.

Differential Diagnoses

 

Workup

Radiography

Radiographic evaluation of a supracondylar humerus fracture (SCHF) consists of an elbow x-ray series that includes anteroposterior (AP) and lateral views of the elbow and any other sites of deformity, pain, or tenderness.[8]  It is essential that a true lateral elbow image be obtained as part of the elbow series. This allows accurate assessment of the anterior humeral line and the anatomic alignment of the distal humerus.[8]  An incorrectly positioned lateral elbow x-ray could potentially lead to misdiagnosis, a missed fracture, or both.

The standard protocol includes an AP image with the patient’s arm supinated in full elbow extension and an orthogonal lateral x-ray. The lateral image should be taken with the patient’s arm flexed at 90º, the humerus horizontal (with the elbow in the same plane as the shoulder), and the wrist in a lateral position.[8, 16]  Achieving the desired position for these projections can be challenging because of the nature of the injury and the presentation of the patient.

Patients who present with an obvious deformity, marked swelling, and severe pain should be considered to have an unstable fracture and should not be moved; repositioning the elbow could result in further soft-tissue injury. The radiographer should angle the beam or use a horizontal beam to obtain required projections. The AP image may have to be obtained with the patient’s arm partially or fully flexed and the humerus against the imaging plate.[16]

On the AP view, the Baumann angle is commonly used to evaluate fractures, in that it maintains an estimation of the carrying angle. The Baumann angle is created by the intersection of a line drawn down the long axis of humeral shaft and a line drawn along the lateral condyle growth plate. A normal Baumann angle is generally considered to be in the range of 70-80º. However, the best assessment involves comparison with the corresponding angle in the contralateral limb. A deviation exceeding 5% indicates coronal plane deformity. This should not be accepted.[9]

On the lateral view, the relation between the anterior humeral line and the ossification center of the capitellum should be examined. In a normal elbow, this line should intersect the middle third of the capitellum. The capitellum moves posteriorly to this reference line in extension-type fractures, whereas it moves anteriorly in flexion-type fractures.[1, 8, 17]  (See the image below.)

(A, B) Anteroposterior (AP) and lateral elbow radi (A, B) Anteroposterior (AP) and lateral elbow radiographs of 6-year-old girl with type 2A supracondylar humerus fracture with no rotational deformity on AP view. Anterior humeral line is crossing anterior to capitellum. (C, D) AP and lateral elbow radiographs of same patient after treatment with collar-and-cuff in elbow hyperflexion. Fracture is now reduced, and anterior humeral line now transects capitellum.

Elbow fat pads are often visible in the case of acute injuries. Hemarthrosis elevates the anterior and posterior fat pads out of the coronoid and olecranon fossa, respectively, making them visible on radiographs. Visualization of fat pads and a clinically painful elbow are suggestive of an occult fracture and warrant treatment as an acute injury with immobilization and orthopedic follow-up. In more than 90% of cases where imaging shows posterior fat pad displacement, a fracture is seen on initial or follow-up radiographs.[18, 19, 9, 8]

As with all pediatric imaging, lead shielding should be used to protect the patient’s gonads.

CT, MRI, and US

Although radiography is the primary method for evaluating acute elbow injuries in the pediatric population, soft-tissue elbow injuries and inflammatory joint conditions can be further investigated with ultrasonography (US) or magnetic resonance imaging (MRI). For further information about these studies, see Imaging in Pediatric Elbow Trauma.

Computed tomography (CT) and CT angiography (CTA) are not indicated in the workup of pediatric SCHFs, because they do not make a significant contribution to assessment or management.[13]  A pulseless ischemic limb in a pediatric patient with a displaced SCHF should instead be explored surgically with support from vascular surgery. CT is indicated in adult patients with SCHFs to assess the fracture pattern and identify intra-articular extension; however, as noted, adult SCHFs are completely different from pediatric SCHFs and thus are managed differently.

 

Treatment

Nonoperative Therapy

Nonoperative management of supracondylar humerus fractures (SCHFs) is indicated for nondisplaced fractures (Gartland type 1) or mildly displaced fractures without rotational deformity (Gartland type 2A).[1, 18, 19]

Gartland type 1 fractures with no medial comminution can be managed with a long arm back slab at 90º of elbow flexion and neutral forearm rotation or a collar-and-cuff, depending on local protocol. When applying the back slab, treating physicians should be mindful of pressure areas and should repeat the neurovascular examination after application. If the degree of swelling allows, it is possible to change to a long arm full cast in 1-2 weeks. The total immobilization time is 4-6 weeks, again depending on local hospital protocol.

Gartland type 2A fractures with mild swelling and no medial comminution can also be treated nonoperatively. A collar-and-cuff with the elbow in hyperflexion is used as a method of achieving reduction and maintaining alignment (see the image below). In this setting, it is important to inform the patient and family members that the collar-and-cuff should not be removed during the treatment period and that the patient should wear clothing covering it.

(A, B) Anteroposterior (AP) and lateral elbow radi (A, B) Anteroposterior (AP) and lateral elbow radiographs of 6-year-old girl with type 2A supracondylar humerus fracture with no rotational deformity on AP view. Anterior humeral line is crossing anterior to capitellum. (C, D) AP and lateral elbow radiographs of same patient after treatment with collar-and-cuff in elbow hyperflexion. Fracture is now reduced, and anterior humeral line now transects capitellum.

During application of the collar-and-cuff, the patient’s fist should be under the chin to permit optimal flexion at the elbow. After application, it is important to check the radial pulse and hand perfusion; hyperflexion of a swollen elbow can affect the blood supply. Additionally, a repeat elbow radiograph should be ordered to ensure that the fracture is in good alignment. The total immobilization time ranges from 4 to 6 weeks, depending on local protocol.

It is worth noting that the management of type 2A fractures remains a subject of debate. It is heavily driven by local guidelines and surgeon preference. Many orthopedic surgeons argue for surgical management with closed reduction and percutaneous pinning (CRPP).

Surgical Therapy

Indications

Indications for closed reduction with percutaneous Kirschner wire (K-wire) fixation (ie, CRPP) include the following[10, 11, 6, 20] :

  • Severe type 2A, type 2B, type 3, and all flexion-type fractures (see the images below)
  • Neurovascular changes
  • Associated ipsilateral upper-limb injuries (5-10% of patients with ipsilateral distal radius fractures)
(A, B) Elbow radiographs of 5-year-old boy with ty (A, B) Elbow radiographs of 5-year-old boy with type 2B supracondylar humerus fracture (SCHF). Type 2B fracture differs from type 2A in that it has additional rotational component. (C, D) Postoperative radiographs of same patient showing cross Kirschner wire (K-wire) configuration in stabilization of SCHF. Intramedullary medial wire placement was done deliberately so as to provide valgus force and counteract any risk of fracture drifting into varus, leading to potential gunstock deformity. Lateral wire was placed to engage medial cortex as shown, for same reason.
(A, B) Elbow radiographs of 5-year-old boy with ty (A, B) Elbow radiographs of 5-year-old boy with type 2B supracondylar humerus fracture. (C, D) Postoperative radiographs of same patient showing two lateral Kirschner wire (K-wire) configurations. Diverging K-wire configurations are as recommended by Skaggs in 2008.
(A, B) Elbow radiographs of 10-year-old girl showi (A, B) Elbow radiographs of 10-year-old girl showing type 3 supracondylar humerus fracture. (C, D) Intraoperative radiographs of same patient demonstrating reduction and fixation of fracture. Two Kirschner wires (K-wires) were used to stabilize lateral column, and one K-wire was used to stabilize medial column.

Indications for open reduction with K-wire fixation include the following[10, 11, 6, 20] :

  • Failure of closed reduction (often due to soft-tissue infolding within the fracture site)
  • Placement of medial wires (often done via a miniopen approach to avoid injuring the ulnar nerve)
  • Flexion type 3 injuries

Surgical treatment may follow a medial approach, an anteromedial approach (for brachial artery exploration), or a miniopen medial approach that includes a mini-incision for K-wire placement (see below).

Timing

The timing of surgical treatment depends on the severity of the injury, the presence of neurovascular compromise, and the patient's fasting status.[1, 12, 7]  At present, there is no consensus regarding optimal surgical timing in the treatment of displaced pediatric SCHFs. Urgent surgical intervention is indicated in patients with significant fracture displacement (type 2B or 3) or nerve palsy. Emergency surgical intervention is indicated in patients with vascular compromise leading to an underperfused limb or in the setting of acute limb ischemia.

Operative details

The surgical techniques employed may vary, as follows.[10, 11, 6, 21, 20]

Use of Kirschner wires

Two lateral K-wires (see the image below) are usually sufficient for maintaining reduction. Reduction should be tested under an image intensifier in internal and external rotation. If instability is noted, consideration should be given to adding a third lateral pin or using a cross-pin construct

(A, B) Elbow radiographs of 5-year-old boy with ty (A, B) Elbow radiographs of 5-year-old boy with type 2B supracondylar humerus fracture. (C, D) Postoperative radiographs of same patient showing two lateral Kirschner wire (K-wire) configurations. Diverging K-wire configurations are as recommended by Skaggs in 2008.

Three lateral K-wires (see the image below) are usually placed when two are insufficient to control rotational or torsional forces. This construct is biomechanically stronger than a two-pin construct and similar in strength to a cross-pin construct.

(A, B) Elbow radiographs of 7-year-old girl with t (A, B) Elbow radiographs of 7-year-old girl with type 3 supracondylar humerus fracture. (C, D) Intraoperative radiographs of same patient demonstrating reduction and fixation of fracture. Three Kirschner wires (K-wires) were used to stabilize lateral column, and one K-wire was used to stabilize medial column. K-wires were sequentially added to achieve stability of each column in both internal and external rotation screenings.

A cross-pin construct (see the image below) is the biomechanically strongest option. Miniopen or open placement of a medial wire may be required to avoid ulnar nerve injury. A medial pin should be inserted with the elbow in extension.

(A, B) Elbow radiographs of 5-year-old boy with ty (A, B) Elbow radiographs of 5-year-old boy with type 2B supracondylar humerus fracture (SCHF). Type 2B fracture differs from type 2A in that it has additional rotational component. (C, D) Postoperative radiographs of same patient showing cross Kirschner wire (K-wire) configuration in stabilization of SCHF. Intramedullary medial wire placement was done deliberately so as to provide valgus force and counteract any risk of fracture drifting into varus, leading to potential gunstock deformity. Lateral wire was placed to engage medial cortex as shown, for same reason.

Important technical points for fixation with lateral-entry pins include the following:

  • Maximize separation of the pins at the fracture site
  • Engage the medial and lateral columns proximal to the fracture
  • Engage sufficient bone in both the proximal segment and the distal fragment
  • Maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins

Closed reduction

The technique for closed reduction includes the following elements:

  • In-line traction with elbow flexed
  • Correction of coronal plane deformity with varus/valgus stress  
  • Correction of sagittal deformity - Place the elbow in hyperflexion; reduce extension-type fractures by thumbing the distal fragment anteriorly; beware of type 4 fractures that are unstable in flexion and extension
  • Confirmation of reduction by placing the elbow in external rotation - Assess the Baumann angle, and identify the anterior humeral line crossing the middle of the capitellum

Open reduction

For the medial approach, the upper limb is placed in external rotation (the position of stability). A curvilinear incision is made from the supracondylar ridge of the medial epicondyle and passing through the elbow joint. The ulnar nerve is identified proximally between the triceps and the medial intermuscular septum and distally within the tunnel posterior to the medial epicondyle. The medial supracondylar ridge of the humerus and the supracondylar fracture are identified. Any soft tissue within the fracture (eg, brachialis muscle trapped inside) is removed to facilitate reduction. The fracture is reduced under direct vision with the aid of an image intensifier. A medial K-wire is placed in external rotation.

The miniopen medial approach is commonly adopted for placement of a medial K-wire to avoid ulnar nerve injury. A 1- to 2-cm incision is made over the medial epicondyle. Blunt dissection with artery forceps is carried down to bone or cartilage. The K-wire is inserted under direct vision with the use of an image intensifier.

The anteromedial approach is preferred for exploration of the brachial artery in limb ischemia, in the interval between the brachialis and brachioradialis proximally and the brachioradialis and pronator teres distally.

Approach to Pulseless Limb

If perfusion of the hand is normal, the following are recommended[13] :

  • Urgent surgical reduction and fixation
  • Repetition of vascular evaluation intraoperatively - Check for hand perfusion and return of radial pulse; exploration is not indicated with an absent radial pulse in a perfused hand
  • Immobilization, elevation, and overnight monitoring 

if the hand is underperfused or ischemic, the following are recommended[13] :

  • Emergency surgical reduction and fixation within 2 hours to reestablish perfusion
  • Repetition of vascular evaluation intraoperatively
  • Open antecubical exploration in the event of ongoing hand underperfusion in a reduced and stabilized fracture (indicative of vascular injury)
  • In a hospital without vascular surgery coverage or the expertise to perform on-table vascular repair, consideration of transfer to a tertiary facility

Postoperative Care

In the immediate postoperative period, the surgeon should recheck the patient's neurovascular status, keeping in mind that neurapraxia secondary to traction and reduction maneuvers is not uncommon. The most common nerve palsy after manipulation is anterior interosseous nerve palsy. In a study of nerve injuries with displaced SCHFs in children younger than 12 years, Khademolhosseini et al reported 100% recovery with ongoing observation.[12]  Nerve entrapment is rare in the manipulation of pediatric SCHFs.

It is particularly important to check vascular status in cases involving preoperative vascular compromise, limb ischemia, or both.

After the immediate postoperative period, the follow-up protocol for SCHFs is highly variable, depending on patient factors, injury severity, surgeon preference, and local hospital protocol. In most Australian centers, the protocol includes repeat radiography at 1 and 2 weeks after the injury, an immobilization time of 3-4 weeks, and pin removal 3-4 weeks after the procedure, depending on patient age.

As with the initial presentation, both an anteroposterior (AP) and a true lateral radiograph should be obtained for accurate assessment of the fracture and the fixation. Positioning for the AP image in this setting may be hindered by the presence of a cast or collar-and-cuff. The humerus is the area of interest and should be placed on the imaging plate (this will result in distortion of the radius and ulna). The patient may have to stand for this view. Alternatively, a horizontal-beam lateral view can be obtained with the patient sitting and the arm elevated on a radiolucent sponge. Positioning for the lateral projection follows the standard protocol.

Complications

Possible complications after treatment of a pediatric SCHF include the following[1, 10, 3, 11, 6, 21, 20, 18, 19, 9, 8, 17, 12] :

  • Pin-site infection
  • K-wire migration
  • Malunion
  • Cubitus valgus
  • Cubitus varus
  • Recurvatum
  • Nerve palsy (direct injury or traction neurapraxia)
  • Vascular injury - Absent radial pulse (~10% of injuries; most common in type 3 injuries); pulseless hand after CRPP (3%)
  • Volkmann contracture - Rare but significant complication, occurring secondary to brachial artery compression in a hyperflexed elbow during fracture immobilization; after surgery, immobilize arm with elbow at no more than 90º of flexion
  • Postinjury elbow stiffness
  • Repeat operation
  • Physeal injury or arrest due to percutaneous wires crossing physis or multiple passes with wires during operation

Activity

As a general rule, returning to sports or activities (especially contact sports) is appropriate once the fractured elbow has achieved clinical and radiologic union and once the patient has regained full range of motion. In the clinical setting, parents are generally told to wait 8 weeks after the injury before allowing any sports or contact activities.

Consultations

Consultations with vascular surgeons are appropriate in the setting of compromised vascularity or perfusion to the injured limb. Acute arterial injuries necessitating vascular repair, though rare, are possible; when such injuries occur, close consultation with a vascular surgeon is indicated.

Long-Term Monitoring

For pediatric SCHFs that have been promptly diagnosed and treated, long-term monitoring usually is not required past 6 months. In the setting of neurapraxia or nerve palsy, monitoring is required until full function is restored.[12]  In the rare event of vascular injury, further follow-up may be indicated. Physeal arrest secondary to percutaneous wire fixation is extremely rare; however, if this becomes a concern, patients should be followed up for longer durations as appropriate. 

 

Guidelines

Guidelines Summary

Practice Guidelines 

  • Paediatric Supracondylar Humerus fractures are common and significant injuries
  • Serious complications include neurovascular injury, compartment syndrome, malunion and Volkmann contracture
  • Timely diagnosis and proper management can prevent post-injury complications 
  • Diagnosed by AP and true lateral x-rays 
  • Lateral condyle fractures are a differential for supracondylar humerus fractures 
  • Type 1 & 2A fractures may be safely treated non-operatively with compliant patients and parents
  • Type 2B, Type 3 and Flexion type fractures require closed +/- open reduction and percutaneous pin fixation
  • Pulseless and ischaemic limbs require emergency reduction and fixation +/- vascular exploration with vascular surgeons
  • The duration of immobilisation depends on injury severity, age of patient and local hospital protocols
  • Paediatric supracondylar fractures are distinctly different injuries to the adult supracondylar humerus fractures 

These are the two guidelines authors found useful in the diagnosis and treatment of supracondylar humerus fractures. One from the Royal Children’s Hospital in Melbourne Australia, and one published on the American Academy of Orthopaedic Surgeons Guidelines.

  1. Royal Children's Hospital Guideline - Melbourne, Australia[18] http://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Outpatient_fracture_clinics/

  2. American Academy of Orthopaedic Surgeons Guideline[19] https://www.aaos.org/research/guidelines/SupracondylarFracture/Summary_of_Recs.pdf