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Supracondylar humeral fractures in children

Supracondylar humeral fractures in children
Literature review current through: Sep 2023.
This topic last updated: Jan 18, 2023.

INTRODUCTION — This topic will discuss the evaluation and treatment of supracondylar fractures in children. Other distal humeral fractures are discussed separately. (See "Evaluation and management of condylar elbow fractures in children" and "Epicondylar and transphyseal elbow fractures in children".)

EPIDEMIOLOGY — Supracondylar humeral fractures account for up to 60 percent of pediatric elbow fractures [1]. They occur most frequently in children between two and seven years of age [2]. Supracondylar fractures result from a fall on an outstretched arm in up to 70 percent of patients [3]. The nondominant extremity is most commonly affected. Children under three years of age typically sustain a supracondylar fracture after a fall from a height of less than three feet (eg, fall from a bed or couch). Most fractures in older children result from higher falls from playground equipment (eg, monkey bars, swings) or other high energy mechanisms [4].

PERTINENT ANATOMY — For children with supracondylar fractures, important aspects of elbow anatomy include:

Bone – The elbow is a complex hinge joint composed of three separate articulations (figure 1):

Ulnohumeral joint

Radiohumeral joint

Radioulnar joint

In children, the supracondylar region encompasses an area of thin, weak bone located in the distal humerus. This region is bordered posteriorly by the olecranon fossa and anteriorly by the coronoid fossa (figure 2). The medial and lateral aspects of the supracondylar region extend distally to the developing medial and lateral condyles and epicondyles.

When a child falls onto an outstretched arm with the elbow in hyperextension, the force of the fall is transmitted through the olecranon to the weak supracondylar region, causing a supracondylar fracture. Depending on the severity of the fracture, posterior displacement of the distal fracture fragment and anterior displacement of the proximal fracture fragment may occur (figure 3). The fracture line typically propagates transversely across the distal humerus through the center of the olecranon fossa (image 1). (See 'Classification' below.)

Blood vessels – The brachial artery is superficial to the brachialis muscle along the anteromedial aspect of the humerus. As the brachial artery passes anterior to the distal humerus, an extensive collateral circulation develops. As the artery extends into the forearm, it splits into the radial and ulnar artery (figure 4).

In patients with posterolateral displacement of the distal fragment of a supracondylar fracture, the brachial artery may be injured when the proximal fragment of the fractured humerus moves medially, piercing the brachialis muscle and reaching the brachial artery (figure 5). In addition, the brachial artery may be tethered to the sharp edge of the proximal fracture fragment by the supratrochlear branch of the anterior ulnar recurrent artery, thereby increasing the risk of brachial artery injury during movement of the injured arm or fracture manipulation (figure 6).

"Scraping" of the brachial artery by the bony fragment may result in intimal damage to the vessel. This injury may subsequently lead to thrombosis and vascular insufficiency. Because of the extensive collateral circulation present at the elbow, it is rare for ischemia of the arm to occur from complete brachial artery occlusion [5]. Median nerve injury often accompanies brachial artery injury.

Nerves – Following a displaced supracondylar fracture, the median (including the anterior interosseous nerve branch), radial, and ulnar nerves are at potential risk for injury (figure 4). The majority of nerve injuries are neurapraxias, where there is temporary loss of nerve function (especially motor function) without anatomic disruption of the nerve [6].

The median nerve crosses the elbow joint with the brachial artery. Posterolateral distal fracture fragment displacement with medial movement of the proximal fracture fragment puts the median nerve and its anterior interosseous nerve branch at the greatest risk of injury (figure 5).

Median nerve injury results in weakness of the flexor muscles of the fingers and loss of two-point sensation on the palmar surface of the thumb and the index and middle fingers [7]. The anterior interosseous nerve (AIN) is the motor branch of the median nerve that is most commonly injured (figure 4) [6-9]. The AIN lacks a superficial sensory component [7,9]. Children and adolescents with AIN syndrome initially have proximal forearm pain followed by weakness in the hand with no sensory deficits. On physical examination, they have a weak "OK" sign and/or a lack of distal interphalangeal flexion at the thumb and index finger when making an "OK" sign (picture 1). (See 'Complications' below.)

The radial nerve runs between the brachialis and brachioradialis muscles before crossing the elbow and penetrating the supinator muscle. Posteromedial distal fracture fragment displacement increases the chance of radial nerve impingement because of posterolateral proximal fracture fragment displacement (figure 5) [6,10]. Injury to the radial nerve results in weakness of wrist extension, hand supination, and thumb extension. In addition, altered sensation is found in the dorsal web space between the thumb and index finger.

The ulnar nerve crosses the elbow posterior to the medial epicondyle and is typically not affected with extension type supracondylar fractures. However, it is prone to injury following flexion type supracondylar fractures (figure 7) [6]. Ulnar nerve injury causes weakness of wrist flexion and adduction, finger spread, and flexion of the distal phalanx of the fifth digit (pinky or little finger). These motor findings are accompanied by altered sensation of the ulnar side of the ring (fourth digit) and little fingers.

MECHANISM OF INJURY — In general, fractures of the distal humerus are most commonly due to a fall on an outstretched hand (FOOSH) or direct trauma to the elbow [3]. (See 'Epidemiology' above.)

Extension and flexion are the two major types of supracondylar fracture and each has a characteristic mechanism of injury [9].

Supracondylar extension fractures – Extension fractures account for 97 to 99 percent of supracondylar fractures and typically result from a FOOSH mechanism with the elbow hyperextended (figure 5) [9].

Supracondylar flexion fractures – Supracondylar flexion fractures account for 1 to 3 percent of supracondylar fractures [9,11]. In contrast to extension injuries, these fractures result from a direct blow to the posterior aspect of the flexed elbow. In these cases, the distal condylar complex is more likely to displace in the anterolateral direction (figure 7) and may entrap the ulnar nerve in a significant proportion of patients [9,12,13].

CLINICAL PRESENTATION — The child with a supracondylar fracture typically has elbow pain, swelling, and very limited to no range of motion at the elbow after a fall on an outstretched arm [5]. The clinician must rapidly assess the injury to identify degree of fracture displacement as well as signs of neurovascular compromise and acute compartment syndrome. (See 'Approach' below.)

INITIAL STABILIZATION

Approach — Most supracondylar fractures result from low-force mechanisms and are not associated with multiple trauma. However, children who fall from a height greater than three times their standing height or 10 feet, whichever is less, are at increased risk for multiple trauma to the head, thorax, and abdomen and may warrant, in addition to a complete physical examination, appropriate ancillary studies. (See "Approach to the initially stable child with blunt or penetrating injury", section on 'Blunt trauma' and "Trauma management: Approach to the unstable child", section on 'Initial approach'.)

An approach to stabilization of children with suspected supracondylar fractures includes:

Initial assessment – Inspect the affected arm to determine severity of the fracture (eg, marked deformity and swelling [displaced] or localized tenderness with intact landmarks [not displaced]) and do a rapid neurovascular assessment. (See 'Inspection and neurovascular examination' below.)

Analgesia – Provide analgesia according to degree of pain (see 'Analgesia' below):

Severe pain (typically associated with deformity and significant swelling) – Opioids (eg, intranasal fentanyl or intravenous morphine)

Mild to moderate pain (typically associated with no deformity and mild swelling) – Ibuprofen

Upper extremity examination – Once pain is controlled, perform a complete examination of the affected arm in a manner that prevents excess movement of the elbow. Identify injuries to adjacent bones or joints. (See 'Upper extremity examination' below.)

Immobilization – Based upon findings, determine the type of immobilization needed prior to radiographs (see 'Immobilization' below). The clinician should not permit active or passive elbow movement in a patient with a suspected supracondylar fracture until a displaced fracture has been excluded by radiography.

Pediatric orthopedic consultation – For patients with the rare findings of an absent distal radial pulse or acute compartment syndrome, obtain emergency pediatric orthopedic consultation while radiographs are obtained. (See 'Orthopedic consultation' below.)

Obtain radiographs – Obtain antero-posterior (AP) and true lateral views of the elbow with the humerus in anatomic position (image 2). Radiographs of shoulder, clavicle, forearm, and/or wrist may also be indicated if examination suggests a fracture in these regions. (See 'Diagnostic imaging' below.)

Management – Provide initial acute management of limb-threatening emergencies, as needed. (See 'Acute management' below.)

Inspection and neurovascular examination — The clinician should carefully inspect the arm for findings indicating unstable, displaced fractures:

Arm deformity, swelling, and bruising – Unstable, displaced supracondylar fractures (Gartland type III fractures) typically have marked swelling and may have an "S-shaped" configuration (image 3 and image 4). Ecchymosis over the anterior or anteromedial aspect of the forearm suggests brachial artery injury; anteromedial bruising is associated with median nerve injury, and anterolateral bruising is associated with radial nerve injury [5,14].

Puckering of the skin in the antecubital fossa – Puckering (figure 8) indicates the proximal humeral fracture fragment has perforated the brachialis muscle and may have injured the brachial artery and/or median nerve.

During inspection, a complete neurovascular evaluation includes an assessment of radial and brachial pulses and the sensory and motor function of the median, radial, and ulnar nerves [9]. Patients with a normal initial neurovascular examination warrant regular repeated evaluation, especially immediately following splinting, fracture manipulation, or movement of the affected extremity.

Pulse — The clinician should compare the radial and brachial pulse with the opposite limb. Initially symmetric and equal pulses with normal perfusion and skin warmth are reassuring but do not entirely exclude vascular injury. However, patients who maintain normal pulse and perfusion over time are unlikely to have a brachial artery injury.

If a radial or brachial pulse is not palpable, a Doppler ultrasound should be used to determine the presence of distal perfusion. For patients who have a wave form and oxygen saturation reading, pulse oximetry can also provide continuous information on distal extremity perfusion (eg, presence of pulsatile flow and oxygenation). These patients also require emergency pediatric orthopedic consultation. (See 'Vascular injury' below.)

Perfusion — Brisk capillary refill, normal color, and a warm hand indicate the presence of some distal perfusion, even when distal pulses are diminished or absent. Maintenance of perfusion despite abnormal pulses often arises from brachial artery spasm that typically resolves after urgent closed reduction and percutaneous pinning.

However, diminished or absent pulses in association with poor distal perfusion, pallor, and a cool hand are concerning signs of ischemia, especially in association with pain upon passive extension of the fingers. Patients with these findings warrant emergency intervention to reestablish limb perfusion. (See 'Upper extremity examination' below and 'Absent pulse' below.)

Neurologic function — The clinician should evaluate the sensory and motor function of the median, radial, and ulnar nerves while minimizing patient discomfort and arm movement (table 1). In a patient with an extremely painful injury, analgesia (eg, intranasal or intravenous fentanyl or intravenous morphine) prior to examination may be necessary to enable the child to cooperate with the examination.

The following tests establish motor function of the major nerves with minimal extremity movements (see 'Pertinent anatomy' above):

Anterior interosseous nerve (branch of median nerve) and radial nerve – "OK" sign (alternatively, ask the patient to pinch your hand) (picture 1) [6,7]

Ulnar nerve – Finger spread against resistance or holding a piece of paper firmly between the middle and ring fingers (figure 9)

Radial nerve – Thumb's up sign (figure 10)

The clinician should perform testing of two-point discrimination (ie, the ability to recognize two points five millimeters apart applied simultaneously to the skin as distinct from a single point) on the following sites to evaluate peripheral nerve sensation:

Dorsal web space between thumb and forefinger – Radial nerve

Palmar index (pointer) finger – Median nerve

Pinky (or little finger) – Ulnar nerve

Although nerve injuries may rarely be associated with long-term sequelae, the majority are neurapraxias, (ie, temporary loss of nerve function [especially motor function]) without anatomical nerve disruption [6,7,9].

Analgesia — For children with adequate distal circulation and no sign of compartment syndrome, initial therapy consists of pain management and immobilization to prevent further distraction of the fracture [15]. Opioid analgesia (eg, intranasal fentanyl or intravenous morphine) is most appropriate for initial pain control in patients with severe pain and should be given prior to radiographic evaluation. Oral analgesia (eg, ibuprofen) typically suffices for patients who have suffered a nondisplaced supracondylar fracture and have mild to moderate pain. In most circumstances, pain relief will result in an improved ability to assess neurovascular status in the apprehensive child.

Upper extremity examination — After pain is controlled, the clinician should carefully examine the upper extremity. Do not perform passive range of motion of the elbow. For patients with deformity, use an assistant to stabilize proximal and distal to the elbow joint while restricting medial or lateral movement of the forearm relative to the humerus during the examination.

Important findings include:

Open wounds - Open supracondylar fractures often manifest as a puncture wound or laceration in or just above the antecubital region. During inspection, limit movement of the arm as much as possible. In patients transferred by ambulance or from another hospital, this task often requires careful removal of previously applied immobilization devices.

Children with open supracondylar fractures more commonly have neurovascular injury and an associated forearm fracture [16].

Distal posterior humeral tenderness – Nondisplaced fractures may have minimal swelling, but the child will not use the affected arm normally. These patients usually have tenderness on palpation of the posterior distal humerus.

Associated injuries – Fractures of the forearm, clavicle, proximal humerus, and wrist can be associated with supracondylar fractures in children [17]. Thus, the humerus, clavicle, forearm, and wrist warrant careful examination for swelling and/or deformity and palpation for bony tenderness. Plain radiographs are obtained for regions with positive findings, as described separately:

Forearm (see "Proximal fractures of the forearm in children" and "Midshaft forearm fractures in children", section on 'Radiographic findings' and "Distal forearm fractures in children: Diagnosis and assessment", section on 'Imaging')

Clavicle (see "Clavicle fractures")

Proximal humerus (see "Proximal humeral fractures in children")

Wrist (see "Overview of acute wrist injuries in children and adolescents", section on 'Carpal fractures')

Signs of compartment syndrome – Signs of compartment syndrome include (see "Acute compartment syndrome of the extremities", section on 'Clinical features'):

Excessive swelling and ecchymosis at the elbow [15]

Increasing forearm pain

Increased pain upon passive extension of the fingers

All of the above and a cold hand with poor perfusion, pallor, and diminished or absent pulse (late finding)

Patients with signs of acute compartment syndrome require emergency pediatric orthopedic consultation. Emergency management of acute compartment syndrome is summarized in the rapid overview (table 2) and below. (See 'Acute compartment syndrome' below.)

Immobilization — Immobilization is particularly important prior to radiographs in children with significantly deformed fractures (image 3 and image 4) to prevent further injury to neurovascular structures (see 'Pertinent anatomy' above). In this situation, use an assistant to stabilize proximal and distal to the elbow joint while restricting medial or lateral movement of the forearm relative to the humerus. The arm should be splinted "as it lies" (typically with elbow flexed 20 to 30 degrees) using prefabricated splinting material or eight layers of plaster with under cast padding (eg, Webril). A loosely applied elastic bandage (eg, Ace wrap) holds the splint in place. (See "Basic techniques for splinting of musculoskeletal injuries".)

Distal neurovascular status should be checked before and after splinting. If any new decrease in pulse or neurologic deficit is found after immobilization, then the splinting material should be removed, the arm position adjusted, and the splint reapplied. (See 'Absent pulse' below and 'Diagnostic imaging' below.)

DIAGNOSIS

Clinical suspicion — The clinician should suspect the diagnosis of a supracondylar fracture in children (typically 2 to 7 years of age) with swelling and/or pain at the distal humerus with inability to move the arm or significantly limited range of motion after a fall on an outstretched hand. Plain radiographs of the elbow will confirm the diagnosis.

Diagnostic imaging — Radiographic diagnosis of a supracondylar fracture requires antero-posterior (AP) and true lateral views of the elbow with the humerus in anatomic position (image 2). Because of the association of supracondylar fractures with forearm fractures, AP and lateral radiographs of the forearm are warranted in patients with clinical findings suggestive of fracture to these areas. Proximal humerus and clavicle radiographs may also be necessary depending on the patient's physical findings. (See 'Associated fractures' below.)

Appropriate analgesia should be provided before extremity radiographs are obtained (see 'Analgesia' above). When obtaining radiographs in the child with a supracondylar fracture, the goal is to obtain the necessary films with minimal movement of the extremity (figure 11). Excessive manipulation of the extremity during radiologic procedures may further exacerbate or precipitate neurovascular injury, especially in patients with type II or type III supracondylar fractures.

In patients with evidence of severe fracture (S-shape configuration or pucker sign, (image 3 and figure 8)), splinting is advisable prior to obtaining radiographs. Alternatively, the clinician and an assistant may accompany the patient and assist with positioning of the deformed extremity while ensuring neurovascular status does not deteriorate. (See 'Immobilization' above.)

In patients with a suspected nondisplaced supracondylar humerus fracture (limited swelling and no obvious deformity), a sling typically provides adequate support while obtaining radiographs.

Ultrasound with Doppler flow should be performed in children with evidence of vascular injury (eg, decreased or absent radial pulse) [18]. (See 'Absent pulse' below.)

Classification — Extension type supracondylar fractures may be further classified according to the modified Gartland classification system [9]:

Type I – Gartland type I supracondylar fracture describes a nondisplaced or minimally displaced (<2 mm) fracture with radiographic evidence of elbow effusion (posterior fat pad sign). Because the anterior and posterior periosteum remains intact, the anterior humeral line transects the middle third of the capitellum (image 5). (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Fat pads'.)

Type II – Gartland type II supracondylar fracture refers to a displaced (>2 mm) fracture with an intact posterior periosteum. Unlike Gartland type I fractures, the anterior humeral line is displaced anteriorly, either hitting the anterior third of the capitellum or missing it entirely, indicating posterior displacement of the distal humeral fracture. In most children, the fracture line is clearly seen and "hinging" of the posterior periosteum and posterior displacement of the distal fracture fragment may occur (image 6). Type II fractures may be further classified as IIA (no rotation or translation (image 6)) or IIB (with rotation or translation (image 7)). (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Anterior humeral line'.)

Type III – Gartland type III supracondylar fracture is a completely displaced fracture with disrupted anterior and posterior periosteum. This injury results in no continuity between the proximal and distal fracture fragments (image 3 and image 4). Type III fractures demonstrate displacement of the distal fragment in two primary directions: posterolateral (the most common pattern) or posteromedial. Posterolateral displacement may tether and damage the brachial artery and median nerve; posterolateral displacement may tether and damage the radial nerve (figure 5) [15]. (See 'Pertinent anatomy' above.)

Type IV – The distinction between a Gartland Type III and IV is not made by plain radiographs alone. A Gartland type IV supracondylar fracture is completely displaced (type III supracondylar fracture) and noted intraoperatively to have multiplanar instability caused by a completely disrupted periosteum.

Associated fractures — Supracondylar fractures are associated with forearm or distal radius fractures in up to 5 percent of cases [19,20]. The combination of supracondylar and forearm fractures increases the possibility of compartment syndrome [5,19,21]. Clinicians should have a low threshold to also obtain radiographs of the forearm in patients with supracondylar fractures, especially if there is a concern of this associated fracture on clinical examination or a complete examination is not possible (eg, younger child) [22]. (See "Proximal fractures of the forearm in children" and "Midshaft forearm fractures in children", section on 'Radiographic findings' and "Distal forearm fractures in children: Diagnosis and assessment", section on 'Imaging'.)

Proximal humerus, clavicle, and wrist fractures may also occur with a supracondylar fracture. Deformity and/or bony tenderness during physical examination dictate appropriate radiographic assessment of these areas in selected patients (table 3 and image 8 and image 9), as described separately:

Clavicle (see "Clavicle fractures")

Proximal humerus (see "Proximal humeral fractures in children")

Radius and ulna (image 8 and image 9)

Wrist (see "Overview of acute wrist injuries in children and adolescents", section on 'Carpal fractures')

DIFFERENTIAL DIAGNOSIS — In most children, the diagnosis of a supracondylar humeral fracture is straightforward and distinguished from other serious arm injuries (ie, other types of distal humeral fractures, proximal forearm fractures, or elbow dislocation) based upon physical findings and plain radiographs, as described in greater detail separately:

(See "Evaluation and management of condylar elbow fractures in children" and "Epicondylar and transphyseal elbow fractures in children".)

(See "Proximal fractures of the forearm in children".)

(See "Elbow injuries in active children or skeletally immature adolescents: Approach", section on 'Posterior elbow dislocation'.)

In children under five years old, radial head subluxation (pulled elbow) may present with no history and a limited range of motion at the elbow on examination that may appear similar to a child with a nondisplaced (Gartland type I) supracondylar fracture. However, the child with radial head subluxation will have absence of bony tenderness over the posterior humerus and, if obtained, radiographs that do not demonstrate a posterior fat pad or cortical disruption. (See "Radial head subluxation (pulled elbow): Evaluation and management".)

ORTHOPEDIC CONSULTATION — Prompt orthopedic consultation should be obtained in any of the following circumstances:

Type II or type III supracondylar fracture

Open supracondylar fracture

Fracture with neurovascular compromise (emergency orthopedic consultation while radiographs are being obtained)

Supracondylar fracture with evidence of acute compartment syndrome (emergency consultation while radiographs are being obtained)

ACUTE MANAGEMENT

Absent pulse — The emergency clinician should rapidly identify children with vascular insufficiency and obtain an emergency consult with an orthopedic surgeon with appropriate pediatric expertise. Rarely, these children will require partial closed reduction in the emergency department in an attempt to restore distal circulation prior to closed or open reduction and stabilization in the operating room (figure 12) [22,23]. Patients who display a cold, white, or cyanotic hand despite operative reduction and fixation warrant operative exploration of the brachial artery and vascular repair. (See 'Vascular injury' below.)

Open fracture — Open fractures are at risk of developing osteomyelitis. Initial treatment includes irrigation, prophylactic antibiotics in selected patients, and tetanus immunization as indicated (table 4). The management of open fractures and related issues are reviewed separately. (See "General principles of fracture management: Early and late complications", section on 'Open fractures'.)

Acute compartment syndrome — Although rare, acute compartment syndrome may occur prior to or after definitive orthopedic care of supracondylar fractures [4,24]. It is more common in children with supracondylar fracture who also have a forearm fracture (sometimes called a "floating elbow"). It is suspected based upon severe and difficult to control pain associated with increased swelling and ecchymosis at the elbow. Distal pallor and loss of pulses are late findings. (See 'Upper extremity examination' above.)

Suspected compartment syndrome requires emergency consultation with an orthopedic surgeon with pediatric expertise. Any dressing, splint, cast, or other restrictive covering should be removed. The limb should not be elevated; elevation can diminish arterial inflow and exacerbate ischemia. Analgesics should be given. (See 'Upper extremity examination' above and "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures'.)

Once confirmed by compartment pressure measurement or by clinical examination by an orthopedic surgeon, definitive treatment consists of fracture alignment and fasciotomy to decompress all involved compartments (table 2). (See "Acute compartment syndrome of the extremities", section on 'Management'.)

If a compartment syndrome is not treated in a timely manner, the associated ischemia and infarction in the forearm flexor muscles may progress to Volkmann ischemic contracture. (See "Pathophysiology, classification, and causes of acute extremity compartment syndrome", section on 'Upper extremity (Volkmann contracture)'.)

DEFINITIVE CARE — For extension-type supracondylar fractures, definitive care is determined by the degree of displacement on plain radiographs.

Gartland type I fracture (nondisplaced) — For patients with a nondisplaced Type I fracture (image 5), we suggest immobilization with a posterior splint and sling rather than a collar and cuff because of limited evidence suggesting better pain control and earlier return to normal activities while immobilized during the first week [25]. If a posterior splint is placed, it should extend from the wrist to the axilla, with the elbow at 90 degrees of flexion and the forearm in neutral position with respect to supination and pronation [25,26].

Posterior splinting is probably sufficient for most children with type I supracondylar fractures [27]. If performed, circumferential casting and extremes of flexion should be initially avoided in most cases to decrease the incidence of compartment syndrome and vascular compromise [28].

Children with nondisplaced or minimally displaced (<2 mm) fractures (eg, Gartland type I fractures) do not require urgent orthopedic evaluation. After splinting, these patients may be referred for follow up within seven days of the injury. The family should be instructed to return immediately for signs of unmanageable pain or compartment syndrome. (See 'Upper extremity examination' above and 'Classification' above.)

The typical duration of immobilization for nondisplaced type I supracondylar fractures is three weeks [29].

Gartland type II, III and IV fractures (displaced) — Gartland type II (image 7 and image 6), III, and IV fractures (image 3 and image 4) require urgent orthopedic consultation for surgical intervention (closed versus open reduction with percutaneous pin placement) [5,15]. For Gartland type II fractures, most pediatric orthopedists now recommend closed reduction and percutaneous pin fixation [5].

After surgery, depending on fracture pattern and initial neurovascular status, children may be monitored in the hospital for postoperative neurovascular function or discharged to home [30]. Most children with Gartland type III fractures undergo hospital admission for monitoring of pulses, nerve function, and forearm compartments. After hospital discharge, the patient is maintained in a splint or cast with percutaneous pins. Repeat radiographs are obtained on a regular basis to assess bone healing. Pins are removed when the distal humerus is no longer tender, usually in three to four weeks [5].

After pin and cast removal, motion exercises may be recommended as tolerated. Studies of children with displaced supracondylar fractures and no neurovascular deficit suggest that formal physical therapy does not appear to improve long-term mobility [31]. However, physical therapy is recommended for children with persistent contractures after three to four months or nerve deficits.

Vascular injury — Absence of the radial pulse is reported in 6 to 20 percent of all supracondylar fractures [32,33]. Vascular injury is most common with type II, III, and IV supracondylar fractures (figure 5) [34]. The approach to these patients depends upon distal perfusion:

Perfused, pulseless hand – Patients who are pulseless but have distal perfusion with a warm hand do well with timely orthopedic consultation and operative fracture reduction and fixation [35,36]. For these patients, vascular surgery is usually not needed [37,38].

Pale, pulseless, and cold hand – Patients who are pulseless and have poor distal perfusion (pale and cold hand) and do not have significant improvement in pulse or Doppler pulse after operative reduction and fixation warrant emergency vascular exploration, especially if intractable pain suggestive of ischemia is present [18,34,35,39,40]. These patients frequently have a brachial artery thrombus or entrapment and occlusion of the brachial artery and median nerve within the fracture site [34,39].

COMPLICATIONS — Long-term complications of supracondylar fractures include:

Neurologic deficit – The frequency of neurologic deficit after supracondylar fractures is 10 to 20 percent. In some series of children with type III extension-type supracondylar fractures, up to 49 percent have a neurologic deficit (figure 5) [4,10,33,41,42]. High risk of ulnar nerve injury also occurs with flexion-type supracondylar fractures (figure 7) [8,41,42].

Although nerve injuries may be associated with long-term sequelae, the majority are neurapraxias that will resolve within two to three months [6,41,43]. Surgical exploration should be considered for nerve deficits that persist beyond three months [5,10,31].

Cubitus varus deformity — Angular deformity (cubitus varus or "gunstock" deformity) is a long-term complication of a supracondylar humeral fracture (figure 13). In contrast to the proximal humeral physis, the distal humerus physis contributes little (15 to 20 percent) to the overall longitudinal growth of the humerus [44]. Thus, remodeling and correction of fracture angulation is limited for children with supracondylar humeral fractures.

Modern surgical techniques (eg, closed reduction with percutaneous pinning) have reduced the frequency of cubitus varus from 58 to approximately 3 percent of children treated for supracondylar fractures [3]. Cubitus varus deformity is mainly cosmetic, and function is usually preserved [1]. However, it is rarely associated with an ulnar nerve palsy that may present many years after the original fracture [45].

Cubitus valgus deformity – Cubitus valgus deformity is much less common than cubitus varus deformity but is similar in typically presenting more of a cosmetic than functional problem; ulnar nerve palsy may also occur [46].

Fishtail deformity — Fishtail deformities refer to the appearance of the distal humerus after fracture healing that is complicated by lateral trochlear avascular necrosis [47]. Patients typically present years after the initial injury with elbow pain. Associated abnormalities include elbow joint space narrowing, synovitis, osteophytes, and radial head subluxation. Fishtail deformities are most common after supracondylar fractures but may also occur after condylar fractures (image 10). (See "Evaluation and management of condylar elbow fractures in children", section on 'Complications'.)

OUTCOMES — Small observational studies suggest that, when managed by experienced pediatric orthopedic surgeons, the prognosis for long-term outcome and function is generally good for children with extension-type supracondylar fractures [48,49]. Many of the associated complications either are self-limited or amenable to functional repair with surgical intervention. (See 'Complications' above.)

For instance, vascular insufficiency often resolves after orthopedic alignment with percutaneous pinning. Similarly, nerve injury typically results from neurapraxia (ie, temporary nerve dysfunction) that resolves without long-term effects [6,43,50]. In addition, joint stiffness may also be treated surgically in most cases [15,51].

However, up to 25 percent of children with Gartland type II or III fractures may have problems with chronic pain, ulnar nerve sensitivity, and/or decreased grip strength [48].

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of definitive fracture management".)

(See "General principles of acute fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Elbow fracture (The Basics)" and "Patient education: How to care for your child's cast (The Basics)")

Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Mechanism of injury – In children, the supracondylar humeral region is an area of thin, weak bone located in the distal humerus (figure 2). Fracture in this region is common after a fall on an outstretched hand (extension-type supracondylar fracture) and may cause injury to the median nerve and the brachial artery (figure 4 and figure 5 and figure 6). Flexion-type supracondylar fractures occur after a direct blow to the posterior elbow (figure 7). They are much less common and associated with ulnar nerve entrapment. (See 'Pertinent anatomy' above and 'Mechanism of injury' above.)

Clinical presentation and initial stabilization – The child with a supracondylar fracture presents with elbow pain, swelling, and very limited to no range of motion. The approach to these injuries includes (see 'Approach' above):

Rapidly assess the degree of swelling and deformity and evidence of neurovascular injury. (See 'Inspection and neurovascular examination' above.)

Provide pain control (eg, intranasal fentanyl or intravenous morphine for severe pain; oral ibuprofen for mild to moderate pain) prior to full upper extremity examination. (See 'Analgesia' above.)

Perform a full upper extremity examination with attention to diminished or absent pulse, neurologic deficit, signs of acute compartment syndrome, open wounds, and signs of associated fractures. (See 'Upper extremity examination' above.)

Provide immobilization based upon clinical findings. Children with signs of unstable fractures such as children with marked elbow deformity and swelling (image 3 and image 4) or puckering of skin in the antecubital fossa (figure 8) have a higher frequency of brachial artery and/or median nerve injury. For these patients, splinting the arm "as it lies" while restricting arm motion as much as possible is advisable prior to obtaining radiographs. Distal neurovascular status should be checked before and after splinting. (See 'Immobilization' above.)

Obtain plain radiographs of the elbow and adjacent regions based upon physical findings, as described below.

Acute management – Children with signs of vascular insufficiency or acute compartment syndrome require emergency consultation with a pediatric orthopedist; acute management includes:

Absent pulse – For patients with an absent radial pulse, the presence or absence of residual arterial flow distal to the fracture should be determined by clinical findings (eg, warm and pink hand versus cold, pale or cyanotic hand). Continuous pulse oximetry, and Doppler ultrasound of the brachial artery supplement the clinical signs. Emergency reduction of the fracture with fixation frequently restores circulation. A persistent cold, pale, or cyanotic hand despite operative reduction and fixation warrants emergency vascular exploration. (See 'Absent pulse' above and 'Vascular injury' above.)

Acute compartment syndrome – Children with supracondylar fractures may present with or develop acute compartment syndrome during their evaluation; patients with a concomitant forearm fracture are at heightened risk. The evaluation and management of an acute compartment syndrome is provided in the rapid overview (table 2). Immediate management includes removing all splints or occlusive dressings and ensuring that the arm is positioned in a neutral position at or below the level of the heart.

Open fractures – Initial treatment includes irrigation, antibiotics in selected patients, and tetanus immunization as indicated (table 4). The management of open fractures and related issues are reviewed separately. (See "General principles of fracture management: Early and late complications", section on 'Open fractures'.)

Diagnosis – Radiographic diagnosis of a supracondylar humeral fracture requires antero-posterior (AP) and true lateral views of the elbow with the humerus in anatomic position (image 2). These should be obtained with minimal movement of the extremity (figure 11). Appropriate analgesia should be provided before extremity radiographs are obtained. (See 'Diagnostic imaging' above and "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Plain radiograph interpretation'.)

Clinicians should have a low threshold to also obtain radiographs of the forearm in patients with supracondylar fractures, especially if there is a concern of an associated fracture on clinical examination or a complete examination is not possible (eg, younger child). Radiographs of the proximal humerus, clavicle, and wrist are also indicated in patients with signs of fracture (eg, bony tenderness, swelling, and limitation of motion) in these regions. (See 'Associated fractures' above.)

Definitive management – Definitive management is determined by radiographic findings (see 'Classification' above and 'Definitive care' above):

Gartland type I fracture (nondisplaced) – For patients with nondisplaced Gartland Type I fractures (image 5), we suggest immobilization with a posterior splint and sling rather than a collar and cuff (Grade 2B). These children can be referred for orthopedic follow-up in seven days and do not require urgent orthopedic evaluation.

Gartland type II, III, and IV fractures (displaced) – Gartland type II (image 7 and image 6), III and IV fractures (image 3 and image 4) require urgent orthopedic consultation and are often treated with operative reduction and fixation.

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References

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