This document discusses elbow fractures in children, with a focus on supracondylar fractures of the humerus. Key points include: - Supracondylar fractures are the most common elbow fracture in children and often require reduction and percutaneous pinning. - A thorough physical exam is important to assess neurovascular status before and after reduction. - Fractures are classified into Types 1-3 based on displacement. Type 3 fractures have the highest risk of complications. - Reduction techniques vary based on fracture type but often involve closed manipulation and fluoroscopy-guided percutaneous pinning. - Complications can include loss of reduction, compartment syndrome, and neurovascular injury. Careful surgical technique and

1. Supracondylar Fracture of
Humerus

2. Elbow Fractures in Children
• Very common injuries (approximately 65% of
pediatric trauma)
• Radiographic assessment - difficult for non-
orthopaedists, because of the complexity and
variability of the physeal anatomy and development
• A thorough physical examination is essential,
because neurovascular injuries can occur before and
after reduction
• Compartment syndromes are rare with elbow
trauma, but can occur

3. Elbow Fractures
Physical Examination
• Children will usually not move the elbow if a fracture is
present, although this may not be the case for non-displaced
fractures
• Swelling about the elbow is a constant feature, except for
non-displaced fracture
• Complete vascular exam is necessary, especially in
supracondylar fractures
– Doppler may be helpful to document vascular status
• Neurologic exam is essential, as nerve injuries are common
– In most cases, full recovery can be expected

4. Elbow Fractures
Physical Examination
• Neurological exam may be limited by the
child’s ability to cooperate because of age,
pain, or fear.
• Thumb extension – EPL
– Radial – PIN branch
• Thumb flexion – FPL
– Median – AIN branch
• Cross fingers/scissors - Ad/Abductors
– Ulnar

5. Elbow Fractures
Physical Examination
• Always palpate the arm and forearm for signs of
compartment syndrome
• Thorough documentation of all findings is important
– A simple record of “neurovascular status is intact” is
unacceptable (and doesn’t hold up in court…)
– Individual assessment and recording of motor, sensory,
and vascular function is essential

6. Elbow Fractures
Radiographs
• AP and Lateral views are important initial views
– In trauma these views may be less than ideal, because it
can be difficult to position the injured extremity
• Oblique views may be necessary
– Especially for the evaluation of suspected lateral condyle
fractures
• Comparison views frequently obtained by primary
care or ER physicians
– Although these are rarely used by orthopaedists

7. Elbow Fractures
Radiograph Anatomy/Landmarks
• Baumann’s angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes
through the physis of the capitellum
• There is a wide range of normal for
this value
– Can vary with rotation of the radiograph
• In this case, the medial impaction
and varus position reduces Bauman’s
angle
-Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk:
Unter besonderer Berucksichtigung der Spatfolgen. I. Allgemeines
und Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.
-Mohammad. The Baumann angle in supracondylar fractures of the
distal humerus in children. J Pediatr Orthop. 1999;19:65–69.

8. • Anterior Humeral Line
– Drawn along the
anterior humeral
cortex
– Should pass through
the middle of the
capitellum
– Variable in very young
children
-Rogers. Plastic bowing, torus and greenstick supracondylar fractures
of the humerus: radiographic clues to obscure fractures of the elbow
in children. Radiology. 1978;128:145.
-Herman. Relationship of the anterior humeral line to the capitellar
ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.
Elbow Fractures
Radiograph Anatomy/Landmarks

9. • The capitellum is
angulated
anteriorly about
30 degrees.
• The appearance
of the distal
humerus is
similar to a
hockey stick. 30
Elbow Fractures
Radiograph Anatomy/Landmarks

10. • The physis of the
capitellum is
usually wider
posteriorly,
compared to the
anterior portion
of the physis
Wider
Elbow Fractures
Radiograph Anatomy/Landmarks

11. • Radiocapitellar
line should
intersect the
capitellum in all
views
• Make it a habit to
evaluate this line
on every pediatric
elbow film
Elbow Fractures
Radiograph Anatomy/Landmarks

12. Supracondylar Humerus Fractures
• Most common fracture around the elbow in children
– 60 percent of elbow fractures
• 95 percent are extension type injuries
– Produces posterior angulation/displacement of the distal
fragment
• Occurs from a fall on an outstretched hand
– Ligamentous laxity and hyperextension of the elbow are
important mechanical factors
• May be associated with a distal radius or forearm
fractures
Omid. Supracondylar Humeral Fractures in Children. J Bone Joint Surg. 2008;90:1121.

13. Supracondylar Humerus Fractures
Classification
• Type 1
– Non-displaced
• Type 2
– Angulated/displaced fracture
with intact posterior cortex
• Type 3
– Complete displacement, with
no contact between
fragments
Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-

14. Type 1
Non-displaced
• Note the non-
displaced fracture
(Red Arrow)
• Note the posterior
fat pad (Yellow Arrows)
-Skaggs. The posterior fat pad sign in association with occult fracture
of the elbow in children. J Bone Joint Surg Am. 1999;81:1429.
-Bohrer. The fat pad sign following elbow trauma. Its usefulness and
reliability in suspecting “invisible” fractures. Clin Radiol. 1970;21:90.

15. Type 2
Angulated/displaced fracture with intact
posterior cortex

16. • In many cases, the type 2
fractures will be impacted
medially
– Leads to varus angulation
• The varus malposition
must be considered when
reducing these fractures
– Apply a valgus force for
realignment
Type 2
Angulated/displaced fracture with intact
posterior cortex

17. Type 3
Complete displacement, with no contact
between fragments

18. Supracondylar Humerus Fractures
Associated Injuries
• Nerve injury incidence is high, between 7 and 16 %
– Median, radial, and/or ulnar nerve
• Anterior interosseous nerve injury is most commonly injured
nerve
• In many cases, assessment of nerve integrity is limited
– Children can not always cooperate with the exam
• Carefully document pre-manipulation exam,
– Post-manipulation neurologic deficits can alter decision making
Cramer. Incidence of anterior interosseous nerve palsy in
supracondylar humerus fractures in children. J Pediatr Orthop.

19. Supracondylar Humerus Fractures
Associated Injuries
• 5% have associated
distal radius fracture
• Physical exam of distal
forearm
• Radiographs if needed
• If displaced pin radius
also
– Difficult to hold
appropriately in splint

20. Supracondylar Humerus Fractures
Associated Injuries
• Vascular injuries are rare, but pulses should always
be assessed before and after reduction
• In the absence of a radial and/or ulnar pulse, the
fingers may still be well-perfused, because of the
excellent collateral circulation about the elbow
• Doppler device can be used for assessment
White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric
supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.

21. Supracondylar Humerus Fractures
Associated Injuries
• Type 3
supracondylar
fracture
– Absent ulnar and
radial pulses
– Fingers had capillary
refill less than 2
seconds.
• The pink, pulseless
extremity
White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric
supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.

22. Supracondylar Humerus Fractures
Anatomy
• The medial and lateral columns are connected
by a thin wafer of bone
– Approximately 2-3 mm wide in the central portion
• If the fracture is malreduced, it is inherently
unstable
– The medial or lateral columns displace easily into
varus or valgus

23. • Type 1 Fractures
– In most cases, these can be treated with
immobilization for approximately 3 weeks, at 90
degrees of flexion
– If there is significant swelling, do not flex to 90
degrees until the swelling subsides
Supracondylar Humerus Fractures
Treatment

24. Supracondylar Humerus Fractures
Treatment
• Type 2 Fractures: Posterior Angulation
– If minimally displaced (anterior humeral line hits
part of capitellum)
• Immobilization for 3 weeks.
• Close follow-up is necessary to monitor for loss of
reduction
– Displaced (anterior humeral line misses capitellum)
• Reduction may be necessary
• The degree of posterior angulation that requires
reduction is controversial
• Check opposite extremity for hyperextension
– If varus/valgus malalignment exists, most authors
recommend reduction.
Fitzgibbons. Predictors of failure of nonoperative treatment for type-
2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

25. Type 2 Fractures
Treatment
• Reduction of these fractures is usually not difficult
– Maintaining reduction usually requires flexion beyond 90°
• Excessive flexion may not be tolerated because of
swelling
– May require percutaneous pinning to maintain reduction
• Most authors suggest that percutaneous pinning is
the safest form of treatment for many of these
fractures
– Pins maintain the reduction and allow the elbow to be
immobilized in a more extended position
Fitzgibbons. Predictors of failure of nonoperative treatment for type-
2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

26. Supracondylar Humerus Fractures
Treatment
• Type 3 Fractures
– These fractures have a high risk of neurologic and/or
vascular compromise
– Can be associated with a significant amount of swelling
– Current treatment protocols use percutaneous pin fixation
in almost all cases
– In rare cases, open reduction may be necessary
• Especially in cases of vascular disruption

27. Supracondylar Humerus Fractures
OR Setup
• The monitor should be
positioned across
from the OR table, to
allow easy
visualization of the
monitor during the
reduction and pinning
-Thometz. Techniques for direct radiographic visualization during closed pinning
of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.
-Tremains. Radiation exposure with use of the inverted-c-arm technique in
upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.

28. Supracondylar Humerus Fractures
OR Setup
• The C-Arm fluoroscopy unit can be
inverted, using the base as a table
for the elbow joint
– All personnel in the room should be
adequately shielded, as radiation
exposure is significantly increased with
inverted c-arm
• Also can use radiolucent board
• The child should be positioned
close to the edge of the table, to
allow the elbow to be visualized by
the c-arm
– Make sure to secure patient’s head
and body
-Thometz. Techniques for direct radiographic visualization during closed pinning
of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.
-Tremains. Radiation exposure with use of the inverted-c-arm technique in
upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.

29. Supracondylar Elbow Fractures
Type 2 with Varus Malalignment
• During reduction of
medially impacted
fractures, valgus
force should be
applied to address
this deformity.

30. Type 3
Supracondylar Fracture

31. Type 3
Operative Reduction
• Closed reduction with
flexion
• AP view with elbow
held in flexed
position to maintain
reduction.

32. Brachialis Sign
Proximal Fragment Buttonholed through Brachialis

33. Milking Maneuver
Milk Soft Tissues over Proximal Spike
Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a
technique of closed reduction and report of initial results. J Pediatr Orthop. 1997;17:298.

34. Adequate Reduction?
• No varus/valgus
malalignment
• Anterior humeral line
should be intact
• Minimal rotation
• Mild translation is
acceptable
From: Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and
Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins, 2004.

35. Medial Impaction Fracture
Type II fracture with medial impaction – not
recognized and varus / extension not reduced

36. Medial Impaction Fracture
Cubitus varus 2 years later

37. Lateral Pin Placement
AP and Lateral views with 2 pins

38. Pin Configuration
Lee. Displaced pediatric supracondylar humerus fractures: biomechanical
analysis of percutaneous pinning techniques. J Pediatr Orthop.

39. C-arm Views
Oblique views with the C-arm can be useful to help verify the reduction.
Note slight rotation and extension on medial column (right image).

40. Supracondylar Humerus Fractures
Pin Fixation
• Different authors have recommended different pin
fixation methods
• The medial pin can injury the ulnar nerve
– Some advocate 2 or 3 lateral pins to avoid injuring the
median nerve
• Space pins as widely as possible
– If the lateral pins are placed close together at the fracture
site, the pins may not provide much resistance to rotation
and further displacement
• Some recommend one lateral, and one medial pin
Sankar. Loss of pin fixation in displaced supracondylar humeral fractures
in children: causes and prevention. J Bone Joint Surg Am. 2007;89:713.

41. Pitfalls of Pin Placement
• Pins Too Close
together
• Instability
• Fracture
displacement
• Get one pin in lateral
and one in medial
column

42. Supracondylar Humerus Fractures
Pin Fixation
• Even many children have anterior subluxation
of the ulnar nerve with hyperflexion of the
elbow
• Some recommend place two lateral pins,
assess fracture stability
• If unstable then extend elbow to take tension
off ulnar nerve and place medial pin
Eberl. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing
of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606.

43. Supracondylar Humerus Fractures
• After stable reduction and pinning
– Elbow can be extended to review the AP radiograph
– Baumann’s angle can be assessed on these radiographs
• Remember there can be a wide range of normal values for this
measurement
• With the elbow extended, the carrying angle of the
elbow should be reviewed, and clinical comparison
as well as radiograph comparison can be performed
to assure an adequate reduction.

44. Supracondylar Humerus Fractures
• If pin fixation is used, the pins are
usually bent and cut outside the
skin
• The skin is protected from the
pins by placing Xeroform and a
felt pad around the pins
• The arm is immobilized
• The pins are removed in the clinic
3 to 4 weeks later
– After radiographs show periosteal
healing
• In most cases, full recovery of
motion can be expected

45. Supracondylar Humerus Fractures:
Indications for Open Reduction
• Inadequate reduction
with closed methods
• Vascular injury
• Open fractures

46. Supracondylar Humerus Fractures:
Complications
• Compartment syndrome
• Vascular injury/compromise
• Loss of reduction/malunion
– Cubitus varus
• Loss of motion
• Pin track infection
• Neurovascular injury with
pin placement
Bashyal. Complications after pinning of supracondylar
distal humerus fractures. J Pediatr Orthop.

47. Supracondylar Humerus Fractures
Flexion type
• Rare, only 2%
• Distal fracture fragment anterior
and flexed
• Ulnar nerve injury more
common
• Reduce with extension
• Often requires 2 sets of hands in
OF
– Hold elbow at 90 degrees after
reduction to facilitate pinning
Mahan. Operative management of displaced flexion supracondylar
humerus fractures in children. J Pediatr Orthop. 2007;27:551.

48. Flexion Type

49. Flexion Type
Pinning