This document provides information on supracondylar humerus fractures in children. It describes the anatomy of the distal humerus that makes these fractures common. The typical mechanism of injury is a fall onto an outstretched hand, causing hyperextension of the elbow. Complications can include vascular injury, nerve palsy, and ipsilateral radius fracture. Treatment involves closed or open reduction based on the fracture classification and presence of complications. Pinning techniques are described to stabilize the reduction. Potential postoperative complications are also outlined.

1. S U P R A C O N D Y L A R H U M E R U S
F R A C T U R E
Noorhuda Abdul Mutalif

2. • This is the most common elbow fracture. They are responsible for 50% to 70% of elbow
fractures in children.
• Incidence—most commonly occur between 3 and 10 years of age.
• Boys > girls, Left side> right side
• The medial and lateral columnsof the distal humerus are connected by a very thin area
of bone at the olecranon fossa. The central thinning and the surrounding narrow
columns predispose this area to fracture.

3. M E C H A N I S M O F I N J U R Y
• The usual mechanism of injury is a hyperextension load on the elbow from falling on
the outstretched arm.
• The distal fragment displaces posteriorly (i.e., extension) in more than 95% of
fractures. As the elbow is forced into hyperextension, the olecranon impinges in the
fossa, serving as the fulcrum for the fracture. The collateral ligaments and the anterior
joint capsule also resist hyperextension, transmitting the stress to the distal humerus
and initiating the fracture
• Flexion-type supracondylar fractures result most often from a direct fall onto the
olecranon of a flexed elbow

4. A S S O C I AT E D I N J U R Y
• Vascular—The brachial artery can be torn or, more commonly, set into spasm in and a
Type III extension fracture. Capillary refill and pulse oximetry are unreliable in this
situation. Doppler and manual palpation of the radial and ulnar arteries should be
undertaken.
• Neurologic—Documentation of a thorough motor and sensory examination of the
involved extremity should be undertaken.
• Nerve injuries occur in 7% to 15% of these fractures. AIN palsy is the most commonly
occurring nerve injury with extension-type supracondylar fractures. Radial nerve injury
has been reported more commonly with posteromedially displaced fractures and
median nerve injuries with posterolateral displacement. Ulnar nerve injuries can occur
with flexion supracondylar fractures but more commonly occur iatrogenically as a result
of medial pin placemen
• 10% incident of ipsilateral radius fracture

6. AP and lateral radiograph of the elbow
Bauman angle @ humerocapitellar line
-70-80 degree, within 10 degree of contralateral elbow

7. Humerothrochlear angle 30-40 degree
Anterior humeral line intersecting capitellum
Hourglass appearance - rotation

8. Anterior fat pad elevation@ sail sign
Posterior fat pad sign
Tear drop
-anterior limb: coronoid fossa
-posterior limb:olecranon fossa
-inferior curved line : trochlear

9. C L A S S I F I C AT I O N
• Mechanism of injury
 Extension type
 Flexion type
• Gartland classification
• AO classification

10. Extension vs flexion type

11. G A R T L A N D
C L A S S I F I C A T I O N
W I L K I N S - M O D I F I E D
G A R T L A N D

12. A O C L A S S I F I C AT I O N

13. M A N A G E M E N T

14. Other indication for surgery:
• Pink pulseless
• Flexion type
• Medial column collapse
• Impending compartment syndrome
• Brachialis sign
 ecchymosis, dimpling/puckering antecubital fossa, palpable subcutaneous bone fragment
 indicates proximal fragment buttonholed through brachialis
 implies more serious injury, higher likelihood of arterial injury, significant swelling, more
difficult closed reduction
• Floating elbow
• Reduce sensation:
• Failure to obtain anatomic reduction, especially with a “rubbery” feeling during attempted
reduction, may indicate that the nerve is interposed at the fracture site, and exploration may be
indicated.

15. P I N K P U L S E L E S S & PA L E P U L S E L E S S
• Pink pulseless: periphery is pink and warm (well perfused) but radial and ulnar artery
not palpable
• Pale pulseless: cold extremity, pale and radial and ulna artery not palpable
• In the event of a pulseless extremity, prompt reduction of the supracondylar fracture
usually restores arterial flow
• Frequently, the neurovascular bundle is found kinked at the fracture site, and liberation
of the artery restores the pulse.
• There may also be evidence of brachial artery injury. Vascular reconstruction should be
performed if the hand remains avascular despite local measures (e.g., release of
tether, lidocaine, warming).
• The fracture should be stabilized before vascular repair.

16. • Pulse + Post CRPP 
pink pulseless remove
K wire reassess
• Pulse+  Post CRPP 
pale pulseless  remove
K wire  reassess
• If vascular status not
improving vascular
exploration

18. C R P P T E C H N I Q U E
• Supine
• C-arm image intensifier
• Radiolucent arm board
• K-wire 2.0 in larger children more than 6 years old, 1.6 in smaller children less
than 6 years old

19. S T E P 1 - T R A C T I O N
• Gently for 10 minutes with 10-15 degree felbow flexion
• The goal is to disengage the humeral shaft from the anterior muscles
and skin, in order to allow accurate reduction of the bony fragments.
• A palpable soft tissue reduction event will often be felt during the
application of traction.
• The pucker sign, if present, will visibly reduce with successful traction.
If the muscle is stuck despite
traction, a milking maneuver
can be attempted.

20. S T E P 2 VA R U S / VA L G U S C O R R E C T I O N
• Performed with a thumb and index finger on the
medial and lateral epicondyles.

21. S T E P 3 R O T A T I O N A L A L I G N M E N T
• This must be done before the two
fragments are brought into apposition.
• If the rotation is not correct, the
fragments must be disengaged before
another attempt at correction of the
rotation.
• In most cases, the distal fragment
requires external rotation.

22. S T E P 4 – P O S T E R I O R D I S P L A C E M E N T
• Thumb is positioned over the olecranon and pushed distally and anteriorly, whilst the elbow is
smoothly flexed.
• If the elbow will not flex fully it is likely that the reduction is incomplete.
• A complete reduction may be felt.
• If a complete reduction can be felt, the arm is fully pronated (in case of a medially displaced
distal fragment) or supinated (in case of laterally displaced distal fragment).

23. F L E X I O N T Y P E R E D U C T I O N
• The reduction maneuver consists of elbow extension, which creates a
challenge for placement of pins.
• Alternatively, it can be manipulated by posteriorly directed pressure along the
axis of the 90° flexed forearm.

24. What to check on I/I?
• Bauman angle on AP view
• Anterior humeral line passing through middle third capitellum
• Hourglass restoration for rotational alignment
• A minimal amount of medial, or lateral, translation, posterior translation, and/or
and/or extension can be accepted, but they make intraosseous pinning more
difficult
Remember to external rotate the arm as one unit when getting lateral view

25. W I R E C O N F I G U R AT I O N

26. • Pin entry points are located in the lateral humeral condyle, distal to its maximal width.
• Techniques to assist correct insertion of the pin within the sagittal plane (lateral view) include:
 Identifying the alignment of the humeral shaft when evaluating the reduction and
marking the sagittal alignment on the skin
 Palpation of the humeral head aiming the pin for its center

29. C R O S S P I N N I N G
Considered when fractureline is high on the medial side, or unable to stabilize
with lateral wires
**Ulnar nerve can sublux forwards onto, or anterior to, the medial epicondyle
with elbow flexion
• The medial epicondyle is palpated
• A 1 cm longitudinal skin incision is made
directly over the prominence of the medial
epicondyle.
• Blunt dissection is performed, until the medial
epicondyle can be palpated and seen.
• A 2.0 mm drill guide, placed directly onto the
medial epicondyle, is used to establish the
entry point of the K-wire.

30. • The lateral K wire inserted first
• The medial K-wire is inserted through
the medial epicondyle and across the
fracture in the medial column
• Crossing point above the fracture line
– aim center for most stable construct

31. O P E N R E D U C T I O N O F S U P R A C O N D Y L A R
F R A C T U R E O F T H E H U M E R U S
Approach:
• Anterior surgical interval is recommended if the neurovascular structures need to be exposed
and in general is the most utilitarian.
• Medial and/or lateral approaches may be used as well if the surgeon is approaching from the
side of torn periosteum. Ulna nerve exploration (medial)
• Posterior approach should be used rarely because it disrupts any remaining intact periosteum
and may disrupt the primary vascular supply to the distal humeral fragment. It also compromises
the tension band effect of the posterior periosteum. Main indication is T or Y fracture of distal
humerus
Open reduction indication:
• Open fracture
• Failed close reduction
• Vascular or nerve exploration

32. A N T E R I O R A P P R O A C H
Landmark:
• brachioradialis forming lateral border of
supinated forearm
• bicep tendon on the anterior cubital fossa
Lazy S incision from above flexion crease medial
side of the biceps, curve across the front of elbow
and curve towards the medial border of
brachioradialis muscle
Internervous plane
• Distally between brachioradialis (radial nerve)
and pronator teres (median nerve)
• Proximally between brachioradialis (radial
nerve) and brachialis muscle
(musculocutaneous nerve)

33. • In these cases, the sharp proximal fracture
end of the distal humerus pierces most of the
deep structures, such as brachialis muscles,
fascia and the integument. As a result, the
exposure of the vessels is already
accomplished in the majority of cases.
• the neurovascular bundle explored by careful
dissection across the anterior aspect of the
metaphyseal fragment until the bundle is
identified
• Just medial to the biceps tendon, the brachial
artery may be present, with the median nerve
just medial to the artery.
• in a patient presenting with a pulseless,
poorly perfused hand, search for the
lacerated ends of the artery that may have

34. • The next step is to identify the distal fragment. This
may be the most difficult step for the first or second
time.
• The distal fragment is posterior and often deeper
and covered by folding periosteum
• With the neurovascular bundle safely retracted
medially and the proximal fragment retracted
laterally, the distal fragment can be exposed.
• The cut edge of the periosteum is grasped and
carefully cut along the fractured edge of the distal
fragment to open the buttonhole
• The distal fragment then can be brought anteriorly
and reduced.

35. R E D U C T I O N A I D
• The distal fragment can be engaged using a small Hohmann's bone lever, and
the shaft fragment is gently maneuvered into position
• Depending on the fracture anatomy, a small pointed reduction clamp may help
to maintain reduction while K-wires are inserted

36. P O S T E R I O R A P P R O A C H
• This procedure is performed with the patient positioned either supine or lateral.

37. • Landmark: bony olecranon process at the upper end of ulna (conical and sharp
apex)
• Incision: Midline longitudinal incision above elbow and curve laterally at just
above the tip of olecranon, curve medially so it lies over the subcutaneous
border of the ulna
• Internervous plane: no true plane

38. • Deep fascia is incised in midline
• The ulnar nerve is isolated and protected with
a latex loop. (ulna is behind the medial
epicondyle)
• Proximally, the ulnar nerve is followed along
its course on the medial intermuscular
septum, and the triceps muscle is retracted
laterally.
• The insertion of the triceps tendon on the
medial side of the olecranon is partially
detached tangentially together with a 1-2 mm
sliver of cartilage.
• This does not impair growth of the olecranon,
but gives a much better approach to the joint.
M E D I A L W I N D O W – O P T I O N 1

39. M E D I A L W I N D O W - O P T I O N 2
• The posterior fascia is split 3-4 mm from the
medial border of the triceps muscle. The muscle is
retracted laterally.
• The ulnar nerve is protected by the fascia and can
be gently moved medially with a smooth round
simple retractor.

40. • The triceps muscle is freed on its lateral
border.
• The triceps fascia is split, the muscle is
mobilized from the lateral intermuscular
septum and humerus, and retracted towards
the medial side.
• Distally, the anconeus muscle is partially
detached from its origin as necessary.
• The insertion of the triceps tendon on the
lateral side of the olecranon is partially
detached tangentially together with a 1-2 mm
sliver of cartilage. This does not impair growth
of the olecranon, but gives a much better
approach to the joint.
The medial and lateral triceps windows can be used together ="triceps flip"
L AT E R A L W I N D O W

41. M I D L I N E W I N D O W
• The triceps tendon is split exactly in the midline from the tip of the olecranon to the upper limit of the
olecranon fossa.
• The triceps tendon and aponeurosis are further split proximally (normally 3-4 cm proximal to the
fracture line)
• After the triceps tendon has been split distally to the tip of the olecranon, an incision is made along the
medial border of the ulna (including cartilage/periosteum).
• The insertion of the tendon, together with the periosteum or small cartilage flap, is then partially
mobilized from the proximal ulna.

42. C L O S U R E
• The capsule is closed with resorbable sutures (3/0).
• Muscles are returned to their anatomical position and the prepared small olecranon flap
is reattached to the ulnar periosteum with resorbable sutures (2/0 or 3/0).
• The fascia should also be closed with 2/0 or 3/0 resorbable sutures, otherwise
muscular hernia might occur.
• Skin and subcutaneous tissue are closed with fine resorbable sutures (this avoids any
distress to the child in removing nonabsorbable sutures).

43. C O M P L I C AT I O N
• Pin migration -most common complication (~2%)
• Infection - typically superficial and treated with oral
antibiotics
• Cubitus valgus -can lead to tardy ulnar nerve palsy
• Cubitus varus (gunstock deformity)
 caused by fracture varus malunion, especially in
medial comminution pattern
 Tardy ulnar nerve palsy -anterior nerve
subluxation is most common cause, nerve
entrapment by scar tissue and fibrous bands of
FCU second most common cause
• Recurvatum
 common with non-operative treatment of Type II
and Type III fractures
• Postoperative stiffness
• Nerve palsy from injury
 usually resolve, nerves rarely torn
 extension type fractures- neuropraxia most
commonly AIN ,mechanism = tenting of nerve on
fracture, or entrapment in the fracture site
 flexion type fractures- most commonly cause
ulnar neuropraxia
• Vascular Injury
• Volkmann ischemic contracture
 rare, but dreaded complication
 may result from elbow hyperflexion casting -
increase in deep volar forearm compartment
pressures and loss of radial pulse with elbow
flexed >90°
 rarely seen with CRPP and postoperative
immobilization in less than 90°

44. R E F E R E N C E
AO Surgery reference
Lovell and Winter’s Paediatric Orthopaedic
Brinker Review of Orthopaedic Trauma