Supracondylar humerus fractures are the most common type of elbow fracture in the pediatric population1. They occur with a fall onto an outstretched hand, or less commonly, a fall onto a flexed elbow. A careful examination of the neurovascular status of the arm is key, as nerve injuries can occur from the trauma and vascular compromise indicates the need for urgent treatment. Though complaints may focus on the elbow, it is important to examine the remainder of the extremity, as concomitant forearm fractures do occur. AP and lateral radiographic views of the elbow are key to classification, and may indicate potential nerves at risk and the appropriate reduction maneuver. The module discusses the general setup and treatment for displaced extension type supracondylar humerus fractures, using the fluoroscopy unit as the operating surface. Cast treatment for non-displaced or minimally displaced supracondylar humerus fractures may be considered2. For fractures that are grossly unstable, for flexion type supracondylar humerus fractures, and for fractures with ipsilateral forearm fractures, a hand table may be considered instead.
Proper patient and equipment positioning
Reduction maneuver for reducing supracondylar humerus fractures
Determining adequate reduction
Proper pin placement and configuration
For this percutaneous procedure, the palpable landmarks center on the capitellum and the olecranon. It may be useful to identify and mark both on the skin, to ensure that the orientation is clear, as the elbow is flexed, extended, and rotated.
Remember that the position of the ulnar nerve if medial pin placement is considered, and the radial nerve that is a risk from a prominent pin more proximally in the spiral groove.
For supracondylar humerus fractures that are difficult to reduce and have bruising in the antecubital fossa, the proximal piece may be piercing the brachialis. The fracture may need to be milked from its position. At the same time, the brachial artery and median nerve, which sit anteriorly may be displaced.
Displaced extension type supracondylar humerus fractures require reduction and surgical stabilization. Those fractures that are not displaced, or minimally displaced where the anterior humeral line still crossly the capitellum, can be treated with casting only.
A sterile tourniquet can be kept on hand in case a reduction is unsuccessful and an incision is required
Expected post operative stay – Most patients can be observed for 23 hours or less and discharged home.
Common – Elbow stiffness, pin migration, infection
Uncommon –vascular injury, neurologic injury, malunion, nonunion, compartment syndrome
- Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012 Feb;20(2):69-77
- Howard A, Mulpuri K, Abel MF, Braun S, Bueche M, Epps H, Hosalkar H, Mehlman CT, Scherl S, Goldberg M, Turkelson CM, Wies JL, Boyer K. The treatment of pediatric supracondylar humerus fractures. American Academy of Orthopaedic Surgeons. J Am Acad Orthop Surg. 2012 May;20(5):320-7