International Orthopaedics (SICOT) (2015) 39:2287–2296

DOI 10.1007/s00264-015-2975-4

REVIEW ARTICLE

Supracondylar humeral fractures in children: current concepts

for management and prognosis
Jaime Zorrilla S. de Neira 1 & Alfonso Prada-Cañizares 1 & Rafael Marti-Ciruelos 2 &
Juan Pretell-Mazzini 3

Received: 29 May 2015 / Accepted: 8 August 2015 / Published online: 28 August 2015
# SICOT aisbl 2015

Abstract Supracondylar humeral fractures are the most com- Introduction

mon elbow fractures in children and represent 3 % of all pae-
diatric fractures. The most common cause is a fall onto an Supracondylar humeral fractures (SCHF) are the most com-
outstretched hand with the elbow in extension, resulting in mon elbow fractures in children, representing 3 % of all pae-
an extension-type fracture (97–99 % of cases). diatric fractures. The incidence between genders is similar due
Currently, the Gartland classification is used, which to the increased involvement of girls in sport activities, and
has treatment implications. Diagnosis is based on plain children with such injuries have a peak age between five and
radiographs, but accurate imaging could be limited due six years. The annual incidence of these fractures is estimated
to patient pain. Based on fracture type, the definitive to be 177.3 per 100,000 children; they have seasonal distribu-
treatment could be either non-operative (type I) or tion, being more frequent in the summer months, and occur
operative (type III/IV); however, when handling type II more often in the left elbow [1]. This article reviews the rele-
fractures controversy remains. Neither pin configuration vant literature on management, complications and prognosis
h a v e s h o w n h i g h e r e f f i c a c y o v e r t h e o t h e r. of SCHF in children.
Complications are ~1 %, the most common being pin
migration, with compartment syndrome as the most dev-
astating. Overall, functional outcomes are good, and Anatomy and biomechanics
physical therapy does not appear to be necessary.
The elbow is a hinge joint formed by the distal humer-
us, radial head and the proximal ulna. The distal humer-
Keywords Supracondylar humeral fractures . Compartment us has two surfaces that articulate with both forearm
syndrome . Pin configuration . Pin migration . Infection . bones: the capitellum with the radial head, and the
Baumann angle . Anterior humeral line trochlea with the articular surface of the olecranon.
The elbow is a very complex anatomical area where
many structures are related, and they must be well un-
derstood by the paediatric orthopaedic surgeon for prop-
* Juan Pretell-Mazzini er supracondylar fracture management (Fig. 1).
[email protected] Displacements of the proximal and/or distal fracture
fragment may compromise any of the elbow structures
1
Department of Orthopaedic Surgery, 12 de Octubre University
due to their close anatomical relationship.
Hospital, Madrid, Spain Bone remodelling in the humerus of children between
2
Pediatric Orthopaedic Division/Department of Orthopaedics,
five and eight years of age generates a decrease in the
12 de Octubre University Hospital, Madrid, Spain anteroposterior diameter of the supracondylar region, in-
3
Miller School of Medicine, Musculoskeletal Oncology/Pediatric
creasing the risk of injury in that region. This region
Orthopaedics Division, Department of Orthopaedic Surgery, coincides with the two fossae of the distal humerus:
University of Miami, Coral Gables, FL, USA olecranon fossa and coronoid fossa. The anterior capsule
2288 International Orthopaedics (SICOT) (2015) 39:2287–2296

of the elbow is thicker and stronger than the posterior fracture displacement measured in the lateral view on
capsule, and its fibres are under tension during exten- a plain radiograph:
sion, maintaining the olecranon within the olecranon
fossa. A collision of the olecranon against the roof of the Type I: Fracture is nondisplaced (subtype Ia) or minimal-
olecranon fossa and the supracondylar region as a conse- ly displaced (<2 mm) (subtype Ib) and is associ-
quence of a fall on an outstretched hand with a hyperextended ated with an intact anterior humeral line. Because
elbow will result in a fracture in that area [2]. of the intact periosteum circumferentially, these
fractures are very stable. The sign of the posterior
and/or anterior fat pad may be the only sign of
bone injury.
Classification Type II: Fracture presents slight displacement (>2 mm) with
a posterior angulation of the distal fragment main-
According to the mechanism of injury, SCHF are clas- taining the posterior cortex intact (subtype IIa) or
sified into two types: extension type (98 %) [3] and when the fracture presents a straight or rotatory dis-
flexion type (2 %). In extension fractures, Gartland clas- placement with contact between the two fragments
sification is used to describe the severity of the injury (subtype IIb). The anterior humeral line does not
and focus therapeutic management. Such fractures are cross through the middle third of the capitellum,
divided into four types according to the degree of but there is no rotational instability because the
posterior cortex is intact. It is important to pay at-
tention to the disruption of the medial column of the
humerus because it can produce varus
malalignment. It is important to remember that in
comminuted and impacted fractures of the medial
column, malrotation can occur in the frontal plane
without being appreciated in the lateral plane.
Type III: Fractures have a posteromedial (IIIa) or postero-
lateral displacement (IIIb) associated with a loss
of integrity of the posterior cortex, resulting in
extension of the distal fragment on the sagittal
plane and rotation in the transverse plane. This
creates loss of relationship between anterior hu-
meral line and capitellum and increased risk of
neurovascular and soft tissue injury.
Type IV: Fractures with multidirectional instability
characterised by complete circumferential tear
of the periosteum and instability in flexion and
extension [11]. This is not diagnosed by imaging
studies but during manoeuvres in the operating
room to reduce the fracture. These types of injury
can be iatrogenic as a result of reduction of a
supracondylar fracture (Fig. 2).

Fig. 1 Anatomical relationships of neurovascular bundles and

supracondylar region. The brachial artery descends superficially by the
anteromedial aspect of the brachial muscle, providing deep collateral
arteries that run down the anterior aspect of the humerus. The median
nerve descends with the brachial artery, the radial nerve runs down the
lateral aspect of the humerus between brachialis and brachioradialis and
the ulnar nerve runs down the posteromedial aspect through the cubital
tunnel of the medial epicondyle Fig. 2 Gartland classification: a type I; b type II; c type III; d type IV
International Orthopaedics (SICOT) (2015) 39:2287–2296 2289

Diagnosis 90°, the first thing that should be assessed is the anterior hu-
meral line (Fig. 4a). In extension-type fractures, this line
Physical examination passes through the anterior third of the capitellum. However,
this line has no significance in children <four years because it
Pain, swelling, refusal to be examined and—in many cases— can pass through the anterior third (31 %), middle third (52 %)
an obvious deformity are common symptoms that help in the or posterior third (18 %) of the capitellum without any patho-
diagnosis. It is very important to explore the entire extremity logical correlation [5]. Other radiographic measurements are
to look for other injuries that may go unnoticed; forearm frac- humeral tear, diaphyseal–condylar angle and coronoid line
tures are often associated, increasing the risk for compartment (Fig. 4b, c, d).
syndrome. Any punctate wound should be considered an open Angular relationships measurable on anteroposterior view
fracture until proven otherwise [3]. During the initial assess- are Baumann angle [6], metaphyseal–diaphyseal angle and
ment, a thorough vascular examination checking pulses and humeroulnar angle (Fig. 5a, b, c).
vascular filling should be performed and repeated after any Cases in which pain makes it difficult to realise
manipulation of the elbow, because mobilising an elbow with anteroposterior plain radiographs, a Jones projection, where
deformity and/or swelling in the antecubital fossa can com- the radiographic beam is directed through the forearm with the
promise neurovascular status [2]. A complete neurological elbow in maximal flexion, should be used.
exam is important because of the high incidence of nerve
injury, the most common being neurapraxia of the anterior
interosseous nerve branch of the median nerve, which disables
Management
thumb opposition to the second finger (OK sign). If there is
severe swelling, uncontrollable pain, bruising or absence of
Treatment options for SCHF in children are based on the
pulses, compartment syndrome should be suspected.
Gartland classification (Table 1).

Imaging studies
Non-operative treatment
Initial imaging study to diagnose this injury is a plain
anteroposterior view of the distal humerus and elbow lateral Type I fractures are ideal for conservative treatment and are
views. It is very important to radiograph the entire limb, in- treated with a brachioantebrachial cast at 90° flexion in neutral
cluding the ipsilateral wrist and shoulder, as well as the unin- forearm rotation for three to four weeks. Monitoring is done
jured contralateral extremity in order to compare the two and by serial radiographs on an outpatient basis, paying particular
look for other lesions that may go unnoticed. In many cases, attention to radiographs taken the first week to assess for
the fracture may go unnoticed, and the fat pad (Fig. 3) could redisplacement [7, 2, 5]. This treatment is also recommended
be the only indirect sign [2], which can also be observed in for patients in whom there is not a clear fracture line but there
two regions: (i) posterior or olecranon, and (ii) anterior, is a fat-pad sign. Treatment of type II fractures is controversial:
formed by the coronoid and the supinating pad [2]. Skaggs Some authors defend a conservative approach to stable type
et al. [4] reported on 35 cases with fat-pad signs, finding that IIA fractures without malrotation and displacement [5, 8]; in
18 cases (53 %) were supracondylar fractures and the remain- this case, parents should be informed about the possibility of
ing 17 were proximal ulna (26 %), lateral condyle (12 %) or surgery if there is redisplacement on subsequent radiographic
radial-neck (9 %) fractures. In the lateral view of the elbow at follow-up. Other authors include all type II fractures in surgi-
cal treatment; according to the American Academy of
Orthopaedic Surgeons (AAOS) recommendations, surgical
treatment for these fractures is consider a moderate recom-
mendation [9].

Operative treatment

General indications

Type II: If such fractures meet any of the characteristics that

make them unstable (malrotation, displacement or
instability), it is safer to proceed with surgical inter-
Fig. 3 Fat-pad sign in a supracondylar fracture of a six year-old child. vention. The ideal treatment for these fractures is
This sign is due to infiltration of fat pads secondary to fracture bleeding closed reduction and pinning with K wires [2, 5].
2290 International Orthopaedics (SICOT) (2015) 39:2287–2296

Fig. 4 Radiographic measurements: a anterior humeral line: an condylar angle: angle between humeral and humeral condyle axes,
imaginary line running through the anterior cortex of the humerus and which normal value is 30–45°; d coronoid line: imaginary line that
must pass through the middle third of the capitellum; b humeral tear: continues tangentially, joining the anterior coronoid edge with the front
radiologic shadow formed by coronoid fossa, olecranon fossa and upper edge of the lateral condyle
edge of ossification nucleus with the humeral shaft; c diaphyseal–

Type III: There is a clear consensus that initial treatment iatrogenic ulnar nerve injury ranged from 0 to 6 % [5]. In a
should be closed reduction and fixation with K systematic review by Slobogean et al. [19], results suggested
wires [7]. A semisterile technique can be used, that there is one iatrogenic ulnar nerve injury for every 28
implying time savings in the operating room and patients treated with the crossed -pinning configuration com-
cost savings [2]. Iobst et al. [10] reported no su- pared with lateral pinning. Similarly, Zhao et al. [20] conclud-
perficial or deep pin-tract infections requiring ed that the crossed-pin fixation carries a higher risk for iatro-
treatment in their study of 304 cases managed with genic ulnar nerve injury than the lateral pinning technique. On
this technique. the other hand, Krusche-Mandl et al. conducted a retrospec-
Type IV: Although these fractures require the most complex tive study on 78 SCHF and found no ulnar injuries but one
management due to instability, initial management iatrogenic radial nerve palsy with crossed pinning. Those au-
must be the same as for types II and III, i.e. closed thors also found that based on primary nerve injury, there was
reduction and pinning with K wires. Leitch et al. a significant influence revealing that older patients had a sig-
recommended preplacement of K wires into the nificantly higher risk of such injuries (p=0.02) [21]. On the
distal fragment before reduction [11]. basis of these data, it may be suggested that percutaneous
crossed pinning carries an increased risk for injury of the ulnar
nerve and that lateral pinning should be recommended when
Operative techniques suitable.
As medial fixation may be inevitable for certain fracture
The gold standard technique is closed reduction and percuta- patterns, several operative techniques have been described to
neous pinning (Fig. 6a, b, c, d) as soon as possible. Acceptable reduce the risk of ulnar nerve injury. Green et al. [22] reported
rotation is achieve once the medial and lateral columns are on 62 patients with displaced SCHF who underwent a mini-
well aligned. The anterior humeral line should pass through incision technique to prevent ulnar nerve injury and found no
the middle third of the capitellum, and the Baumann angle ulnar nerve injuries. This technique demonstrates that crossed-
must be restored. Some degree of malrotation can be tolerated, pin configuration can be performed safely and reliably and is
but no varus deformity. In unstable cases, two fluoroscopic an appropriate treatment option for unstable SCHF.
machines can be used to maintain fracture reduction [12]. Historically K wires have been used for internal fixation,
Different pin configurations have been described: two but due to the potential danger of infection and the need for a
crossed pins; two lateral pins and one crossed pin; only one second procedure to remove them, alternative options have
side pin (usually two or three are used). From a biomechanical been described. Fu et al. reported the use of absorbable poly-
standpoint, the greatest resistance to rotation is achieved D,L-lactic-acid pins on 56 cases with irreducible Gartland III
through a mediolateral crossed-pinning configuration [13]. fractures through an open approach and found excellent func-
However, other authors described equivalent torsional rigidity tional and radiologic results, avoiding a second procedure to
and/or fixation between either three or two lateral pins and remove the implants [23]. Even though these results are prom-
crossed pins [14–17]. According to Carter et al. [18] who ising, implant cost is a consideration, as pin removal can be
conducted a survey of 309 paediatric orthopaedic surgeons, done in the office; the procedure also has a low morbidity rate
the preferred method of percutaneous fixation was fairly even- Other techniques for stabilising a displaced SCHF have
ly distributed between crossed-pin configuration (30 %), two been described, including elastic stable intramedullary nails
lateral pins (33 %) and three lateral pins (37 %). [24] and external fixator [25, 26], with good functional out-
Babal et al. conducted a meta-analysis and reported on comes. For open reduction, the anterior approach is recom-
5148 patients with 5154 fractures. Overall, incidence rates of mended because it can often be done via a cosmetic incision in
International Orthopaedics (SICOT) (2015) 39:2287–2296 2291

Evolving operative management concepts

Timing of surgical intervention

Historically, an SCHF continues to be treated as an emergen-

cy, even though the outcomes reported in the literature no
longer support this practice. Several authors have studied this
practice using different cutoff times, such as eight hours [28],
12 h [29] and 21 hours [30]. No differences have been noted
regarding perioperative complications [28–30], need for open
reduction [28, 30], superficial pin-tract infections [28] or iat-
rogenic nerve injury [28]. Carter et al. [18] reported that 81 %
of respondents preferred to initially splint type III fractures
and plan fixation the following morning.

Open fractures: general management principles

and surgical approaches

Open SCHF are uncommon. The number of studies on paedi-

atric open fractures in the upper extremity is limited, although
it seems clear that they are less frequent than open forearm
fractures and usually presented as type I and II, with type III
being very infrequently [31], according to Gustilo’s classifi-
cation [32]. Initial management does not vary from other open
fractures in children.
Assessing for the presence of associated injuries (mecha-
nism of injury), status of soft tissues and neurovascular in-
volvement should be the first step when dealing with these
type of fractures. Once this is done, tetanus prophylaxis and
antibiotic treatment must be administered in the emergency
room and radiographs taken. The patient must be taken to
the operating room, where under general anaesthesia, wound
irrigation and debridement is be performed [33]. The next step
is to proceed with closed reduction and fracture fixation, if
feasible; however, if this is not possible, an external fixator
Fig. 5 a Baumann angle: angle that forms the middle diaphyseal humeral
line with the epiphyseal line of the lateral condyle; normal values are or open reduction through an anterior approach should be
between 9 and 26°, with the same value for both elbows, and if <9°, performed [2].
indicates varus angulated supracondylar fracture with possible The most common and feared complication of open frac-
comminution of the medial column; b metaphyseal–diaphyseal angle: tures is infection. The incidence of infection after upper-
angle between midline of the humeral shaft and the line formed
between the two furthest points of the widest area of the distal humerus; extremity open fractures is reported to be 0–2.5 %, whereas
c humeroulnar angle: formed by two imaginary lines that run through after type 1 open fractures in children, it is reported as being
both shafts 1.9 % [31]. A direct correlation of infection rate and patient
age has been reported, especially after the age of 12 years [34].
the antecubital crease [2, 27] and allows visualisation of the There is no defined antibiotic protocol for such fractures, but
brachial artery and median nerve, if needed. usually, a third-generation cephalosporin is used for type I and

Table 1 Evidence-based
recommendations based on Fracture Treatment Recomendation
Gartland classification for treating
supracondylar humeral fractures Gartland type I Conservative B // Moderate
in children Gartland type II–III Closed reduction and internal fixation B // Moderate
2–3 lateral needle reduction B // Weak
Displaced fractures after a closed reduction Open reduction and osteosynthesis B // Weak
2292 International Orthopaedics (SICOT) (2015) 39:2287–2296

Fig. 6 A six year-old boy who

fell onto his left outstretched hand
resulting in pain and swelling of
his left elbow. In the emergency
room, plain radiographs showed a
Gartland type III fracture: a
anteroposterior view; b lateral
view. After initial evaluation, the
patient underwent closed
reduction and pinning using a
lateral divergent configuration: c
anteroposterior intra-operative
fluoroscopic view showing three
divergent pins on the lateral
aspect of the left distal humerus; d
lateral intra-operative
fluoroscopic view showing slight
flexion of the distal fragment, but
with good pin positions

II open fractures, adding an aminoglycoside for type III open all orthopaedic surgeons due to urgency of treatment, difficul-
fractures. Vascular and nerve injuries are relatively common in ty in managing the vascular injury and lack of a appropriate
open supracondylar fractures, with an incidence of ~12–20 % treatment protocol. In the operating room, the fracture should
[35]. In the case of vascular involvement, quick fracture re- be reduced with the usual technique and percutaneous pin-
duction is mandatory, and if it does not recover, an open ap- ning, and after 15–20 minutes, neurovascular status should
proach is required to look for vascular injury. However, nerve be reassessed. Two different situations may arise depending
injuries recover spontaneously in ~86–100 % of cases on the presence or absence of pulse [39, 40]:
[35–37]. Ozkül et al. [38] reported on 26 open supracondylar
fractures, finding 15 % (4/26) vascular involvement but vas- (1) If the hand has a good capillary refill (pink), an elbow
cular repair necessary in only one patient and nerve injury in plaster in 40–60° of flexion should be applied and the
34 % (9/26) of cases; complete recovery was seen in all cases. elbow monitored intensively.
Contrary to other fractures, the rate of wound infection, oste- (2) If the hand does not have good capillary refill, then a
omyelitis, compartment syndrome or Volkman’s ischaemic vascular examination must be performed, and repair of
contracture is considerably lower. An increase in length of a damaged vessel is a possible scenario (Fig. 7a, b). In
hospitalization has also been reported, with a mean duration this case, fasciotomies should be considered.
of 5.4 days (range 3–8) which is longer than in closed frac-
tures (mean 2 days). This could be explained by differences in In any case, arteriography should not be performed because
antibiotic treatment, wound care and additional injuries requir- it delays fracture reduction and can also cause vasospasm [29].
ing close monitoring. Regardless of differences in presenta- Although this algorithm is accepted by many authors, other
tion and treatment between open and closed fractures, func- studies promote urgent vascular exploration [41].
tional outcome reported in the literature is similar [38].

Pink, pulseless hand Complications

A pink, pulseless hand is one with capillary refill present but A 1 % complication rate has been reported following
radial pulse absent. This situation is one of the most feared by SCHF treatment; complications can appear prior to or
International Orthopaedics (SICOT) (2015) 39:2287–2296 2293

paralysis and pulselessness are unreliable signs and symptoms

of compartment syndrome in children. An increasing
analgaesia requirement in combination with other clinical
signs, such as agitation and anxiety, is a more sensitive indi-
cator [48]. Ramachandra et al. reported on 11 patients who
developed compartment syndrome (all forearm) in association
with SCHF. Although theirs was an uncontrolled study, they
suggested that delay in initial treatment may have been con-
tributory [37]. If the diagnosis of compartment syndrome has
been made, emergent fasciotomy should be performed. Very
good results were reported by Bae et al. when fasciotomy was
performed within 30.5 hours of injury [48].
Fig. 7 A seven year-old girl fell on her outstretched left hand resulting in
pain and swelling of the left elbow. in the emergency room, plain radiographs Cubitus varus
were taken showing a a Gartland type III fracture. Because she presented
with a pulseless arm, she was was taken to the operating room where Cubitus varus is a triplanar deformity consisting of varus an-
closed reduction was performed unsuccessfully, and the hand became
gulation in the coronal plane, internal rotation in the axial
pale. b An anterior open approach for reduction was performed; the
brachial artery was entrapped within the fracture and was removed plane and extension in the sagittal plane. Although cubitus
successfully, with a subsequent return of pulse varus has been conventionally described as a cosmetic defor-
mity with little functional significance, there is growing
arising from surgical treatment, with good long-term awareness of long-term complications, including chronic pain,
outcomes [42]. ulnar-nerve palsy [49, 50], tardy posterolateral rotatory insta-
bility [51], snapping elbow [43] and increased risk of lateral
Pin migration/loss of reduction condyle and other secondary fractures [51, 52]. O’Driscoll
et al. [51] reported on 22 patients with lateral elbow pain
Pin migration is the most common post-operative complication, and recurrent posterolateral instability. They observed tardy
reported in up to 2 % of cases [43]; loss of reduction has been posterolateral rotatory instability of the elbow that developed
reported in 20–30 % of Gartland type II and type III fractures approximately two to three decades after SCHF occurred.
when treated nonoperatively [44, 45]. When surgical treatment Mechanical axis, olecranon and triceps line of pull are all
has been performed, a 2.9 % of loss of reduction can be expect- displaced medially causing subsequent repetitive external ro-
ed [46]. Sankar et al. [46] identified three potential technical tation torque on the ulna, which stretches the lateral collateral
errors causing loss of reduction: (1) failure to achieve bicortical ligament complex and leads to posterolateral rotatory instabil-
fixation with two or more pins; (2) failure to achieve adequate ity. Reconstruction of the lateral collateral ligament and valgus
pin separation (>2 mm) at the fracture site; (3) failure to pass osteotomy can relieve symptoms of instability. Even in the
through both fragments with two or more pins, but no failures absence of functional problems, which are mostly late sequel-
were noted when three pins were used [46]. ae, parents are often dissatisfied with the appearance of their
child’s arm and request treatment. In a meta-analysis conduct-
ed by Spencer et al. [53], all surgical treatments performed to
Infection correct this deformity, including lateral closing wedge, dome,
complex (multiplanar) and distraction osteogenesis, were
Few data exist with regard to the incidence of infection asso- analysed. The authors found an overall rate of 87.8 % to be
ciated with sterile or semisterile conditions during which per- good to excellent, but none of the techniques proved to be the
cutaneous pinning of SCHF is performed; however, rates of safest or most effective. Nerve injury, residual varus and un-
up to 1 % of superficial infections [10, 43] and 0.2 % of deep sightly scarring could be potential complications.
infections [43] have been reported. This suggests that an op-
erative approach is safe, and administration of perioperative
antibiotics is not indicated [43]. Outcomes

Compartment syndrome Functional and radiological assessment

Compartment syndrome is a rare complication that occurs in Flynn’s criteria are probably the most frequently used tools for
approximately one to three per 1000 fractures [47] but with assessing functional and cosmetic outcomes in patients with
very serious consequences. Pain, limb pallor, paresthesia, SCHF (Table 2). These criteria allow for clinical evaluation to
2294 International Orthopaedics (SICOT) (2015) 39:2287–2296

Table 2 Flynn’s criteria for functional and cosmetic assessment of were observed early after cast removal, with progressive im-
supracondylar humeral fracture treatment
provement over time for up to 48 weeks after the original
Results Rating Functional factor: Cosmetic factor: injury. No physical therapy was used in any of patients in that
motion loss (°) carrying-angle loss (°) study.
The efficacy of physical therapy in restoring elbow motion
Satisfactory Excellent 0–5 0– 5
after either closed reduction and pinning [57] or open reduc-
Good 5–10 5–10
tion and pinning [60] has been addressed by randomised stud-
Fair 10–15 10–15
ies, and they show no benefit.
Unsatisfactory Poor >15 >15

Flynn’s criteria are based on comparison of the functional component of

the affected limb with the contralateral healthy limb. Flexion, extension
and cosmetic differences in terms of carrying angle are compared. The
lesser of the two results is considered the final result References

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