Supracondylar Humeral Fracture

Introduction
Supracondylar fractures are a common elbow injury in children accounting for 16% of all
pediatric fractures and two-thirds of all hospitalizations for pediatric elbow injuries. These
are often significant fractures that may be associated with morbidity due to malunion,
neurovascular complications, and compartment syndrome.1

Anatomy of Elbow Joint

Figure 1 – Anatomy and Ossification Center of Elbow Joint in Children1

Epidemiology
Supracondylar fractures of the humerus account for 55% to 80% of total elbow fractures in
children and up to two thirds of paediatric elbow injuries requiring hospitalization.
Supracondylar fractures usually occur as result of a fall from height or from sports or leisure.
Their incidence has been estimated at 177.3 per 100 000.3 Although they can occur
throughout childhood, the median age is approximately six years, with higher incidence
between five and eight years. There is a higher incidence of supracondylar fractures in boys,
affecting the non-dominant arm 1.5 times more frequently.3

Pathoanatomy
Age is a key factor in the incidence of supracondylar fractures. This is a fracture that occurs
more frequently in skeletally immature children than adults. The peak age for supracondylar
fractures is between 6 and 7 years of age. At this age, the supracondylar area is undergoing
remodeling and is typically thinner with a more slender cortex, predisposing this area to
fracture. The typical mechanism is a fall onto an outstretched hand that puts a hyperextension
load on the arm. The distal fragment displaces posteriorly in over 95% of cases. As the elbow
is forced into hyperextension, the olecranon serves as a fulcrum and focuses the stress on the
distal humerus causing fracture. The rare flexion-type supracondylar fracture is often the
result of a fall directly onto a flexed elbow.1

Classification
According to the mechanism of injury, SCHF are classified into two types: extension type (98
%) and flexion type (2 %). In extension fractures, Gartland classification is used to describe
the severity of the injury and focus therapeutic management. Such fractures are divided into
four types according to the degree of fracture displacement measured in the lateral view on a
plain radiograph:

Type I: Fracture is nondisplaced (subtype Ia) or minimally displaced (<2 mm) (subtype Ib)
and is associated with an intact anterior humeral line. Because 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.

Type II: Fracture presents slight displacement (>2mm) with a posterior angulation of the
distal fragment maintaining the posterior cortex intact (subtype IIa) or when the fracture
presents a straight or rotatory displacement with contact between the two fragments (subtype
IIb). The anterior humeral line does not cross through the middle third of the capitellum, but
there is no rotational instability because the posterior cortex is intact. It is important to pay
attention 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 posterolateral 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 humeral 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. 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

Figure 2 – Gartland Classification of Supracondylar Humeri Fracture

Clinical Manifestations
Although elbow deformity is usually the most striking aspect (especially in very displaced
fractures), examination of the entire extremity is essential to exclude associated distal radius
(most frequent), forearm or proximal humerus fractures. In displaced extension-type
fractures, the so-called ‘S-deformity’ is usually present. however, light ecchymosis or
swelling can be the only external manifestation of a minimally displaced extension fracture or
a flexion-type fracture. Signs such as extensive ecchymosis, soft-tissue swelling and skin
puckering indicate severe trauma.3

Special attention should be taken when skin puckering is present. This sign appears when the
proximal fragment transects the brachialis muscle, ‘puckering’ the deep dermis. For this
reason, when skin puckering is present, severe displacement and soft-tissue damage,
including brachial artery and median nerve entrapment, should be expected, although no
differences are found in long-term outcomes with correct management. Vascular status
evaluation is paramount in displaced fractures. It has been reported that vascular compromise
exists in up to 10% to 20% of displaced fractures. It is mandatory to check the distal pulse
and hand perfusion pre-operatively and post-operatively.3

Neurological examination can be challenging. In the acute setting, the pain and anxiety of the
child and his/her parents can make the examination difficult. however, enough time should to
be taken to assess adequately the pre-operative neurological status. The median nerve and
anterior interosseous nerve (AIN) can be assessed with active flexion of the distal
interphalangeal joint of index and thumb. For the radial nerve, thumb extension is usually
easy to achieve, even in the young child. For ulnar nerve assessment, at least first
interosseous contraction is usually easy to achieve. The inability to perform a complete
neurovascular assessment should be documented for medicolegal reasons. Compartment
syndrome should always be borne in mind, especially when skin puckering, severe
ecchymosis/ swelling, vascular alterations or concomitant forearm fractures are present. 3

A true lateral view of the elbow is essential because the majority of classifications and
treatment algorithms are based on the degree of extension or flexion displacement. The main
anatomical landmark to be evaluated in the lateral view is the anterior humeral line (AhL).
This line continues the anterior cortical of the humerus and, in a normal elbow, should
traverse the capitellum in its middle third. In a displaced fracture in extension, the AhL will
pass anteriorly or may not even cross the capitellum. In case of a flexion-type fracture, the
AhL passes posteriorly to the capitellum. The lateral view also allows assessing the degree of
displacement and the integrity of the posterior cortex. The anterior and posterior ‘fat-pad
sign’ can also be evaluated in the lateral radiograph. While diagnosis of displaced fractures is
usually evident, diagnosis of minimally or nondisplaced fractures can be challenging. The
posterior fatpad sign is suggestive of the presence of a non-displaced fracture of the elbow.3

For X-ray imaging are made standard projections: AP image with the extended elbow,
forearm in neutral position; lateral projection, the elbow in flexion if possible up to 90º. In the
analysis of X-ray images is necessary to point out some characteristics of the angles, which
are used to estimate the position of fragments: Baumann angle, AHL (anterior humeral line),
and humerotrochlear angle.4

Figure 3 – Left: Clinical Feature of Supracondylar Humeral Fracture; Right: X- Ray:

Treatment
Reduction
Fractures can be reduced by closed or open means. The fracture is first reduced in the coronal
plane with the elbow in extension while gentle traction is applied. When skin puckering is
present because the proximal fragment is transecting the brachialis muscle, the ‘milkman’s
manoeuvre’ of the anterior part of the arm is useful to release the proximal fragment.
Surgeons need to be aware of the higher risk of neurovascular injury associated with skin
puckering. Later, pronating or supinating the forearm corrects rotation of the fragment.
Finally, the elbow is flexed while pushing the olecranon to the correct extension. Maintaining
the elbow in maximum flexion to stabilize the fracture until fixation with percutaneous
pinning is performed.
Sometimes, maintaining the elbow flexed does not stabilize fractures while pinning (fractures
with an oblique line and Gartland type IV fractures). In those cases, a K-wire can be passed
through the distal fragment from medial to lateral and used as a joystick to reduce the fracture
and maintain reduction while pinning.3

Approach
The anterior approach is the most widely used approach for open reduction. This approach is
especially indicated when vascular repair is necessary. It is a safe approach and results are
similar to or better than a traditional lateral approach. The lateral approach is the standard
approach for elbow surgery. However, in supracondylar fractures, which are extra-articular, it
does not give any advantage over the anterior approach and increases the risk of radial nerve
injury and stiffness. The bilaterotricipital posterior approach (Alonso-Llames approach) was
initially described at our institution to treat supracondylar fractures. The posterior approach is
an easy and safe approach that allows surgeons to manage both columns for proper
reduction.3

Fixation
Before fixation, angular and rotational alignment are assessed. We check rotational alignment
both clinically and radiologically. Many studies have been published comparing lateral-entry
and crossed pin fixation. Regarding biomechanical stability, results of studies are
controversial. While there are studies supporting the idea that crossing pins provides more
stability, no differences are seen in others. Once the fracture has been fixated, the surgeon can
extend the elbow and check for stability. If the fracture remains unstable, a third lateral-entry
point pin or a pin inserted from the medial part of the elbow is inserted.3

Treatment by Classification
Gartland type I
Non-displaced or type I fractures can be managed easily with a long-arm cast or splint (Fig.
5). There is not usually severe swelling or ecchymosis, so elbow flexion up to 80° to 90° and
mid pronation-supination are well tolerated.3
Gartland type II
Closed reduction and casting of these fractures is becoming less popular because of the
excessive flexion of the elbow beyond 90° needed to maintain reduction, which increases the
risk of compartment syndrome and neurovascular injuries. if any doubt exists about the need
for reduction, a closed reduction and percutaneous pinning fixation of a Gartland type II
fracture is indicated.3
Types III and IV
It is widely accepted that type III and type IV fractures should be managed surgically.
Nowadays, closed reduction and percutaneous pinning is the gold standard for all displaced
fractures. Blount’s method with closed reduction and hyperflexion of the elbow to maintain
reduction is no longer used because of the risk of compartment syndrome or neurovascular
injury. however, Pham et al have described their results with Blount’s method when treating
Gartland type IIB and III supracondylar fractures.3

Reference
1. Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus.
Curr Rev Musculoskelet Med. 2008;1(3-4):190-196. doi:10.1007/s12178-008-9027-2
2. Zorrilla S. de Neira J, Prada-Cañizares A, Marti-Ciruelos R, Pretell-Mazzini J.
Supracondylar humeral fractures in children: current concepts for management and
prognosis. Int Orthop. 2015;39(11):2287-2296. doi:10.1007/s00264-015-2975-4
3. Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar
fractures of the humerus in children. EFORT Open Rev. 2018;3(10):526-540.
doi:10.1302/2058-5241.3.170049
4. Madjar-Simic I, Talic-Tanovic A, Hadziahmetovic Z, Sarac-Hadzihalilovic A.
Radiographic assessment in the treatment of supracondylar humerus fractures in
children. Acta Inform Medica. 2012;20(3):154-159. doi:10.5455/aim.2012.20.154-159