Distal Humeral Fractures
(Supracondylar Fractures)
By Danielle Campagne, MD, University of California, San Francisco
Reviewed/Revised Dec 2022
Symptoms and Signs | Diagnosis | Treatment | Key Points
Distal humeral fractures usually result from a fall on an outstretched
arm or direct force; they may be associated with neurovascular injury.
(See also Overview of Fractures.)
Distal humeral fractures are common among children aged 3 to 11 years. The usual injury
mechanism is a fall on an outstretched arm with the elbow extended or direct force, often
causing posterior displacement or angulation.
The brachial artery or median or radial nerve may be damaged, particularly when the
fracture is posteriorly displaced or angulated. Neurovascular injury sometimes leads to
compartment syndrome of the forearm, which can cause Volkmann ischemic contracture (a
flexion contracture at the wrist resulting in a clawlike hand deformity). Fractures are usually
intra-articular, causing hemarthrosis.
Symptoms and Signs of Distal Humeral Fractures
The elbow area is painful and swollen, and the elbow's range of motion is limited.
Ecchymoses over the anterior medial forearm suggest brachial artery injury.
Diagnosis of Distal Humeral Fractures
Anteroposterior and lateral x-rays
A fracture line may not be visible, but other x-ray findings may suggest fracture. They include
Posterior fat pad
Anterior fat pad (sail sign)
Abnormal anterior humeral line
Abnormal radiocapitellar line
A posterior fat pad on a true lateral x-ray of the elbow is always abnormal; this finding is
specific for joint effusion but not highly sensitive.
A displaced anterior fat pad may indicate joint effusion but is not specific.
However, if a posterior fat pad is seen or if a large anterior fat pad (sail sign) is present, an
occult fracture should be assumed and should be treated as such.
The anterior humeral line is a line drawn along the anterior border of the humerus on a
true lateral x-ray. Normally, this line transects the middle of the capitellum. If the line
transects none or only the anterior part of the capitellum, a posteriorly displaced distal
humeral fracture is possible; then oblique views are taken, and other imaging may be done.
The radiocapitellar line is a line drawn through the midshaft of the radius on a true lateral
x-ray of the elbow; normally, it bisects the capitellum. If it does not, an occult fracture should
be suspected.
If findings in children are compatible with a distal
humeral fracture, x-rays should be reviewed closely Pearls & Pitfalls
for evidence of occult fracture (eg, a posterior fat
If findings in children are
pad, abnormalities in the anterior humeral or
compatible with a distal
radiocapitellar line).
humeral fracture, review
A complete neurovascular examination is done if a x-rays closely for
fracture is suspected. Particular attention should be evidence of occult
fracture (eg, a posterior
paid to the median, radial, and ulnar nerves. Distal
fat pad, abnormalities in
pulses should be compared with those of the
the anterior humeral or
opposite limb, particularly if ecchymoses or
radiocapitellar line).
enlarging swelling (which suggest brachial artery
injury) are present on the anterior medial forearm.
Anterior humeral line and
radiocapitellar line
Normally, the anterior
humeral line, which is drawn
along the anterior border of
the humerus on a lateral x-ray,
transects the middle of the
capitellum. If the line transects
none or only the anterior part
of the capitellum, a distal
humeral fracture with
posterior displacement may be
present.
The radiocapitellar line, which
is drawn through the midshaft
of the radius, normally bisects
the capitellum. If it does not,
an occult fracture should be
suspected.
X-rays of the Elbow
Treatment of Distal Humeral Fractures
Early orthopedic consultation
For nondisplaced fractures or occult fractures, splinting
For displaced fractures, often open reduction with internal fixation (ORIF)
For clinically suspected fractures, splinting and close follow-up
Displaced supracondylar fractures should be splinted in the position that they are in; they
should not be reduced because of the risk of reduction-related median nerve and radial
artery injury.
Most fractures are managed by an orthopedic surgeon because long-term complications are
a risk. Most patients are admitted for neurovascular observation, although some clinicians
splint and discharge patients who have nondisplaced fractures if patients can be trusted to
return for follow-up the next day.
Posteriorly displaced or angulated distal humeral fractures, in particular, should be reduced
by an orthopedic surgeon because nerves and/or the radial artery can be injured during
reduction. Casting with closed reduction may be tried but is typically not recommended
because ORIF is usually necessary.
If a fracture is suspected clinically (eg, children cannot move their elbow in a normal range of
motion) and x-rays appear normal, the joint should be splinted and close follow-up should
be arranged.
Pearls & Pitfalls
Splint displaced
supracondylar humeral
fractures in the position
that they are in; do not
try to reduce them.
Key Points
Distal humeral fractures are more common among children.
These fractures can injure the radial artery or median nerve.
Check x-rays for posterior and anterior fat pads, and use the anterior
humeral line and radiocapitellar line to determine whether an occult
fracture is likely.
For treatment, consult an orthopedic surgeon.
Proximal Humeral Fractures Radial Head Fractures
