Chapter 16: Supracondylar Fractures of the Distal Humerus

David L. Skaggs, John M. Flynn

Chapter Outline

Introduction to Supracondylar Fractures of the Distal Humerus

Current evidence and consensus suggest displaced supracondylar fractures are best treated operatively with fixation.3,90,140,187 Modern techniques for the treatment of supracondylar humerus (SCH) fractures in children have dramatically decreased the rates of malunion and compartment syndrome.3,19,66,103,116,120,140,173 Discussion continues regarding the urgency of operative treatment and the management of the pulseless supracondylar. In some locations the treatment of supracondylar fractures in children is shifting to pediatric subspecialists. In New England in 1991, 37% of patients were treated by pediatric orthopedic specialists; by 1999 this figure rose to 68%.99 
SCH fractures are the most common elbow fractures seen in children,39,55,143 and the most common fracture requiring surgery in children. The peak age range at which most supracondylar fractures occur is 5 to 6 years.37 

Principles of Management of Supracondylar Fractures of the Distal Humerus

Mechanism of Injury and Anatomy of Supracondylar Fractures of the Distal Humerus

Supracondylar fractures may be divided into extension and flexion types, depending on the direction of displacement of the distal fragment. Extension-type fractures, which account for approximately 97% to 99% of SCH fractures121 are usually caused by a fall onto the outstretched hand with the elbow in full extension (Fig. 16-1). SCH fractures most frequently result from falling, commonly off playground equipment.171 It has been reported that the overall safety of playground design can influence the likelihood of an SCH fracture, with children using the least safe playgrounds having almost five times the rate of SCH fracture as those using the safest playgrounds.145 
Figure 16-1
Mechanism of injury—elbow hyperextension.
 
A: Most children attempt to break their falls with the arm extended, and the elbow then hyperextends. B: The linear applied force (large arrow) leads to an anterior tension force. Posteriorly, the olecranon is forced into the depths of the olecranon fossa (small arrow). C: As the bending force continues, the distal humerus fails anteriorly in the thin supracondylar area. D: When the fracture is complete, the proximal fragment can continue moving anteriorly and distally, potentially harming adjacent soft tissue structures such as the brachialis muscle, brachial artery, and median nerve.
A: Most children attempt to break their falls with the arm extended, and the elbow then hyperextends. B: The linear applied force (large arrow) leads to an anterior tension force. Posteriorly, the olecranon is forced into the depths of the olecranon fossa (small arrow). C: As the bending force continues, the distal humerus fails anteriorly in the thin supracondylar area. D: When the fracture is complete, the proximal fragment can continue moving anteriorly and distally, potentially harming adjacent soft tissue structures such as the brachialis muscle, brachial artery, and median nerve.
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Figure 16-1
Mechanism of injury—elbow hyperextension.
A: Most children attempt to break their falls with the arm extended, and the elbow then hyperextends. B: The linear applied force (large arrow) leads to an anterior tension force. Posteriorly, the olecranon is forced into the depths of the olecranon fossa (small arrow). C: As the bending force continues, the distal humerus fails anteriorly in the thin supracondylar area. D: When the fracture is complete, the proximal fragment can continue moving anteriorly and distally, potentially harming adjacent soft tissue structures such as the brachialis muscle, brachial artery, and median nerve.
A: Most children attempt to break their falls with the arm extended, and the elbow then hyperextends. B: The linear applied force (large arrow) leads to an anterior tension force. Posteriorly, the olecranon is forced into the depths of the olecranon fossa (small arrow). C: As the bending force continues, the distal humerus fails anteriorly in the thin supracondylar area. D: When the fracture is complete, the proximal fragment can continue moving anteriorly and distally, potentially harming adjacent soft tissue structures such as the brachialis muscle, brachial artery, and median nerve.
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The majority of this chapter is on extension-type fractures, with flexion-type fractures being covered at the end of the chapter. The medial and lateral columns of the distal humerus are connected by a thin segment of bone between the olecranon fossa posteriorly and coronoid fossa anteriorly resulting in a high risk of fracture to this area (Fig. 16-2). In a normal anatomic variant the olecranon fossa may be absent (Fig. 16-3). Another normal anatomic variant is the supracondylar process which is present to some extent in about 1.5% of adult cadavers51 and should not be mistaken for fracture pathology. However, this anatomic variant can be the site of median nerve compression (Fig. 16-4). 
The thin bone makes the fracture unstable.
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Figure 16-2
Supracondylar fractures occur through the thinnest portion of the distal humerus in the AP plane.
The thin bone makes the fracture unstable.
The thin bone makes the fracture unstable.
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Figure 16-3
Normal anatomic variant in which there is no bone in the olecranon fossa.
 
Note the minimally displaced radial neck fracture.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
Note the minimally displaced radial neck fracture.
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Figure 16-3
Normal anatomic variant in which there is no bone in the olecranon fossa.
Note the minimally displaced radial neck fracture.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
Note the minimally displaced radial neck fracture.
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Figure 16-4
 
A: AP radiograph of the distal humerus demonstrating a supracondylar process, a normal anatomic variant. B: Lateral radiograph demonstrating a supracondylar process.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: AP radiograph of the distal humerus demonstrating a supracondylar process, a normal anatomic variant. B: Lateral radiograph demonstrating a supracondylar process.
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Figure 16-4
A: AP radiograph of the distal humerus demonstrating a supracondylar process, a normal anatomic variant. B: Lateral radiograph demonstrating a supracondylar process.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: AP radiograph of the distal humerus demonstrating a supracondylar process, a normal anatomic variant. B: Lateral radiograph demonstrating a supracondylar process.
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With forced elbow hyperextension, the olecranon forcefully pushes into the olecranon fossa and acts as a fulcrum, while the anterior capsule simultaneously provides a tensile force on the distal humerus at its insertion. The resulting injury is an extension-type SCH fracture. It has been postulated that ligamentous laxity with resulting elbow hyperextension may predispose to an SCH fracture136 but this association is unclear.128 

Posteromedial Versus Posterolateral Displacement of Extension-Type Supracondylar Fractures of the Distal Humerus

The periosteum plays a key role in regards to treatment. With extension-type injuries, the anterior periosteum is likely torn. The intact posterior periosteal hinge provides stability to the fracture and facilitates reduction with a flexion reduction maneuver. Many authors have described adding forearm pronation to assist in reduction, but this should not be automatic. The direction of fracture displacement often indicates whether the medial or lateral periosteum remains intact. With a posteromedially displaced fracture, the medial periosteum is usually intact. Elbow flexion and forearm pronation places the medial and posterior periosteum on tension, which corrects varus and extension malalignment and adds to stability of fracture reduction (Fig. 16-5). The medial periosteum however is often torn in a posterolaterally displaced fracture, in which case pronation may be counterproductive. Instead, in a posterolaterally displaced supracondylar fracture, forearm supination in addition to flexion may be better because the lateral periosteum is usually intact. If the posterior periosteal hinge is also disrupted, the fracture becomes unstable in both flexion and extension and this has been recently described as a multidirectionally unstable, modified Gartland type IV fracture.118 
Figure 16-5
Laterally torn periosteum in a posteromedially displaced supracondylar humerus fracture.
 
(From Skaggs DL. Closed reduction and pinning of supracondylar humerus fractures. In: Tolo VT, Skaggs DL, eds. Masters Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007.)
(From 


Skaggs DL
. Closed reduction and pinning of supracondylar humerus fractures. In: 

Tolo VT,

Skaggs DL, eds.
Masters Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007.)
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Figure 16-5
Laterally torn periosteum in a posteromedially displaced supracondylar humerus fracture.
(From Skaggs DL. Closed reduction and pinning of supracondylar humerus fractures. In: Tolo VT, Skaggs DL, eds. Masters Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007.)
(From 


Skaggs DL
. Closed reduction and pinning of supracondylar humerus fractures. In: 

Tolo VT,

Skaggs DL, eds.
Masters Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007.)
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Generally, medial displacement of the distal fragment is more common than lateral displacement, occurring in approximately 75% of patients in most series. Whether the displacement is medial or lateral is important because it determines which soft tissue structures are at risk from the penetrating injury of the proximal metaphyseal fragment. Medial displacement of the distal fragment places the radial nerve at risk, and lateral displacement of the distal fragment places the median nerve and brachial artery at risk (Fig. 16-6).119 
Figure 16-6
Relationship to neurovascular structures.
 
The proximal metaphyseal spike penetrates laterally with posteromedially displaced fractures and places the radial nerve at risk; with posterolaterally displaced fractures, the spike penetrates medially and places the median nerve and brachial artery at risk.
 
(From Choi PD, Skaggs DL. Closed reduction and percutaneous pinning of supracondylar fractures of the humerus. In: Wiesel S, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott William & Wilkins; 2010, with permission.)
The proximal metaphyseal spike penetrates laterally with posteromedially displaced fractures and places the radial nerve at risk; with posterolaterally displaced fractures, the spike penetrates medially and places the median nerve and brachial artery at risk.
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Figure 16-6
Relationship to neurovascular structures.
The proximal metaphyseal spike penetrates laterally with posteromedially displaced fractures and places the radial nerve at risk; with posterolaterally displaced fractures, the spike penetrates medially and places the median nerve and brachial artery at risk.
(From Choi PD, Skaggs DL. Closed reduction and percutaneous pinning of supracondylar fractures of the humerus. In: Wiesel S, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott William & Wilkins; 2010, with permission.)
The proximal metaphyseal spike penetrates laterally with posteromedially displaced fractures and places the radial nerve at risk; with posterolaterally displaced fractures, the spike penetrates medially and places the median nerve and brachial artery at risk.
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Radiographic Diagnosis of Supracondylar Fractures of the Distal Humerus

All patients with a history of a fall onto an outstretched hand as well as pain and inability to use the extremity should undergo a thorough radiologic evaluation. If physical examination does not localize the trauma to the elbow alone, this may include obtaining anteroposterior (AP) and lateral views of the entire upper extremity. Comparison views are rarely required by an experienced physician, but occasionally may be needed to evaluate an ossifying epiphysis. Beware that the emergency room physician's interpretation of elbow fractures in children has been reported to have an overall accuracy of only 53%.167 
Radiographic examination begins with a true AP view of the distal humerus. (In contrast, an AP of an elbow in 90 degrees of flexion will give a roughly 45-degree angulated view of the distal humerus and proximal radius and ulna.) A true AP of the distal humerus allows a more accurate evaluation of the distal humerus and decreases the error in determining Baumann's angle. The lateral film should be taken as a true lateral with the humerus held in the anatomic position and not externally rotated (Fig. 16-7). Oblique views of the distal humerus occasionally may be helpful when a supracondylar fracture or occult condylar fracture is suspected but not seen on standard AP and lateral views, but should not be routinely ordered to evaluate for a supracondylar fracture. 
Figure 16-7
X-ray positioning.
 
The correct method of taking a lateral view is with the upper extremity directed anteriorly rather than externally rotated.
The correct method of taking a lateral view is with the upper extremity directed anteriorly rather than externally rotated.
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Figure 16-7
X-ray positioning.
The correct method of taking a lateral view is with the upper extremity directed anteriorly rather than externally rotated.
The correct method of taking a lateral view is with the upper extremity directed anteriorly rather than externally rotated.
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Initial radiographs may be negative except for a posterior fat pad sign (Fig. 16-8). A series of patients with traumatic elbow pain and a posterior fat pad sign but no visible fracture found that 53% (18/34) had a SCH fracture, 26% (9/34) a fracture of the proximal ulna, 12% (4/34) a fracture of the lateral condyle, and 9% (3/34) a fracture of the radial neck.176 
Figure 16-8
 
A: Lateral radiograph demonstrating an elevated posterior fat pad (white arrow) and a normal hourglass which is anteriorly tilted if there is not a displaced fracture. B: Another example of an elevated fat pad.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Lateral radiograph demonstrating an elevated posterior fat pad (white arrow) and a normal hourglass which is anteriorly tilted if there is not a displaced fracture. B: Another example of an elevated fat pad.
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Figure 16-8
A: Lateral radiograph demonstrating an elevated posterior fat pad (white arrow) and a normal hourglass which is anteriorly tilted if there is not a displaced fracture. B: Another example of an elevated fat pad.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Lateral radiograph demonstrating an elevated posterior fat pad (white arrow) and a normal hourglass which is anteriorly tilted if there is not a displaced fracture. B: Another example of an elevated fat pad.
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Two main radiographic parameters are used to evaluate the presence of a supracondylar fracture. The anterior humeral line (AHL) should cross the capitellum on a true lateral of the elbow. Previous editions of this text and others have stated that in a normal elbow the AHL should pass through the middle third of the capitellum. However, it has been demonstrated in recent studies that in a normal elbow the AHL passes through the middle third of the capitellum only 52% of the time in children under 10 years of age, and in children younger than 4 years of age the AHL is equally likely to pass through the anterior third of the capitellum as the middle third (Fig. 16-9).87 In an extension-type supracondylar fracture, the capitellum is posterior to this line. Note that the “hourglass” should be tilted slightly forward in a true lateral view of a normal elbow (Fig. 16-8A) and can help aid in the diagnosis of a type II SCH fracture. 
Figure 16-9
Anterior humeral line should cross the capitellum on a true lateral of the elbow, though not necessarily through the middle third of the capitellum as was previously believed.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-9
Anterior humeral line should cross the capitellum on a true lateral of the elbow, though not necessarily through the middle third of the capitellum as was previously believed.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Baumann's angle, also referred to as the humeral capitellar angle, is the angle between the long axis of the humeral shaft and the physeal line of the lateral condyle (normal range, about 9 to 26 degrees) (Fig. 16-10). Interpretation of Baumann's angle is open to variability. One study reports one of five observers measure Baumann's angle from the same radiograph greater than 7 degrees different from the other four observers.169 A rule of thumb is that a Baumann's angle ≥10 degrees is OK. A decrease in Baumann's angle compared to the other side is a sign that a fracture is in varus angulation. 
Figure 16-10
Baumann's angle is between the line perpendicular to the long axis of the humeral shaft and the physeal line of the lateral condyle.
 
A decrease in Baumann's angle may indicate medial comminution.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
A decrease in Baumann's angle may indicate medial comminution.
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Figure 16-10
Baumann's angle is between the line perpendicular to the long axis of the humeral shaft and the physeal line of the lateral condyle.
A decrease in Baumann's angle may indicate medial comminution.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
A decrease in Baumann's angle may indicate medial comminution.
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If the AP and lateral views show a displaced type II or III supracondylar fracture but do not show full detail of the distal humeral fragment, we usually obtain further x-ray evaluation to define the fracture anatomy with particular emphasis on (a) impaction of the medial column, (b) supracondylar comminution, and (c) vertical split of the epiphyseal fragment. T-condylar fractures (Fig. 16-11) can initially appear to be supracondylar fractures, but these generally occur in children over 10 years of age, in whom supracondylar fractures are less likely (see Chapter 17). 
Figure 16-11
Occult T-condylar.
 
A: Original x-rays appear to show a type III posteromedial supracondylar fracture. B: After manipulation, the vertical intercondylar fracture line (arrows) was visualized.
A: Original x-rays appear to show a type III posteromedial supracondylar fracture. B: After manipulation, the vertical intercondylar fracture line (arrows) was visualized.
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Figure 16-11
Occult T-condylar.
A: Original x-rays appear to show a type III posteromedial supracondylar fracture. B: After manipulation, the vertical intercondylar fracture line (arrows) was visualized.
A: Original x-rays appear to show a type III posteromedial supracondylar fracture. B: After manipulation, the vertical intercondylar fracture line (arrows) was visualized.
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In a young child, an epiphyseal separation215 can mimic an elbow dislocation. In an epiphyseal separation, the fracture propagates through the physis without a metaphyseal fragment. This fracture occurs in very young children with primarily chondral epiphyses. On physical examination, the patient appears to have a supracondylar fracture with gross swelling about the elbow and marked discomfort. The key to making the diagnosis and differentiating this injury from an elbow dislocation radiographically is seeing that the capitellum remains aligned with the radial head. Usually a thin metaphyseal fragment, which may make one think of a lateral condyle fracture can be seen, which technically makes this a Salter II fracture (Fig. 16-12). In such cases, more data is required to initiate treatment. An arthrogram may be helpful (Fig. 16-13). In selected patients, magnetic resonance imaging or ultrasonography215 may also aid in evaluating the injury to the unossified epiphysis. 
Figure 16-12
 
A: Twelve-month-old, Salter II fracture resulting from child abuse. Note the radius points to the capitellum in all views, so this is not a dislocation. B: Lateral view. C: Oblique view shows the thin metaphyseal fragment, which defines this as a Salter II fracture. D: This fracture was not recognized at presentation to the emergency department. This AP view is 1-month-old. E: Lateral view 1 month after injury.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Twelve-month-old, Salter II fracture resulting from child abuse. Note the radius points to the capitellum in all views, so this is not a dislocation. B: Lateral view. C: Oblique view shows the thin metaphyseal fragment, which defines this as a Salter II fracture. D: This fracture was not recognized at presentation to the emergency department. This AP view is 1-month-old. E: Lateral view 1 month after injury.
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A: Twelve-month-old, Salter II fracture resulting from child abuse. Note the radius points to the capitellum in all views, so this is not a dislocation. B: Lateral view. C: Oblique view shows the thin metaphyseal fragment, which defines this as a Salter II fracture. D: This fracture was not recognized at presentation to the emergency department. This AP view is 1-month-old. E: Lateral view 1 month after injury.
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Figure 16-12
A: Twelve-month-old, Salter II fracture resulting from child abuse. Note the radius points to the capitellum in all views, so this is not a dislocation. B: Lateral view. C: Oblique view shows the thin metaphyseal fragment, which defines this as a Salter II fracture. D: This fracture was not recognized at presentation to the emergency department. This AP view is 1-month-old. E: Lateral view 1 month after injury.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Twelve-month-old, Salter II fracture resulting from child abuse. Note the radius points to the capitellum in all views, so this is not a dislocation. B: Lateral view. C: Oblique view shows the thin metaphyseal fragment, which defines this as a Salter II fracture. D: This fracture was not recognized at presentation to the emergency department. This AP view is 1-month-old. E: Lateral view 1 month after injury.
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A: Twelve-month-old, Salter II fracture resulting from child abuse. Note the radius points to the capitellum in all views, so this is not a dislocation. B: Lateral view. C: Oblique view shows the thin metaphyseal fragment, which defines this as a Salter II fracture. D: This fracture was not recognized at presentation to the emergency department. This AP view is 1-month-old. E: Lateral view 1 month after injury.
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Figure 16-13
 
A: Salter II fracture in a 20-month-old is a bit easier to appreciate on arthrogram. B: Lateral view after reduction and pinning.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Salter II fracture in a 20-month-old is a bit easier to appreciate on arthrogram. B: Lateral view after reduction and pinning.
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Figure 16-13
A: Salter II fracture in a 20-month-old is a bit easier to appreciate on arthrogram. B: Lateral view after reduction and pinning.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Salter II fracture in a 20-month-old is a bit easier to appreciate on arthrogram. B: Lateral view after reduction and pinning.
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Supracondylar Fractures of the Distal Humerus Classification (Table 16-1)

Table 16-1
Modified Gartland Classification of Supracondylar Fractures
Comments
Type I Undisplaced Fat pad present acutely
Type II Hinged posteriorly Anterior humeral line anterior to capitellum
Type III Displaced No meaningful cortical continuity
Type IV Displaces into extension and flexion Usually diagnosed with manipulation under fluoroscopic imaging
Medial comminution (not truly a separate type) Collapse of medial column Loss of Baumann's angle
X
A modified Gartland classification of SCH fractures is the most commonly accepted and used system.3,72,140,187 The modified Gartland classification had higher K values for intra- and interobserver variability than did fracture-classification systems previously studied according to a study by Barton et al.18 

Type I

A Gartland type I fracture is a nondisplaced or minimally displaced (<2 mm) supracondylar fracture with an intact AHL. There may or may not be any evidence of osseous injury: The posterior fat pad sign may be the only evidence of fracture. There should be an intact olecranon fossa, no medial or lateral displacement, no medial column collapse, and a normal Baumann's angle. These fractures are stable. 

Type II

A Gartland type II fracture is a displaced (>2 mm) supracondylar fracture with a presumably intact, yet hinged, posterior cortex. The AHL is usually anterior to the capitellum on a true lateral of the elbow (Fig. 16-14), though in mildly displaced fractures, the AHL may touch the capitellum (Fig. 16-15). Because of the intact posterior hinge there is generally little or no rotational deformity on an AP radiograph. In common usage, significant rotational deformity noted on an AP view, such as a loss of Baumann's angle, leads some to call the fracture a type III fracture. However, the presence of cortical contact technically means it is a worse type II but not a type III fracture. 
Figure 16-14
 
A: Type II SCH fracture with anterior humeral line anterior to the capitellum. B: AP radiograph of a type II SCH fracture in a 6-year-old girl. Note that Baumann's angle is intact. C: In the reduced position the anterior humeral line crosses the capitellum. D: AP radiograph following reduction and pinning. Note the good position of the pins demonstrating wide separation of the pins at the fracture site.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Type II SCH fracture with anterior humeral line anterior to the capitellum. B: AP radiograph of a type II SCH fracture in a 6-year-old girl. Note that Baumann's angle is intact. C: In the reduced position the anterior humeral line crosses the capitellum. D: AP radiograph following reduction and pinning. Note the good position of the pins demonstrating wide separation of the pins at the fracture site.
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A: Type II SCH fracture with anterior humeral line anterior to the capitellum. B: AP radiograph of a type II SCH fracture in a 6-year-old girl. Note that Baumann's angle is intact. C: In the reduced position the anterior humeral line crosses the capitellum. D: AP radiograph following reduction and pinning. Note the good position of the pins demonstrating wide separation of the pins at the fracture site.
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Figure 16-14
A: Type II SCH fracture with anterior humeral line anterior to the capitellum. B: AP radiograph of a type II SCH fracture in a 6-year-old girl. Note that Baumann's angle is intact. C: In the reduced position the anterior humeral line crosses the capitellum. D: AP radiograph following reduction and pinning. Note the good position of the pins demonstrating wide separation of the pins at the fracture site.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: Type II SCH fracture with anterior humeral line anterior to the capitellum. B: AP radiograph of a type II SCH fracture in a 6-year-old girl. Note that Baumann's angle is intact. C: In the reduced position the anterior humeral line crosses the capitellum. D: AP radiograph following reduction and pinning. Note the good position of the pins demonstrating wide separation of the pins at the fracture site.
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A: Type II SCH fracture with anterior humeral line anterior to the capitellum. B: AP radiograph of a type II SCH fracture in a 6-year-old girl. Note that Baumann's angle is intact. C: In the reduced position the anterior humeral line crosses the capitellum. D: AP radiograph following reduction and pinning. Note the good position of the pins demonstrating wide separation of the pins at the fracture site.
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Figure 16-15
Lateral radiograph of an elbow with a supracondylar humerus fracture (black arrows) and an elevated posterior fat pad (white arrows).
 
The anterior humeral line (thin white line) passes through the capitellum, but not through the middle third, so some posterior angulation is present. This fracture may be considered borderline between a type II fracture (since there is some posterior angulation) and a type I fracture, as the anterior humeral line touches the capitellum.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
The anterior humeral line (thin white line) passes through the capitellum, but not through the middle third, so some posterior angulation is present. This fracture may be considered borderline between a type II fracture (since there is some posterior angulation) and a type I fracture, as the anterior humeral line touches the capitellum.
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Figure 16-15
Lateral radiograph of an elbow with a supracondylar humerus fracture (black arrows) and an elevated posterior fat pad (white arrows).
The anterior humeral line (thin white line) passes through the capitellum, but not through the middle third, so some posterior angulation is present. This fracture may be considered borderline between a type II fracture (since there is some posterior angulation) and a type I fracture, as the anterior humeral line touches the capitellum.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
The anterior humeral line (thin white line) passes through the capitellum, but not through the middle third, so some posterior angulation is present. This fracture may be considered borderline between a type II fracture (since there is some posterior angulation) and a type I fracture, as the anterior humeral line touches the capitellum.
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Type III

A Gartland type III fracture is a displaced supracondylar fracture with no meaningful cortical contact (Figs. 16-16 and 16-17). There is usually extension in the sagittal plane and rotation in the frontal and/or transverse planes. The periosteum is extensively torn, and soft tissue and neurovascular injuries often accompany this fracture. 
Figure 16-16
Type III supracondylar fracture.
 
AP view shows overlap of distal and proximal fragments.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
AP view shows overlap of distal and proximal fragments.
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Figure 16-16
Type III supracondylar fracture.
AP view shows overlap of distal and proximal fragments.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
AP view shows overlap of distal and proximal fragments.
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Figure 16-17
Lateral view of fracture demonstrating no meaningful cortical continuity.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-17
Lateral view of fracture demonstrating no meaningful cortical continuity.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Type IV

Leitch et al. retrospectively reviewed 297 displaced extension-type supracondylar fractures and described 9 of 297 (3%) with multidirectional instability. These fractures are characterized by an incompetent periosteal hinge circumferentially and defined by being unstable in both flexion and extension.118 This multidirectional instability is usually determined under anesthesia at the time of operation when on a lateral view the capitellum is anterior to the AHL with elbow flexion, and posterior to the AHL with elbow extension (Figs. 16-18 and 16-19). This pattern of instability may be because of the initial injury sustained or may occur iatrogenically during repeated attempted reductions. Classifying this as a separate type of fracture is warranted as it has treatment implications, as discussed later in this chapter, and has gained wide acceptance.3 
Figure 16-18
Intraoperative imaging demonstrates distal fragment falls into extension.
 
(From Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006; 88(5):980–985.)
(From 


Leitch KK,

Kay RM,

Femino JD
, et al.
Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture.
J Bone Joint Surg Am.
2006;
88(5):980–985.)
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Figure 16-18
Intraoperative imaging demonstrates distal fragment falls into extension.
(From Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006; 88(5):980–985.)
(From 


Leitch KK,

Kay RM,

Femino JD
, et al.
Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture.
J Bone Joint Surg Am.
2006;
88(5):980–985.)
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X
Figure 16-19
As the elbow is flexed the distal fragment falls into flexion, thus defining a Gartland type IV fracture.
 
(From Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type IV fracture. J Bone Joint Surg Am. 2006; 88(5):980–985.)
(From 


Leitch KK,

Kay RM,

Femino JD
, et al.
Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type IV fracture.
J Bone Joint Surg Am.
2006;
88(5):980–985.)
View Original | Slide (.ppt)
Figure 16-19
As the elbow is flexed the distal fragment falls into flexion, thus defining a Gartland type IV fracture.
(From Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type IV fracture. J Bone Joint Surg Am. 2006; 88(5):980–985.)
(From 


Leitch KK,

Kay RM,

Femino JD
, et al.
Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type IV fracture.
J Bone Joint Surg Am.
2006;
88(5):980–985.)
View Original | Slide (.ppt)
X

Alternative Classification System of Supracondylar Fractures of the Distal Humerus

An alternative classification system has been described in 2006 that could cause confusion as it unfortunately uses similar terms (type I to IV) as the established Gartland Classification, but with different definitions.179 According to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Pediatric Comprehensive Classification, these fractures are classified with regard to the degree of displacement at four levels (I to IV): No displacement (type I), displacement in one plane (type II), rotation of the distal fragment with displacement in two planes (type III), and rotation with displacement in three planes (or no contact between bone fragments) (type IV).179 

The Special Case of Medial Comminution in Supracondylar Fractures of the Distal Humerus

A potential pitfall is to underappreciate the extent of loss of normal alignment in fractures with comminution and collapse of the medial column (Fig. 16-20). Medial collapse signifies malrotation in the frontal plane (which defines the injury as at least a type II fracture) and is associated with a loss of Baumann's angle and varus malalignment. The lateral view (Fig. 16-21) may show reasonable alignment, which may lull the inexperienced into not appreciating the seriousness of this fracture, which requires reduction and usually pin fixation to prevent late malunion. 
Figure 16-20
Medial comminution is a subtle radiographic finding and indicates a more unstable variant which may collapse into varus if not treated appropriately.
 
From Staying Out of Trouble in Pediatric Orthopaedics.
 
(From Tolo VT, Skaggs DL, eds. Masters Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
From Staying Out of Trouble in Pediatric Orthopaedics.
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Figure 16-20
Medial comminution is a subtle radiographic finding and indicates a more unstable variant which may collapse into varus if not treated appropriately.
From Staying Out of Trouble in Pediatric Orthopaedics.
(From Tolo VT, Skaggs DL, eds. Masters Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
From Staying Out of Trouble in Pediatric Orthopaedics.
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Figure 16-21
Note the lateral view does not show significant displacement.
 
This view alone would suggest nonoperative treatment may be sufficient.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
This view alone would suggest nonoperative treatment may be sufficient.
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Figure 16-21
Note the lateral view does not show significant displacement.
This view alone would suggest nonoperative treatment may be sufficient.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
This view alone would suggest nonoperative treatment may be sufficient.
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Bahk et al.16 reported that fractures with greater than 10 degrees of obliquity in the coronal plane or 20 degrees in the sagittal plane were more likely than fractures with less obliquity to result in malunion. 

Signs and Symptoms of Supracondylar Fractures of the Distal Humerus

An elbow or forearm fracture should be suspected in a child with elbow pain or failure to use the upper extremity after a fall. A careful examination of the entire arm should be performed, and any area with tenderness or swelling should have radiographs as multiple fractures (such as a supracondylar fracture and a radius/ulna fracture) are not uncommon (Fig. 16-22). In children with acute elbow pain and failure to use the upper extremity, the differential diagnosis should include fracture, nursemaid's elbow, inflammatory arthritis, and infection. 
Figure 16-22
Occult ipsilateral fracture.
 
Type II supracondylar fracture (open arrow) with an occult distal radial fracture (solid arrows).
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
Type II supracondylar fracture (open arrow) with an occult distal radial fracture (solid arrows).
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Figure 16-22
Occult ipsilateral fracture.
Type II supracondylar fracture (open arrow) with an occult distal radial fracture (solid arrows).
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
Type II supracondylar fracture (open arrow) with an occult distal radial fracture (solid arrows).
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With a type I supracondylar fracture, there is tenderness about the distal humerus and restriction of motion, particularly lack of full elbow extension. X-rays may be negative except for a posterior fat pad sign. In type III fractures, gross displacement of the elbow is evident (Fig. 16-23). 
Figure 16-23
 
A: Clinical appearance. B: The S-shaped configuration is created by the anterior prominence of the proximal fragment's spike and extension of the distal fragment.
A: Clinical appearance. B: The S-shaped configuration is created by the anterior prominence of the proximal fragment's spike and extension of the distal fragment.
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Figure 16-23
A: Clinical appearance. B: The S-shaped configuration is created by the anterior prominence of the proximal fragment's spike and extension of the distal fragment.
A: Clinical appearance. B: The S-shaped configuration is created by the anterior prominence of the proximal fragment's spike and extension of the distal fragment.
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An anterior pucker sign may be present if the proximal fragment has penetrated the brachialis and the anterior fascia of the elbow (Fig. 16-24). Skin puckering results from the proximal segment piercing the brachialis muscle and engaging the deep dermis. This is a sign of considerable soft tissue damage. If any bleeding from a punctate wound is present, this should be considered an open fracture. 
Figure 16-24
The pucker sign.
 
This patient had penetration of the proximal fragment's spike into the subcutaneous tissue. In the AP view (A), there is a large puckering or defect in the skin where the distal fragment has pulled the skin inward. Laterally (B), there is puckering of the skin (arrow) in the area where the spike has penetrated into the subcutaneous tissue.
This patient had penetration of the proximal fragment's spike into the subcutaneous tissue. In the AP view (A), there is a large puckering or defect in the skin where the distal fragment has pulled the skin inward. Laterally (B), there is puckering of the skin (arrow) in the area where the spike has penetrated into the subcutaneous tissue.
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Figure 16-24
The pucker sign.
This patient had penetration of the proximal fragment's spike into the subcutaneous tissue. In the AP view (A), there is a large puckering or defect in the skin where the distal fragment has pulled the skin inward. Laterally (B), there is puckering of the skin (arrow) in the area where the spike has penetrated into the subcutaneous tissue.
This patient had penetration of the proximal fragment's spike into the subcutaneous tissue. In the AP view (A), there is a large puckering or defect in the skin where the distal fragment has pulled the skin inward. Laterally (B), there is puckering of the skin (arrow) in the area where the spike has penetrated into the subcutaneous tissue.
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Careful motor, sensory, and vascular examinations should be performed in all patients; this may be quite difficult in a young child but should be attempted. Sensation should be tested in discrete sensory areas of the radial nerve (dorsal first web space), median nerve (palmar index finger tip), and ulnar nerve (ulnar side little finger tip). If a child is not cooperative or has altered mental status, a wet cloth may be wrapped around the hand and check for wrinkling of the skin, though in practice this is rarely done. Motor examination should include finger, wrist, and thumb extension (radial nerve), index finger distal interphalangeal flexion and thumb interphalangeal flexion (anterior interosseous nerve, or AIN), finger flexion strength (median), and interossei (ulnar nerve) muscle function. In young children the interosseous nerve may be tested by asking the child to pinch something with their thumb and first finger, while palpating the first dorsal interosseous for muscle contracture. If you cannot determine sensory and/or motor function accurately preoperatively, it should be recorded as such in the chart and communicated clearly to all caregivers. Misinformation preoperatively makes decision making postoperatively difficult when a nerve deficit is discovered. 
The vascular examination should include determining the presence of pulse, as well as warmth, capillary refill, and color of the hand. Assessment of the vascular status is essential, as series report up to 20% of displaced fractures present with vascular compromise.33,42,147,166 The vascular status may be classified into one of three categories. 
  1.  
    Hand well perfused (warm and red), radial pulse present.
  2.  
    Hand well perfused, (warm and red) radial pulse absent.
  3.  
    Hand poorly perfused (cool and blue or blanched), radial pulse absent.
During the physical examination, a very high index of suspicion is needed in order not to miss a developing compartment syndrome in fractures with considerable swelling and/or ecchymosis, anterior skin puckering, and/or absent pulse, which are red flags for possible compartment syndrome. Tenseness of the volar compartment should be evaluated, and the amount of swelling about the elbow should be noted. Pain with passive finger extension and flexion should be tested and the findings should be accurately recorded. Recent studies show that increasing anxiety and need for pain medicine may be the earliest warning of compartment syndrome. (Pediatric patients with compartment syndromes often present with the 3 A's: Anxiety, agitation, and increasing analgesic requirement.) In the initial examination of a child with a severe supracondylar fracture with high parental and patient anxiety, it is easy to overlook vital information. 

Treatment Options for Supracondylar Fractures of the Distal Humerus (Table 16-2)

 
Table 16-2
Current Treatment Options
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Table 16-2
Current Treatment Options
PRO CON
Casting in situ Good for type I fractures Not for displaced fractures
Closed reduction and casting No surgery Cannot reliably hold reduction.
Risks compartment syndrome if elbow flexed to hold reduction.
X-rays difficult to interpret in flexed position.
Closed reduction and pinning Predictable good outcome
Few complications
Can be technically challenging to the inexperienced
Open reduction and pinning Allows exposure and repair of neurovascular structures.
Removes impediments to reduction.
Can make fracture less stable if periosteum is taken down with exposure.
Scarring.
Traction Salvage for rare severely comminuted fractures.
Rarely if ever used at major centers.
Prolonged hospitalization
Malunion
X

Initial Management of Supracondylar Fractures of the Distal Humerus

Displaced supracondylar fractures requiring a reduction should be initially splinted with the elbow in a comfortable position of approximately 20 to 40 degrees of flexion, while avoiding tight bandaging or splinting. Excessive flexion or extension may compromise the limb's vascularity and increase compartment pressure.20,124 The elbow and hand should then be gently elevated above the heart. A careful examination of the neurologic and vascular status is vital in all patients with a supracondylar fracture as well as an assessment of the potential for compartment syndrome. The remainder of the limb should be assessed for other injuries and radiographs should include any area which is tender, swollen, or lacks motion. 

Urgency of Treatment of Supracondylar Fractures of the Distal Humerus

Several studies have concluded that delay of surgery of 8 to 21 hours did not have any deleterious effects on the outcomes of children with supracondylar fractures.82,93,117,129,168 These studies were all retrospective and may have reported good results in large part because of the selection bias of experienced pediatric orthopedic surgeons selecting which fractures required urgent treatment. Although there is little published data to support our opinion, we and others believe that if conditions such as poor perfusion, an associated forearm fracture, firm compartments, skin puckering, antecubital ecchymosis, or very considerable swelling are present, operative treatment should not be delayed.3,152 

How Late Can Fractures be Reduced?

Little has been written about how long after injury a fracture can still be closed reduced. Silva et al. reported on 42 type II SCH fractures which were treated 7 to 15 days after injury. They found closed anatomic reduction was achieved in all fractures, with equal outcomes to fractures treated within 7 days of injury.170 We would caution that in very young children reliable fracture reduction 2 weeks after injury as early callus formation is less likely. Two children closed reduced 8 days after injury developed avascular necrosis of the trochlea.170 Though these numbers are small, this phenomena seems worthy of further study. 

Closed Reduction and Casting

Closed reduction and casting is still performed in some orthopedic centers. Most pediatric orthopedic surgeons now reserve cast immobilization for stable, nondisplaced fractures (type I) and closed reduction with percutaneous pinning for all unstable, displaced fractures (types II and III). Mildly displaced fractures can be reduced closed, using the intact posterior periosteum as a stabilizing force and then holding reduction by flexing the elbow greater than 120 degrees. Less flexion increases the risk of loss of reduction. Immobilization techniques include collar and cuff sling or casting with careful antecubital fossa and olecranon relief and padding. The concern with closed reduction and flexion >120 degrees is the risk of vascular compromise and/or compartment syndrome in the presence of anterior swelling and compression. As mentioned, mild fractures treated closed (type II) need to be monitored closely for neurovascular compromise and loss of reduction. Follow-up radiographs can be difficult to interpret with elbow flexion >120 degrees. If necessary, rereduction or conversion to pinning needs to occur before full healing occurs so close radiographic follow-up is necessary in the first 3 weeks. 

Closed Reduction and Pinning

This is the most common operative treatment of supracondylar fractures. An initial attempt at closed reduction is indicated in almost all displaced supracondylar fractures that are not open fractures. Under general anesthesia the fracture is first reduced in the frontal plane with fluoroscopic verification. The elbow is then flexed while pushing the olecranon anteriorly to correct the sagittal deformity and reduce the fracture. Criteria for an acceptable reduction include restoration of Baumann's angle (which is generally >10 degrees) on the AP view, intact medial and lateral columns on oblique views, and the AHL passing through the middle third of the capitellum on the lateral view. As there is considerable rotation present at the shoulder, minor rotational malalignment in the axial plane can be tolerated at the fracture site. However, any rotational malalignment is detrimental to fracture stability, so if present, be extra careful in assessing stability of reduction, and probably use a third pin. 
The fracture reduction is held with two to three Kirschner wires (K-wires), as discussed later in this chapter. The elbow is immobilized in 40 to 60 degrees of flexion, depending on the amount of swelling and vascular status. If there is a considerable gap in the fracture site or the fracture is irreducible with a so-called rubbery feeling on attempted reduction, the median nerve and/or brachial artery may be trapped in the fracture site and an open reduction should be performed (Fig. 16-25). 
Figure 16-25
Brachial artery and median nerve may be trapped at the fracture site.
 
If a reduction feels rubbery, and a gap at the fracture site is seen on imaging, entrapment is possible, especially in the setting of vascular compromise or median nerve or anterior interosseous nerve injury.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
If a reduction feels rubbery, and a gap at the fracture site is seen on imaging, entrapment is possible, especially in the setting of vascular compromise or median nerve or anterior interosseous nerve injury.
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Figure 16-25
Brachial artery and median nerve may be trapped at the fracture site.
If a reduction feels rubbery, and a gap at the fracture site is seen on imaging, entrapment is possible, especially in the setting of vascular compromise or median nerve or anterior interosseous nerve injury.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
If a reduction feels rubbery, and a gap at the fracture site is seen on imaging, entrapment is possible, especially in the setting of vascular compromise or median nerve or anterior interosseous nerve injury.
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Crossed Pins Versus Lateral-Entry Pins

The two main issues with crossed pin versus lateral-entry pinning of SCH fractures are: (1) Risk of ulnar nerve injury and (2) risk of loss of reduction. Iatrogenic injury to the ulnar nerve with use of crossed pins has been reported to be as low as 0% but two large series of supracondylar fractures have shown the prevalence to be 5% (17 of 345) and 6% (19 of 331).31,38,92,120,154,159,175,211 Others have reported that these injuries occur more commonly.159,204 
Three recent meta-analysis have examined the issue of pin configuration and iatrogenic nerve injury. Slobogean et al.,178 in 2010 reported on 32 trials with 2,639 patients and found there is an iatrogenic ulnar nerve injury for every 28 patients treated with crossed pins compared to lateral pinning. Babal et al.13 in 2010 reported on a systematic review of 35 articles discussing medial and lateral pinning versus lateral-entry pinning and found that iatrogenic ulnar nerve injury occurred in 40 of 1,171 (3.4%) of cross pins and 5 of 738 (0.7%) of lateral-entry pins. Woratanarat et al. in 2012 included 18 studies and 1,615 SCH fractures. They reported the risk of iatrogenic ulnar nerve injury to be 4.3 times higher in cross pinning compared to lateral pinning. They found no difference in loss of fixation, late deformity, or Flynn criteria between the two types of pinning.206 
In addition, several clinical studies reporting no difference in loss of reduction between lateral-entry pins and cross-pin fixation,73,121,208 or good results with lateral pins alone.116,173 Although rare, radial nerve laceration by a medially inserted K-wire has been reported.59 A prospective, surgeon-randomized study was performed on 104 children with type III SCH fractures, with surgeons using their preferred techniques of cross pins or lateral-entry pins. The authors found no statistical difference in the radiographic outcomes between lateral-entry and cross-pin techniques, but two cases of iatrogenic injury to the ulnar nerve occurred with medially placed pins.73 
Zaltz et al.211 reported that in children less than 5 years of age, when the elbow is flexed more than 90 degrees, the ulnar nerve migrated over, or even anterior to, the medial epicondyle in 61% (32/52) of children. Wind et al.204 showed that the location of the ulnar nerve cannot be adequately determined by palpation to allow blind medial pinning. Unfortunately, even making an incision over the medial epicondyle to make certain the ulnar nerve is not directly injured by a pin does not ensure protection of the nerve.175 
In a series of six cases of iatrogenic ulnar nerve injuries with early exploration, the nerve was directly penetrated by the pin in two of six cases (33.3%), with constriction of the cubital tunnel occurring in three of six cases (50%), and the nerve being fixed anterior to the medial epicondyle in one of six (16.7%) cases.154 Thus even if direct penetration of the ulnar nerve is avoided, simply placing a medial epicondyle entry pin adjacent to the nerve may cause injury presumably by constriction of the cubital tunnel or kinking of the nerve. Iatrogenic ulnar nerve injuries usually resolve, but there have been several reports of permanent iatrogenic ulnar nerve injuries.151,154,175 
Skaggs et al.175 reported a series of 345 SCH fractures treated by percutaneous pinning and showed that the use of a medial pin was associated with a 4% (6/149) risk of ulnar nerve injury when the medial pin was placed without hyperflexion and 15% (11/71) if the medial pin was placed with hyperflexion. None of the 125 fractures treated with lateral-entry pins alone resulted in iatrogenic injury. This is consistent with the findings of Zaltz et al.211 of anterior subluxation of the ulnar nerve with elbow flexion beyond 90 degrees. Thus one apparently undeniable conclusion is that if a medial pin is used, place the lateral pin(s) first, then extend the elbow and place the medial pin without hyperflexion of the elbow. Of course, the simplest way to avoid iatrogenic nerve injuries is not to place a medial pin. In a series of 124 consecutive fractures stabilized with lateral-entry pins, regardless of displacement or fracture stability, no iatrogenic ulnar nerve injuries were reported.173 
The second issue with pin configuration is stability of pin configuration. Biomechanical studies of stability of various pin configurations have been somewhat misleading. Two studies evaluated the torsional strength of pin configurations and found crossed pins to be stronger than two lateral pins.141,213 Unfortunately, in these studies the two lateral pins were placed immediately adjacent to each other and not separated at the fracture site as is recommended clinically for lateral-entry pins.86,163,173 In synthetic humeri study, Srikumaran et al.184 found cross pins to be stronger than two lateral-entry pins, but did not test three lateral-entry pins. Lee et al.115 found that two divergent lateral pins separated at the fracture site were superior to crossed pins in extension loading and varus but were equivalent in valgus (Fig. 16-26). The greater strength seen with divergence of the pins was attributed to the location of the intersection of the two pins and greater divergence between the two pins, which would allow for some purchase in the medial column as well as the lateral column (Figs. 16-4 and 16-5). 
Figure 16-26
 
Three pinning techniques in study by Lee et al.116 A: Crossed: One medial and one lateral pin. B: Divergent: Two divergent lateral pins. C: Parallel: Two parallel lateral pins.
Three pinning techniques in study by Lee et al.116 A: Crossed: One medial and one lateral pin. B: Divergent: Two divergent lateral pins. C: Parallel: Two parallel lateral pins.
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Figure 16-26
Three pinning techniques in study by Lee et al.116 A: Crossed: One medial and one lateral pin. B: Divergent: Two divergent lateral pins. C: Parallel: Two parallel lateral pins.
Three pinning techniques in study by Lee et al.116 A: Crossed: One medial and one lateral pin. B: Divergent: Two divergent lateral pins. C: Parallel: Two parallel lateral pins.
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Bloom et al.26 reported three lateral divergent pins were equivalent to cross pinning and both were stronger than two lateral divergent pins. Another study with simulated medial comminution showed three lateral divergent pins had equivalent torsional stability to standard medial and lateral crossed pinning.114 Feng et al.60 reported that two and three lateral-entry pins had comparable construct stiffness to each other, and both were greater than crossed pins to all types of stress, except in valgus, in which cross pins had greater stiffness. Thus, contemporary biomechanical studies mostly support clinical recommendations of lateral-entry pins.3,140,163,173 
In a biomechanical study of synthetic humeri, Gottschalk et al.79 reported that construct strength increased when pin size was increased from 1.6 to 2 mm, but did not increase when a third pin was added. Srikumaran et al.184 also reported increased stability with 2.8-mm pins compared with 1.6-mm pins in any configuration in synthetic humeri. The same group reported that in a clinical series of 159 patients larger pins led to less loss of fracture reduction in the sagittal plane. Simply, the bigger the pin, the more stable the fixation.186 
Skaggs et al. demonstrated no malunions or loss of fixation in a series of 124 consecutive fractures treated with lateral-entry pins. From this successful series, combined with a failure analysis of eight fractures performed outside of this series they concluded the important technical points for fixation with lateral-entry pins are: (1) Maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins, and the use of three pins for type III fractures.173 Gordon et al.77 further validated this point by recommending two lateral pins initially for type III fractures then stressing the fixation under fluoroscopy to determine the need for an additional third lateral pin. Lee et al. reported 92% excellent clinical results using three lateral pins in 61 consecutive type II and II fractures. They found no loss of reduction of any fracture, no cubitus varus, no hyperextension or loss of motion, no iatrogenic nerve injury, no additional surgery, and one patient with a minor pin track infection.116 
Intraoperative stability testing of lateral-entry pin fixation has been advocated. In a study of 21 children with type III fractures, after closed fracture reduction, two lateral-entry pins were inserted.212 Stability was then assessed by comparing lateral fluoroscopic images in internal and external rotation. If the fracture remained rotationally unstable, a third lateral-entry wire was inserted, and images were repeated. A medial wire was used only if instability was demonstrated after the insertion of three lateral wires. Rotational stability was achieved with two lateral-entry wires in six cases, three lateral-entry wires in 10 cases, and with an additional medial wire in five cases. No patients required a reoperation using this protocol. The authors concluded that supracondylar fractures that are rotationally stable intraoperatively after wire fixation are unlikely to displace postoperatively. It is notable that they found 26% of these type III fractures were rotationally stable with two lateral-entry wires. 
In a study of eight other cases of SCH fractures, which lost reduction, Sankar et al. reported loss of fixation in all cases was because of technical errors that were identifiable on the intraoperative fluoroscopic images and that could have been prevented with proper technique. They identified three types of pin-fixation errors: (1) Failure to engage both fragments with two pins or more, (2) failure to achieve bicortical fixation with two pins or more, and (3) failure to achieve adequate pin separation (>2 mm) at the fracture site.163 A systematic review of 35 articles reported loss of reduction in 0 of 849 of crossed pins and 4 of 606 (0.7%) of lateral-entry pins.29 Based upon this study and the previous series by Skaggs et al.,173 we recommend a minimum of two pins for a type II fracture and three pins for a type III fracture. 
Two prospective randomized clinical trial comparing lateral- and cross-pinning techniques in the treatment of displaced SCH fractures showed no statistically significant difference between the two treatment groups in any radiographic or clinical outcome measures103,192 including nerve injury. It is interesting that following the randomized clinical trial103 the same eight surgeons who pretrial used cross pins in 59% of SCH fractures changed their practice to use cross pins in only 15% of cases posttrial.122 
Dorgan's technique has been described in which cross pins are used, with the medial column pin placed from the lateral side, in a proximal–lateral to distal–medial direction, with the potential benefit being avoiding iatrogenic injury to the ulnar nerve. Potential downsides to this technique include iatrogenic injury to the radial nerve, technical difficulty of precise pin placement, and a higher reported infection rate (7%) than other techniques.150 
An alternative technique using antegrade insertion of elastic intramedullary nailing has been described.54 Using this technique, in a retrospective study of 127 patients, the authors reported 6% (7/127) had long-term functional loss of motion, 5% malunion (7/127) but no ulnar nerve injury and no secondary surgeries. The authors cite avoidance of iatrogenic ulnar nerve injury and not using a cast as advantages of this technique (Fig. 16-27).110 
Figure 16-27
When the tips were being advanced into the metaphysis, the more distally implanted nail is rotated 180 degrees toward the medial column.
 
Correspondingly, the tip of the most proximally inserted nail remained directed laterally. Both nails are advanced one at a time by T-handle or gentle hammer blows as far as a few millimeters proximal to the fracture line. Progression of the nails into the distal humerus is controlled under fluoroscopy and both implants reliably introduced into the distal fragment to impact the nails into the distal metaphyseal bone.
 
(Adapted from Dietz HG, Schmittenbecher PP, Slongo T, et al. AO Manual of Fracture Management: Elastic Stable Intramedullary Nailing in Children. Stuttgart: Thieme Medical Publishers; 2006:53–62. Copyright and permission by AO Foundation, Davos, Switzerland.)
Correspondingly, the tip of the most proximally inserted nail remained directed laterally. Both nails are advanced one at a time by T-handle or gentle hammer blows as far as a few millimeters proximal to the fracture line. Progression of the nails into the distal humerus is controlled under fluoroscopy and both implants reliably introduced into the distal fragment to impact the nails into the distal metaphyseal bone.
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Figure 16-27
When the tips were being advanced into the metaphysis, the more distally implanted nail is rotated 180 degrees toward the medial column.
Correspondingly, the tip of the most proximally inserted nail remained directed laterally. Both nails are advanced one at a time by T-handle or gentle hammer blows as far as a few millimeters proximal to the fracture line. Progression of the nails into the distal humerus is controlled under fluoroscopy and both implants reliably introduced into the distal fragment to impact the nails into the distal metaphyseal bone.
(Adapted from Dietz HG, Schmittenbecher PP, Slongo T, et al. AO Manual of Fracture Management: Elastic Stable Intramedullary Nailing in Children. Stuttgart: Thieme Medical Publishers; 2006:53–62. Copyright and permission by AO Foundation, Davos, Switzerland.)
Correspondingly, the tip of the most proximally inserted nail remained directed laterally. Both nails are advanced one at a time by T-handle or gentle hammer blows as far as a few millimeters proximal to the fracture line. Progression of the nails into the distal humerus is controlled under fluoroscopy and both implants reliably introduced into the distal fragment to impact the nails into the distal metaphyseal bone.
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Open Reduction

Open reduction is indicated in cases of failed closed reduction, a loss of pulse or poorly perfused hand following reduction, and open fractures. In the past, open reductions led to concerns of elbow stiffness, myositis ossificans, ugly scarring, and iatrogenic neurovascular injury. However, several reports have shown the low rate of complications associated with open reduction, and this is in the setting of more severe soft tissue and bony injuries. Weiland et al.198 reported on 52 displaced fractures treated with open reduction via a lateral approach. There was a 10% (5 of 52) rate of moderate loss of motion but no cases of infection, nonunion, or myositis ossificans. A series by Fleuriau-Chateau et al.62 of 34 patients treated with open reduction via an anterior approach reported a 6% (2 of 34) unsatisfactory loss of motion but no cases of infection, myositis ossificans, malunion, or Volkmann contracture. Reitman et al.156 reported that 8% of 862 consecutive supracondylar fractures were treated with open reduction. The reasons for open reduction rather than conventional closed reduction percutaneous pinning were irreducible fractures, vascular compromise, open fractures, and entrapped nerves. The open reduction was performed via the torn periosteum either anteromedial or anterolateral depending on direction of distal fragment displacement. Seventy-eight percent (51) of 65 patients had an excellent or good result according to the criteria of Flynn and Zink.64 Loss of motion was reported in four cases. Ay et al.12 found no loss of motion or clinical deformity in 61 patients treated with open reduction. In a prospective, randomized controlled study of 28 children, Kaewpornsawan95 compared closed reduction and percutaneous pin fixation with open reduction (through a lateral approach); the patients treated with percutaneous pin fixation showed no differences with regard to cubitus varus, neurovascular injury, the range of motion, the infection rate, the union rate, or the criteria of Flynn et al. In older children with SCH fractures (8 to 14 years of age) Mollon et al.133 reported a mean loss of 30 degrees of elbow flexion at final follow-up in those patients treated with open reduction internal fixation compared to those treated with closed reduction percutaneous pinning. 
The direct anterior approach to the elbow is extremely useful for open reduction, particularly in cases of neurovascular compromise. The anterior approach has the advantages of allowing direct visualization of the brachial artery and median nerve as well as the fracture fragments. The exposure is through the torn periosteum and disrupted brachialis and therefore does not further destabilize the fracture. When performed through a relatively small (5 to 8 cm) transverse incision above the cubital fossa at the fracture site, the resulting scar is much more aesthetic than that of the lateral approach, and scar contraction limiting elbow extension is not an issue. A series of 26 patients treated with the anterior approach showed equivalent results to the traditional lateral or combined lateral with medial approach in terms of malunion, Flynn's criteria64 and range of motion. 
The posterior approach for an extended supracondylar fracture risks; (1) a higher rate of loss of motion; (2) further fracture instability with exposure through intact periosteum; and (3) more importantly the risk of avascular necrosis secondary to disruption of the posterior end arterial supply to the trochlea of the humerus (Fig. 16-28).30,209 
Figure 16-28
Intraosseous blood supply of the distal humerus.
 
A: The vessels supplying the lateral condylar epiphysis enter on the posterior aspect and course for a considerable distance before reaching the ossific nucleus. B: Two definite vessels supply the ossification center of the medial crista of the trochlea. The lateral vessel enters by crossing the physis. The medial one enters by way of the nonarticular edge of the medial crista.
 
(From Haraldsson S. On osteochondrosis deformans juvenilis capituli humeri including investigation of the intraosseous vasculature in the distal humerus. Acta Orthop Scand. 1959; 38(Suppl):1–232, with permission.)
A: The vessels supplying the lateral condylar epiphysis enter on the posterior aspect and course for a considerable distance before reaching the ossific nucleus. B: Two definite vessels supply the ossification center of the medial crista of the trochlea. The lateral vessel enters by crossing the physis. The medial one enters by way of the nonarticular edge of the medial crista.
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Figure 16-28
Intraosseous blood supply of the distal humerus.
A: The vessels supplying the lateral condylar epiphysis enter on the posterior aspect and course for a considerable distance before reaching the ossific nucleus. B: Two definite vessels supply the ossification center of the medial crista of the trochlea. The lateral vessel enters by crossing the physis. The medial one enters by way of the nonarticular edge of the medial crista.
(From Haraldsson S. On osteochondrosis deformans juvenilis capituli humeri including investigation of the intraosseous vasculature in the distal humerus. Acta Orthop Scand. 1959; 38(Suppl):1–232, with permission.)
A: The vessels supplying the lateral condylar epiphysis enter on the posterior aspect and course for a considerable distance before reaching the ossific nucleus. B: Two definite vessels supply the ossification center of the medial crista of the trochlea. The lateral vessel enters by crossing the physis. The medial one enters by way of the nonarticular edge of the medial crista.
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Incidence of Complications Lessened

Open reduction has been increasingly accepted because there are relatively few complications with this method. Surgical experience9,11,35,45,62,68,74,95,106,139,156 has dispelled the fears of infection, myositis ossificans, and neurovascular injury.72,165,180,197 The incidence of neurovascular complications from the procedure itself was essentially zero. Four patients with myositis ossificans (1.4%) were reported, all in a single series.76 
The most frequent complication of surgical management appears to be a loss of range of motion. One of the reasons given in the past for loss of motion was the use of a posterior approach. It has been stated that approaching the fracture through the relatively uninvolved posterior tissues induces added scar leading to stiffness. In earlier reported series using a posterior approach, loss of range of motion was significant. Preferred use of the anterior approach has resulted in a lower stiffness rate and complications similar to closed treatment. Most often the fractures treated with open reduction are the more severe fractures that are open, have vascular compromise, and/or an irreducible fracture because of soft tissue interposition. Residual cubitus varus occurred in as many as 33% of patients in some of the earlier series,6,47,76,118 most because of inadequate surgical reduction. When good reduction was obtained, the incidence of cubitus varus deformity was low. Surgical intervention alone does not guarantee an anatomic reduction; the quality of the reduction achieved at the time of surgery is important. 
Lal and Bhan111 reported that delayed open reduction 11 to 17 days after injury, did not increase the frequency of myositis ossificans. If a supracondylar fracture is unreduced or poorly reduced, delayed open reduction and pin fixation appear to be justified. Agus et al.4 showed that delay in reduction and pinning can be safely accomplished after skeletal traction and malreduction. 
Open supracondylar fractures generally have an anterior puncture wound where the metaphyseal spike penetrates the skin (Fig. 16-29). Even if the open wound is only a small puncture in the center of an anterior pucker, open irrigation and debridement are indicated. The anterior approach, using a transverse incision with medial or lateral extension as needed, is recommended. The neurovascular bundle is directly under the skin and tented over the metaphyseal fragment, so care should be taken in approaching this fracture surgically. The skin incision can be extended medially proximally and laterally distally if needed. However, usually only the transverse portion of the incision is required, which gives a better aesthetic result. The brachialis muscle is usually transected because it is a muscle belly to its insertion on the coronoid attachment and is highly vulnerable to trauma from the proximal metaphyseal fragment. The fracture surfaces are examined and washed, and a curette is used to remove any dirt or entrapped soft tissue. Once the debridement and washing are complete, the fracture is reduced by mobilizing the periosteum out of the way and flexing the distal humerus. Stabilization is with K-wires. All patients with open fractures are also treated with antibiotics: Generally, cefazolin for Gustilo types I, II, and IIIA injuries, with the addition of appropriate antibiotics to cover gram-negative organisms for type IIIB and C fractures. 
Figure 16-29
Open supracondylar humerus fracture.
 
The distal humerus metaphysis is completely protruding through the transverse open wound. Fortunately, the pulse was intact, and the hand was viable.
 
(From Waters PW, Bae DS. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
The distal humerus metaphysis is completely protruding through the transverse open wound. Fortunately, the pulse was intact, and the hand was viable.
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Figure 16-29
Open supracondylar humerus fracture.
The distal humerus metaphysis is completely protruding through the transverse open wound. Fortunately, the pulse was intact, and the hand was viable.
(From Waters PW, Bae DS. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
The distal humerus metaphysis is completely protruding through the transverse open wound. Fortunately, the pulse was intact, and the hand was viable.
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Supracondylar Fractures of the Distal Humerus Treatment with Traction

Traction as definitive treatment for supracondylar fractures in children is largely of historic interest in most modern centers. Indications for traction may include severe comminution, lack of anesthesia, medical conditions prohibiting anesthesia, lack of an experienced surgeon, or temporary traction to allow swelling to decrease. Devnani53 reported using traction in the gradual reduction of eight fractures with late presentation (mean of 5.6 days), though 18% of these children went on to a corrective osteotomy for malunion. Rates of cubitus varus from 9% to 33% have been reported in some series,89,149 whereas others have reported excellent results.47,70,181,210 Nevertheless, 11 to 22 days of inhospital traction is difficult to justify given the excellent results with closed reduction and pinning, which usually requires no more than one night hospitalization and is associated with a low rate of intraoperative complications. Advocates of traction in the treatment of supracondylar fractures describe use of overhead traction with use of an olecranon wing nut14,144,207 (Fig. 16-30) as giving superior results to sidearm traction. 
Figure 16-30
Overhead olecranon wing nut traction.
 
The arm is suspended by a threaded wing nut through the olecranon (short arrow). The forces maintaining the reduction (long arrows) are exerted upward (A) through the pin and sideways through a counter-sling against the arm. The forearm is supported with a small sling (double arrow). By placing the traction rope eccentric to the screw's axis, a torque can be created to correct varus or valgus alignment (B).
The arm is suspended by a threaded wing nut through the olecranon (short arrow). The forces maintaining the reduction (long arrows) are exerted upward (A) through the pin and sideways through a counter-sling against the arm. The forearm is supported with a small sling (double arrow). By placing the traction rope eccentric to the screw's axis, a torque can be created to correct varus or valgus alignment (B).
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Figure 16-30
Overhead olecranon wing nut traction.
The arm is suspended by a threaded wing nut through the olecranon (short arrow). The forces maintaining the reduction (long arrows) are exerted upward (A) through the pin and sideways through a counter-sling against the arm. The forearm is supported with a small sling (double arrow). By placing the traction rope eccentric to the screw's axis, a torque can be created to correct varus or valgus alignment (B).
The arm is suspended by a threaded wing nut through the olecranon (short arrow). The forces maintaining the reduction (long arrows) are exerted upward (A) through the pin and sideways through a counter-sling against the arm. The forearm is supported with a small sling (double arrow). By placing the traction rope eccentric to the screw's axis, a torque can be created to correct varus or valgus alignment (B).
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Supracondylar Fractures of the Distal Humerus Treatment by Fracture Type

Type I (Nondisplaced)

Simple immobilization with a posterior splint applied at 60 to 90 degrees of elbow flexion with side supports is all that is necessary.36,202 If there is unequivocally no significant swelling about the elbow, circumferential or bivalved casts may be used, with education of the parents as to elevation and the signs and symptoms of compartment syndrome. The elbow should not be flexed greater than 90 degrees. Using Doppler examination of the brachial artery after supracondylar fractures, Mapes and Hennrikus124 found that flow was decreased in the brachial artery in positions of pronation and increased flexion. Before the splint is applied, it should be confirmed that the pulse is intact and that there is good capillary refill with the amount of elbow flexion intended during immobilization. A sleeve sling or D-ring stockinette sling helps decrease torsional forces about the fracture. 
X-rays are obtained 3 to 7 days after fracture to document lack of displacement. If there is evidence of significant distal fragment extension, as judged by lack of intersection of the AHL with the capitellum, the fracture should be treated with closed reduction and percutaneous pinning to secure the reduction. 
An acceptable position is determined by the AHL transecting the capitellum on the lateral x-ray, a Baumann's angle of greater than 10 degrees or equal to the other side, and an intact olecranon fossa. The duration of immobilization for supracondylar fractures is 3 to 4 weeks, whether type I, II, or III. In general, no physical therapy is required after this injury. Patients may be seen 4 to 6 weeks after immobilization is removed to ensure that range of motion and strength are returning normally. As the outcome in type I fractures is predictably excellent if alignment is maintained at the time of early healing, follow-up visits are optional depending on family and medical circumstances. 
Remember that the initial x-ray is a static representation of the actual injury that may involve soft tissue disruption much greater than one might expect from the minimal bony abnormality. Excessive swelling, nerve or vascular disruption, or excessive pain are indicative of a more significant injury that a type I fracture in which case periosteal disruption may render this fracture inherently unstable. Also, beware of any medial comminution that could allow the fracture to collapse into varus during immobilization. 

Type II Fracture (Hinged Posteriorly, with Posterior Cortex in Continuity)

This fracture category encompasses a broad array of soft tissue injuries. Careful assessment of the soft tissue injury is critical in treatment decision making. As the posterior cortex is in continuity, good stability should be obtained with closed reduction. 
Significant swelling, obliteration of pulse with flexion, neurovascular injuries, excessive angulation, and other injuries in the same extremity are indications for pin stabilization. 
The optimal treatment of type II fractures has evolved to the current trend of operative intervention rather than cast immobilization. The distal humerus provides 20% of the growth of the humerus and thus has little remodeling potential. The upper limb grows approximately 10 cm during the first year, 6 cm during the second year, 5 cm during the third year, 3.5 cm during the fourth year, and 3 cm during the fifth year of life.55 In toddlers (<3 years) some remodeling potential is present so the surgeon may accept nonoperative treatment of a type II fracture in which the capitellum abuts the AHL but does not cross it. Whereas, in a child who is 8 to 10 years old, there is only 10% of growth of the distal humerus remaining so adequate reduction and stabilization is essential to prevent malunion. 
Three studies support the initial treatment of type II fractures with closed reduction and casting. Hadlow et al.84 make the point that pinning all type II fractures in their series of initial closed reduction and casting meant that 77% (37 of 48) of patients would have undergone an unnecessary operative procedure. However, 23% (11 of 48) of the patients in that series lost reduction following closed reduction and underwent delayed operative fixation. Fourteen percent (2 of 14) that were followed had a poor outcome by Flynn criteria.63 A retrospective review of 25 elbows treated with closed reduction and casting by Parikh et al. showed a 28% (7 of 25) loss of reduction, 20% (5 of 25) need for delayed surgery, and 2% (2 of 25) unsatisfactory outcome according to Flynn criteria.63 
Similarly Fitzgibbons et al.61 reported a 20% loss of reduction in the closed treatment of 61 type II fractures. They noted failure was more likely to occur in more displaced fractures in which the AHL did not touch the capitellum, and in those children with wider upper arms. They conclude that “a reasonable protocol might consist of urgent pinning for fractures in which the capitellum extends beyond the AHL, while less displaced fractures could be reduced, placed in a cast, and followed at 1-week intervals.”61 In a series of 155 type II SCH fractures treated nonoperatively, Camus et al.34 reported fractures were found to have radiographic evidence of sagittal-plane (80% with abnormal AHL, decreased humerocapitellar angle), coronal-plane (47% with abnormal Baumann's angle), and rotational (44% with poor Griffet index) deformities. 
In contrast, a consecutive series of 69 children with type II fractures treated with closed reduction and pinning reported no radiographic or clinical loss of reduction, no cubitus varus, no hyperextension, and no loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery.173 In another study of type II fractures, 189 consecutive cases of closed reduction and percutaneous pinning were reviewed. There were 2% (4/189) pin tract infections, of which three were treated successfully with oral antibiotics and pin removal 1.5% (3/191) and one (0.5%: 1/191) had operative irrigation and debridement for a wound infection not involving the joint. There were no nerve or vascular injuries, and no loss of reduction, delayed unions, or malunions. The authors conclude that pinning type II supracondylar fractures leads to a high probability of satisfactory outcome compared with previous studies of closed reduction without pinning.177 
Another reason for advocating operative treatment of these injuries is that the amount of hyperflexion needed to maintain reduction in unpinned type II fractures would predispose these patients to increased compartment pressures.20 In a study by Mapes and Hennrikus124 using Doppler examination, positions of pronation and increased flexion caused decreased flow in the brachial artery. They recommended a position of flexion and supination for “vascular safety.” Pinning these fractures obviates the need for immobilization with considerable elbow flexion. To truly stabilize an extension fracture treated closed, greater than 120 degrees of flexion is required.108 The basic concept is that any fracture that would require elbow flexion greater than 90 degrees to hold reduction increases the risk of neurovascular compromise and therefore, should instead have the reduction held by pins, and immobilized with the elbow in less flexion (usually about 45 to 70 degrees). If pinning is chosen, two lateral pins163,173,175,191 through the distal humeral fragment, engaging the opposite cortex of the proximal fragment, are generally sufficient to maintain fracture alignment (Fig. 16-31) (Figs. 16-14C, D and 16-24) though in many series three pins are often used.173 The posterior cortex and intact periosteum provide some degree of inherent stability. Cross pinning of a type II fracture is generally not needed. The techniques for crossed and lateral pinning are described later on in this chapter. If pin stabilization is used, the pins are left protruding through the skin and are removed at 3 to 4 weeks after fixation, generally without the need for sedation or anesthesia. 
Figure 16-31
Properly placed divergent lateral-entry pins.
 
On the AP view, there should be maximal pin separation at the fracture site, the pins should engage both medial and lateral columns just proximal to the fracture site, and they should engage an adequate amount of bone proximal and distal to the fragments. On the lateral view, pins should incline slightly in the anterior to posterior direction in accordance with normal anatomy.
 
(From Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004; 86(4):702–707, with permission.)
On the AP view, there should be maximal pin separation at the fracture site, the pins should engage both medial and lateral columns just proximal to the fracture site, and they should engage an adequate amount of bone proximal and distal to the fragments. On the lateral view, pins should incline slightly in the anterior to posterior direction in accordance with normal anatomy.
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Figure 16-31
Properly placed divergent lateral-entry pins.
On the AP view, there should be maximal pin separation at the fracture site, the pins should engage both medial and lateral columns just proximal to the fracture site, and they should engage an adequate amount of bone proximal and distal to the fragments. On the lateral view, pins should incline slightly in the anterior to posterior direction in accordance with normal anatomy.
(From Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am. 2004; 86(4):702–707, with permission.)
On the AP view, there should be maximal pin separation at the fracture site, the pins should engage both medial and lateral columns just proximal to the fracture site, and they should engage an adequate amount of bone proximal and distal to the fragments. On the lateral view, pins should incline slightly in the anterior to posterior direction in accordance with normal anatomy.
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Type III Fractures

If the child presents to the emergency room with the extremity in either extreme flexion or extension, carefully place the arm in 30 degrees of flexion to minimize vascular insult and compartment pressure. In type III fractures, the periosteum is usually torn, there is no cortical contact between the fragments, and soft tissue injury may accompany the fracture. Careful preoperative evaluation is mandatory. If circulatory compromise is indicated by absent pulse and a pale hand, or if compartment syndrome is suspected, urgent reduction and skeletal stabilization are mandatory. The standard of care in most modern centers for the treatment of type III fractures is operative reduction and pinning. 
Cast immobilization techniques have been described as well. Because type III fractures are intrinsically unstable, the elbow must be held in extreme flexion to prevent the distal fragment from rotating; these fractures tend to rotate into extension with flexion of less than 120 degrees.131 If the arm can be flexed to 120 degrees with an intact pulse, some believe casting can be used as primary treatment. Usually, however, severe swelling prevents the elbow from being kept in hyperflexion or compartment syndrome could result. In most series,3,45,108,147,195 the results of type III fractures treated with closed reduction and cast immobilization are not as good as those treated with pinning. Hadlow et al.,84 however, suggested that selective use of casting is beneficial, reporting that in their series, 61% of type III and 77% of type II fractures were successfully treated without pinning. 
When a cast is used as primary treatment, it should be worn for 3 to 4 weeks. Although a number of historic series used casting as primary treatment, most recent reports favor pinning of this fracture because of concerns about vascular compromise, compartment syndrome, and malunion. It must be emphasized that flexion of the elbow with a type III (Fig. 16-32) supracondylar fracture up to 90 degrees or greater significantly increases the risk of compartment syndrome and should rarely, if ever, be done if modern operative facilities and an experienced surgeon are available. 
Figure 16-32
Figure-of-eight wrap.
 
In the figure-of-eight cast, both the padding and the plaster are wrapped in a figure-of-eight manner (arrows). Flexion of a swollen elbow with a supracondylar fracture beyond 90 degrees increases the risk of compartment syndrome and is generally not recommended if operative treatment is available.
 
(From Wilkins KE. The management of severely displaced supracondylar fractures of the humerus. Tech Orthop. 1989; 4:5–24, with permission.)
In the figure-of-eight cast, both the padding and the plaster are wrapped in a figure-of-eight manner (arrows). Flexion of a swollen elbow with a supracondylar fracture beyond 90 degrees increases the risk of compartment syndrome and is generally not recommended if operative treatment is available.
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Figure 16-32
Figure-of-eight wrap.
In the figure-of-eight cast, both the padding and the plaster are wrapped in a figure-of-eight manner (arrows). Flexion of a swollen elbow with a supracondylar fracture beyond 90 degrees increases the risk of compartment syndrome and is generally not recommended if operative treatment is available.
(From Wilkins KE. The management of severely displaced supracondylar fractures of the humerus. Tech Orthop. 1989; 4:5–24, with permission.)
In the figure-of-eight cast, both the padding and the plaster are wrapped in a figure-of-eight manner (arrows). Flexion of a swollen elbow with a supracondylar fracture beyond 90 degrees increases the risk of compartment syndrome and is generally not recommended if operative treatment is available.
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The Special Case of Medial Column Comminution of Supracondylar Fractures of the Distal Humerus

Fractures with medial comminution may not have the dramatic displacement of most type III fractures, but must be treated with operative reduction because collapse of the medial column will lead to varus deformity in an otherwise minimally displaced supracondylar fracture (Fig. 16-20).50 De Boeck et al. recommended closed reduction with percutaneous pinning when a fracture has medial comminution even in otherwise minimally displaced fractures to prevent cubitus varus. In this retrospective review, zero of six patients with medial comminution who underwent operative fixation had cubitus varus whereas four of seven (57%) patients who were treated nonoperatively developed cubitus varus. 

Author's Preferred Treatment for Supracondylar Fractures of the Distal Humerus

Type I Fractures of Supracondylar Fractures of the Distal Humerus

These fractures are managed in a long-arm cast with approximately 60 to 90 degrees of elbow flexion for approximately 3 weeks. Follow-up x-rays at 1 week are recommended for assessment of fracture position. 

Type II Fractures of Supracondylar Fractures of the Distal Humerus

We prefer closed reduction and pinning of most type II supracondylar fractures. Two lateral pins are chosen as the initial postreduction fixation method in nearly all cases (Fig. 16-14). If two lateral pins fail to provide acceptable fixation we do not hesitate to place a third lateral pin. We believe it is safer to hold a type II fracture reduced with pins, rather than flexing the elbow greater than 90 degrees. See below section for a detailed technique description (Table 16-3). 
 
Table 16-3
Decision Making on Lateral X-Rays
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Table 16-3
Decision Making on Lateral X-Rays
This is a typical type I fracture. The anterior humeral line (AHL) clearly goes through the capitellum. Cast with no more than 90 degrees of elbow flexion. Flynn-ch016-unimage001.png
This technically a type I fracture by definition as the AHL touches the capitellum. However, this fracture is at risk for displacement as the hourglass is not tilting forward, and the posterior cortex is broken as well. Initial treatment is casting at no more than 90 degrees of elbow flexion with the need for close follow-up stressed. Flynn-ch016-unimage002.png
This is a typical type II fracture, with the AHL missing the capitellum and the distal fragment hinged posteriorly. This is treated with closed reduction and pinning. Flynn-ch016-unimage003.png
As there is a hint of translation at the posterior cortex, this may be considered a type III fracture and should be reduced and pinned. Flynn-ch016-unimage004.png
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As a type I fracture is treated nonoperatively, and type II fractures are treated operatively, the lateral radiograph, which distinguishes these two fractures deserves special consideration. Below are some examples and authors' thoughts. Please assume the AP radiographs have a normal Baumann's angle. 

Type III Fractures—Closed Reduction and Percutaneous Pinning of Supracondylar Fractures of the Distal Humerus

Once in the operating room, the patient receives a general anesthetic and prophylactic antibiotics. We prefer to have the fluoroscopy monitor opposite to the surgeon for ease of viewing (Fig. 16-33). 
Figure 16-33
Positioning the fluoroscopy monitor on the opposite side of the bed allows the surgeon to easily see the images while operating.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-33
Positioning the fluoroscopy monitor on the opposite side of the bed allows the surgeon to easily see the images while operating.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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The patient is positioned supine on the operating table, with the fractured elbow on a short radiolucent arm board.173 Some surgeons use the wide end of the fluoroscopy unit as the table, which is probably fine for type II fractures, but this set-up will not allow for rotation of the fluoroscopy unit to obtain lateral images of the elbow. In cases of unusual instability in which rotation of the arm risks loss of reduction, the child's shoulder needs to be flexible enough to allow for 90 degrees of external rotation to safely obtain a lateral of the elbow. It is essential that the child's arm is far enough onto the arm board that the elbow can be well visualized with fluoroscopy. In very small children this may mean having the child's shoulder and head on the arm board (Fig. 16-34). 
Figure 16-34
In small children, imaging of the elbow may be difficult if the arm is not long enough to reach the center of the fluoroscopy unit.
 
By placing the child's head in the crack between the operating room table and the arm board, the elbow is more easily imaged, and the child's head is unlikely to be inadvertently pulled off the side of the bed during the procedure.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
By placing the child's head in the crack between the operating room table and the arm board, the elbow is more easily imaged, and the child's head is unlikely to be inadvertently pulled off the side of the bed during the procedure.
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Figure 16-34
In small children, imaging of the elbow may be difficult if the arm is not long enough to reach the center of the fluoroscopy unit.
By placing the child's head in the crack between the operating room table and the arm board, the elbow is more easily imaged, and the child's head is unlikely to be inadvertently pulled off the side of the bed during the procedure.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
By placing the child's head in the crack between the operating room table and the arm board, the elbow is more easily imaged, and the child's head is unlikely to be inadvertently pulled off the side of the bed during the procedure.
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The patient's arm is then draped and prepped. First, traction is applied with the elbow flexed at about 20 degrees to avoid the possibility of tethering neurovascular structures over an anteriorly displaced proximal fragment. For badly displaced fractures hold significant traction for 60 seconds to allow soft tissue realignment, with the surgeon grasping the forearm with both hands, and the assistant providing countertraction in the axilla (Fig. 16-35). 
Figure 16-35
Reduction maneuver: Traction with elbow flexed 20 to 30 degrees.
 
Assistant provides countertraction against patient's axilla (white arrow) to allow for significant traction to be applied.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
Assistant provides countertraction against patient's axilla (white arrow) to allow for significant traction to be applied.
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Figure 16-35
Reduction maneuver: Traction with elbow flexed 20 to 30 degrees.
Assistant provides countertraction against patient's axilla (white arrow) to allow for significant traction to be applied.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
Assistant provides countertraction against patient's axilla (white arrow) to allow for significant traction to be applied.
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If it appears that the proximal fragment has pierced the brachialis, the “milking maneuver” is performed.146 In this maneuver, the biceps are forcibly “milked” in a proximal to distal direction past the proximal fragment, often culminating in a palpable release of the humerus posteriorly through the brachialis (Fig. 16-36). 
Figure 16-36
Brachialis muscle interposition is indicated on the left.
 
The “milking maneuver” frees the brachialis muscle from its location in the fracture, allowing a closed reduction.
The “milking maneuver” frees the brachialis muscle from its location in the fracture, allowing a closed reduction.
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Figure 16-36
Brachialis muscle interposition is indicated on the left.
The “milking maneuver” frees the brachialis muscle from its location in the fracture, allowing a closed reduction.
The “milking maneuver” frees the brachialis muscle from its location in the fracture, allowing a closed reduction.
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Next, with the elbow almost straight, varus and valgus angular alignment is corrected by movement of the forearm. Medial and lateral fracture translation is realigned with direct movement of the distal fragment by the surgeon with image confirmation. The elbow is then slowly flexed while applying anterior pressure to the olecranon with the surgeon's thumb(s) (Fig. 16-37). 
Figure 16-37
Reduction maneuver: Flex elbow while pushing anteriorly on olecranon with the thumb(s).
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-37
Reduction maneuver: Flex elbow while pushing anteriorly on olecranon with the thumb(s).
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Following a successful reduction, the child's elbow should sufficiently flex so that the fingers touch the shoulder. If not, the fracture is still likely not reduced and is in too much extension (Fig. 16-38). 
Figure 16-38
If fingers cannot touch shoulder, flexion deformity may not be reduced.
Flynn-ch016-image038.png
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If during the reduction maneuver the fracture does not stay reduced, and a “rubbery” feeling is encountered instead of the desired “bone-on-bone” feeling, the median nerve and/or brachial artery may be trapped within the fracture site (Fig. 16-25). If this occurs, an open reduction is generally necessary to remove the neurovascular structures from the fracture site. 
Many have described using pronation to assist in reduction, but this should not be automatic. In the most common posterior-medially displaced fracture the medial periosteum is usually intact. In this instance, pronation may assist in reduction by placing the medial periosteum in tension, and closing down the otherwise open lateral column (Fig. 16-5). However, the medial periosteum is often torn in a posterior laterally displaced fracture, and in which case pronation may be counterproductive and supination may be helpful. 
The reduction is then checked by fluoroscopic images in AP, lateral, and oblique planes. Verify four points to check for a good reduction: (1) the AHL intersects the capitellum (Fig. 16-39), (2) Baumann's angle is greater than 10 degrees (Fig. 16-40), (3, 4) the medial and lateral columns are intact on oblique views (Figs. 16-41 and 16-42). 
Figure 16-39
Anterior humeral line should cross the capitellum on a true lateral of the elbow.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-39
Anterior humeral line should cross the capitellum on a true lateral of the elbow.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-40
The Baumann's angle is between the line perpendicular to the long axis of the humeral shaft and the physeal line of the lateral condyle.
 
A decrease in the Baumann's angle may indicate medial comminution.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
A decrease in the Baumann's angle may indicate medial comminution.
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Figure 16-40
The Baumann's angle is between the line perpendicular to the long axis of the humeral shaft and the physeal line of the lateral condyle.
A decrease in the Baumann's angle may indicate medial comminution.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
A decrease in the Baumann's angle may indicate medial comminution.
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Figure 16-41
Oblique fluoroscopic view of the elbow demonstrating continuity of the medial column following adequate fracture reduction.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-41
Oblique fluoroscopic view of the elbow demonstrating continuity of the medial column following adequate fracture reduction.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-42
Demonstration of lateral column continuity.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-42
Demonstration of lateral column continuity.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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If difficulty is encountered maintaining fracture reduction when eternally rotating the shoulder for a lateral view of the elbow, consider moving the C-arm instead of the patient's arm (Fig. 16-43). 
Figure 16-43
In very unstable fractures, rotation of the shoulder into external rotation to obtain a lateral image of the elbow may lead to a loss of reduction.
 
In these rare instances, rotation of the C-arm, rather than the elbow, is a useful trick.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007, with permission.)
In these rare instances, rotation of the C-arm, rather than the elbow, is a useful trick.
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Figure 16-43
In very unstable fractures, rotation of the shoulder into external rotation to obtain a lateral image of the elbow may lead to a loss of reduction.
In these rare instances, rotation of the C-arm, rather than the elbow, is a useful trick.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007, with permission.)
In these rare instances, rotation of the C-arm, rather than the elbow, is a useful trick.
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We will accept some translation of the distal fragment (up to perhaps 5 mm), as long as the above criteria are met. 
Similarly, we will accept a moderate amount of persistent rotational malalignment, as long as the above criteria are met, as the shoulder joint has so much rotation it is highly unlikely to cause a functional problem. Once reduction is satisfactory, tape the elbow in the reduced position of elbow hyperflexion with elastic tape to prevent loss of reduction while pinning (Fig. 16-44). 
Figure 16-44
Fracture reduction is maintained by taping elbow in hyperflexed position.
 
The wire may be pushed through the skin and into the cartilage, using the cartilage of the distal lateral condyle as a pincushion that will hold the K-wire in place while carefully examining the AP and lateral images.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
The wire may be pushed through the skin and into the cartilage, using the cartilage of the distal lateral condyle as a pincushion that will hold the K-wire in place while carefully examining the AP and lateral images.
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Figure 16-44
Fracture reduction is maintained by taping elbow in hyperflexed position.
The wire may be pushed through the skin and into the cartilage, using the cartilage of the distal lateral condyle as a pincushion that will hold the K-wire in place while carefully examining the AP and lateral images.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
The wire may be pushed through the skin and into the cartilage, using the cartilage of the distal lateral condyle as a pincushion that will hold the K-wire in place while carefully examining the AP and lateral images.
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The elbow is positioned on a folded towel. The surgeon then palpates the lateral humeral condyle. Most commonly, .062-in smooth K-wires are used (Zimmer, Warsaw, IN), though at times smaller or larger sizes may be considered if the child is particularly small or large. The aim of pin placement is to maximally separate the pins at the fracture site to engage both the medial and lateral columns (Fig. 16-30). Whether the pins are divergent or parallel, or which pin is placed first is of little importance. Care must be taken to ensure there is sufficient bone engaged in the proximal and distal fragments. It is acceptable to cross the olecranon fossa which adds two more cortices to improve fixation, but note this means the elbow cannot be fully extended until the pins are removed. In the sagittal plane, to engage the most bone with the K-wire in the distal fragment the reduced capitellum lies slightly anterior to the plane of the fracture, thus the pin may start a bit anterior to the plane of the fracture and angulate about 10 to 15 degrees posteriorly to maximize osseous purchase. A key element to ensure a correctly placed pin is to feel the pin go through the proximal cortex. If this feeling is not clearly appreciated, careful fluoroscopic imaging often reveals the pin did not engage the proximal fragment. As a general rule we recommend two pins for Gartland type II fractures, and three pins for Gartland type III fractures. Even though two good pins are probably sufficient, placing three pins increases the odds of actually having two good ones. 
The K-wire is placed against the lateral condyle without piercing skin and checked under AP fluoroscopic guidance to assess the starting point. The K-wire is held free in the surgeon's hand at this point, not in the drill, to allow maximum control. If the starting point and trajectory is correct, the wire may be pushed through the skin and into the cartilage, using the cartilage of the distal lateral condyle as a pincushion, (Fig. 16-43) that will hold the K-wire in place while you carefully examine the AP and lateral images. If imaging verifies correct pin placement, then advance the pin with a drill. Precise pin placement is an important part of the procedure that should not be rushed. We believe incorrect pin placement is the cause of loss of reduction in most fractures. Whether the pins are divergent or parallel are of little importance as long as the pins are well separated at the fracture site. 
The reduction is again checked under fluoroscopy with lateral (Fig. 16-45), oblique (Fig. 16-46), and AP views (Fig. 16-47). 
Figure 16-45
Assessment of sagittal alignment with lateral view.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-45
Assessment of sagittal alignment with lateral view.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-46
Both oblique views are checked to assess reduction of medial and lateral columns.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-46
Both oblique views are checked to assess reduction of medial and lateral columns.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Figure 16-47
If the lateral and oblique views show good reduction, the tape is removed and reduction and pin placement are checked, in the AP view with elbow in relative elbow extension.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
View Original | Slide (.ppt)
Figure 16-47
If the lateral and oblique views show good reduction, the tape is removed and reduction and pin placement are checked, in the AP view with elbow in relative elbow extension.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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X
Stress should be applied in varus and valgus under fluoroscopy to ensure. If there is any instability, you want to know about it now, rather than a week later. If there is instability, we will add another lateral-entry pin (Fig. 16-48). In the exceptionally rare instance when three lateral pins do not stabilize the fracture, or there is an oblique fracture pattern preventing multiple lateral-entry pins, a medial pin may be considered. After placing lateral-entry pins, the elbow is fully extended to relax tension on the ulnar nerve and surrounding tissue, and the surgeon can palpate the medial epicondyle which is posterior to the center plane of the distal humerus. The entry site for medial pin placement is anterior on the medial epicondyle. A small incision is made to expose and protect the ulnar nerve. A drill guide is used to prevent binding of the perineural soft tissues that could kink the nerve. After desired pin placement is confirmed on fluoroscopy, the medial epicondyle and nerve are inspected to be certain there is no injury, impingement, or kinking of the nerve throughout flexion–extension arc of motion. 
Figure 16-48
 
A: AP radiograph of a type III fracture in a 6-year-old boy. B: Lateral view. C: AP radiograph 3 weeks postoperative. D: lateral view.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: AP radiograph of a type III fracture in a 6-year-old boy. B: Lateral view. C: AP radiograph 3 weeks postoperative. D: lateral view.
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A: AP radiograph of a type III fracture in a 6-year-old boy. B: Lateral view. C: AP radiograph 3 weeks postoperative. D: lateral view.
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Figure 16-48
A: AP radiograph of a type III fracture in a 6-year-old boy. B: Lateral view. C: AP radiograph 3 weeks postoperative. D: lateral view.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
A: AP radiograph of a type III fracture in a 6-year-old boy. B: Lateral view. C: AP radiograph 3 weeks postoperative. D: lateral view.
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A: AP radiograph of a type III fracture in a 6-year-old boy. B: Lateral view. C: AP radiograph 3 weeks postoperative. D: lateral view.
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We save the images in which the reduction looks the “worst,” particularly if some translational or rotational malreduction is accepted, to have them for comparison during postoperative visits to determine if movement of the fracture occurred. Vascular status is assessed. The wires are bent and cut. Take care to leave the wires at least 1 to 2 cm off the skin after, to prevent migration of the wires under the skin. A sterile felt square with a slit cut into it is then placed around the wires to protect the skin (Fig. 16-49). 
Figure 16-49
Skin is protected from pins with felt squares.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
View Original | Slide (.ppt)
Figure 16-49
Skin is protected from pins with felt squares.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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Foam is applied to the arm on the anterior and posterior aspects of the elbow to allow for swelling (Fig. 16-50). The cast is then applied in 45 to 70 degrees of elbow flexion, as flexion to 90 degrees may needlessly increase the risk of compartment syndrome (Fig. 16-51). Remember that the pins, not the cast, are holding the fracture reduction. We use fiberglass casting material for its strength, weight, and radiolucency and feel that when properly applied, fiberglass does not lead to a tight cast. 
Figure 16-50
Sterile foam is placed directly on skin.
 
If there is any circumferential dressing placed under the foam, it may be restricting.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007, with permission.)
If there is any circumferential dressing placed under the foam, it may be restricting.
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Figure 16-50
Sterile foam is placed directly on skin.
If there is any circumferential dressing placed under the foam, it may be restricting.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007, with permission.)
If there is any circumferential dressing placed under the foam, it may be restricting.
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Figure 16-51
Cast with elbow flexion no more than 70 degrees and less flexion for very swollen elbows.
 
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
View Original | Slide (.ppt)
Figure 16-51
Cast with elbow flexion no more than 70 degrees and less flexion for very swollen elbows.
(From Tolo VT, Skaggs DL, eds. Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
(From 


Tolo VT,

Skaggs DL, eds.
Master Techniques in Orthopaedic Surgery: Pediatric Orthopaedics. Philadelphia, PA: Lippincott; 2007:1–15, with permission.)
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X
If there is any question of perfusion following fracture reduction in the operating room, the surgical prep (betadine) may be removed to evaluate the skin color. In addition, a Doppler may be used to assess pulse. In the case of a poorly perfused hand following reduction, in a case where the hand was well perfused prior to reduction, one must assume the artery, or adjacent tissue is trapped in the fracture site. The pins should be immediately removed and allow the fracture to return to its unreduced position. If there is no pulse postoperatively in an arm that had no pulse preoperatively, but the hand is warm and well perfused, our preference is to observe the child in hospital for 48 hours with the arm mildly elevated (Fig. 16-52). This is especially true if there is associated neuropathy preoperatively. The rich collateral circulation about the elbow is generally sufficient. The presence or absence of a pulse by Doppler does not change our management at this point, but will make us feel better if a pulse can be heard. 
Figure 16-52
Author's preferred algorithm for management of the pulseless supracondylar humerus fracture.
Flynn-ch016-image052.png
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Type IV Fractures of the Supracondylar Fractures of the Distal Humerus

Although this extremely unstable fracture could be treated with open reduction, we follow the protocol recommended by Leitch et al.118 First place two K-wires into the distal fragment. Next, the fracture is reduced in the AP plane and verified by imaging. At this point, rather than rotating the arm for a lateral image as is commonly done in more stable fracture patterns, the fluoroscopy unit is rotated into the lateral view (Fig. 16-42). The fracture is then reduced in the sagittal plane, and the K-wires are driven across the fracture site. Often times the reduction is in midposition of flexion and extension (∼60 degrees) and requires holding the reduction with distraction by the surgeon while the assistant places the first lateral-entry stabilizing pin. 

Postoperative Care in Supracondylar Fractures of the Distal Humerus

Swanson et al.188 reports acetaminophen is as effective as narcotic analgesics for providing pain control after supracondylar fracture surgery in children and Kay et al.101 reports perioperative ketorolac (a nonsteroidal anti-inflammatory) does not increase the risk of complications following operative fracture care. We use acetaminophen and an NSAID as the first-line drugs for pain relief as narcotics are historically associated with more side effects. 
Patients with minimal swelling felt to be at little risk for compartment syndrome may be discharged to home with appropriate postoperative instructions, but otherwise children are generally admitted overnight for elevation and observation. We recommend the elbow is elevated over the heart for at least 48 hours postoperatively. The patient customarily returns 5 to 7 days postoperatively at which time AP and lateral radiographs are obtained. In the unlikely event a loss of reduction were to occur, this would be noted in sufficient time for rereduction. This return visit is probably not necessary in most cases.148 The cast is generally removed 3 weeks postoperatively, at which time radiographs are obtained out of the cast. The pins are removed in the outpatient setting at this time. Range-of-motion exercises are taught to the family, targeting gentle flexion and extension, to be started a few days after cast removal. The child returns 6 weeks postoperatively for a range of motion check, with no radiographs at that time. 

Pearls and Pitfalls Related to Supracondylar Fractures of the Distal Humerus

  •  
    Aim to separate the pins as far as possible at the fracture site—this is more important than whether the pins are divergent or parallel.
  •  
    To optimize pin placement, think of the cartilaginous distal humerus as a pincushion. With the K-wires in your fingers (not the drill) push them into the cartilage in the exact location and trajectory you want. Verify with imaging, then advance the pin with a drill.
  •  
    In general, plan on a minimum of two pins for type II fractures and three pins for type III fractures.
  •  
    If the first pin is in between where you really wanted two pins, just leave it and place one on either side of it for a total of three pins.
  •  
    A small amount of translation or axial rotational malalignment may be accepted rather than doing an open reduction, but accept very little frontal or sagittal plane angular malalignment.
  •  
    Following reduction and fixation, stress the fracture under live imaging to the point where you are confident it will not fall apart postoperatively.
  •  
    Cast the elbow in significantly less than 90 degrees of flexion to avoid compartment syndrome, the pins are holding the reduction, not the cast.
  •  
    If you chose to place a medial pin, extend the elbow when placing the pin to keep the ulnar nerve posteriorly out of harm's way.

Open Reduction and Pinning in Supracondylar Fractures of the Distal Humerus

We prefer a transverse anterior incision above and parallel to the antecubital fossa at the fracture site about 4 to 5 cm long which allows access to the neurovascular structures and is aesthetic (Fig. 16-48C). If more visualization is needed, this incision can be extended medially or laterally based on displacement. Care must be taken in dissecting as the neurovascular bundle may be immediately superficial as it is pushed against the skin by the proximal fragment. Usually there is significant disruption of the brachialis muscle. The first major structure to be incised is the bicipital aponeurosis (lacertus fibrosus) which runs just superficial to the median nerve and brachial artery: From the biceps tendon it runs medially to the superficial flexors of the forearm. Just medial to the biceps tendon the brachial artery is noted, with the median nerve just medial to the artery. If the artery cannot be located in a patient presenting with a pulseless, poorly perfused hand search for the lacerated ends of the artery which may have retracted (Fig. 16-53). 
Figure 16-53
The brachial artery was lacerated by the proximal fragment.
 
Bulldogs have been placed on each end of the artery to control bleeding, and the median nerve is within the vessel loop.
 
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
Bulldogs have been placed on each end of the artery to control bleeding, and the median nerve is within the vessel loop.
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Figure 16-53
The brachial artery was lacerated by the proximal fragment.
Bulldogs have been placed on each end of the artery to control bleeding, and the median nerve is within the vessel loop.
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
Bulldogs have been placed on each end of the artery to control bleeding, and the median nerve is within the vessel loop.
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Once the brachial artery and median nerve are identified, they should be retracted out of the fracture site. Reduction may be more challenging than one would imagine. One reduction technique is for the surgeon to push downward on the proximal fragment, while an assistant applies traction to the forearm with the elbow flexed at 90 degrees. Often the periosteum is also entrapped in the fracture site. A freerer can be used as a lever to elevate the periosteum and assist the reduction. Once a reduction has been obtained pinning may be accomplished in the same manner as in closed reduction with percutaneous pinning. 

Complications in Supracondylar Fractures of the Distal Humerus

Vascular Injury in Supracondylar Fractures of the Distal Humerus

Preoperative Evaluation and Care

Approximately 1% to 15% of patients with supracondylar fractures present with an absent pulse but only a minority of these patients will require vascular repair.37,42,56,81,119,147,164,166 At the initial evaluation the presence or absence of a pulse and perfusion of the hand should be determined. Perfusion of the hand is estimated by color, warmth, pulp turgor, and arterial capillary refill, but there is no clear evidence of the degree of reliability of these objective standards. Capillary refill by itself can be deceiving. For example after wrapping a rubber band around a finger there is instant venous capillary refill but no artery inflow or venous outflow, so this must be differentiated from normal arterial capillary refill. Generally accepted normal perfusion criteria (viable hand) are capillary refill equivalent to the opposite side and less than 3 to 5 seconds, normal pulp turgor and pink color. The clinician must distinguish between the nonviable and viable hand upon presentation and throughout care. 
Hand perfusion, not presence or absence of a pulse, appears to be predictive of the need for arterial repair and risk of compartment syndrome. Choi et al.42 reported on 25 pulseless patients whose hand was well perfused at presentation and none (0%) required vascular repair or developed a compartment syndrome. In contrast, of eight patients who presented with poor distal perfusion, compartment syndrome developed in 25% and 38% underwent vascular repair. 
An absent radial pulse is not in itself an emergency, as collateral circulation may keep the limb well perfused in the short term and potentially even long term. In the case of a pulseless, perfused hand, urgent, but nonemergent, reduction with pinning in the operating room is indicated.100,140,161,166 However, in the presence of an associated nerve injury, there is higher risk of a compartment syndrome and more cautious close observation until surgery is indicated.134 If the arm is pulseless and also has signs of poor perfusion (white color, decreased turgor, and/or slow capillary refill), this is an emergency.3 When a patient with a severely displaced supracondylar fracture presents to the emergency room and has compromised vascularity to the limb, the arm should be splinted with the elbow in approximately 20 to 40 degrees of flexion100,140 to protect further injury as the patient progresses directly to surgery. 
Fracture reduction should not be delayed by any waiting time for an angiographic study, as reduction of the fracture usually restores the pulse.3,41 Several reports have shown angiography to be an unnecessary test that has no bearing on treatment.43,147,164,166 Shaw et al.166 reported on a series of 143 type III supracondylar fractures, 17 of which had vascular compromise. All underwent reduction and percutaneous pinning without preoperative angiogram. In 3 of the 17 (18%) patients, restored blood flow to the hand did not occur after reduction and required open exploration. In 14 of the 17 (82%) patients, restored blood flow to the hand occurred without complications. The authors concluded that prereduction angiography would add nothing to the management of these injuries. Another study utilized angiogram in 4 of 17 (24%) dysvascular SCH fractures and found that the angiogram did not alter the course of management in any of the cases.43 Choi et al.41 reported that of 25 patients presenting with a pulseless but well-perfused hand, 100% did well clinically without arterial repair—52% (11) had a palpable pulse following surgery, and 48% (10) remained pulseless but well perfused. Cheng et al.37 in a series of 623 supracondylar fractures reported nine cases presenting with an absent radial pulse (1.4%), of which only one required exploration. 

Operative Treatment of a White, Pulseless Hand in Supracondylar Fractures of the Distal Humerus

Closed Reduction, Percutaneous Pinning of Supracondylar Fractures of the Distal Humerus

Standard treatment for a pulseless hand is closed reduction and percutaneous pinning. After closed reduction and stabilization, the pulse and perfusion of the hand should be evaluated. Usually hand perfusion is restored. Most extension-type supracondylar fractures are reduced and pinned with the elbow in hyperflexion. With more than 120 degrees of elbow flexion, the radial pulse generally is lost, and the hand becomes pale, even in patients with an initially intact pulse and a viable hand. Following pinning when the arm is extended, the pulse frequently does not return immediately. This is presumably secondary to arterial spasm, aggravated by swelling about the artery and decreased peripheral perfusion in the anesthetized, somewhat cool intraoperative patient. 
Because of this phenomenon, up to 10 to 15 minutes should be allowed for recovery of perfusion in the operating room before any decision is made regarding the need for exploring the brachial artery and restoring flow to the distal portion of the extremity. Because most patients without a palpable pulse regain and maintain adequate distal perfusion, the absence of a palpable pulse alone is not an indication for exploring a brachial artery. 
If there is a poor or absent pulse, and/or poor perfusion, there is a high risk of compartment syndrome, and a low threshold for intraoperative compartment pressure measurements and documentation. In cases of poor limb perfusion for over 6 hours, prophylactic forearm compartment release should be performed. 

Postreduction White (Poorly Perfused), Pulseless Hand in Supracondylar Fractures of the Distal Humerus

Following reduction a poorly perfused pulseless hand requires urgent treatment.3,140,187 If there was a pulse before fracture reduction, one must assume the artery or surrounding tissue is trapped at the fracture site, and pins should be pulled, and the artery explored. If there was not adequate perfusion before fracture reduction, and the hand remains poorly perfused, arterial exploration should be performed urgently. 
Exploration through an anterior approach allows evaluation of arterial kinking by entrapped adjacent soft tissues or incarceration of the artery between the fracture fragments.11,62 Once the artery is freed from the fracture, associated arterial spasm may be relieved by application of lidocaine, warming, and 10 to 15 minutes of observation. Following anatomic fracture reduction and decompression of the neurovascular bundle of a pulseless limb, if the hand remains poorly perfused, vascular reconstruction is indicated by an appropriate specialist. 

Postreduction pink (Perfused), Pulseless Hand in Supracondylar Fractures of the Distal Humerus

If the pulse does not return, but the hand is well perfused following reduction, treatment is controversial.158,187 Our practice is to admit the child to the hospital with gentle arm elevation and careful observation for at least 48 hours. The patient should be observed for increasing narcotic requirements, increasing pain, and decreased passive finger motion. (The 3 A's of a pending pediatric compartment syndrome: Increasing anxiety, agitation, and analgesic requirement.) Multiple authors report good results with observation of the postreduction pink pulseless hand.3,41,71,75,81 However, a very low threshold for returning to the operating room for vascular exploration, decompression, and/or reconstruction along with forearm fasciotomies must be maintained rather than assuming that perfusion from collaterals is sufficient. There are known disastrous cases of permanent impairment in this setting. 
Alternatively, vascular reconstruction may be performed in the pink pulseless hand. There has been some variance of results of reconstruction long term. Sabharwal et al.161 have shown that early repair of the brachial artery has a high rate of symptomatic reocclusion or residual stenosis and recommended a period of close observation with frequent neurovascular checks before more invasive correction of this problem is contemplated. Many other studies report good results following vascular repair105,164,166 including an analysis of 19 studies with a patency rate of 91% in 54 patients with surgically repaired arteries.200 Repair by microscopic techniques appear to have better long-term results. 
Lally et al. reported on the long-term follow-up of 27 patients who had brachial artery ligation as a child for renal transplant. Decreased mean systolic pressure was noted in the affected limp in about 25% of patients and 67% had mildly decreased exercise tolerance. There was no significant difference in limb circumference or length. Perhaps most importantly, no patient specifically complained of problems with the ligated side.113 

Vascular Studies of Supracondylar Fractures of the Distal Humerus

There is currently no generally accepted evidence that further vascular studies beyond pulse and perfusion lead to improved outcomes, though this is an area of active research. A review of articles subsequent to 1980 in the vascular surgical literature concludes: “Both angiography and color duplex ultrasound provide little benefit in the management of these patients. A child with a pink pulseless hand postfracture reduction can be managed expectantly unless additional signs of vascular compromise develop, in which exploration should be undertaken.”81 Similarly, some surgeons in the past have recommended pulse oximetry155 for evaluating postreduction circulation, though this has not been shown to unequivocally discriminate the nonviable from the viable hand. 

Special Case: Pulseless with Median Nerve Injury

If the arm is pulseless and has a median or AIN deficit special attention is warranted.158 With injury to both the brachial artery and a nerve, we may assume that significant soft tissue damage has occurred, which places the child at higher risk for a compartment syndrome. The pain of a compartment syndrome may be masked by the nerve injury, so very careful assessment and monitoring for a compartment syndrome is needed throughout the perioperative period, with a low threshold for vascular exploration and/or compartment release.134 Mangat et al.123 reported on seven patients who were pulseless with a median or AIN injury, and all seven patients were found to have the brachial artery trapped or tethered at the fracture site. They recommend early exploration of the brachial artery in a Gartland type III supracondylar fracture in patients who present with an absent pulse and a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment. In contrast, they found only 20% of pulseless extremities without a nerve deficit had the artery trapped or tethered. 

Exploration of the Brachial Artery

Often, during the open reduction of the fracture, release of a fascial band or an adventitial tether resolves the problem of obstructed flow. In some patients, however, a formal vascular repair and/or vein grafting is required, at which time many orthopedic surgeons will consult colleagues with vascular expertise. The brachial artery is approached through an anteromedial transverse incision at the level of the fracture above the antecubital fossa. Often this provides excellent exposure of the fracture site and neurovascular bundle. Distal and proximal extension can be performed with z-limbs if necessary as described in the author's preferred method for open reduction (Fig. 16-48C). 
If the hand is still nonviable after reduction and pinning the fracture, care must be taken because the neurovascular bundle may be difficult to identify when it is surrounded by hematoma or lies in a very superficial position. At the level of the fracture, the artery may seem to disappear into the fracture site, covered with shredded brachialis muscle. This occurs when the artery is likely tethered by a fascial band or arterial adventitia attached to the proximal metaphyseal spike pulling the artery in the fracture site. Dissection is often best accomplished proximally to distally, along the brachial artery, identifying both the artery and the median nerve. Arterial injury is generally at the level of the supratrochlear artery (Fig. 16-54), which provides a tether, making the artery vulnerable at this location. Arterial transection or direct arterial injury can be identified at this level. 
Figure 16-54
Arterial pathology.
 
The supratrochlear branch that arises from the anterior ulnar recurrent artery may bind the main trunk of the brachial artery against the sharp end of the proximal fragment.
 
(From Rowell PJW. Arterial occlusion in juvenile humeral supracondylar fracture. Injury. 1974; 6:254–256, with permission.)
The supratrochlear branch that arises from the anterior ulnar recurrent artery may bind the main trunk of the brachial artery against the sharp end of the proximal fragment.
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Figure 16-54
Arterial pathology.
The supratrochlear branch that arises from the anterior ulnar recurrent artery may bind the main trunk of the brachial artery against the sharp end of the proximal fragment.
(From Rowell PJW. Arterial occlusion in juvenile humeral supracondylar fracture. Injury. 1974; 6:254–256, with permission.)
The supratrochlear branch that arises from the anterior ulnar recurrent artery may bind the main trunk of the brachial artery against the sharp end of the proximal fragment.
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If arterial spasm is the cause of inadequate flow, and collateral flow is not sufficient to maintain the hand, attempts to relieve the spasm may be tried. Once the artery is no longer kinked or tethered, direct application of papaverine or local anesthetic to the artery has been found to be beneficial. Sympathetic block with a stellate ganglion block may prolong the vasodilatory effect. If these techniques do not relieve the spasm, and if collateral flow is insufficient to maintain a viable hand, there most likely is an intimal injury and occlusion. In these rare situations, the injured portion of the vessel is excised and a reverse vein graft of appropriate size is inserted, usually from the same extremity. Prophylactic release of forearm fascia is indicated in cases of prolonged ischemia to prevent a reperfusion compartment syndrome. When flow is restored, the wound is closed, the patient is placed in a splint with the elbow in approximately 60 degrees of flexion, and the forearm in neutral pronation and supination. Postoperative monitoring should include temperature, pulse oximetry, and frequent examinations of perfusion and for signs of compartment syndrome or ischemia. Although injecting urokinase has been suggested to increase flow,32 we no longer advocate that technique because of systemic risks. 
There is a single case report of a 6-year-old boy who developed a brachial artery pseudoaneurysm following an SCH fracture.78 The patient presented with a type III SCH extension-type fracture with a pulseless, well-perfused hand. Following fracture reduction and pinning the radial pulse was palpable. At 5-week follow-up the patient had diminished sensation and strength in the radial nerve distribution, accompanied by diminished radial pulse, and swelling in the antecubital fossa. Ultrasound revealed a large pseudoaneurysm of the left brachial artery which was treated with an interposition vein graft. 

Compartment Syndrome (see Chapter 6 for More In-Depth Discussion of Compartment Syndrome and Surgical Technique)

The prevalence of compartment syndrome in the setting of a supracondylar fracture is estimated to be 0.1% to 0.5%.19,20 The classic five “P's” for the diagnosis of compartment syndrome – pain, pallor, pulselessness, paresthesias, and paralysis – are poor indicators of a compartment syndrome in children. Bae et al. report increasing analgesia requirement in combination with other clinical signs are more sensitive and earlier indicators of compartment syndrome in children. They found 10 children with access to patient-controlled or nurse-administered analgesia had increasing requirement for pain medication.15 Resistance to passive finger movement and dramatically increasing pain after fracture are clinical signs of compartment syndrome of the forearm. Special attention must be paid to supracondylar fractures with median nerve injuries, as the patient will not feel pain in the volar compartment.134 A compartment syndrome of the forearm may occur with or without brachial artery injury and in the presence or absence of a radial pulse. 
If the supracondylar fracture's mechanism of injury is high energy as evidenced by crushing or associated fractures there is an increased risk for compartment syndrome. Blakemore et al.24 found a 7% incidence of forearm compartment syndrome (3 of 33 patients) with the combined injury of supracondylar fracture and radial fracture. Ring et al.157 found 6 of 10 pediatric floating elbows with pending or true compartment syndromes and recommend pinning of both distal radius and SCH fractures. An arterial injury in association with multiple injuries or crush injury further diminishes blood flow to the forearm musculature and increases the probability of a compartment syndrome. 
In a multicenter review Ramachandran et al.152 identified 11 cases in which children with supracondylar fracture developed compartment syndrome despite presenting with closed, low-energy injuries and no associated fractures or vascular compromise. This series is disturbing as it demonstrates that compartment syndrome still occurs with modern treatment, even in children who may be thought to be at low risk. They found that in 10 of 11 patient's charts, excessive swelling was noted at time of presentation. The 10 cases with severe elbow swelling documented at presentation had a mean delay until surgery of 22 hours. This study suggests excessive swelling combined with delay in treatment is a risk factor for development of compartment syndrome. The authors also noted that even if distal pulse is found by palpation or Doppler examination, an evolving compartment syndrome may be present. 
If one is concerned that a compartment syndrome may be evolving, initial management includes removing all circumferential dressings. Battaglia et al.20 documented the relationship between increasing elbow flexion above 90 degrees and increasing volar compartment pressure, so the elbow should be extended to a position well below 90 degrees. The volar compartment should be palpated, and the elbow should be extended. We believe that the fracture should be immediately stabilized with K-wires to allow proper management of the soft tissues. 
Another factor that contributes to the development of compartment syndrome is warm ischemic time after injury. When blood flow is compromised and the hand is pale with no arterial flow, muscle ischemia is possible, depending on the time of oxygen deprivation. After fracture reduction and flow restoration, the warm ischemic time should be noted. If this time is more than 6 hours, compartment syndrome secondary to ischemic muscle injury is likely. Prophylactic volar compartment fasciotomy can be performed at the time of arterial reconstruction. The exact indication for prophylactic fasciotomy in the absence of an operative revascularization is uncertain. Even when the diagnosis is delayed or if the compartment syndrome is chronic, fasciotomy has been shown to be of some value. 
Blakey et al.25 report on the experience of their specialized center over a 21-year period. At a mean of 3 months after sustaining an SCH fracture, 23 children with ischemic contractures of the forearm were referred. The authors recommend that urgent exploration of the vessels and nerves in a child with a “pink pulseless hand” following fracture reduction with persistent and increasing pain suggest critical ischemia. No further conclusions regarding acute care of patients with a pink pulseless hand that does not have increasing pain suggestive of ischemia can be drawn from this retrospective study of established ischemic contractures. 

Neurologic Deficit in Supracondylar Fractures of the Distal Humerus

A meta-analysis of 3,457 extension-type SCH fractures found an overall neuropraxia rate of 13%, with the AIN (5%) being the most common, followed by the radial nerve 4%.13 AIN palsy presents as paralysis of the long flexors of the thumb and index finger without sensory changes. Complete median nerve injury has also been described with these fractures because of contusion or transection of the nerve at the level of the fracture and presents with sensory loss in the median nerve distribution as well as motor loss of all muscles innervated by the median nerve.182,186 Nerve transections are rare and almost exclusively involve the radial nerve.17,46,125,126 
The direction of the fracture's displacement determines the nerve most likely to be injured. If the distal fragment is displaced posteromedially, the radial nerve is more likely to be injured. Conversely, if the displacement of the distal fragment is posterolateral, the neurovascular bundle is stretched over the proximal fragment, injuring the median nerve or AIN or both. In a flexion type of supracondylar fracture, which is rare, the ulnar nerve is the most likely nerve to be injured (Fig. 16-6). 
Open reduction and exploration of the injured nerve is not necessarily indicated in cases of nerve injury in a closed fracture. Neural recovery, regardless of which nerve is injured, generally occurs with observation after 2 to 2.5 months, but may take up to 6 months.31,100 
Culp et al.46 reported identification of eight injured nerves in five patients in which spontaneous recovery did not occur by 5 months after injury. Neurolysis was successful in restoring nerve function in all but one patient. Nerve grafting may be indicated for nerves not in continuity at the time of exploration. Decompression and neurolysis for perineural fibrosis is generally successful in restoring nerve function. There is no indication for early electromyographic analysis or treatment other than observation for nerve deficit until 3 to 6 months after fracture. 
In their series of radial nerve injuries with humeral fractures, Amillo et al.7 reported that of 12 injuries that did not spontaneously recover within 6 months of injury, only one was associated with a supracondylar fracture. Perineural fibrosis was present in four patients, three nerves were entrapped in callus, and five were either partially or totally transected. 
In the supracondylar area, nerve compression and perineural fibrosis appears to be the most common cause of prolonged nerve deficit. Although nerve injury is related to fracture displacement, a neural deficit can exist with even minimally displaced fractures. Sairyo et al.162 reported one patient in whom radial nerve palsy occurred with a slightly angulated fracture that appeared to be a purely extension-type fracture on initial x-rays. Even in patients with mild injuries, a complete neurologic examination should be performed before treatment. An irreducible fracture with nerve deficit is an indication for open reduction of the fracture to ensure that there is no nerve entrapment. Chronic nerve entrapment in healed callus can give the appearance of a hole in the bone, Metev's sign. 
Iatrogenic injury to the ulnar nerve has been reported to occur in 1% to 15% of patients with supracondylar fractures.31,57,92,154,159,175 In a large series of type III supracondylar fractures, the rate of iatrogenic injury to the radial nerve was less than 1%. The course of the ulnar nerve through the cubital tunnel, between the medial epicondyle and the olecranon, makes it vulnerable when a medial pin is placed. Rasool154 demonstrated with operative exploration that the pin usually did not impale the ulnar nerve, but more commonly constricted the nerve within the cubital tunnel by tethering adjacent soft tissue. These findings were later confirmed by an ultrasonographic study by Karakurt et al.98 Zaltz et al.211 reported that in children less than 5 years of age, when the elbow is flexed more than 90 degrees, the ulnar nerve migrated over, or even anterior to, the medical epicondyle in 61% (32/52) of children. It has been suggested that placement of lateral-entry pins first, followed by elbow extension to relax tension on the ulnar nerve and subsequent placement of a medial pin could decrease the risk of iatrogenic nerve injury. Using this technique these authors reported a 1.1% (2/187) rate of iatrogenic ulnar nerve injury with medial pins.57 
If an iatrogenic ulnar nerve injury occurs following placement of a medial pin, there is a lack of literature on which to base treatment. Lyons et al.120 reported on 17 patients with iatrogenic ulnar nerve injuries presumably due to a medial pin. All 17 patients had complete return of function, though many not until 4 months. Only 4 of the 17 (24%) had the medial pins removed. This study demonstrates ulnar nerve function can eventually return without pin removal. Brown and Zinar31 reported four ulnar nerve injuries associated with pinning of supracondylar fractures, all of which resolved spontaneously 2 to 4 months after pinning. Rasool154 reported six patients with ulnar nerve injuries in whom early exploration was performed. In two patients, the nerve was penetrated, and in three, it was constricted by a retinaculum over the cubital tunnel, aggravated by the pin. In one patient, the nerve was subluxed and was fixed anterior to the cubital tunnel by the pin. Full recovery occurred in three patients, partial recovery in two, and no recovery in two. Royce et al.159 reported spontaneous recovery of ulnar nerve function in three patients. One nerve that was explored had direct penetration, and the pin was replaced in the proper position. Two patients had late-onset ulnar nerve palsies discovered during healing, and the medial pin was removed. 
If an immediate postoperative neural injury is documented, we prefer to explore the ulnar nerve and to replace the pin in the proper position or convert to a lateral pin construct. Common sense suggests that removal of the causative factor (the medial pin) earlier rather than later may lead to a quicker recovery of the nerve. Routine exploration of the ulnar nerve is not recommended.31,63,154,211 
Preventing ulnar nerve injury is obviously more desirable than treating ulnar neuropathy. Because of the frequency of ulnar nerve injury with crossed pinning, most surgeons prefer to use two or three lateral pins if possible and no medial pin. Successful maintenance of alignment of type III supracondylar fractures with lateral pins has been reported in many series.38,103,173,175,191 In our opinion the only technique for avoiding iatrogenic ulnar nerve injury across is to use lateral-entry pins, and avoid the use of cross pins. However, one meta-analysis of 3,457 extension-type fractures reported an iatrogenic neurapraxia rate of 1.9% for laterally placed pins.13 As 97% of these patients were studied retrospectively, we suspect that many if not most of these “iatrogenic” nerve injuries were really due to inaccurate preoperative neurologic examinations.13 

Elbow Stiffness in Supracondylar Fractures of the Distal Humerus

Clinically significant loss of motion after extension-type supracondylar fractures is rare in children. In a study of 45 children with SCH fractures who did not undergo physical therapy, 90% range of motion (ROM) returned at 30 days for extension and 39 days for flexion.196 In another report of 63 patients with closed reduction percutaneous pinning of supracondylar fractures of the humerus stabilized with either two or three lateral-entry pins, elbow ROM returned to 72% of contralateral elbow motion by 6 weeks after pinning and progressively increased to 86% by 12 weeks, 94% by 26 weeks, and 98% by 52 weeks.214 Pins were removed by 3 to 4 weeks. No patient participated in formal physical therapy. 
Although most children do not require formal physical therapy, we generally teach the parents range-of-motion exercises to be performed at home following pin and cast removal at about 3 to 4 weeks. A follow-up appointment to assess range of motion is scheduled about 4 to 8 weeks later, and if motion is not nearly normal at that time, a physical therapy to improve elbow motion is begun. 
Significant loss of flexion can be caused by a lack of anatomic fracture reduction: Either posterior distal fragment angulation, posterior translation of the distal fragment with anterior impingement, or medial rotation of the distal fragment with a protruding medial metaphyseal spike proximally (Fig. 16-55). In young children with significant growth potential, there may be significant remodeling of anterior impingement, and any corrective surgery should be delayed at least 1 year. Although anterior impingement can significantly remodel, there is little remodeling of persistent posterior angulation or hyperextension. 
Figure 16-55
Distal fragment rotation.
 
A: Posterior angulation only of the distal fragment. B: Pure horizontal rotation without angulation. C: Pure posterior translocation without rotation or angulation. D: Horizontal rotation with coronal tilting, producing a cubitus varus deformity. There is a positive crescent sign.
 
(From Marion J, LaGrange J, Faysse R, et al. Les fractures de l'extremite inferieure de l'humerus chez l'enfant. Rev Chir Orthop. 1962; 48:337–413, with permission [C, D].)
A: Posterior angulation only of the distal fragment. B: Pure horizontal rotation without angulation. C: Pure posterior translocation without rotation or angulation. D: Horizontal rotation with coronal tilting, producing a cubitus varus deformity. There is a positive crescent sign.
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Figure 16-55
Distal fragment rotation.
A: Posterior angulation only of the distal fragment. B: Pure horizontal rotation without angulation. C: Pure posterior translocation without rotation or angulation. D: Horizontal rotation with coronal tilting, producing a cubitus varus deformity. There is a positive crescent sign.
(From Marion J, LaGrange J, Faysse R, et al. Les fractures de l'extremite inferieure de l'humerus chez l'enfant. Rev Chir Orthop. 1962; 48:337–413, with permission [C, D].)
A: Posterior angulation only of the distal fragment. B: Pure horizontal rotation without angulation. C: Pure posterior translocation without rotation or angulation. D: Horizontal rotation with coronal tilting, producing a cubitus varus deformity. There is a positive crescent sign.
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Pin Tract Infections

The reported prevalence of pin tract infections in SCH fractures ranges from less than 1% to 2.5% with closed reduction and standard pinning techniques.19,38,173 In a retrospective review of 622 operative treated patients, one patient developed a deep infection with septic arthritis and osteomyelitis (0.2%). Five additional patients had superficial skin infections and were treated with oral antibiotics for a total infection rate of 6 of 622 patients (1%).19 
Pin tract infections generally resolve with pin removal and antibiotics. Fortunately, by the time a pin tract infection develops the fracture is usually stable enough to remove the pin without loss of reduction. However, an untreated pin tract infection can result in a septic joint and should thus be treated as soon as is recognized or suspected. 

Pin Migration

In one retrospective series of 622 patients, the most common complication was pin migration necessitating unexpected return to the operating room for pin removal in 11 patients (1.8%). This complication can be minimized by both bending at least 1 cm of pin at a 90-degree angle, at least 1 cm from the skin, and protecting the skin with thick felt over the pin (Fig. 16-48A) or using commercially available pin covers. 

Myositis Ossificans in Supracondylar Fractures of the Distal Humerus

Myositis ossificans is a remarkably rare complication of supracondylar fractures, but it can occur (Fig. 16-56). This complication has been described after closed and open reduction, but vigorous postoperative manipulation or physical therapy is believed to be the most commonly associated factor.107,147 
Figure 16-56
Myositis ossificans.
 
Ossification of the brachialis muscle developed in this 8-year-old who had undergone multiple attempts at reduction.
 
(Courtesy of John Schaeffer, MD.)
Ossification of the brachialis muscle developed in this 8-year-old who had undergone multiple attempts at reduction.
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Figure 16-56
Myositis ossificans.
Ossification of the brachialis muscle developed in this 8-year-old who had undergone multiple attempts at reduction.
(Courtesy of John Schaeffer, MD.)
Ossification of the brachialis muscle developed in this 8-year-old who had undergone multiple attempts at reduction.
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In a report of two patients with myositis ossificans after closed reduction of supracondylar fractures, Aitken et al.5 noted that limitation of motion and calcification disappeared after 2 years. Postoperative myositis ossificans can be observed with the expectation of spontaneous resolution of both restricted motion and the myositis ossificans. There is no indication for early excision. O'Driscoll137 reported a single case of myositis ossificans associated with sudden onset of pain posttrauma in which a 1-year-old lesion of myositis ossificans was fractured. With excision, the pain was relieved, and full range of motion returned. 

Nonunion of Supracondylar Fractures of the Distal Humerus

The distal humeral metaphysis is a well-vascularized area with remarkably rapid healing, and nonunion of a supracondylar fracture is rare, with only a single case described by Wilkins and Beaty201 after open reduction. We have not seen nonunion of this fracture. With infection, devascularization, and soft tissue loss, the risk of nonunion would presumably increase. 

Avascular Necrosis in Supracondylar Fractures of the Distal Humerus

Avascular necrosis of the trochlea after supracondylar fracture has been reported. The blood supply of the trochlea's ossification center is fragile, with two separate sources. One small artery is lateral and courses directly through the physis of the medial condyle. It provides blood to the medial crista of the trochlea. If the fracture line is very distal, this artery can be injured, producing avascular necrosis of the ossification center and resulting in a classic fishtail deformity. Kim et al.102 identified 18 children with trochlear abnormalities after elbow injuries, five of which were supracondylar fractures. MRI indicated low-signal intensity on T2 indicative of cartilage necrosis. Cubitus varus deformity developed in all cases. 
Symptoms of avascular necrosis of the trochlea do not occur for months or years. Healing is normal, but mild pain and occasional locking develop with characteristic radiologic findings and motion may be limited depending on the extent of AVN. An important risk for AVN of the trochlea is following an open reduction of a supracondylar fracture through a posterior approach which presumably disrupts the blood supply of the trochlea (Fig. 16-57). 
Figure 16-57
Avascular necrosis of the trochlea developed following open reduction through a posterior approach.
 
The child had limited motion and symptoms of occasional catching.
 
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
The child had limited motion and symptoms of occasional catching.
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Figure 16-57
Avascular necrosis of the trochlea developed following open reduction through a posterior approach.
The child had limited motion and symptoms of occasional catching.
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
The child had limited motion and symptoms of occasional catching.
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Loss of Reduction in Supracondylar Fractures of the Distal Humerus

Sankar et al.163 in a series of 322 fractures reported 2.9% had postoperative loss of fixation. All eight were Gartland type III fractures treated with just two pins (seven lateral entry and one cross pin). In all cases, loss of fixation was due to technical errors that were identifiable on the intraoperative fluoroscopic images and that could have been prevented with proper technique. They identified three types of pin-fixation errors: (1) Failure to engage both fragments with two pins or more, (2) failure to achieve bicortical fixation with two pins or more, and (3) failure to achieve adequate pin separation (>2 mm) at the fracture site (Fig. 16-58). 
Figure 16-58
Illustrations depicting errors in pin-fixation technique.
 
A: The black arrow demonstrates the anterior pin failing to transfix the proximal bone. B: The black arrow demonstrates one pin without bicortical purchase. C: The black arrow demonstrates pins too close together at the fracture site.
A: The black arrow demonstrates the anterior pin failing to transfix the proximal bone. B: The black arrow demonstrates one pin without bicortical purchase. C: The black arrow demonstrates pins too close together at the fracture site.
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Figure 16-58
Illustrations depicting errors in pin-fixation technique.
A: The black arrow demonstrates the anterior pin failing to transfix the proximal bone. B: The black arrow demonstrates one pin without bicortical purchase. C: The black arrow demonstrates pins too close together at the fracture site.
A: The black arrow demonstrates the anterior pin failing to transfix the proximal bone. B: The black arrow demonstrates one pin without bicortical purchase. C: The black arrow demonstrates pins too close together at the fracture site.
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Clinical experience of a series of 124 consecutive SCH fractures including completely unstable fractures has taught us that lateral-entry pins, when properly placed, are usually strong enough to maintain reduction of even the most unstable SCH fracture.173 

Cubitus Varus

Cubitus varus, also known as a “gunstock deformity” has a characteristic appearance in the frontal plane (Fig. 16-59). The malunion also includes hyperextension, which leads to increased elbow extension and decreased elbow flexion (Figs. 16-60 and 16-61). The appearance of cubitus varus deformity is distinctive upon x-ray. On the AP view, the angle of the physis of the lateral condyle (Baumann's angle) is more horizontal than normal (Fig. 16-62). On the lateral view, hyperextension of the distal fragment posterior to the AHL goes along with the clinical findings of increased extension and decreased flexion of the elbow (Fig. 16-63). 
Figure 16-59
Five-year-old girl with cubitus varus of right elbow following a malunion of a supracondylar humerus fracture.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-59
Five-year-old girl with cubitus varus of right elbow following a malunion of a supracondylar humerus fracture.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-60
Hyperextension of right elbow.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-60
Hyperextension of right elbow.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-61
Decreased flexion of right elbow.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-61
Decreased flexion of right elbow.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-62
AP radiograph of the girl in preceding clinical photos.
 
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-62
AP radiograph of the girl in preceding clinical photos.
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission of Children's Orthopaedic Center, Los Angeles, CA.)
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Note the anterior humeral line is anterior to the capitellum.
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Figure 16-63
Lateral radiograph shows overlapping of the distal humerus with the olecranon (arrow) producing the typical crescent sign.
Note the anterior humeral line is anterior to the capitellum.
Note the anterior humeral line is anterior to the capitellum.
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Some authors have proposed that unequal growth in the distal humerus causes cubitus varus deformity,91,144 though this is unlikely as there is not enough growth in this area to cause cubitus varus within the time it is recognized. The most common reason for cubitus varus in patients with supracondylar fractures is likely malunion rather than growth arrest.10,33,47,63,198 Cubitus varus can be prevented by making certain Baumann's angle is intact at the time of reduction and remains so during healing. Pirone et al.147 reported cubitus varus deformities in 8 of 101 (7.9%) patients treated with cast immobilization compared to 2 of 105 (1.9%) patients with pin fixation, with ages ranging from 1.5 to 14 years (mean of 6.4 years). A decrease in frequency of cubitus varus deformity after the use of percutaneous pin fixation has been reflected in other recent series,27,28,63,64,97,130,147 with one large retrospective73 and one prospective study104 reporting no cases of cubitus varus. 
The distal humerus growth is 20% of that of its overall length. In a 5-year-old, therefore, the amount of distal humeral growth in 1 year is approximately 2 mm, making it unlikely that growth asymmetry is a significant cause of varus deformity that occurs within the first 6 to 12 months after fracture. Avascular necrosis of the trochlea or medial portion of the distal humeral fragment can result in progressive varus deformity, however. In a series of 36 varus deformities reported by Voss et al.,194 only four patients had medial growth disturbance and distal humeral avascular necrosis as a cause of progressive varus deformity. 
Treatment for cubitus varus has in the past been considered for cosmetic reasons only. However, there are several consequences of cubitus varus such as an increased risk of lateral condyle fractures, pain, and tardy posterolateral rotatory instability, which may be indications for an operative reconstruction with a supracondylar humeral osteotomy.1,2,22,48,127,137,183 Our experience suggested many patients have elbow discomfort with significant cubitus varus. Takahara et al.190 reported nine patients with distal humeral fractures complicating varus deformity. Supracondylar fractures as well as epiphyseal separations were included in these nine fractures. Further problems complicating varus deformity involved the shoulder. Tardy ulnar nerve palsy has also been associated with varus and internal rotational malalignment.83,132 
Cubitus varus deformity is also associated with a significant increase in late ulnar nerve palsies, as reported in the Japanese literature.2,23,193 With a cubitus varus deformity, the olecranon fossa moves to the ulnar side of the distal humerus,138 and the triceps shifts a bit ulnar ward. Investigators theorized that this ulnar shift might compress the ulnar nerve against the medial epicondyle, narrowing the cubital tunnel and resulting in chronic neuropathy. In a recent report,2 a fibrous band running between the heads of the flexor carpi ulnaris was thought to cause ulnar nerve compression. 
Treatment of Cubitus Varus Deformity
As for the treatment of any posttraumatic malalignment, options include: (a) Observation with expected remodeling, (b) hemiepiphysiodesis and growth alteration, and (c) corrective osteotomy. Observation is generally not appropriate because hyperextension may remodel to some degree in a young child (Fig. 16-64). In an older child, little remodeling occurs even in the joint's plane of motion. 
Figure 16-64
A hyperextension deformity in the distal humerus may remodel somewhat, whereas varus and valgus deformity do not.
 
Hyperextension deformity in the distal humerus after fracture (A). Four years later (B), a more normal distal humeral anatomy is seen with remodeling of the hyperextension deformity; 2 years later, (C), a normal distal humeral anatomy is reconstituted.
Hyperextension deformity in the distal humerus after fracture (A). Four years later (B), a more normal distal humeral anatomy is seen with remodeling of the hyperextension deformity; 2 years later, (C), a normal distal humeral anatomy is reconstituted.
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Figure 16-64
A hyperextension deformity in the distal humerus may remodel somewhat, whereas varus and valgus deformity do not.
Hyperextension deformity in the distal humerus after fracture (A). Four years later (B), a more normal distal humeral anatomy is seen with remodeling of the hyperextension deformity; 2 years later, (C), a normal distal humeral anatomy is reconstituted.
Hyperextension deformity in the distal humerus after fracture (A). Four years later (B), a more normal distal humeral anatomy is seen with remodeling of the hyperextension deformity; 2 years later, (C), a normal distal humeral anatomy is reconstituted.
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Hemiepiphysiodesis of the distal humerus may rarely be of value, but only to prevent cubitus varus deformity from developing in a patient with clear medial growth arrest or trochlear avascular necrosis. If untreated, medial growth disturbance will lead to lateral overgrowth and progressive deformity. Lateral epiphysiodesis will not correct the deformity, but will prevent it from increasing. Voss et al.194 used hemiepiphysiodesis with osteotomy in two patients with growth arrest and varus deformity. The humerus varies in length by a few centimeters from one individual to another, but in general, it is about 30 cm long at skeletal maturity. Approximately 65% of the length of the humerus is achieved by age 6 years. A 6-year-old child has approximately 10 cm of growth left in the entire humerus, with only approximately 2 cm provided by the distal physis. Growth arrest, in the absence of avascular necrosis or collapse, will be a very slowly evolving phenomenon, and epiphysiodesis in a child older than 6 years will have little effect on longitudinal growth. In general, prevention of increasing deformity from medial growth arrest is the only role for lateral epiphysiodesis. Because of the slow growth rate in the distal humerus, we do not believe there is any role for lateral epiphysiodesis in correcting a varus deformity in a child with otherwise normal physis. 
Osteotomy
Osteotomy is the only way to correct a cubitus varus deformity with a high probability of success. High complication rates in historic series have led to some controversy about the value of a distal humeral corrective osteotomy for cubitus varus deformity. In a review of 41 patients undergoing distal humeral osteotomies for malunions following SCH fractures at two major pediatric centers, Weiss et al.199 reported a complication rate of 53% with a 32% return to the operating room in surgeries performed between 1987 and 1997. However, in surgeries performed from 1998 to 2002, the complication rate was 14% with a 0% reoperation rate. This group found when lateral-entry pins were used to fix the osteotomy there were significantly less complications.199 
Because malunion is the cause of most cubitus varus deformities, the angular deformity usually occurs at the level of the fracture. Rotation and hypertension may contribute to the deformity, but varus is the most significant factor.40 Hyperextension can produce a severe deformity in some patients. An oblique configuration (Fig. 16-65) places the corrective osteotomy's center of rotation as close to the actual level of the deformity as possible. On an AP x-ray of the humerus with the forearm in full supination, the size of the wedge and the angular correction needed are determined. An “incomplete” lateral closing wedge osteotomy may be performed, leaving a small medial hinge of bone intact. The osteotomy usually is fixed with two K-wires placed laterally. In the absence of an intact medial hinge, two lateral wires probably are not sufficient to secure this osteotomy.194 Wilkins and Beaty201 recommended crossed wires in this situation. In general, an oblique lateral closing wedge osteotomy with a medial hinge will correct the varus deformity, with minimal correction of hyperextension.8,21,44,67,69,80,94,96,109,189,194,205 A transverse lateral closing wedge has more risk of a lateral bump with poor aesthetics. Residual rotational deformity was not found to be a significant problem in studies by Voss et al.194 and Oppenheim et al,142 which is logic given the amount of rotation available from the shoulder. The French osteotomy67 aims to enable axial rotational correction as well, but does so at the expense of stability and we do not use this osteotomy. 
Figure 16-65
 
A: By moving the apex of the closing wedge distally, the osteotomy's center of rotation is moved closer to the deformity. B: Upon closing a distally based wedge osteotomy, there is less translational effect than in a more proximally based osteotomy.
A: By moving the apex of the closing wedge distally, the osteotomy's center of rotation is moved closer to the deformity. B: Upon closing a distally based wedge osteotomy, there is less translational effect than in a more proximally based osteotomy.
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Figure 16-65
A: By moving the apex of the closing wedge distally, the osteotomy's center of rotation is moved closer to the deformity. B: Upon closing a distally based wedge osteotomy, there is less translational effect than in a more proximally based osteotomy.
A: By moving the apex of the closing wedge distally, the osteotomy's center of rotation is moved closer to the deformity. B: Upon closing a distally based wedge osteotomy, there is less translational effect than in a more proximally based osteotomy.
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Japanese surgeons88 described a dome osteotomy in which a curved osteotomy is made in the supracondylar area. Proponents of this osteotomy suggest that multiplane correction is possible without inducing translation in the distal fragment and that rotation can be corrected. DeRosa and Graziano52 described a step-cut osteotomy in which the distal fragment is slotted into the proximal fragment and the osteotomy is secured with a single screw. Functional outcomes are generally good, but the preoperative functional deficit is nearly always minor in patients with cubitus varus deformities. 
Hyperextension deformity may remodel over time (Fig. 16-62), but correction is slow and inconsistent. In one series,194 hyperextension deformities remodeled as much as 30 degrees in very young children, but in older children, there was no significant remodeling in the flexion/extension plane. If hyperextension appears to be a major problem, osteotomy should also be directed at this deformity rather than simple correction of the varus deformity; this situation requires a multiplane osteotomy. 

Author's Preferred Treatment for Supracondylar Fractures of the Distal Humerus

We prefer to use a Wiltse type osteotomy, similar to that described by DeRosa but with the complete cut distal as possible, just superior to the olecranon fossa, to have the axis of rotation of the osteotomy as close as possible to the deformity (Fig. 16-66).174 Preoperative templating is performed to determine the angle of correction required for correction of the varus and, if necessary, for correction of any extension deformity. Templating is based on AP of bilateral upper extremities centered on the elbow combined with clinical examination comparing one arm to the other in terms of frontal plane appearance and arc of motion. For example, if the affected arm has 20 degrees more extension and 20 degrees less flexion than the contralateral arm, a 20-degree wedge is planned in the sagittal plane. 
Figure 16-66
This osteotomy can address frontal and sagittal plane malalignment, and offer some inherent bony stability, while not producing a lateral bump which occurs with simple closing wedge osteotomies.
Hollow arrows show triangles of bone that are removed, solid arrow shows rotation of fragment.
Hollow arrows show triangles of bone that are removed, solid arrow shows rotation of fragment.
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A longitudinal incision measuring approximately 6 cm is made over the lateral distal humerus. The antebrachial cutaneous nerve and its branches may be identified and protected. The radial nerve is generally proximal to the field of dissection. Dissection is carried out in the interval between the brachioradialis and triceps. Subperiosteal dissection is performed to expose the distal humerus. There is sometimes scarring from fracture healing about the area of fracture. Posterior dissection is continued to the olecranon fossa as a landmark, but not distal to it to prevent harming the blood supply to the trochlea. Chandler retractors are used for circumferential protection with special care medially near the ulnar nerve. An osteotomy is performed just above the olecranon fossa perpendicular to the shaft of the humerus. The proximal humerus is delivered out of the wound, to allow the more complex part of the osteotomy to be performed with maximal visualization and protection. At this second cut, the osteotomy is angled correctly to account for sagittal malalignment. On average, about a 20-degree anterior closing wedge is performed, but this may be adjusted as needed to make certain the postfixation image demonstrates the AHL is through the midthird of the capitellum. A small lateral portion of the proximal fragment is left intact and a similarly shaped area with a 90-degree angle is made in the lateral portion of the distal fragment using a rongeur to allow the pieces to fit together for added stability. This technique is adopted from the osteotomy described by Wiltse.203 This prevents excessive lateral translation of the distal fragment, keeps the axis of rotation near the site of deformity, and has some inherent stability if done correctly. Once correction is achieved, bony contact is maximized by further cuts if needed. Three .062-in or 2-mm Kirschner wires are then placed across the osteotomy site from lateral to medial. A goniometer is used to measure alignment. Elbow flexion and extension are then checked to ensure that fingers can touch the ipsilateral shoulder and full extension is achieved. The wound is irrigated, a small amount of local bone graft from the excised wedge is packed around the osteotomy site but making certain bone graft is not in the olecranon fossa. After closure, flexion and extension are checked under live imaging to ensure that there is no motion at the osteotomy site. A long-arm cast is applied in 60 to 80 degrees of flexion with the arm at neutral in regards to supination and pronation. The cast is removed when good callus is demonstrated on radiographs, usually approximately 4 weeks postoperatively, and the pins are removed in clinic at that time. In eight cases performed by one of us with this technique there has been full frontal and sagittal plane correction with no complications (Figs. 16-67 to 16-70).174 
Figure 16-67
AP radiograph of elbow of 5-year-old girl in cubitus varus with Baumann's angle about 0 degrees.
 
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-67
AP radiograph of elbow of 5-year-old girl in cubitus varus with Baumann's angle about 0 degrees.
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-68
Lateral radiograph demonstrates capitellum is posterior to the anterior humeral line.
 
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-68
Lateral radiograph demonstrates capitellum is posterior to the anterior humeral line.
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-69
Intraoperative AP image demonstrates restoration of Baumann's angle after Wiltse type osteotomy.
 
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-69
Intraoperative AP image demonstrates restoration of Baumann's angle after Wiltse type osteotomy.
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
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Figure 16-70
Lateral intraoperative image demonstrates the anterior humeral line now intersects the capitellum.
 
Postoperatively a normal arc of elbow flexion and extension was restored.
 
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
Postoperatively a normal arc of elbow flexion and extension was restored.
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Figure 16-70
Lateral intraoperative image demonstrates the anterior humeral line now intersects the capitellum.
Postoperatively a normal arc of elbow flexion and extension was restored.
(Reproduced with permission from Children's Orthopaedic Center, Los Angeles, CA.)
Postoperatively a normal arc of elbow flexion and extension was restored.
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Controversies Related to Supracondylar Fractures of the Distal Humerus

Flexion-type Supracondylar Fractures of the Distal Humerus

Flexion-type supracondylar humeral fractures account for about 2% of humeral fractures.121 A flexion pattern of injury may not be recognized until reduction is attempted because initial radiographs are inadequate. A key to recognizing a flexion-type supracondylar fracture is that it is unstable in flexion, whereas extension-type fractures generally are stable in hyperflexion. A laterally displaced supracondylar fracture may actually be a flexion-type injury. 

Etiology and Pathology of Supracondylar Fractures of the Distal Humerus

The mechanism of injury is generally believed to be a fall directly onto the elbow rather than a fall onto the outstretched hand with hyperextension of the elbow (Fig. 16-71). The distal fragment is displaced anteriorly and may migrate proximally in a totally displaced fracture. The ulnar nerve is vulnerable in this fracture pattern,65,85,121,160 and it may be entrapped in the fracture or later in the healing callus.112 A meta-analysis of 146 flexion-type SCH fractures found an overall neuropraxia rate of 15%, with the ulnar nerve injury as the most common nerve injured (91%).13 
Figure 16-71
Flexion mechanism.
 
Flexion-type fractures usually result from a blow to the posterior aspect of the elbow. The obliquity of the fracture line may be opposite that of an extension type. The large white arrows demonstrate the usual direction of fragment displacement.
Flexion-type fractures usually result from a blow to the posterior aspect of the elbow. The obliquity of the fracture line may be opposite that of an extension type. The large white arrows demonstrate the usual direction of fragment displacement.
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Figure 16-71
Flexion mechanism.
Flexion-type fractures usually result from a blow to the posterior aspect of the elbow. The obliquity of the fracture line may be opposite that of an extension type. The large white arrows demonstrate the usual direction of fragment displacement.
Flexion-type fractures usually result from a blow to the posterior aspect of the elbow. The obliquity of the fracture line may be opposite that of an extension type. The large white arrows demonstrate the usual direction of fragment displacement.
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X-Ray Findings of Supracondylar Fractures of the Distal Humerus

The x-ray appearance of the distal fragment varies from mild angular deformity to complete anterior displacement. Anterior displacement may be accompanied by medial or lateral translation. Associated fractures of the proximal humerus and radius can occur and any tenderness in these areas mandate full x-ray evaluation of the upper extremity. Fracture classification is similar to extension-type supracondylar fractures72: Type I, nondisplaced fracture; type II, minimally angulated with cortical contact; and type III, totally unstable displaced distal fracture fragment. 

Treatment of Supracondylar Fractures of the Distal Humerus

In general, type I flexion-type supracondylar fractures are stable nondisplaced fractures that can simply be protected in a long arm cast.58,135,153 If mild angulation, as in a type II fracture, requires some reduction in extension, the arm can be immobilized with the elbow fully extended. X-ray evaluation with the elbow extended is easily obtained and accurate in determining the adequacy of reduction. Reduction is assessed by evaluating Baumann's angle, the AHL intersecting the lateral condyle and the integrity of the medial and lateral columns at the olecranon fossa. If reduction cannot be obtained, as is often the case, or if rotation persists, soft tissue interposition, possibly the ulnar nerve, should be suspected. De Boeck49 studied 22 flexion-type supracondylar fractures. He found cast treatment to be satisfactory in nondisplaced cases. In the other 15 cases, closed reduction and percutaneous pinning was successful in most patients. 
A problem with type III flexion supracondylar fractures is that reduction is not easy to achieve and when achieved, the elbow is usually in extension, making it technically challenging to stabilize the distal fragment using pins. 
Type I and II fractures (Figs. 16-72 and 16-73) are generally reduced if any angular displacement is seen on fluoroscopic intraoperative evaluation. Type II fractures can be immobilized in an extension cast with the elbow fully extended (Fig. 16-73). The cast is removed at 3 weeks. If closed reduction is performed without skeletal stabilization, follow-up x-rays usually are taken at 1 week and when the cast is removed at 3 weeks. True lateral x-rays in a fully extended cast are important, and may require a few attempts or use of live fluoroscopy. 
Figure 16-72
Type I flexion injury.
 
A type I flexion supracondylar fracture pattern (arrows) in a 6-year-old below-the-elbow amputee. There is only about a 10-degree increase in the shaft condylar angle. The patient was treated with a simple posterior splint.
A type I flexion supracondylar fracture pattern (arrows) in a 6-year-old below-the-elbow amputee. There is only about a 10-degree increase in the shaft condylar angle. The patient was treated with a simple posterior splint.
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Figure 16-72
Type I flexion injury.
A type I flexion supracondylar fracture pattern (arrows) in a 6-year-old below-the-elbow amputee. There is only about a 10-degree increase in the shaft condylar angle. The patient was treated with a simple posterior splint.
A type I flexion supracondylar fracture pattern (arrows) in a 6-year-old below-the-elbow amputee. There is only about a 10-degree increase in the shaft condylar angle. The patient was treated with a simple posterior splint.
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Figure 16-73
Closed reduction, extension cast.
 
A: A 5-year-old girl sustained a type II flexion pattern. B: She was manipulated into extension and found to be stable, and thus was maintained in a long-arm cast in extension.
A: A 5-year-old girl sustained a type II flexion pattern. B: She was manipulated into extension and found to be stable, and thus was maintained in a long-arm cast in extension.
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Figure 16-73
Closed reduction, extension cast.
A: A 5-year-old girl sustained a type II flexion pattern. B: She was manipulated into extension and found to be stable, and thus was maintained in a long-arm cast in extension.
A: A 5-year-old girl sustained a type II flexion pattern. B: She was manipulated into extension and found to be stable, and thus was maintained in a long-arm cast in extension.
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Pinning is generally required for unstable type II and III flexion supracondylar fractures. The pinning technique described for extension-type supracondylar fractures is not appropriate for this fracture, because its instability in flexion precludes pinning with the elbow hyperflexed. In a flexion-type supracondylar fracture the posterior periosteum is torn, so reduction can be obtained in extension which places tension across the intact anterior periosteum. In general, a slightly less than anatomic reduction can be accepted as long as (a) there is no soft tissue interposition of tissue, (b) Baumann's angle is close to the other side, and (c) neither flexion nor extension is seen on the lateral view. Although rotating the arm is often possible for a lateral view of extension supracondylar fracture, the C-arm must be moved to obtain satisfactory x-ray results when pinning a flexion-type supracondylar fracture, because they are often rotationally unstable even when reduced (Fig. 16-43). 
Pinning is generally performed with the elbow in approximately 30 degrees of flexion, holding the elbow in a reduced position. If closed reduction can be obtained, pinning can be accomplished in this position. Placing two lateral-entry pins in the distal fragment first, allows them to be used as a joy stick and help manipulate the fracture into a reduced position, at which time the pins may be driven across the fracture site (Fig. 16-74). 
Figure 16-74
 
A: Lateral view of a flexion-type supracondylar fracture. The capitellum in front of the anterior humeral line. B: AP view of fracture often underestimates the amount of displacement if an AP is taken of a bent elbow rather than a true AP of the distal humerus. C: Intraoperative view shows anatomy has been restored, with the anterior humeral line crossing the middle third of the capitellum. D: AP view demonstrates three well-placed lateral pins with maximal separation at fracture site, with all pins engaging solid bone.
A: Lateral view of a flexion-type supracondylar fracture. The capitellum in front of the anterior humeral line. B: AP view of fracture often underestimates the amount of displacement if an AP is taken of a bent elbow rather than a true AP of the distal humerus. C: Intraoperative view shows anatomy has been restored, with the anterior humeral line crossing the middle third of the capitellum. D: AP view demonstrates three well-placed lateral pins with maximal separation at fracture site, with all pins engaging solid bone.
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A: Lateral view of a flexion-type supracondylar fracture. The capitellum in front of the anterior humeral line. B: AP view of fracture often underestimates the amount of displacement if an AP is taken of a bent elbow rather than a true AP of the distal humerus. C: Intraoperative view shows anatomy has been restored, with the anterior humeral line crossing the middle third of the capitellum. D: AP view demonstrates three well-placed lateral pins with maximal separation at fracture site, with all pins engaging solid bone.
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Figure 16-74
A: Lateral view of a flexion-type supracondylar fracture. The capitellum in front of the anterior humeral line. B: AP view of fracture often underestimates the amount of displacement if an AP is taken of a bent elbow rather than a true AP of the distal humerus. C: Intraoperative view shows anatomy has been restored, with the anterior humeral line crossing the middle third of the capitellum. D: AP view demonstrates three well-placed lateral pins with maximal separation at fracture site, with all pins engaging solid bone.
A: Lateral view of a flexion-type supracondylar fracture. The capitellum in front of the anterior humeral line. B: AP view of fracture often underestimates the amount of displacement if an AP is taken of a bent elbow rather than a true AP of the distal humerus. C: Intraoperative view shows anatomy has been restored, with the anterior humeral line crossing the middle third of the capitellum. D: AP view demonstrates three well-placed lateral pins with maximal separation at fracture site, with all pins engaging solid bone.
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A: Lateral view of a flexion-type supracondylar fracture. The capitellum in front of the anterior humeral line. B: AP view of fracture often underestimates the amount of displacement if an AP is taken of a bent elbow rather than a true AP of the distal humerus. C: Intraoperative view shows anatomy has been restored, with the anterior humeral line crossing the middle third of the capitellum. D: AP view demonstrates three well-placed lateral pins with maximal separation at fracture site, with all pins engaging solid bone.
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If the fracture is held in anatomic position with pins, a flexed-arm cast can be used to provide better patient comfort, but a cast with the elbow in almost full extension is acceptable. 
Open reduction may be required for flexion-type supracondylar fractures. Open reduction is best performed through an anteromedial or posterior approach, rather than an anterior approach, as is used for extension-type supracondylar fractures. With flexion-type fractures, brachialis remains intact and must be retracted to expose the fracture, necessitating a medial extension to the anterior approach. To ensure that the ulnar nerve is not entrapped in the fracture site, exploring the ulnar nerve or at least identification is probably advisable with this fracture, which is another reason for a medial approach to open reduction. 

Anteromedial Open Reduction of Flexion-type Supracondylar Fractures

The surgeon makes a transverse incision across the antecubital fossa, curving proximally posterior to the neuromuscular bundle. Dissection is carried down to the level of the superficial fascia of the forearm and antecubital fossa. The neurovascular bundle is identified and retracted medially. The brachialis and biceps tendons are retracted laterally to expose the fracture site and facilitate reduction. If there is medial soft tissue impingement or a question of ulnar nerve entrapment within the fracture, the dissection should be carried around posterior to the medial epicondyle, so the ulnar nerve and fracture can be identified. 
Postoperative immobilization is maintained for 3 or 4 weeks until good callus formation is present. Pins are generally left out through the skin and removed in the office without the need for anesthetic. No immediate rehabilitation is given, but the patient is encouraged to begin gentle activities with the arm and to begin regaining motion without a stressful exercise program. 

Author's Preferred Treatment

In general, we treat type I flexion supracondylar fractures with a splint or cast with the elbow flexed for comfort. Minimally displaced type II fractures that reduce in extension are treated in an extension cast. Unstable types II and III fractures are pinned. Open reduction through an anteromedial or posterior approach is used if an anatomic closed reduction cannot be obtained. If a posterior approach is used care is taken to avoid posterior soft tissue dissection of distal fragment to avoid injuring the blood supply to the trochlea. The ulnar nerve is identified and protected throughout the exposure and fracture stabilization. 

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