Most common < 10 years, peak age 5-8 y.o.

80% of all pediatric distal humerus fractures

2:1 males


Extension type: Extension type accounts for 90-98% of all supracondylar fx’s

Gartland Classification

I: nondisplaced

IIA: displaced, posterior cortex intact; rotationally stable

intact posterior cortex acts like a hinge

IIB: displaced, posterior cortex intact; rotationally unstable

III: completely displaced, no cortical contact

most often a medial periosteal sleeve intact when medially displaced and visa versa

Closed Reduction

Reduction Maneuver

Traction: disengages the proximal fragment from the brachialis ms

Coronal plane correction: medial or lateral translation

Axial plane correction: correction of internal rotation deformity

Distal fragment reduced: push with thumb on olecranon

Elbow flexion >100°

Pronation: tightens medial periosteal sleeve


Closed reduction is NOT attempted in type III fx’s

Reduction under flouro control is recommended

In the laterally intact periosteal sleeve, supinate to lock it in

Assessing adequacy of reduction:

Jones view: hyperflexionn shoot through elbow; distal humerus resting on c-arm for coronal reduction assessment…difficult to interpret due to imposition of the proximal forearm

Baumann’s Angle: comparison to uninjured side, difference >5degrees is unacceptable

Anterior Humeral Line

Other Methods: restoration of olecranon fossa anatomy, humero-ulnar angle, crescent sign (overlapping of the ossification centers of the lateral epicondyle and olecranon on a lateral view is unacceptable)

Definitive Treatment

Type I Fracture

Immobilization: long arm cast in 90° elbow flexion, neutral forearm

Repeat radiographs @ 1 week: checking fracture hasn’t drifted into varus

3 weeks: protected ROM, elbow exercises


Conservative treatment guided by lack of displacement, rarity of NV comprismise

May or may not admit overnight for assessment of NV status, compartments

Type II Fracture

Hyperflexion required to maintain reduction

Immobilization: long arm cast, long arm cast split, or long posterior splint with lateral struts

Observe overnight for NV and compartment assessment

3 weeks: protected ROM, elbow exercises

CRPP: significant swelling, inadequate circulation with elbow flexion, rotationally unstable injury


Millis et al CORR 1984 showed that 120degrees of flexion needed to maintain closed reduction of type II supracondylar fractures

Casting these injuries as means of definitive treatment carries risk of compartment syndrome, as swelling is not allowed in the cast…this is especially true with the greater amount of flexion used to maintain the reduction

Type III fracture:

higher energy injury

Increased swelling and soft tissue injury

Difficult reduction, therefor: "Splint it where it lies" f/b CRPP

More complications: Admit for NV and compartment assessment

CRPP Technique

Sterile draped C-arm operating surface

Lateral pin first

0.062mm small child

5/64inch older child

Starting point: lateral condyle immediately lateral to olecranon fossa

Across capitellum and distal humeral physis

Engage medial humeral cortex

2 lateral pins may achieve stability


Maintain ~120 flx full pronation / use Jones view of elbow / may externally rotate through the shoulder to avoid moving C-arm / fracture site

First pin: don’t attempt perfect center of lat cond; want to leave room for 2nd lateral pin

Medial pin:

*80-90° elbow flexion: Less elbow flexion for medial pin as more flexion will bring ulnar nerve volar into Kwire’s path, and lateral pin is providing some stability. Utilize c-arm before firing to assure you are not in the ulnar groove

*Starting point: Different angle taken with medial pin will make it more transverse than lateral pin

*Mini-incision over medial epicondyle

*Spread with hemostat assuring ulnar nerve position

Post Operative Care

Leave pins protruding

Re-assess vascular status before drape removal

Splint: 60-90° elbow flexion with neutral forearm

Admit overnight for NV checks

Pin removal in 3-4 weeks: PT usually not required

Open Reduction


Irreducible by closed methods

Vascular comprimise

Open fractures


Wilkins Ortho Clin 1990 talked about brachialis entrapment in fracture site consistently requires open reduction

Vascular: poor color after closed reduction; kids vascular exam comments on pink warm digits as an actual palpable pulse not necessarily as important

Open Approach

Transverse Antecubital Incision

Enlarge Incision:

Medial side: proximal

Lateral side: distal


Posterolateral displacement with NV comprimise: anteromedial approach

Consider: area of NV injury and periosteal disruption


Neurologic Injury

5-19% of supracondylar farctures

Type III supracondylar fractures:

Median nerve 52% (especially posteromedial displacement)

Radial nerve: 28%

Most are neuropraxic injuries

Motor Recovery: 7-12 weeks

Sensory: ~6 months


Nerve injury can also occur s/p CRPP Royce et al JPO 1991: 143 supracondylars treated CRPP 4 nerve palsies were found, ALL from medial pin. They also found an iatrogenic nerve injury rate of 2-3% after CRPP. This is why Pediatrics Ortho attendings often prefer 2 lateral pins before going medial.

Wound / Nerve Exploration Indications

Culp et al JBJS 1990 nerve injury in supracondylar fx’s: 5 months after injury with NO clinical or EMG evidence of return

Open fracture over disrupted nerve

Neurologic impairment after closed reduction

Arterial Injury


Shaw et al JOT 1990: immediate CRPP restored pulse in 13/17 pulseless supracondylar fractures. Their study also found that arteriography preoperatively would not have contributed to the management of these injuries as thos still lacking a pulse after CRPP were opened and explored acutely and found to have brachial artery disruption at the fracture site.

Angular Deformity_

Distal Humeral Physis: 20% of longitudinal growth

Remodeling: plane of motion only

NO coronal remodeling

NO axial remodeling

Cubitus Varus: Cosmetic in the short term

Recent studies show that in the long term, varus may lead to posterolateral rotary instability of the elbow

Caused by malreduction

11% due to medial distal physeal disruption

Osteotomy: cosmetic procedure

Delay until 1 year post injury to await possibility of medial growth arrest being responsible for deformity; if so lateral epiphysiodesis would accompany osteotomy

Osteotomy Options:

Lateral closing wedge osteotomy

Dome rotational osteotomy

Step-cut lateral closing wedge osteotomy

Compartment Syndrome

*1% incidence: Ottolengi et al European study with 830 supracondylars

Volkman’s Contracture

Be aggressive

Compartment syndrome may be masked by median nerve disruption


Clinical signs

Pressure >30 mm Hg OR within 30 mm Hg of DBP

Flexion-type Supracondylar

1-10% of all supracondylar

Gartland Classification

Reduction Maneuver: elbow extension

Varus force addresses anterolateral displacement

Treatment: CRPP

Casting in elbow extension difficult for patient to deal with

Gartland Classification: nondisplaced / intact anterior cortex / complete displacement usually ant lat

Across to lateral column

Cross lateral pin above olecranon fossa

Engage lateral humeral cortex