Overview
· Most common elbow fracture in children
· Peak age: 5–7 years
· Mechanism: fall on outstretched hand
· Extension-type: >95%
· Flexion-type: <5% (often due to a direct fall onto a bent elbow)
· Treatment is most commonly closed reduction and percutaneous pinning (CRPP), with urgency guided by hand perfusion status.
Clinical Presentation
· In a typical case, a child presents with elbow pain, swelling, and deformity after trauma.
· The arm may have an “S-shaped” contour or obvious posterior prominence of the olecranon if the distal fragment is displaced posteriorly.
· A detailed neurovascular examination is mandatory at presentation and during follow-up. Median nerve or anterior interosseous nerve injuries are most common in extension-type fractures, while ulnar nerve injury is more often seen in flexion-type patterns. Most nerve injuries are neuropraxias and resolve spontaneously.
· 3–19% have vascular compromise of the brachial artery. Any “pucker” or dimpling of anterior skin indicates that the sharp proximal fragment has tented or pierced the brachialis muscle and skin, foreshadowing a difficult reduction.
Imaging
· Standard anteroposterior and lateral elbow radiographs are required.
· The posterior fat pad sign suggests an occult fracture.
· On the lateral view, the anterior humeral line should intersect the middle third of the capitellum; failure to do so indicates displacement.
· Baumann angle measurement on the AP view helps assess coronal alignment and detect varus malalignment
Classification
Gartland Classification
· Type I: nondisplaced
· Type II: displaced with posterior hinge intact
· Type III: completely displaced
· Type IV: multidirectional instability (Complete periosteal disruption)
Treatment
· Type I (nondisplaced) fractures are managed non-operatively with immobilization in a cast or splint for ~3–4 weeks.
· For type II fractures (angulated but partially intact), treatment may be individualized: if alignment is acceptable and stable, casting in 90° flexion can be attempted, but many type IIs benefit from CRPP to prevent late displacement,
· Definitive treatment for type III injuries is urgent CRPP under anesthesia.
· Two or three smooth Kirschner wires are typically used to hold the reduction. Crossed medial-lateral pin configurations provide biomechanical stability but carry a risk of ulnar nerve injury; as a result, many surgeons preferentially use two or three lateral-entry pins in extension-type fractures.
· If a closed reduction is unsuccessful or the fracture is irreducible due to soft-tissue interposition (e.g. muscle, median nerve, or brachial artery trapped in the fracture), conversion to open reduction is indicated.
· Open reduction and pinning will also be required for open fractures after thorough irrigation and debridement.
· However, when closed methods fail or the fracture is complex (e.g. proximal fragment button-holed through muscle or multidirectionally unstable Gartland type IV), timely open reduction is the appropriate course.
Surgical Indications
· All Gartland type III and IV fractures
· Type II fractures with instability or malalignment
· Open fractures
· Vascular compromise
· Floating elbow injuries
Emergent surgery
· Pulseless, poorly perfused hand
· Immediate reduction required
· Vascular exploration if perfusion does not return
Pulseless but pink hand
· Observe closely after reduction
· Frequent neurovascular checks
· Explore if perfusion deteriorates
Prognosis
· With appropriate treatment, outcomes are generally excellent.
· Most children regain near-full elbow range of motion within weeks.
· Pin tract infections are uncommon and usually minor, treatable with pin removal and antibiotics if they occur.
· Cubitus varus (gunstock deformity) due to malunion may represent a cosmetic issue with little functional limitations.
· Cubitus valgus resulting from fracture malunion may lead to tardy ulnar nerve palsy.
· Permanent neurovascular deficits.
· Volkmann ischemic contracture is a rare but serious complication related to elbow hyperflexion casting and is uncommon after CRPP with immobilization under 90° of flexion.
Differential Diagnosis
When evaluating a child with elbow trauma, consider other injuries that can mimic or coexist with a supracondylar fracture:
· Lateral condyle fracture
· Elbow dislocation
· Distal humeral physeal separation (infants)
· Monteggia fracture-dislocation
· Medial epicondyle fracture
References
1. Surd A, Muresan R, Ciongradi CI, Sur LM, Ardelean LR, Usatiuc LO, Snakovszki K, Munteanu C, Sârbu I. Modern Treatment of Supracondylar Humeral Fractures in Children. Children (Basel). 2025 Apr 25;12(5):556. doi: 10.3390/children12050556.
Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):190-6. doi: 10.1007/s12178-008-9027-2
3. Hasan SU, Pervez A, Usmani SUR, Tahseen MU, Asghar S, Ahmed JW, Manal I. Comparative analysis of pinning techniques for supracondylar humerus fractures in paediatrics: A systematic review and meta-analysis of randomized controlled trials. J Orthop. 2023 Aug 16;44:5-11. doi: 10.1016/j.jor.2023.08.005.