From the Guidelines
The management of supracondylar fractures should prioritize closed reduction and percutaneous pinning (CRPP) for displaced type II and III fractures, as well as flexion-type fractures, to minimize complications and improve outcomes, as recommended by the American Academy of Orthopaedic Surgeons 1. The approach to managing supracondylar fractures involves initial stabilization followed by definitive treatment based on fracture classification.
- For non-displaced (type I) fractures, immobilization with a long arm cast in 90° of flexion for 3-4 weeks is usually sufficient.
- Minimally displaced (type II) fractures may require closed reduction under sedation followed by casting.
- Displaced (type III) fractures generally need surgical intervention with CRPP using Kirschner wires, ideally within 24 hours of injury to minimize complications. Key considerations in the management of supracondylar fractures include:
- Neurovascular monitoring for compartment syndrome and vascular compromise, particularly watching for the "5 P's" (pain, pallor, paresthesia, paralysis, and pulselessness) 1.
- Pin removal typically occurs at 3-4 weeks, followed by progressive range of motion exercises. The goal of treatment is to maintain anatomic alignment while minimizing complications like malunion, cubitus varus deformity, and neurovascular injury, as highlighted in a study published in The Journal of the American Academy of Orthopaedic Surgeons 1. In cases with vascular injury, the management approach should prioritize restoration of vascularity and perfusion, with admission and observation for patients with suspected vascular injury after closed reduction and pinning 1.
From the Research
Management Approach for Supracondylar Fractures
The management of supracondylar fractures involves several considerations, including the stability of the fracture, the presence of nerve or arterial injury, and the timing of surgery.
- Closed reduction and percutaneous K-wire stabilization are commonly recommended for unstable displaced fractures 2.
- The geometry of wire fixation and the management of nerve and arterial injury are also important considerations in the treatment of supracondylar fractures 2.
- Post-operative management may involve immobilization with a cast or splint, with both methods being effective in reducing complications such as post-operative discomfort, pain, and infection 3.
Location and Type of Fracture
Supracondylar fractures can occur in either an extension or flexion pattern, with both patterns having three types distinguished by the degree of displacement 4.
- Extension fractures, type III patterns, usually require operative intervention in the form of a closed reduction with percutaneous pin fixation 4.
- Flexion fractures, type II displaced fractures, often require pin fixation, and type III displaced fractures usually require an open reduction 4.
- The location of the fracture, including the degree of displacement and the presence of neurovascular injury, is important in determining the appropriate treatment approach 4, 5.
Current Concepts in Management
Current concepts in the management of supracondylar humerus fractures in children include:
- Closed reduction and percutaneous pinning as the mainstay of surgical management 5.
- Waiting until 12 to 18 hours after injury to perform surgery, provided the child's neurovascular and soft-tissue statuses permit 5.
- Using two to three lateral pins for stabilizing most fractures 5.
- Considering the problems of a pulseless hand, compartment syndrome, and posterolateral rotatory instability in the management of these fractures 5.
- The duration of immobilization postoperatively, with some studies suggesting that shorter immobilization periods may not yield a higher rate of complications 6.