What is the management for a moderately displaced supracondylar fracture in a 7-year-old female?

Management of Moderately Displaced Supracondylar Fracture in a 7-Year-Old Female

Closed reduction and percutaneous pinning with lateral K-wires is the recommended treatment for moderately displaced supracondylar fractures in children. 1, 2

Initial Assessment and Classification

• Supracondylar fractures are the most common elbow fractures in the pediatric population
• Moderately displaced fractures (Gartland Type II) have partial cortical contact but are angulated
• Key assessment points:
  • Neurovascular status (particularly ulnar, median, and radial nerves)
  • Soft tissue condition
  • Presence of vascular compromise

Treatment Algorithm

1. Surgical Management

• Primary treatment: Closed reduction and percutaneous pinning 1, 2
  • Provides superior outcomes compared to casting alone
  • Significantly lower rates of malunion and loss of reduction 3
  • Can be performed within 12-18 hours of injury if neurovascular status is stable 4

2. Pin Configuration

• Preferred configuration: 2-3 lateral pins 1, 2
  • Provides adequate stability for most fractures
  • Avoids risk of iatrogenic ulnar nerve injury associated with medial pinning
  • Cross-pinning (medial and lateral pins) may be considered for unstable fractures but carries higher risk of ulnar nerve injury 5

3. Surgical Technique

• Patient positioned supine with arm on radiolucent table
• Closed reduction under general anesthesia with image intensifier guidance
• Reduction maneuver:
  • Traction
  • Correction of medial/lateral displacement
  • Correction of rotation
  • Extension of fracture followed by flexion to maintain reduction
• Pin insertion with elbow in 60-90° flexion to reduce neurovascular compromise
• Pins left outside skin for later removal

4. Post-Operative Care

• Above-elbow posterior splint with elbow at 60-90° flexion for 3-4 weeks
• Regular radiographic evaluation at 1,3, and 6 weeks to ensure fracture stability 1
• Pin removal at 3-4 weeks (typically in clinic without anesthesia)
• Progressive range of motion exercises after splint removal

Outcomes and Complications

• Expected outcomes with proper surgical management:

  • Excellent to good results in 80-90% of cases 3, 5
  • Return to full function within 6-12 weeks

• Potential complications to monitor:

  • Pin tract infection (6-7%) 5
  • Iatrogenic nerve injury (particularly ulnar nerve, 3-4%) 5
  • Cubitus varus deformity (1-2%) 5
  • Elbow stiffness (preventable with early mobilization) 1
  • Compartment syndrome (rare but requires immediate intervention)

Important Considerations

• Non-operative treatment with casting alone is associated with higher rates of malunion and poor functional outcomes for moderately displaced fractures 3, 2
• Open reduction is reserved for cases where:
  • Closed reduction fails to achieve acceptable alignment
  • Vascular compromise persists after reduction
  • Open fracture requires debridement
• Unlike adult supracondylar fractures which often require open reduction and plating, pediatric fractures respond well to closed reduction and percutaneous pinning 1

Follow-up Protocol

• First follow-up at 7-10 days for wound check and radiographs
• Second follow-up at 3-4 weeks for pin removal and splint discontinuation
• Final follow-up at 6-8 weeks to assess range of motion and function
• Additional follow-up as needed based on clinical progress