Current Treatment Recommendations for Supracondylar Fractures

Closed reduction with pin fixation is the preferred treatment for most displaced pediatric supracondylar fractures of the humerus. 1, 2

Classification and Initial Management

Supracondylar fractures are commonly classified using the Gartland system, with type I being non-displaced, type II partially displaced with posterior cortical contact, and type III completely displaced with no cortical contact 2
For displaced fractures (Gartland type II and III), closed reduction with percutaneous pin fixation is superior to reduction and casting alone in terms of maintaining reduction and preventing malunion 2
Vascular assessment is critical - if there is no pulse, rapid closed reduction with percutaneous fixation should be performed immediately without waiting for arteriography 3

Lateral-entry pin fixation (using 2-3 pins) is recommended as the primary fixation method for most displaced supracondylar fractures 2
Medial pinning carries a higher risk of iatrogenic ulnar nerve injury (though still rare at 0.3%) and should be avoided when adequate stability can be achieved with lateral pins alone 4, 2
When placing pins, they should be left protruding through the skin under a cast for approximately 3-4 weeks before removal in the office setting 3

For unstable fractures where closed reduction cannot achieve adequate alignment, open reduction may be necessary to prevent varus or other malposition 2
Nerve injuries are common with supracondylar fractures (11.9% preoperatively), with anterior interosseous nerve palsy being most frequent (5.3%), but these are not contraindications to closed reduction and pinning 4, 3
For flexion-type supracondylar fractures (which are less common), the condylar mass should be pushed posteriorly along the axis of the forearm with the elbow in flexion and the hand in full supination 5

Pin migration is the most common complication (1.8%), potentially requiring unplanned return to the operating room 4
Infection rates are low (1.0% overall, with deep infection at 0.2%) even with simple betadine preparation and minimal draping 4
Preoperative antibiotics appear to have minimal effect on infection rates 4
Cubitus varus (gunstock deformity) is a potential long-term complication that can be minimized with proper reduction and fixation 6, 3

For adolescent patients with supracondylar fractures, there is insufficient evidence to make specific recommendations regarding open reduction and stable fixation, as adolescents have different fracture patterns and potentially slower healing 7
In adults and elderly patients, traditional management techniques may be less satisfactory due to decreased remodeling potential and slower functional recovery 5

Despite being the most common elbow fracture in children, high-quality scientific data on treatment is lacking, with few randomized controlled trials 7
Areas needing further research include:
- Criteria for accepting adequate closed reduction 7
- Comparison of medial versus lateral entry pin fixation with focus on patient outcomes 7
- Management of fractures that cannot be reduced by closed means 7
- Treatment of associated vascular compromise 7
- Optimal timing for pin removal and activity resumption 7

Failing to document nerve status before intervention can lead to confusion about iatrogenic versus traumatic nerve injuries 3
Delaying treatment in cases with vascular compromise can lead to compartment syndrome 4
Inadequate pin fixation can result in loss of reduction and subsequent malunion 2
Inappropriate use of medial pins without proper technique increases risk of iatrogenic ulnar nerve injury 2