What is the treatment for a supracondylar fracture?

Treatment of Supracondylar Fracture

For displaced pediatric supracondylar humerus fractures, perform closed reduction with percutaneous pin fixation using 2-3 laterally introduced pins, avoiding medial pins to reduce iatrogenic ulnar nerve injury risk. 1

Treatment Algorithm by Fracture Severity

Nondisplaced or Minimally Displaced Fractures (Type I)

• Treat with long arm casting 2
• This applies to both extension-type and flexion-type fractures when displacement is minimal 2

Displaced Fractures (Type II and III)

Primary treatment approach:

• Closed reduction with percutaneous pin fixation is the preferred method over reduction and casting alone 1
• Use 2-3 laterally introduced pins for stabilization 1
• Avoid medial pin placement due to increased risk of iatrogenic ulnar nerve injury 1

Pin configuration considerations:

• Lateral-only pinning provides adequate stability while minimizing nerve injury risk 1
• The crossed pin technique (including a medial pin) carries higher complication rates despite theoretical biomechanical advantages 1

When Closed Reduction Fails

Indications for open reduction:

• Perform open reduction if varus malposition or other malalignment persists after closed reduction attempt 1
• Open reduction has acceptable outcomes when necessary, though closed methods should be attempted first 3
• Aktekin et al found greater stiffness with open reduction compared to closed reduction with pinning, but Li et al reported lower loss of reduction rates with open techniques 3

Management of Vascular Compromise

Immediate Assessment

• Evaluate perfusion status and pulse presence before any intervention 3

Fracture with Vascular Compromise (Pale, Pulseless Hand)

Emergent reduction is indicated:

• The practitioner must use clinical judgment regarding timing and location of reduction 3
• In cases of a pale hand without pulses, immediate fracture manipulation may be warranted rather than delaying transfer to a specialized center 3

After Reduction and Pinning

If absent pulses with underperfused hand (cold, pale):

• Perform open exploration of the antecubital fossa immediately 3, 4, 5
• This consensus recommendation prioritizes preventing catastrophic outcomes including limb loss, ischemic contracture, and permanent nerve injury 3
• Management includes warming the extremity, vascular surgery consultation, and exploration for brachial artery entrapment 4, 5
• Observe in-hospital for at least 24 hours after vascularity is restored 4, 5

If absent pulses but hand remains perfused:

• Evidence is insufficient to recommend for or against exploration 3
• Clinical judgment and vascular surgery consultation are essential 3

Special Considerations for Flexion-Type Fractures

• Flexion-type fractures have higher rates of requiring open reduction and carry increased risk of ulnar nerve injury or entrapment 2
• Severity may be underappreciated on initial radiographs—maintain high clinical suspicion 2
• These fractures require special surgical setup and planning due to unique instability patterns 2

Postoperative Management

Pin Removal Timing

• Evidence is insufficient to recommend optimal timing for pin removal 3
• Balance risks of prolonged pinning (infection, stiffness) against early removal (redisplacement, refracture) 3
• When adequate intraoperative fixation is achieved, the next radiograph can be obtained at 3 weeks for pin removal rather than at 1 week 6

Rehabilitation

• Early active motion is critical to prevent stiffness 4, 5
• Evidence is insufficient to recommend for or against routine supervised physical/occupational therapy 3
• Optimal timing for unrestricted activity remains inconclusive 3

Common Pitfalls

• Underestimating flexion-type fracture severity on initial radiographs—these require heightened vigilance 2
• Using medial pins unnecessarily—lateral-only pinning provides adequate stability with lower nerve injury risk 1
• Delaying vascular exploration when hand remains pale and pulseless after reduction—this risks limb loss 3
• Obtaining unnecessary early follow-up radiographs—if intraoperative fixation is adequate, loss of reduction occurs in only 3.8% of cases 6