What is the management of supracondylar fractures?

Management of Supracondylar Fractures

For pediatric supracondylar fractures, treatment is determined by the Gartland classification: undisplaced (Type I) fractures require posterior splint immobilization, minimally displaced (Type IIa) fractures can be managed with closed reduction under sedation and immobilization if adequate alignment is achieved, and displaced (Type II-III) fractures require closed reduction with percutaneous pinning. 1, 2

Initial Assessment and Classification

Neurovascular Examination

• Perform immediate and thorough neurovascular assessment at presentation, as nerve injuries occur in approximately 10% of cases and vascular compromise can lead to catastrophic outcomes including limb loss 3
• Assess for absent pulses, cold/pale hand, and nerve function (anterior interosseous, radial, ulnar nerves) 4
• Document capillary refill, hand warmth, and motor/sensory function in all nerve distributions 3

Radiographic Classification

• Use the Gartland classification system to guide treatment decisions 1, 2
• Measure specific radiographic parameters: Baumann angle, humerocondylar angle (HCA), perpendicular distance from anterior humeral line to capitellum, and hourglass angle (HGA) 5
• The HGA and perpendicular distance show excellent interobserver reliability (ICC 0.805 and 0.769 respectively) compared to poor reliability for HCA (ICC 0.342) 5

Treatment by Fracture Type

Type I (Undisplaced) Fractures

Use posterior splint immobilization rather than collar-and-cuff, as it provides superior pain control within the first 2 weeks after injury. 1, 2

• Apply a posterior splint that allows inspection of the limb while providing adequate stabilization 1
• This recommendation is based on moderate-quality evidence from the AAOS showing better pain relief compared to collar-and-cuff methods 1, 2
• Monitor regularly with follow-up radiographs to ensure the fracture remains undisplaced during healing 1
• If displacement occurs during treatment, proceed to closed reduction with percutaneous pinning 1

Type IIa (Minimally Displaced) Fractures

Attempt closed reduction under procedural sedation, as sedation is strongly associated with successful maintenance of reduction (83% success with sedation vs 56% without). 5

• Closed reduction under sedation achieved successful outcomes in 76.6% of cases without requiring surgical intervention 5
• Following reduction, verify improvement in radiographic parameters: HGA should improve by approximately 7.4 degrees and perpendicular distance by 1.9 mm 5
• Fractures that fail to improve HGA by at least 6.2 degrees following closed reduction are at higher risk for requiring secondary surgical intervention 5
• Immobilize in a long-arm cast or splint after successful reduction 5
• Critical pitfall: Attempting reduction without adequate sedation significantly decreases success rates and should be avoided 5

Type II-III (Displaced) Fractures

Perform closed reduction with percutaneous pinning for all displaced fractures to prevent cubitus varus deformity. 6

• Closed reduction and casting alone for unstable Type III fractures resulted in cubitus varus deformity in multiple cases, regardless of forearm position (supination vs pronation) 6
• Operative fixation is advised for Type III fractures rather than relying on closed reduction and immobilization alone 6
• The position of forearm immobilization (supination vs pronation) does not significantly affect the incidence of elbow malunion deformity 6

Management of Vascular Compromise

After Reduction with Persistent Underperfusion

If the patient has absent wrist pulses AND a cold, pale hand after reduction and pinning, perform immediate open exploration of the antecubital fossa. 4

• The catastrophic risks of persistent inadequate perfusion include limb loss, ischemic muscle contracture, nerve injury, and functional deficit 4
• In most patients, limb perfusion improves after reduction alone 4
• Consultation with vascular surgery may be necessary 4

Absent Pulses with Perfused Hand

• The AAOS guidelines cannot make a definitive recommendation for or against exploration in patients with absent pulses but a warm, pink, perfused hand after reduction 4
• Clinical judgment and close monitoring are required in this scenario 4

Postoperative Management

Pin Removal and Mobilization

• No high-quality evidence exists to recommend optimal timing for pin removal, though standard practice is approximately 3-4 weeks of immobilization 2
• Balance the risks: prolonged pinning may cause pin tract infection or stiffness, while early removal increases risk of redisplacement 4
• Use clinical judgment based on radiographic evidence of healing and patient symptoms 1

Rehabilitation

• The AAOS cannot recommend for or against routine supervised physical or occupational therapy due to insufficient evidence 4, 1
• Guide rehabilitation decisions based on the child's recovery of motion and function using clinical judgment 1
• No evidence supports specific timing for allowing unrestricted activity after healing 4, 1

Common Pitfalls to Avoid

• Do not use collar-and-cuff as first-line treatment for Type I fractures, as it provides inferior pain control 1, 2
• Do not attempt closed reduction of Type IIa fractures without procedural sedation, as success rates drop significantly 5
• Do not rely on closed reduction and casting alone for unstable Type III fractures, as this leads to cubitus varus deformity regardless of forearm position 6
• Do not delay vascular exploration in patients with absent pulses and an underperfused hand after reduction, as this risks limb loss 4
• Nerve injuries occur frequently but most resolve spontaneously; however, no evidence supports specific indications for electrodiagnostic studies or nerve exploration 4