Treatment of Medial Supracondylar Fracture
For displaced medial supracondylar fractures (Gartland type II and III), perform closed reduction with percutaneous pin fixation; for nondisplaced fractures (Gartland type I), use nonsurgical immobilization with a collar and cuff or posterior splint. 1
Treatment Algorithm Based on Fracture Displacement
Nondisplaced or Minimally Displaced Fractures (Gartland Type I)
- Nonsurgical immobilization is the treatment of choice for acute or nondisplaced supracondylar fractures or those with only a posterior fat pad sign 1
- Immobilization options include collar and cuff or posterior back-slab splinting, both showing equivalent outcomes 1
- This approach maintains the ability to inspect the injured limb for potential vascular compromise 1
Displaced Fractures (Gartland Type II and III)
- Closed reduction with percutaneous pin fixation is the preferred treatment for all displaced type II and III supracondylar fractures 1, 2, 3
- The periosteum on the medial and posterior aspects is often intact, which aids in reduction 4
- Flexion of the elbow must be maintained during immobilization 4
Special Considerations Requiring Open Reduction
Open reduction may be necessary in specific clinical scenarios:
- Vascular compromise that develops during or after closed reduction attempts 2
- Failed closed reduction, particularly in obese children with higher BMI 5
- Prominent medial spike with smaller medial spike angle, which may indicate muscle entrapment or fracture instability 5, 6
- Medial condyle impaction or buckling that cannot be adequately reduced closed 6
Critical Pitfall: Medial Condyle Impaction
- Fractures with impaction or buckling of the medial condyle are frequently underestimated and undertreated 6
- Simple immobilization without reduction in these cases leads to cubitus varus deformity 6
- If medial condyle collapse is present, closed reduction with percutaneous pinning prevents varus angulation 6
Management of Complications
Vascular Compromise
- This is the most critical concern, as it can lead to long-term loss of nerve and muscle function 1
- If ischemia develops, olecranon skeletal traction is useful 4
- Open reduction should be considered when vascular compromise persists 2
Nerve Injuries
- Closed reduction with pin fixation remains the preferred treatment even with associated nerve injuries, including anterior interosseous nerve palsies 2, 3
- The AAOS guidelines do not provide specific recommendations for timing of electrodiagnostic studies or nerve exploration 3
Technical Considerations
- Obesity is a significant risk factor for requiring open reduction and should lower your threshold for surgical intervention 5
- Internal fixation with percutaneous pins should only be performed after satisfactory reduction is achieved 4
- Neuropathies, ischemia, and angular deformities are not rare complications that require vigilant monitoring 4