What is the treatment for a supracondylar fracture?

Treatment of Supracondylar Fractures

For displaced supracondylar fractures, closed reduction with percutaneous pinning is the primary treatment approach, with open reduction reserved for cases where closed methods fail or when vascular compromise persists after reduction. 1

Initial Assessment and Vascular Evaluation

Before any intervention, immediately evaluate perfusion status and pulse presence to guide treatment urgency 1:

• If the hand is pale without pulses, perform immediate fracture manipulation rather than delaying for transfer 1
• If the hand remains underperfused with absent pulses, proceed directly to open exploration of the antecubital fossa 1, 2
• Use clinical judgment regarding timing and location of reduction based on vascular status 1

Treatment Algorithm by Fracture Type

Type I (Undisplaced)

• Treat with long arm casting 3
• No surgical intervention required 4

Type II (Displaced in One Plane)

• Not all Type II fractures require surgery—those with isolated extension deformity without rotational or coronal malalignment can be successfully managed nonoperatively with close follow-up 5
• Fractures with rotational deformity, varus/valgus malalignment, or shaft-condylar angle <30 degrees require surgical pinning 5
• In one large prospective series, 72% of Type II fractures were successfully treated nonoperatively, suggesting that routine pinning of all Type II fractures results in unnecessary surgery 5

Type III and IV (Displaced in Two or Three Planes)

• Closed reduction with percutaneous pinning is the standard approach 1
• Attempt closed reduction first before considering open techniques 1
• Open reduction is acceptable when closed methods fail, though it carries greater risk of stiffness 1

Flexion-Type Fractures

• These warrant special attention due to higher rates of open reduction requirement and ulnar nerve injury risk 3
• Nondisplaced flexion-type fractures can be treated with long arm casting 3
• Displaced flexion-type fractures require surgical reduction and stabilization with special considerations for reduction position and pinning technique 3

Management of Vascular Complications

Critical pitfall: Delaying vascular exploration when the hand remains pale and pulseless after reduction risks limb loss 1

Vascular injury management includes 2, 6:

• Warming the extremity 2, 6
• Immediate vascular surgery consultation 6
• Open exploration of the antecubital fossa for brachial artery entrapment 2, 6
• In-hospital observation for at least 24 hours after vascularity is restored 2, 6

Postoperative Management

• Early active motion is critical to prevent stiffness 1, 2, 6
• Evidence is insufficient for optimal timing of pin removal, but balance risks of prolonged pinning against premature removal 1
• Regular radiographic evaluation during follow-up is recommended 2

Key Technical Considerations

• Open reduction shows lower loss of reduction rates but greater stiffness compared to closed reduction with pinning 1
• The severity of flexion-type fractures may be difficult to appreciate on initial radiographs, requiring high clinical suspicion 3
• Type III and IV fractures have >20% ineffective retention rates, necessitating careful follow-up 4