What is the recommended evaluation and management of a supracondylar humerus fracture in a child (age 5‑10)?

Management of Pediatric Supracondylar Humerus Fractures (Ages 5-10)

For displaced supracondylar humerus fractures in children, closed reduction with percutaneous pinning is the definitive treatment, while nondisplaced fractures should be immobilized with a posterior splint. 1, 2, 3

Initial Evaluation

Immediate Neurovascular Assessment

• Perform thorough neurovascular examination at presentation, assessing for absent pulses, cold/pale hand, and nerve function—this is critical as vascular compromise can lead to limb loss. 2
• Nerve injuries occur in approximately 10% of supracondylar fractures, though most are neurapraxias that resolve with conservative management. 2, 4
• Document the presence or absence of radial pulse, hand perfusion (color, temperature, capillary refill), and motor/sensory function of radial, median, and ulnar nerves. 4

Radiographic Evaluation

• Obtain anteroposterior and lateral radiographs of the elbow to assess fracture displacement and pattern. 2
• Use the Gartland classification system to guide treatment decisions (Type I: nondisplaced, Type II: displaced with intact posterior cortex, Type III: completely displaced). 5, 6

Treatment Algorithm by Fracture Type

Gartland Type I (Nondisplaced)

• Immobilize with a posterior splint rather than collar-and-cuff, as it provides superior pain control within the first 2 weeks after injury. 2
• Obtain radiographic follow-up during the first 3 weeks and at cessation of immobilization to confirm the fracture remains nondisplaced. 7
• Immobilization duration is typically 3-4 weeks, though optimal timing lacks high-quality evidence. 2

Gartland Type II and III (Displaced)

• Perform closed reduction with percutaneous pinning as the preferred treatment, which demonstrates superior outcomes compared to closed reduction and casting alone. 2, 3
• This approach has a number needed to treat of 20 for preventing cubitus varus and 7 for achieving excellent outcomes by Flynn's criteria. 2
• Use either two to three lateral pins or a crossed pin configuration (one lateral, one medial)—both yield successful outcomes when performed with proper technique. 3, 5
• Surgery can be safely delayed 12-18 hours after injury if neurovascular status permits, though no definitive time threshold exists. 1, 5

Open Reduction Indications

• Consider open reduction when closed reduction fails to achieve adequate alignment, though this may result in greater stiffness compared to closed methods. 1, 2
• Open reduction shows lower loss of reduction rates but higher stiffness rates compared to successful closed reduction. 1, 2

Management of Vascular Compromise

Absent Pulse with Poor Perfusion (Cold, Pale Hand)

• Perform emergent closed reduction immediately—this is a limb-threatening emergency. 1, 4
• If perfusion does not improve after reduction and pinning, perform immediate open exploration of the antecubital fossa. 1, 2
• The catastrophic risks of persistent inadequate perfusion include limb loss, ischemic muscle contracture, nerve injury, and functional deficit. 1, 2
• Obtain vascular surgery consultation for management of arterial injuries. 2

Absent Pulse with Adequate Perfusion (Pink, Warm Hand)

• The AAOS guidelines cannot definitively recommend for or against exploration in this scenario. 1
• Minimal management requires careful monitoring for 48 hours for loss of perfusion or development of compartment syndrome. 4
• According to the 2016 AAOS appropriateness criteria, treatment decisions should be individualized based on vascular status and perfusion patterns. 1

Critical Pitfall

• Never delay vascular exploration when the hand remains pale and pulseless after reduction—this risks limb loss. 2
• Nerve palsy accompanying pulselessness warrants immediate exploration, as this suggests more severe vascular injury. 4

Postoperative Management

Pin Removal and Mobilization

• Remove pins at approximately 3-4 weeks, though optimal timing lacks high-quality evidence. 1, 2
• Begin early active motion after pin removal to prevent elbow stiffness—this is critical for functional recovery. 2
• The AAOS guidelines cannot recommend for or against routine supervised physical or occupational therapy, as no studies addressed this question. 1

Expected Outcomes

• When properly treated with closed reduction and percutaneous pinning, expect excellent outcomes in approximately 90% of patients by Flynn's criteria. 3, 6
• The most common long-term complication is cubitus varus deformity, with incidence ranging from 3-57% historically, though adequate reduction and pinning has dramatically decreased this rate. 8
• Pin tract infections occur in approximately 10-30% of cases but are typically minor and resolve with local care. 3

Special Considerations for Ages 5-10

• This age group represents the peak incidence for supracondylar fractures, accounting for approximately 60% of all pediatric elbow fractures. 3, 8
• The mechanism is typically a fall on an outstretched hand with the elbow in extension (extension-type fracture in 90-95% of cases). 6
• Boys have higher incidence than girls in this age range. 3