NONOPERATIVE MANAGEMENT supracondylar fractures DIFFERENTIAL DIAGNOSIS

■ Fracture of elbow (other than involving the supracondylar humeral region) 

■ Salter-Harris fractures involving the elbow 

■ Nursemaid’s elbow 

■ Infection 

■ The indications for nonoperative management of supracondylar fractures of the humerus are limited to nondisplaced fractures (type I). 

■ The anterior humeral line transects the capitellum on the lateral radiograph. 

■ The Baumann angle is 10 degrees or equal to the other side. 

■ The olecranon fossa and medial and lateral cortices are intact. 

■ Nonoperative management consists of immobilization of the elbow in no more than 90 degrees of flexion in a splint or cast. 

■ As the brachial artery becomes compressed with increasing flexion of the elbow, the clinician must ensure that the distal radial pulse is intact and that there is adequate perfusion distally. 

■ Historically, some supracondylar fractures of the humerus were managed with traction (overhead versus side). With the relative safety of percutaneous pinning techniques, however, the use of traction has been limited.

■ The two main options for percutaneous pin fixation are the lateral-entry pin and crossed-pin techniques. 

■ Most fractures can be stabilized successfully by the lateralentry pin technique.6 

■ Two pins are usually adequate for type II fractures; three pins are recommended for type III fractures. 

■ Biomechanical studies have revealed comparable stability in the lateral-entry and crossed-pin techniques.

■ An advantage of the lateral-entry pin technique is the significantly lower risk of iatrogenic nerve injury. The ulnar nerve is at risk when pins are inserted medially (5% to 6% risk). 

■ The crossed-pin technique may be indicated if persistent instability is noted intraoperatively after placement of three lateral-entry pins.

■ Displaced supracondylar fractures of the humerus (including Gartland type II and III) require reduction. Usually, reduction can be achieved by closed means. The preferred method for fixation is percutaneous pinning. 

■ Indications for open reduction of supracondylar fractures of the humerus are limited but include open injuries, fractures irreducible by closed means, and fractures associated with persistent vascular compromise even after adequate closed reduction. 

■ All imaging studies are reviewed. A high index of suspicion for associated fractures, especially of the forearm, is important; if present, there is an increased risk of compartment syndrome. 

■ Complete preoperative neurologic and vascular examination is performed and documented. 

■ The contralateral arm should be examined, and the carrying angle of the contralateral arm should be noted. 

■ The timing of surgery remains controversial. Recent retrospective studies suggest that a delay in treatment of the majority of supracondylar fractures is acceptable.1 

■ Fractures with “red flags” (eg, significant swelling and signs of neurologic and especially vascular compromise or an associated forearm fracture) usually require urgent treatment.

■ The patient is positioned supine on the operating room table. 

■ The fractured elbow is placed on a radiolucent armboard (FIG 4A). The arm should be far enough onto the armboard to allow for complete visualization of the elbow and distalhumerus. In smaller children, the child’s shoulder and head may need to rest on the armboard as well. 

■ The wide end of a fluoroscopy unit is sometimes used as a table. 

■ In cases of severe instability of the fracture, use of the fluoroscopy unit as an armboard is suboptimal because reduction of the fracture is frequently lost with rotation of the arm, which is needed for AP and lateral views of the elbow. 

■ The fluoroscopy monitor is placed opposite to the surgeon for ease of viewing (FIG 4B)