CHILDREN
Paediatric supracondylar
fractures: an overview of
current management and
guide to open approaches
SA Edwardson
O Murray
J Joseph
R Duncan
Abstract
Supracondylar fractures of the humerus are common fractures in children.
Closed reduction and percutaneous pinning is the primary method of man-
agement, though 2e12% of these fractures require open reduction. There is
no conclusive evidence to dictate the best surgical approach to the fracture.
This paper aims to review supracondylar fractures of the humerus and dis-
cusses the early and late associated complications. The treatment options
are then examined, with a focus on the preferred surgical approach to
open reduction. If an orthopaedic surgeon is going to learn only one
approach for reduction of these challenging fractures, then we recommend
becoming familiar with the anterior approach. This is the approach one
would need to use in most open fractures and in those where exploration
of the brachial artery is indicated. It gives access to the neurovascular struc-
tures, to the fracture site and also to the soft tissues that are likely to block
reduction. The cosmetic and functional outcomes are reported to be good.
Keywords approaches; closed reduction; complications; cubitus varus;
humeral fracture; open reduction; supracondylar percutaneous pinning
Introduction
Supracondylar humeral fractures (SCHFs) are the most common
fracture type in children under 8 years old.1,2 The treatment of
SA Edwardson BSc (Hons) Medical Student, Department of Orthopaedic
Surgery, Royal Hospital for Sick Children, Glasgow, UK. Conflict of
interest: none declared.
O Murray (FRCS(Orth) ST7 Trauma and Orthopaedics, Department of Or-
thopaedic Surgery, Royal Hospital for Sick Children, Glasgow, UK.
Conflict of interest: none declared.
J Joseph FRCS(Orth) ST7 Trauma and Orthopaedics, Department of Or-
thopaedic Surgery, Royal Hospital for Sick Children, Glasgow, UK.
Conflict of interest: none declared.
R Duncan FRCS(Ed)(Orth) Consultant Paediatric Orthopaedic Surgeon,
Department of Orthopaedic Surgery, Royal Hospital for Sick Children,
Glasgow, UK. Conflict of interest: none declared.
ORTHOPAEDICS AND TRAUMA 27:5
these fractures can cause a great deal of anxiety for the on-call
surgeon, especially with regard to the diagnosis and manage-
ment of fractures with vascular compromise. This paper de-
scribes the aetiology and pathology of SCHFs, including early and
late complications. We then examine various treatment options,
focussing on open reduction and the advantages and disadvan-
tages of different surgical approaches.
Overview
SCHFs account for two-thirds of all hospitalizations for elbow
injuries3 in children. Boys have historically been more
commonly affected, though more recent figures show that the
incidence in girls is now almost the same. The injury is signifi-
cant and there is a substantial risk of neurovascular complica-
tions, compartment syndrome and malunion.4
SCHFs are caused by either an extension or flexion injury
mechanism. Extension fractures account for around 95% of cases
and typically result from a fall on the outstretched hand with a
fully extended elbow. The force of the fall is transmitted through
the olecranon to the weak bone of the olecranon fossa and the
supracondylar region of the humerus, causing a fracture. The
distal condylar complex may then displace posterolaterally or
posteromedially.5 The fracture line typically propagates trans-
versely across the distal humerus through the centre of the
olecranon fossa (Figure 1). These fractures can be classified
using the modified Gartland classification6 (Table 1).
Flexion fractures account for around 6% of cases. These
fractures result from a direct blow to the posterior aspect of the
flexed elbow. In this situation the distal condylar complex is
more likely to displace anterolaterally.7 It is important to recog-
nize flexion injuries, as the technique of pinning will need to be
modified from that used to treat extension injuries.
These cases can be treated either with traction or by closed
reduction and casting, but in order to achieve stable reduction of
an extension injury the elbow must be flexed by more than 100 .
The amount of swelling may make this position unsafe, as it may
result in compression of the brachial artery and its collateral
vessels.7 Closed reduction and percutaneous pinning maintains
fracture reduction without the need for immobilisation of the
elbow in excessive flexion. If a fracture requires reduction, the
literature supports closed reduction and percutaneous pinning as
the treatment of choice.3
Closed reduction & percutaneous pinning
A detailed technique of closed reduction and percutaneous
pinning has been previously described by the senior author.8 The
technique involves general anaesthesia and good quality fluo-
roscopy. Traction is used to realign the fragments and should be
carried out for a sufficient period of time to disimpact the frag-
ments. Flexion of the elbow with an anteriorly directed force on
the olecranon process usually results in reduction of the fracture.
Some fractures reduce better with the forearm in pronation and
others with the forearm in supination. A satisfactory reduction is
recognized when the medial and lateral columns of the humerus
are restored, with no rotational malalignment. The ossification
centre of the capitellum should lie anterior to the anterior hu-
meral line on the lateral view. Taping the elbow in flexion fa-
cilitates pinning, especially when no assistant is available. The
303 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN

first month after cast removal sees the greatest increase in flexion
and extension range, but improvement can be seen for up to 48
weeks after the injury. Patients that require open reduction tend
to have a 10% decrease in relative elbow motion in comparison
to those managed nonoperatively.10

Timing of surgery
Timing from injury to surgery for fractures without vascular
compromise has been a hotly debated topic. It has been suggested
that an excessive delay in treatment leads to a greater risk of
complications, and a higher chance that the fracture will need an
open reduction. The recent AAOS Clinical Practice Guideline is
unable to recommend a time threshold in this situation.11 Some
literature suggests an increased probability of open reduction
being required if there is a time interval greater than 8 h between
injury and surgery.12 Yildirimetal13 found that the probability of
open reduction increased by a factor of 4 for every 5 h, starting
15 h after injury. However, this is challenged by other studies14,15
which were unable to find any significant difference in peri-
operative complication rates between early and delayed surgi-
cal treatment.

The pulseless supracondylar humerus fracture

Figure 1
use of 2 mm smooth wires is recommended, as they are stiffer
and it is easier to insert them accurately. Pinning may be done
with either divergent wires inserted from the lateral side or with
crossed medial and lateral wires. Using the latter method, the
medial wire should be inserted through a small incision to ensure
that the ulnar nerve is not injured during pinning.
Closed reduction and pinning can be associated with various
complications, such as neurovascular compromise, skin prob-
lems, compartment syndrome, Volkmann’s ischaemia and cubi-
tus varus. Some series quote an incidence of cubitus varus as
high as 60.9%, but most report much less than this.9
After closed reduction and pinning of a SCHF, temporary
elbow stiffness is frequently a cause for concern. In general, the
The incidence of vascular complications presenting as an absent
or diminished radial pulse has been reported to be between
3.2%16 and 14.3%.17 The management of these injuries has been
debated by vascular and orthopaedic surgeons, especially with
regards to the indications for exploration of the brachial artery in
a child with a well-perfused hand but an absent radial pulse e
the pink pulseless hand. The majority of studies recommend
closed reduction and pinning as a primary means of treatment.
However, in up to 28% of cases, pulselessness persists and if this
is associated with poor circulatory status (i.e. if the hand remains
white) then immediate exploration of the brachial artery is
indicated. However, if after reduction the hand is pulseless but
remains warm and pink, most authors suggest a “watch and
wait” approach. The anterior approach is most often used for
exploration of the brachial artery as it easily visualizes all of the
relevant structures and provides access for vascular reconstruc-
tion if required.18,19
There is no doubt that the cubital fossa should be explored in
patients with an absent pulse and an underperfused hand which

The Gartland classification, used to distinguish between the characteristics of the three types of supracondylar humerus
fractures6
Type I Type II Type III

Nondisplaced with an anterior humeral line
that intersects the capitellum, an intact
olecranon fossa, no medial or lateral
displacement, no medial column collapse,
and a normal Baumann angle.
Extended but not completely translated with
some cortical contact.
The anterior humeral line does not intersect
the capitellum. There may be some rotational
displacement and tilt into varus.
A circumferential break in the cortex with
displacement of the fracture fragments.
The distal fragment is displaced posteriorly
with the metaphyseal fragment impaled into
the brachialis muscle and anterior soft tissues.
This type has the greatest likelihood of nerve
and vascular injury.

Table 1

ORTHOPAEDICS AND TRAUMA 27:5 304 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN

does not improve after reduction of the fracture. The AAOS
Clinical Practice Guideline11 states that the reviewers felt that
there was no evidence to say whether a pink pulseless hand,
where the pulse fails to return after reduction but the hand re-
mains pink, should have a cubital fossa exploration or not. A
consensus view is that the limb should be closely observed for
signs of ischaemia of the hand or of the forearm muscles and
exploration performed if there are concerns.
In a child in whom the radial pulse does not return after
closed reduction of the fracture, careful observation is manda-
tory, including assessment of muscle and nerve function. Per-
sisting or increasing pain with deepening of any nerve lesion
should prompt urgent exploration of the cubital fossa, to estab-
lish whether or not the affected nerve or the brachial artery is
trapped within the fracture site.
Which approach if it needs to be opened?
Failure to achieve a closed reduction may be due to interposition
of structures such as the brachialis muscle, median nerve or
brachial artery. Irreducible fractures are uncommon; 2e12%
require open reduction.4 Surgical exposure can be accomplished
by a variety of approaches. The ideal surgical approach should
permit a safe and anatomic reduction of the fracture, allow ac-
cess to all important structures in the cubital fossa, produce good
functional and cosmetic outcomes and be associated with as few
complications as possible.
Approaches to the paediatric elbow need to be performed with
care to avoid damage to the physis and the epiphysis e many
approaches used in the adult cannot be used in the child. In
particular, when using the lateral exposure great care must be
taken to preserve the soft tissue on the posterior aspect of the
lateral condyle, as this is where the majority of the blood supply
enters and extensive dissection can result in osteonecrosis.
The aims of surgery are to anatomically reduce the medial and
lateral columns of the distal humerus and restore the normal
alignment in the sagittal plane. Secure fixation is achieved by
pinning, which can be performed using lateral divergent or crossed
medial and lateral wires.20 Open reduction of a SCHF can be
difficult because of the distortion of the normal anatomy. Great
care is required to identify the major nerves and vessels. These
structures can lie out of position e on occasion the displacement at
the time of injury can cause the median nerve and brachial artery to
lie behind the humeral fragment, blocking reduction. Superficial
“veins” should never be divided until the brachial artery has been
identified with absolute certainty. Identification of the normal
anatomical landmarks can also be difficult because of swelling as a
result of the injury. If in doubt, fluoroscopy should be used. A
tourniquet can be used, but is not essential. Good lighting is
essential, particularly when using medial or lateral approaches. A
headlight is invaluable in these situations. Intraoperative radio-
graphs or fluoroscopy are mandatory.
Evidence
A summary of the literature regarding open reduction of SCHFs is
provided in Tables 2 and 3. The primary indications for open
reduction are:
 Failure of closed reduction
 Open fracture
 A dysvascular limb.
Surgical approaches
Posterior approach
This approach takes place through uninjured tissues. A posterior
approach may be performed with the child prone, supine or in
the lateral decubitus position. Prone positioning makes it easier
to get good images using fluoroscopy. A midline longitudinal
incision is used and flaps are raised deep to the deep fascia.
These flaps allow exposure of each column of the distal humerus
around either side of the triceps-tendon. The triceps muscle may
be split longitudinally or a distally based musculotendinous flap
can be turned down. It provides good exposure of the fracture
fragments, and inserting divergent lateral or crossed wires is
straightforward. The ulnar nerve can be identified through the
same incision, allowing safe placement of a medial pin. It is
generally safe and reliable due to the lack of large vessels or
major nerves in this anatomical space, provided that dissection is
distal to the radial groove of the humerus.20
This approach is performed without visualizing the median
nerve and brachial artery, so these structures are at low risk of
damage,20 but care is required when reducing the fracture using

A summary of the relevant literature on outcomes of open reduction of supracondylar humerus fractures and the relevant
study characteristics (where available)
Author Journal Year Number of Vascular Nerve Open
patients injury injury fracture

Mohammed and Rymaszewski Injury 1995 10 0 3 1

Kaewpornsawan1 et al. J Paediat Orthop B 2001 14 0 2 0
Kumar et al. Injury 2002 44 4 2 0
Ozkoc et al.2 Arch Orthop Trauma Surg 2004 44 0 0 0
Ay et al.39 J Paediatr Orthop B 2005 61 7 9 2
Kazimoglu et al.40 Int Orthop 2009 37 0 3 1
Manandhar et al. JNMA J Nepal Medic Assoc 2011 25 e e e
Ersan et al.22 J Paediat Orthop B 2012 84 e e e

Table 2

ORTHOPAEDICS AND TRAUMA 27:5 305 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN

A representation of the literature relevant to outcomes of open reduction of supracondylar humerus fractures and the
relevant study characteristics (where available)
Author Journal Year Number of Vascular Nerve Open
patients injury injury fracture

Mohammed and Rymaszewski Injury 1995 10 0 3 1

Kaewpornsawan1 et al. J Paediat Orthop B 2001 14 0 2 0
Kumar et al. Injury 2002 44 4 2 0
Ozkoc et al.2 Arch Orthop Trauma Surg 2004 44 0 0 0
Ay et al.39 J Paediatr Orthop B 2005 61 7 9 2
Kazimoglu et al.40 Int Orthop 2009 37 0 3 1
Manandhar et al. JNMA J Nepal Medic Assoc 2011 25 ? ? ?
Ersan et al.22 J Paediat Orthop B 2012 84 ? ? ?

Table 3

a bone lever to make sure that they are not injured during limb almost along the line of the skin crease of the cubital fossa
reduction and that they do not become trapped within the frac- (see Figure 2e4). The proximal limb of the S should lie medially
ture. Clearly this approach does not allow inspection or repair of to allow better access to the brachial artery. Great care must be
the brachial artery. taken to correctly identify the major structures across the front of
the elbow as this approach is directly through the zone of injury
Medial approach and the anatomical arrangement of vital structures may be dis-
The child should be positioned supine, with the arm on an arm torted. This is the least commonly used surgical approach to the
board and the shoulder externally rotated. The skin incision elbow and may be the most technically demanding option. It is
should lie just behind the medial epicondyle, taking care to the approach of choice for open fractures with an anterior
identify and protect the ulnar nerve, which lies deep to the deep wound. It is useful for providing access to the neurovascular
fascia. It can be difficult to identify because of bruising to the soft
tissues. Dissection between biceps/brachialis and the common
flexor origin will allow exposure of the fracture site. It gives good
exposure of the medial column, but provides poor access to the
lateral column and the lateral side of the joint. This approach
allows safe placement of the medial pin away from the ulnar
nerve.20 Again, the ulnar nerve must be identified and protected
during this approach. Note that if the superficial flexor muscles
are retracted too strongly, the median nerve and its anterior
interosseous branch can also be injured.20

Lateral approach
The child should be positioned supine with the arm on an arm
board and the shoulder internally rotated. The skin incision is
centred on the lateral epicondyle. After incising the deep fascia,
the fracture can be approached between triceps and brachior-
adialis. Care is needed in the proximal part of this incision to
avoid damage to the radial nerve. It emerges from the radial
groove of the humerus approximately one (patient) hands
breadth above the lateral epicondyle to lie between brachialis
and brachioradialis. This approach provides a good exposure of
the lateral column. It is generally safe and less technically
demanding than other approaches, as less dissection is required
and there are no major neurovascular structures present. This
approach does not provide adequate access to medial structures,
so a separate medial incision may also be required, particularly if
a crossed pin configuration is to be used.21

Anterior approach
The child should be positioned supine with the arm on an arm
board. The skin incision should be S-shaped, with the transverse Figure 2 Site of S-shaped transverse incision for anterior open reduction.

ORTHOPAEDICS AND TRAUMA 27:5 306 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN
structures of the cubital fossa, which is particularly relevant in
cases where the brachial artery needs to be explored.16 It also
gives ready access to the fracture fragments. Because this
approach concerns a zone already damaged by the trauma, it
eliminates haematoma in the brachialis muscle and allows
placement of the fragments in the untouched shell of posterior
periosteum.22,23 A separate medial incision will be needed if a
crossed wire configuration is to be used.
If more distal exposure is required, careful incision of the
bicipital aponeurosis is necessary to avoid radial artery damage.
Although rarely required, it is important to emphasize that to
protect the posterior interosseous nerve, the supinator muscle
can be detached from its insertion at the radial neck, with the
forearm in supination.21
Complications
Complications may result from the injury itself or the subsequent
management of that injury.
Nerve injuries
Most nerve injuries are associated with type III displaced frac-
tures. The most commonly injured nerve is the anterior inter-
osseous branch of the median nerve, most likely due to the
arrangement of the posterior motor fascicles within the median
nerve, which are exposed to the zone of injury. The diagnosis of
injury to this nerve is often missed. The second most common
nerve injury is to the ulnar nerve (strongly associated with
posterolateral fracture patterns), closely followed by the radial
nerve (linked to posteromedial fractures).24
The ulnar nerve can also be injured during medial percuta-
neous pin placement. This can be due to direct penetration of the
nerve by the pin, constriction of the cubital tunnel by the pin
while the elbow is flexed, medial pin injury to an unstable ulnar
nerve (which subluxates or dislocates anteriorly when the elbow
is in flexion), and nerve contusion/oedema. Ulnar nerve injury
can occur as commonly as in 15% of cases with medial pin
placement. Iatrogenic ulnar nerve injury is much less likely in
patients treated with pins inserted from the lateral side.24
Most commonly, a nerve injury is a neurapraxia related to the
original injury rather than to treatment and these will gradually
recover over the ensuing months. If there are no signs of re-
covery after 12 weeks then further evaluation is indicated.24 After
the fracture is reduced and stabilized, re-evaluation of the pa-
tient’s neurovascular status is essential. A new nerve injury that
only appears post-operatively should be assumed to be due to a
complication of surgery until proven otherwise. Replacement or
readjustment of the wire fixation may be required.
Ischaemia
Ischaemia of the forearm and hand can either be caused by
arterial injury (from laceration, thrombus or intimal tear) or
compartment syndrome (from haemorrhage or post-ischaemic
swelling). If left untreated, both can result in a Volkmann’s
contracture.24 Early recognition and prompt management is
essential.
Deformity
Cubitus varus is the most common significant long-term
complication following supracondylar humeral fracture.25
ORTHOPAEDICS AND TRAUMA 27:5
It was suggested by Siris26 in 1939 that physeal injury could
account for this deformity. However this is now refuted, as
supracondylar humeral fractures by definition do not involve the
physis and the angular deformity is not progressive following
fracture union.25 It is therefore now accepted that this deformity
occurs as a result of inadequate fracture reduction and fixation,
with medial (internal) rotation of the distal fragment allowing
varus collapse.27
The deformity is three-dimensional, consisting of medial (in-
ternal) rotation, with apex anterior (extension) and varus angu-
lation. The sagittal plane malunion (extension) has the potential
to remodel, but the coronal plane deformity (varus) and rotation
do not,28 and with longitudinal limb growth the deformity can
appear to worsen even though the degree of angulation does not
change.
Cubitus varus is primarily a cosmetic deformity. The main
indication for intervention is therefore poor cosmesis and Takagi
et al. suggest a side-to-side difference of 20  should be used as
a cut-off before recommending intervention.4
There are however also functional concerns. Patients often
lack a degree of elbow flexion due to the hyper-extension mal-
union, the degree of which depends on the degree of malunion.
O’Driscoll et al. identified an increased risk of posterolateral
rotatory instability of the elbow 20e30 years after varus mal-
union secondary to increased strain on the lateral ligament
complex.29 Malunion also predisposes to tardy ulnar nerve palsy
secondary to nerve entrapment and fibrous tissue tethering.30,31
It has also been suggested by Davids et al. that cubitus varus
increases the risk of lateral humeral condyle fracture with a fall
secondary to increased distraction and shear forces across the
lateral compartment.32 Whether or not the increased risk of
lateral condyle fracture and elbow instability justify correction of
the deformity when the child and family are satisfied with the
appearance of the limb is not yet clear.29
The goal of corrective surgery is to restore alignment, range of
motion and cosmesis and the 3 important steps in surgical
correction are: [1] the approach [2] the osteotomy and [3] the
fixation.
The posterior approach can be performed as a triceps splitting,
triceps-tendon transecting or triceps sparing technique.24 This
approach provides excellent visualization of the distal humerus
but requires a long incision with significant dissection and
therefore there is a higher risk of post-operative stiffness. There
have also been reports of distal fragment avascular necrosis
when using a triceps-transecting approach.33
The lateral approach is used most commonly. Subperiosteal
exposure of the humerus is utilized to prevent damage to the
medial and lateral neurovascular bundles.24
Although many osteotomies have been described, there are
primarily four types. These are a simple lateral closing wedge
osteotomy (Figure 5), a three-dimensional osteotomy (Figure 8), a
modified step cut osteotomy with translation of the distal fragment
(Figure 7) and a rotational dome osteotomy (Figures 6e8).34
A lateral closing wedge osteotomy is the simplest and most
commonly used but it only corrects the varus angulation and not
the rotational or sagittal plane elements. A further problem with
this osteotomy is that it leaves the patient with a lateral promi-
nence, unless medial translation of the distal fragment is also
incorporated into the correction. Usui et al.35 describe a three-
307 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN
Figure 3
dimensional osteotomy that involves removal of a lateral wedge
with rotation and correction of hyper-extension. This therefore
allows correction of elements that are not addressed with a
simple lateral closing wedge osteotomy; however it adds
complexity and reduces the surface area for fixation and so in-
creases the risk of non-union or failure of fixation.
With a modified step cut osteotomy, a triangular osteotomy is
performed and the lateral edge of the distal fragment is moved
Figure 4
ORTHOPAEDICS AND TRAUMA 27:5
Figure 5
into the apex of the proximal osteotomy site. The degree of
correction is increased as the apex of the triangle is moved
medially.
A dome is a curved osteotomy that is performed through a
posterior approach. This allows correction of the deformity in all
planes however it is technically demanding.8
With regards to fixation, smooth k-wires are unreliable, with a
high incidence of loss of correction compared to threaded fixa-
tion and are therefore not recommended.24 Adequate fixation can
be achieved by buried threaded wires in young children, screws
in older children, or plate fixation in adolescents.24
Figure 6
308 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN
Figure 7
The senior author prefers a posterior triceps splitting
approach with a laterally based closing wedge osteotomy incor-
porating some medial translation to reduce the lateral promi-
nence. The osteotomy is secured with a small fragment T-plate.
Avascular necrosis (AVN)
Although very rare, AVN of the capitellum and trochlea have
been reported as long-term complications of supracondylar
fractures. Because the capitellar blood supply enters the distal
humerus posterolaterally and distally, a fracture that exits the
lateral column very distally may lead to avascular changes here.
Similarly, low fractures exiting medially may be at increased risk
Figure 8
ORTHOPAEDICS AND TRAUMA 27:5
for avascularity affecting the trochlea. Distal humeral AVN and
the resulting fishtail deformity may be associated with a
decreased range of motion, the development of a cubitus valgus
deformity and occasionally a subsequent tardy ulnar nerve
palsy.36
Elimination of the more lateral trochlear blood supply (as with
SCHF with T-shaped intercondylar extension), a classic fishtail
deformity of the distal humerus may occur. This deformity in-
volves the loss of the normal crista dividing the capitellum from
the trochlear groove and central involution of the distal articular
surface. This allows the proximal ulnar to “settle” into the distal
humerus. This presents clinically as absence of the olecranon
prominence, normally seen when the elbow is maximally flexed.
If both vascular routes to the distal humerus have been
compromised, this can result in total aplasia of the trochlea. It is
likely that this will progress to a cubitus varus deformity with
potential posterolateral rotatory instability at the ulnohumeral
articulation.24 Tardy ulnar nerve palsy can also develop due to
nerve instability over a hypoplastic medial condyle and scarring
or tethering as the nerve enters the flexor carpi ulnaris. This can
eventually lead to stretching and friction of the ulnar nerve as it
moves over the medial epicondyle, causing the gradually pro-
gressive neuropathy.36
Myositis ossificans
This complication, if extensive, can often result in poor elbow
motion. It is not common (1e2%) and may indeed be self-
limiting, with resolution over 1e2 years. The occurrence and
severity of myositis ossificans may naturally be expected to be
greater in cases treated with open reduction, particularly with
increased time from injury to surgery. Surgical excision of the
affected tissue should be performed only if the ectopic bone is
clearly demonstrated to be causative of motion loss, conservative
attempts to regain motion have failed and adequate time from
that of the injury has transpired such that the lesion is
quiescent.37
Does the approach used for open reduction affect the outcome?
Functional outcomes
The commonest method of recording functional outcome is by
using Flynn’s criteria.38 These are presented in Table 4.Func-
tional outcomes are generally very good after open reduction.
Some papers suggest superiority of the anterior approach: be-
tween 67.4%21 and 72.2%39“excellent” results. Although Kazi-
moglu et al.40 quote a 91.7% rate of excellent results with the
lateral approach, this result is somewhat called into question by
the 50% success reported by Ersan et al.22 The use of the pos-
terior approach produced a “good” outcome in 71% of patients.2
A systematic review of 7 studies by Mazzini et al.4 found a
statistically significant difference between different surgical ap-
proaches. It favours lateral, medial, and anterior approaches, and
notes a high frequency of “poor” results from the posterior
approach.
Cosmetic outcomes
The majority of studies evaluate cosmesis after treatment to be
“very good”, with similar measures of satisfaction to that of
closed reduction. A systematic review4 found little statistical
309 Ó 2013 Elsevier Ltd. All rights reserved.
 CHILDREN
The popularly used Flynn’s criteria. This tool uses
motion restriction and changes in carrying angle in
order to assess the success of treatment of
supracondylar humerus fractures38
Result Motion restriction Changes in carrying
(flexion and extension) angle (loss)
Excellent 0 e5 0 e5
Good 5 e10 5 e10
Unsatisfactory 10 e15 10 e15
Bad >15 >15
Table 4
difference in cosmetic outcome according to treatment, sup-
porting this view. The only statistically significant difference
noted was a high frequency of “poor” outcomes following a
posterior approach. It is important to note that this review only
analysed three studies which involved posterior incisions.
The majority of studies in this area do not compare one sur-
gical approach to another, with the majority of data coming from
trials of open vs closed reduction of SCHF. The appearance of the
scar seems to be good regardless of the approach, although there
are some concerns about posterior, and also lateral scars.
Complications related to open reduction
Ay et al.39 reported their experience with the anterior approach
and found that 11% of children had pre-operative vascular
insufficiency, 4.9% had an anterior interosseous nerve paralysis
and 9.8% had a radial nerve palsy. After open reduction via an
anterior approach, all damaged structures were easily located
and repaired where necessary. Full neurological recovery
occurred in all patients within 3 months.4
The medial approach for open reduction has been reported to
be associated with a 9.1% incidence of post-operative anterior
osseous nerve palsy and a 2.3% incidence of ulnar nerve palsy.
However, all of these cases resolved spontaneously with full
recovery occurred in 3 months.4 There is little evidence to sug-
gest that one approach is associated with fewer complications
than any other.
Conclusions
The majority of SCHFs can be managed by closed means with
percutaneous pinning techniques. If an open reduction is required,
then there is remarkably little consensus in the literature to guide
the surgical approach. It is likely that a surgeon’s training and their
personal preference currently dictate the choice of surgical expo-
sure. The literature suggests that the anterior approach produces
excellent cosmesis, as well as providing clear visualization of all
structures at risk, but can be technically difficult.22,23 Open
reduction of an SCHF is not required very often. Open fractures
usually produce a wound in the cubital fossa, which can be
extended into a formal anterior approach. Exploration of the
brachial artery is achieved by an anterior approach. It therefore
makes sense to use the anterior approach when dealing with
irreducible closed injuries. Learning a number of different ap-
proaches to deal with these fractures is attractive, but because the
ORTHOPAEDICS AND TRAUMA 27:5
need for open surgery is so rare, and two of the indications
mandate an approach from the front, we suggest that the anterior
approach may be the best one to be prepared to perform. A
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Practice points
C SCHFs can be acutely complicated by injury to the anterior
interosseous nerve (most commonly), ulnar nerve (5% due to
medial pinning) and radial nerve. Neuropraxia should resolve
within 6 months.
C Ischaemic complications can arise from either arterial injury or
compartment syndrome. It is important to notice these signs
quickly and act before this leads to Volkmann’s contracture.
C AVN is very uncommon in SCHF, but if present can lead to
severe joint deformity, reduced range of motion, and potential
tardy ulnar nerve palsy
C Myositis ossificans occurs only in 1e2% of SCHF and is usually
self-limiting over 1e2 years.
C Angular deformity, most notably cubitus varus, is the most
common complication after SCHF. It results in some joint
discomfort, motion limitation and increased risk of secondary
injury.
311 Ó 2013 Elsevier Ltd. All rights reserved.