- Closed Reduction and
Percutaneous Pinning of
Chapter 5 Supracondylar Fractures of
the Humerus
-----------------------------------------------. ---------------------------------------------------------------~
t Paul D. Choi and David L. Skaggs
DEFINlTION
• Supracondylar fractures of the humerus are common in-
juries in children. As many as 67% of children hospitalized
with elbow injuries have supracondylar fractures; supracondy-
lar fractures of the humerus represent 17% of all childhood
fractures.4 .s
• The peak age at fracture is 5 to 7 years.
• The cause of injury is most commonly a fall from height
(70%).
• The vast majority of supracondylar fractures of the humerus
are of the extension type (97%).3 Flexion-type injuries also
OCCUl'.
• Open injuries occur in 1% of cases. Concurrent fractures,
most commonly involving the distal radius, scaphoid, and
proximal humerus, occur in 1% of cases. Associated neurovas-
cular injuries can occur, with preoperative nerve injury exist-
ing in 8% of cases and vascular insufficiency present in 1% to
2% of cases.1
ANATOMY
• The periosteum most corwnonly fails anteriorly with
extension-type supracondylar fractures of the hwnerus.
With posteromedial displacement, the periosteum also
fails laterally.
Therefore, with posteromedially displaced fractures,
forearm pronation can aid in the reduction (FIG 1 ).
With posterolateral displacement, the periosteum also
fails medially.
Forearm supination usually aids in the reduction of
these posterolaterally displaced fractures.
• The direction of displacement bas implications for which
neurovascular structures are at risk from the penetrating injury
of the proximal metaphyseal fragment (FIG 2 ).
Medial displacement of the distal fragment places the ra-
dial nerve at risk.
Lateral displacement of the distal fragment places the me-
dian nerve and brachial artery at risk.
• The ulnar nerve courses through the cubital tunnel posterior
to the medial epicondyle. It is at particular risk with flexion-
type fractures or when a medial pin is placed for fracture
fixation.
The ulnar nerve subluxates anteriorly as the elbow is
flexed. Therefore, the elbow should be relatively extended if
a medial pin is placed for fracture fixation.
PATIIOGENESIS
• Supracondylar fractures of the humerus generally occur as a
result of a fall onto an outstretched band with the elbow in full
extension.
• The distal humerus is very thin at the supracondylar region,
a critical factor in producing a consistent injury pattern and
failure in the supracondylar humeral region.
During a fall with the elbow in full extension, the olecra-
non in its fossa acts as a fulcrwn.
The capsule, as it inserts distal to the olecranon fossa and
proximal to the physis, transmits an extension force to this
region, resulting in failure and fracture.
• With the elbow in full extension and the elbow becoming
tightly interlocked, bending forces are concentrated in the dis-
tal humeral region.
• Increased ligamentous laxity, leading to hyperextension of
the elbow, may be a contributing factor to this injury pattern.
NATURAL HISTORY
• The physis of the distal humerus contributes little to the
overall growth of the humerus (20% of the hwnerus); there-
fore, the remodeling capacity of supracondylar fractures of the
humerus is limited. Near-anatomic reduction of these fractures
is important.
• The majority of supracondylar fractures of the humerus
(other than extension type I fractures) are unstable; therefore,
stabilization in the form of cast immobilization or preferably
operative fixation is usually necessary.
PATIENT HISTORY AND PHYSICAL
FINDINGS
• Evaluation of the child with an elbow injury must include an
overall assessment to look for associated trauma (especially in
the proximal humerus and distal radius regions) as well as as·
aociated neurovascular injury.
• The physical examination may reveal swelling, tenderness,
ecchymosis, and deformity. The pucker sign. which occurs as
a result of the proximal fracture fragment spike penetrating
through the bracbialis and anterior fascia into the subcuta-
neous tissue, may be present.
• Thorough neurovascular examination of the involved ex·
tremity is critical. Physical examinations to perform include:
Assessing for potential associated injury to the ulnar
nerve. Finger abduction and adduction (interossei) strength
is tested. Sensation in the palmar little finger is tested.
Asaeaaing for potential associated injury to the radial
nerve. Finger, wrist, and thumb extension (extensor digito·
rum communis, extensor indicis proprius, extensor carpi ra-
dialis longus and brevis, extensor carpi ulnaris, extensor
pollicis longus) is tested. Sensation in the dorsal first web
apace is tested.
Asaeaaing for potential associated injury to the median
nerve. Thenar strength (abductor pollicis brevis, flexor
25
26 Section I lRAUMA
FIG 1 • Reduction of a posteromedially displaced supracondylar
fracture of the humerus. Pronation of the forearm closes the
hinge and aids in reduction.
pollicis brevis, opponens pollicis) is tested. Sensation in the
palmar index finger is tested.
Assessing for potential associated injury to the anterior in·
terosseous nerve. Index distal interphalangeal flexion (flexor
digitorum profundus index) and thumb interphalangeal
flexion (flexor pollicis longus) are tested.
IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Initial imaging studies should include plain radiographs of
the elbow-anteroposterior (AP), lateral, and sometimes
oblique views.
• Comparison views of the contralateral elbow are sometimes
helpful.
The fat-pad sign, particularly posterior, represents
an intra-articular effusion and can be associated with a
supracondylar fracture of the humerus (53% of the time)
(FIG 3A).7
On the AP view, the Baumann angle correlates with the
carrying angle and should be 70 to 78 degrees or symmetric
with the contralateral elbow (FIG 38).
On the lateral view, the anterior humeral line (line drawn
along the anterior aspect of the humerus) should intersect
the capitellum (FIG 3C).
• The most commonly used classification system, the Gartland
classification, is based on plain radiographic appearance:
Extension type I: nondisplaced
Extension type n: capitellum displaced posterior to ante·
rior humeral line with variable amount of extension and an·
gulation; posterior cortex of the humerus is intact
Extension type m: completely displaced with no cortex
intact
Flexion type
nerve
~...,__--Brachial
artsry
FIG 2 • Relationship to neurovascular structures. The proximal
metaphyseal spike penetrates laterally with posteromedially dis-
placed fractures and places the radial nerve at risk. Wrth pos-
terolaterally displaced fractures, the spike penetrates medially
and places the median nerve and brachial artery at risk.
DIFFERENTIAL DIAGNOSIS
• Fracture of elbow (other than involving the supracondylar
humeral region)
Salter-Harris fractures involving the elbow
• Nursemaid's elbow
• Infection
NONOPERATIVE MANAGEMENT
• The indications for nonoperative management of supra-
condylar fractures of the humerus are limited to nondisplaced
fractures (type 1).
The anterior humeral line tran5e(;ts 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 increas-
ing flexion of the elbow, the clinician must ensure that the
distal radial pulse is intact and that there is adequate perfu-
sion distally.
• Historica11y, some supracondylar fractures of the humerus
were managed with ttaction (overhead versus side). With the
relative safety of percutaneous pinning techniques, however,
the use of ttaction has been limited.
SURGICAL MANAGEMENT
• The two main options for percutaneous pin .fixation are the
lateral-entty pin and crossed-pin techniques.
• Most fractures can be stabilized successfully by the lateral-
entty pin technique.6
Two pins are usually adequate for type ll fractures; three
pins are recommended for type m fractures.
• Biomechanical studies have revealed comparable stability in
the lateral-entty and crossed-pin techniques.
 Chapter 5 Q.OSED REDUCDON AND PERC.UTANEOUS PINNING OF SUPRACONDYLAR FRAC1URES OF 1HE HUMERUS
c capitellum.
• An advantage of the lateral-entry pin technique is the sig-
n.ificandy 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 in-
stability is noted intraoperatively after placement of three
lateral-entty pins.
Preoperative Planning
• Displaced supracondylar fractures of the humerus (includ-
ing Gartland type 0: and III) require reduction. Usually, reduc-
tion 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 impor-
27 -
FIG :J • A. Posterior fat-pad sign. The
presence of a posterior fat-pad sign
suggests an intra-articular effusion and
can be associated with an occult supra-
condylar fracture of the humerus. B.
The Baumann angle is variable but in
general is >10 degrees. C. On a lateral
view of the elbow, the anterior
humeral line should intersect the
tant; if present, there is an increased risk of compartment
syndrome.
• Complete preoperative neurologic and vascular examina-
tion 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 retro·
sped:ive studies suggest that a delay in treatment of the major·
ity of supracondylar fractures is acceptable.1
• Fractures with "red fla~" (eg, significant swelling and
signs of neurologic and especially vascular compromise
or an associated forearm fracture) usually require urgent
treatment.
Positioning
• 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 distal
28 Section I lRAUMA

A B
FIG 4 • A. Positioning of patient. The injured elbow is positioned on a radiolucent armboard. In smaller chil-
dren, the child's shoulder and head may also need to rest on the armboard to allow full views of the elbow
and distal humerus. B. Positioning the fluoroscopy monitor on the opposite side of the bed allows the surgeon
to see the images easily while operating.

humerus. In smaller children, the child•s shoulder and head
may n~ to rest on the armboard as wen.
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 n~ed for AP and lateral views of the
elbow.
• The .fluoroscopy monitor is placed opposite to the surgeon
for ease of viewing (FIG 48).

CLOSED REDUCTION
• Traction is applied with the elbow in 20 to 30 degrees of
flexion (IECH FIG 1A) to prevent tethering of the neu-
rovascular structures over the anteriorly displaced proxi-
mal fragment.
• For severely displaced fractures, where the proximal
fragment is entrapped in the brachialis muscle, the
...milking maneuver... is performed (IECH FIG 11).
• The soft tissue overlying the fracture is manipulated
in a proximal to distal direction.
• Once length is restored, the medial and lateral columns
are realigned on the AP image.
• Varus and valgus angular alignment is restored.
• Medial and lateral translation is also corrected.
• For the majority of fractures (ie, extension type}, the flex-
ion reduction maneuver is performed next (IECH FIG 1C).
• The elbow is gradually flexed while applying anterior
pressure on the olecranon (and distal condyles of the
humerus} with the thumbs.
• The elbow is held in hyperflexion as the reduction is ar
sessed by fluoroscopy.
• Reduction is adequate if the following criteria are
fulfilled:
• The anterior humeral line crosses the capitellum.
• The Baumann angle is >10 degrees or comparable to
the contralateral side.
• Oblique views show intact medial and lateral
columns.
• The forearm is held in pronation for posteromedial
fractures.
• The forearm is held in supination for posterolateral
fractures.
• For unstable fractures, the fluoroscopy machine instead
of the arm is rotated to obtain lateral views of the elbow
(IECH RG 1D).
 Chapter 5 Q.OSED REDUCDON AND PERC.UTANEOUS PINNING OF SUPRACONDYLAR FRAC1URES OF 1HE HUMERUS 29 II

TECH AG 1 • A. Reduction. Traction is applied with the elbow flexed 20 to 30 degrees.

Countertraction should be provided by the assistant with pressure applied to the axilla. B.
If the fracture is difficult to reduce, the proximal fracture fragment may be interposed in
the brachialis muscle. The •milking maneuver• is performed to free the fracture from the
overlying soft tissue. C. The elbow is flexed while pushing anteriorly on the olecranon with
the thumbs. D. For unstable fractures, the fluoroscopy unit instead of the arm is rotated to
obtain lateral views of the elbow.

LATERAL-ENTRY PIN tECHNIQUE

• Once satisfactory reduction is obtained, K-wires can be
inserted percutaneously for fracture stabilization.
• 0.062-inch smooth K-wires are commonly used.
• Smaller or larger sizes may be used depending on the
size of the child.
• The goals of the lateral-entry pin technique are to maxi-
mally separate the pins at the fracture site and to engage
both the medial and lateral columns (TECH FIG 2.A-C).
• The pins can be divergent or parallel •
• Sufficient bone must be engaged in the proximal and
distal fragments.
• Pins may cross the olecranon fossa.
• As a general rule, two pins are adequate for type II frac-
tures; three pins are recommended for type Ill fractures.
• The K-wire is positioned against the lateral condyle wit~
out piercing the skin (TEat FIG 2D}.
• The starting point is assessed under AP fluoroscopic
guidance.
• The K-wire is held freehand to allow maximum control.
• Once a satisfactory starting point and trajectory are co~
firmed, the K-wire is pushed through the skin and into
the cartilage.
• The cartilage of the distal lateral condyle functions as
a pincushion.
• The starting point and trajectory are assessed by AP and
lateral fluoroscopic guidance.
• When satisfactory starting point and trajectory are con-
firmed, the pin is advanced with a drill until at least two
cortices are engaged.
• At this point, the reduction is again assessed.
• The reduction must appear satisfactory on AP, lateral,
and two oblique views•
• The elbow is rotated to allow for oblique views of the
medial and lateral columns.
• Additional pins are inserted (TECH FIG 2E-H).
• The elbow is stressed under live fluoroscopy in both the
AP and lateral planes•
• Once satisfactory reduction and stability are confirmed,
the vascular status is again assessed.
• Upon completion, the pins can be bent and cut approxi-
mately 1 to 2 em off the skin•
30 Section I lRAUMA

'IECH FIG 2 • A-C. Lateral-entry pin technique: optimal pin configuration. The pins
are separated at the fracture site to engage the medial and lateral columns. A.
Optimal pin configuration for two pins (AP view). B. Optimal pin configuration for
three pins (AP view). C. Optimal pin configuration (lateral view). D. The pin is held
freehand. Once starting point and trajectory are confirmed under fluoroscopic guid-
ance, the pin is pushed through the skin and into the cartilage. E,F. Assessment of
coronal alignment on AP and lateral views. G. Externally and internally rotated
oblique views are used to assess the medial and lateral columns. H. Stress fracture.
The elbow should be stressed under live fluoroscopy to confirm adequate stability.
 Chapter 5 Q.OSED REDUCDON AND PERC.UTANEOUS PINNING OF SUPRACONDYLAR FRAC1URES OF 1HE HUMERUS
CROSSED~IN tECHNIQUE
• If satisfactory stability cannot be achieved by lateral-
entry pins or if the surgeon is more comfortable with lat-
eral- and medial-entry pins, the crossed-pin technique
can be performed.
• The lateral-entry pins are inserted first: this will allow
the elbow to extend when placing the medial-entry
pins.
• The ulnar nerve subluxates anteriorly with increasing
flexion of the elbow; therefore, the ulnar nerve may
be at risk when medial-entry pins are placed with the
elbow in 90 degrees or more of flexion.
• After insertion of the lateral-entry pins, the elbow is ex-
tended to 20 to 30 degrees of flexion (RECH RG 3A).
• A small incision is made over the medial epicondyle.
31 II
• Blunt dissection is performed down to the level of the
medial epicondyle.
• A pin is positioned on the medial epicondyle (1ECH FIG 31).
• The starting position and trajectory are assessed under
fluoroscopic guidance•
• When a satisfactory starting point and trajectory are co~
firmed, the pin is advanced with a drill until at least two
cortices are engaged (.TECH FIG 3C:::,D). The medial col-
umn should be engaged.
• Ideally, the pin should be separated from the other
pins maximally at the fracture site.
• The reduction and stability of the fracture are assessed
just as with the lateral-entry pin technique. The vascular
status is similarly evaluated•

1ECH RG 3 • Crossed-pin technique. A. To minimize risk of iatrogenic injury to the ulnar nerve, the elbow is
extended to 20 to 30 degrees of flexion before the pins are inserted medially. B. The starting point is on the
medial epicondyle. C.D. The medial pin should engage the medial column and at least two cortices.
32 Section I TRAUMA

PEARLS AND PITFALLS

Clinical examination • A thorough preoperative neurologic and vascular examination should be performed and documented.
• The surgeon should look for "red flags" such as ecchymosis, excessive swelling, puckering of skin, and
associated fractures which may be indications for an urgent reduction.
Indications • Nondisplaced (type I) fractures can be treated nonoperatively with splint or cast immobilization.
• Fractures with medial comminution or impaction should be treated operatively to avoid cubitus varus.
• Displaced fractures require reduction (usually closed) and operative fixation (usually percutaneous pinning).
Reduction • Traction is applied with the elbow in 20 to 30 degrees of flexion.
Lateral-entry pin • Maximal pin separation at the fracture site to engage the medial and lateral columns is the goal.
placement • For type II fractures, two pins are usually adequate; for type Ill fractures, additional fixation with a third
pin is usually indicated.
Medial-entry pin • Lateral-entry pins are inserted first so that the elbow can be extended to 20 to 30 degrees of flexion,
placement allowing for safer insertion of medial-entry pins.

POSTOPERATIVE CARE COMPLICATIONS

• The ann is immobilized, preferably in a cast (sometimes a
splint), with the elbow in 45 to 60 degrees of flexion.
Flexing the elbow to 90 degrees, as is used for most other
casting, will im:rease the risk of compartment syndrome be-
cause the fracture reduction is stabilized by the pins, not the
cast.
Sterile foam may be directly applied to the skin before
cast application to allow for postoperative swelling.
• The ann is immobilized for 3 to 4 weeks, with follow-up
evaluations at 1 and 3 (or 4) weeks. Postoperative radiographs
(AP and lateral views) are obtained.
• Pins are usually discontinued at 3 to 4 weeks postoperatively.
• Range-of-motion exercises are initiated shortly after pins
and immobilization are discontinued.
• Return to full activity typically occurs by 6 to 8 weeks
postoperatively.
OUTCOMES
• Studies have suggested that treatment of supracondylar frac-
tures can be delayed without significant added risk in appro-
priately selected patients.
• Multiple studies have reported on the efficacy and high
safety profile of the lateral-entry pin technique.
A consecutive series of 124 patients with type II and type
ill supracondylar fractures of the humerus were evaluated. 6
Fractures were stabilized by the lateral-entry pin technique.
There were no cases of malunion or iatrogenic nerve injury.
One patient had a pin-track infection.
• Elbow stiffness
• Infection
• Vascular injury
• Neurologic injury
• Malunion
• Nonunion
• Avascular necrosis
• Myositis ossificans
REFERENCES
1. Gupta N, Kay R, Leitch K, et al. Effects of swgical delay on peri-
operative complications and need for open reduction in supra-
condylar humerus fractures in children. J Pediatr Orthop 2004;24:
245-248.
2. Kasser JR, Beaty JH. Supracondylar fractures of the distal humerus.
In: Rockwood and Wilkins' Fractures in Cbildren, 6 ed. Philaddphia:
Lippincott Williams & Wilkins, 2005:543-590.
3. Mahan ST, May CD, Kocher MS. Operative management of dis-
placed flexion supracondylar humerus fractures in children. J Pediatr
Orthop 2007;27:551-556.
4. Mangwani J, Nadarajah R, Paterson JMH Supracondylar humeral
fractures in children. J Bone Joint Surg Br 2006;88B:362-365.
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children. JAm Acad Orthop Surg 1997;5:19-26.
6. Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-entry pin fixation in
the management of supracondylar fractures in children. J Bone Joint
Surg Am 2004;86A:702-707.
7. Skaggs DL, Mirzayan R. The posterior fat pad sign in association
with occult fracture of the elbow in cbildren. J Bone Joint Surg Am
1999;81A:1429-1433.