Supracondylar Fracture of the Humerus — Treatment

Overview

Gartland Classification & Treatment Algorithm

Key radiographic aid: Baumann's angle (~75°) on AP film — angle between humeral shaft axis and capitellum growth plate — used to confirm acceptable reduction.

Baumann's Angle (~75°) on AP radiograph — used to assess adequacy of reduction (Rosen's Emergency Medicine)

Closed Reduction Technique (Types II–III)

1. Procedural sedation/anesthesia
2. Assistant fixes the upper arm; operator grasps the wrist
3. Apply steady traction in line with the limb (forearm in neutral/thumb-up)
4. Correct medial/lateral displacement with the free hand at the elbow
5. Once length and angulation corrected: thumb on anterior proximal fragment, fingers behind olecranon → gently flex elbow to reduce distal fragment
6. Immobilize in above-elbow cast at 110–120° flexion (if no vascular risk)
7. Do NOT hyperflex if there is significant swelling → risk of vascular compromise

>20° of angulation after reduction warrants orthopedic consultation for K-wire pinning.

Percutaneous K-Wire Fixation

Intraoperative C-arm fluoroscopy: percutaneous K-wire placement for Gartland Type III supracondylar fracture stabilization

• Standard approach: 2 lateral divergent pins ± 1 medial pin
• If periosteal hinge is broken, K-wires are mandatory, supplemented by above-elbow cast
• Supplemented with an above-elbow cast post-operatively
• Trend toward delayed fixation (up to 24 hrs) is now accepted unless emergent indications exist

Timing of Surgery

Neurovascular Complications — Management

White Pulseless Hand

• Surgical emergency: immediate reduction
• If pulse does not return after reduction → vascular exploration by vascular surgeon

Pink Pulseless Hand (controversial)

• If adequate limb perfusion, no compartment syndrome, and no neurological deficit:
  • Reduce and stabilize the fracture
  • Expectant approach to vascular injury — pulse often returns within 24–48 hours

Nerve Injury

• Common (often anterior interosseous nerve with extension-type); usually a neuropraxia
• Most resolve with fracture reduction, stabilization, and resolution of swelling
• No immediate surgical exploration unless vascular injury co-exists

Volkmann's Ischaemic Contracture

• Rare but feared complication from missed compartment syndrome due to excessive swelling
• Do not place elbow in deep flexion if significant swelling is present
• If deep flexion is the only way to hold the fracture → proceed to K-wire fixation instead

Malunion

• Cubitus varus ("gunstock deformity") is the most common malunion — from inadequate reduction of varus angulation
• The elbow remodels flexion-extension plane deformity well; varus/valgus malunion remodels poorly
• Requires careful attention to reduction quality and K-wire placement to avoid angular malunion

Flexion-Type Fractures

• Rare (<5%); distal fragment displaced anteriorly
• More difficult to reduce and maintain
• Usually require K-wire fixation for stability