Supracondylar Humerus Fracture
- Fysiobasen
- Oct 6
- 7 min read
A supracondylar humerus fracture is a break in the distal part of the humerus, just above the elbow joint, and is the most common elbow fracture in children. The injury often occurs after a fall on an outstretched arm and may lead to serious complications such as nerve injury, circulatory compromise, and compartment syndrome¹.
Anatomy and Vulnerable Structures
The distal humerus comprises both articular and non-articular structures:
Articular: the lateral capitellum (articulating surface with the radius) and the medial trochlea (articulating surface with the ulna)
Non-articular: the medial and lateral epicondyles, the coronoid and radial fossae anteriorly, and the olecranon fossa posteriorly
Muscle and nerve structures:
Medial epicondyle: origin for the flexor musculature and the site of the ulnar nerve
Lateral epicondyle: origin for the extensors
Brachialis lies anterior to the humerus, with the brachial artery and median nerve just superficial to it
The radial nerve passes between the brachialis and brachioradialis
Muscle force and attachment sites often influence rotational displacement and translation of the fracture².
Epidemiology
Supracondylar humerus fracture is the second most common fracture in children overall and the most common elbow injury. It most frequently affects children aged 5–8 years, with a peak around 6 years³.
• Accounts for 55–80% of all elbow fractures in children
• More common in boys and in the non-dominant arm
• 10–20% present with reduced circulation on arrival
• Nerve injuries occur in 6.5–19%, most often neuropraxia⁴
Mechanism of Injury
The injury typically follows a fall on an outstretched hand (FOOSH). This causes the olecranon to act as a fulcrum against the olecranon fossa, forcing the humerus into posterior bending.
Types:
Extension type (97–99%): most common; begins with anterior periosteal injury, and the distal fragment displaces posteriorly⁴
Flexion type (1–3%): due to a direct blow to the flexed elbow; the fragment displaces anteriorly and often in the coronal plane²
Children are particularly vulnerable because the bone structure in the supracondylar region is thin and undergoing remodelling at ages 6–7 years⁵.
Clinical Presentation
Patients typically present with a painful, swollen elbow after a fall, and reduced movement of the arm.
Typical findings:
• Swelling and bruising around the elbow and forearm²
• Visible deformity (S-shaped in cases with dislocation)
• Skin puckering over the elbow due to brachialis penetration⁴
• Possible open wounds or bleeding in severe injuries
Vascular Assessment
Up to 20% have compromised circulation in the affected arm. Palpate both radial and ulnar pulses. In the absence of a palpable pulse, assess:
Skin colour and temperature
Capillary refill (<2 seconds)
Oxygen saturation with pulse oximetry²
Classification of circulatory status:
Class I: Good perfusion with pulse
Class II: Good perfusion without pulse
Class III: Poor perfusion without pulse
Neurological Assessment
Nerve injury must be assessed before and after treatment. Most are neuropraxias that resolve spontaneously.
AIN (anterior interosseous branch of the median nerve): weak “OK” sign, no sensory deficit
Radial nerve: decreased sensation on the dorsum of the hand, weak wrist extension
Ulnar nerve: affected in flexion-type injuries; sensory loss and weakness in intrinsic hand muscles² ⁴
Compartment Syndrome
A potentially life-threatening complication. Look for:
Swelling and severe pain
Skin puckering
Signs of circulatory compromise
Early diagnosis and surgical decompression may be life-saving.
Diagnostic Procedures
Plain radiography is the primary tool for diagnosing supracondylar humerus fractures. Images should include:
True anteroposterior (AP) view of the distal humerus
True lateral view of the elbow
With minimal displacement, the fracture may be subtle; a positive fat-pad sign may be the only indicator².
On the lateral view, assess:
Anterior humeral line: should intersect the middle third of the capitellum. In extension-type fractures the capitellum lies posterior to the line; in flexion-type, anterior³.
Coronoid line, fishtail sign, and anterior/posterior fat-pad signs
Posterior cortex: to evaluate for complete cortical breach
On the AP view, assess:
Baumann’s angle: between the long axis of the humerus and the capitellar physeal line (normal 64–82°). Lower values indicate varus alignment and possible medial collapse.
Ulnohumeral angle: between the humerus and proximal ulna – offers better assessment of axis deviation than Baumann’s angle⁴.
Classification
Modified Gartland Classification (2006):
Type I: Undisplaced or minimally displaced fractures (<2 mm); the fat-pad sign may be the only finding. Stable injury⁵.
Type II: Displacement >2 mm with intact posterior cortex. The anterior humeral line does not intersect the middle third of the capitellum. No rotation on AP.
Type III: Complete displacement with periosteal disruption. Neurovascular injuries and malrotation in the frontal plane are common⁴ ⁷.
Type IV: Multidirectional instability. Complete failure of periosteal support, unstable in both flexion and extension.
Complications
Acute complications:
Vascular compromise: “Pink pulseless hand” occurs in 10–20% of type II–III fractures, most commonly involving the brachial artery².
Compartment syndrome: occurs in 0.1–0.3%. Risk increases with flexion >90° and with concomitant forearm fractures. The elbow should be immobilized at 30° (acute) and 60–70° (postoperative) to reduce pressure².
Neurological injury: occurs in 10–20%, especially in type III injuries. Most are neuropraxias that resolve spontaneously⁴.
Long-term complications:
Cubitus varus (gunstock deformity): due to malalignment after healing. May cause delayed ulnar neuropathy, rotational instability, and increased refracture risk. Modern pinning techniques have reduced its prevalence from 58% to ~3%⁴.
Volkmann’s contracture: the result of untreated ischaemic compartment syndrome, causing permanent flexion deformity of the elbow and wrist².
Treatment
Medical Management
Management depends on injury type (Gartland):
Type I:
• Long arm splint/cast in 80–90° flexion
• Avoid casts >90° due to risk of vascular compromise
• Radiographic follow-up at 1 and 2 weeks
Type II:
• Closed reduction and percutaneous pinning is recommended over casting alone
• Pin removal after approximately 3 weeks⁹
Type III and IV:
• Closed reduction and pinning is the gold standard
• Open reduction if closed reduction fails or with interposed soft tissue (median nerve, brachial artery)
Surgical approaches:
Anterior approach: best when vascular repair is required
Lateral approach: safe, but may increase stiffness
Posterior approach (Alonso-Llames): discouraged due to a high complication rate
Physiotherapy Management
Physiotherapy is crucial for restoring motion, strength, and function after fracture.
Treatment goals:
• Restore pain-free, full range of motion
• Prevent muscle atrophy and stiffness
• Rebuild strength and upper-limb function
• Promote the child’s overall motor development
Interventions and assessments:
• Pain scoring: Numerical Pain Rating Scale (NPRS) or faces scale for children
• Range of motion: goniometry
• Strength: manual muscle testing
• Function: ASK-p (Activities Scale for Kids – performance)
• Flynn’s criteria: evaluates both cosmetic outcome (carrying angle) and functional loss (ROM)¹⁰
Neurovascular assessment must always be performed postoperatively and throughout rehabilitation.
Evidence and the Role of Physiotherapy
Physiotherapy after paediatric supracondylar humerus fractures is debated—particularly regarding its effectiveness and necessity. Several studies suggest that children often regain function and motion without structured physiotherapy after cast removal.
A randomized controlled trial by Schmale et al. (2014) showed that children treated either conservatively with casting or with surgical pinning followed by casting did not benefit from physiotherapy during a five-week period after cast removal⁹. Another study from 2018 confirms this: children with uncomplicated fractures regained functional ROM within 12 weeks without physiotherapy¹⁰.
Reasons for limited effect may include:
• Children aged 5–10 years are naturally active through daily activities and play
• Therapeutic intervention may have been either too aggressive or too cautious
• Limited evidence for the effect of strengthening programmes in this age group⁹ ¹⁰
In contrast, physiotherapy has a much larger role in complicated fractures, especially in adults or when neurovascular injury is present.
Recommendation:
• Early, graded optimal loading is important. Activities that provoke pain or stress the humerus should be avoided in the early phase.
• Active participation in play and daily activities is recommended over passive mobilization.
• Strenuous activities (lifting, carrying, pushing) should be avoided in the first week after immobilization.
Advice and Exercises During and After Immobilization
During immobilization (≈3 weeks)
• Keep adjacent joints moving: shoulder, wrist, and fingers should be moved actively several times daily
• Use the arm sling correctly
• Postural training: emphasize upright posture and gentle scapular retraction
1–2 weeks after cast removal
• Heat therapy: may ease stiffness
• Soft-tissue treatment: gentle massage of forearm musculature
• Active and active-assisted ROM: e.g., dowel/pole exercises within pain limits, performed frequently throughout the day
• Isometric strengthening: for upper-arm and forearm musculature
• Use the hand in daily tasks: eating, writing, dressing, etc.
• Avoid loading: no heavy lifting or pushing
After 2 weeks
• Progressive ROM and strengthening: include play-based activities such as ball games, self-care/dressing tasks, etc.
• Focus on function and interaction
Conclusion
Supracondylar humerus fractures are the most common elbow fractures in children, with the highest incidence between 5–8 years. The injury is often due to a FOOSH mechanism and requires thorough neurovascular assessment both before and after treatment.
• Type I fractures are managed with casting alone
• Type II–IV are best treated with closed reduction and percutaneous pinning
• Complications include vascular compromise, nerve injury, cubitus varus, and Volkmann’s contracture
In children with uncomplicated fractures, active participation in everyday activities is recommended over passive physiotherapy. In severe injuries, physiotherapy plays a central role in rehabilitation.
Sources
Gray H. Anatomy of the human body. Lea & Febiger; 1878.
Kumar V, Singh A. Fracture supracondylar humerus: A review. Journal of clinical and diagnostic research: JCDR. 2016 Dec;10(12):RE01.
Zhang XN, Yang JP, Wang Z, Qi Y, Meng XH. A systematic review and meta-analysis of two different managements for supracondylar humeral fractures in children. Journal of orthopaedic surgery and research. 2018 Dec 1;13(1):141.
Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT open reviews. 2018 Oct;3(10):526-40.
Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med 2008;1:190-196.
Gjennomgått - Trukket
Alton TB, Werner SE, Gee AO. Classifications in brief: the Gartland classification of supracondylar humerus fractures.
Coupal S, Lukas K, Plint A, Bhatt M, Cheung K, Smit K, Carsen S. Management of Gartland Type 1 Supracondylar Fractures: A Systematic Review. Frontiers in Pediatrics. 2022 May 19;10:863985.
Schmale GA, Mazor S, Mercer LD, Bompadre V. Lack of benefit of physical therapy on function following supracondylar humeral fracture: a randomized controlled trial. The Journal of Bone and Joint surgery. American Volume. 2014 Jun 4;96(11):944.
Jha SC, Shakya P, Baral P. Efficacy of Physiotherapy in Improving the Range of Motion of Elbow after the Treatment of Pediatric Supracondylar Humeral Fracture. Birat Journal of Health Sciences. 2018 Sep 5;3(2):432-6.
