Supracondylar Humerus Fracture

Supracondylar humerus fracture is the most common elbow fracture in children, occurring most frequently between five and eight years of age after a fall on an outstretched hand. The injury requires prompt neurovascular assessment and appropriate treatment to prevent lasting complications and ensure optimal function.

Clinically Relevant Anatomy

The supracondylar region of the humerus is particularly vulnerable to fracture due to its unique anatomical structure. The distal humerus consists of both articular and non-articular parts forming a complex unit. Anteriorly lie the coronoid and radial fossae, while the olecranon fossa is posterior. The medial epicondyle is an important origin for the forearm flexors, and the ulnar nerve courses in a groove on its posterior aspect. The lateral epicondyle serves as the origin for the forearm extensors and plays a key role in movement and stability; these muscles may contribute to rotation and displacement in fractures. In addition, the brachial artery and median nerve pass anteriorly across the distal humerus, making them vulnerable in fractures. The brachial artery runs anteromedially just above the brachialis muscle, and the radial nerve crosses the elbow between brachialis and brachioradialis before piercing the supinator. This close proximity of bony structures to major nerves and vessels explains why injuries in this area often have complex

Epidemiology

Supracondylar humerus fractures account for a substantial proportion of paediatric elbow fractures and are the most common humeral fracture in children. Median age is around six years, with peak incidence between five and eight years. The fracture constitutes 55–80% of all elbow fractures in children and two-thirds of all cases requiring hospital admission. Reported incidence is 177.3 per 100,000 children, with a male predominance. The injury occurs more often in the non-dominant arm, likely due to protective reflexes during a fall. Vascular complications are common, seen in 10–20% of cases; fracture reduction usually leads to rapid circulatory improvement. Neurological injuries affect 6.5–19% of cases, most being neurapraxias with a good prognosis.

Mechanism of Injury / Aetiology

• The most common mechanism is a fall on an outstretched hand (FOOSH), producing an extension-type fracture (97–99% of cases).

• In children, the supracondylar region is a weak point during growth, especially at 6–7 years, when the cortex is thin and structurally weaker.

• During a FOOSH, the olecranon is driven into the olecranon fossa; with increasing extension the olecranon acts as a lever, creating an anterior distraction through the elbow capsule. The fracture begins anteriorly and propagates posteriorly.

• With high-energy trauma, the posterior cortex may also fail, causing complete posterior displacement of the distal fragment. The posterior periosteum acts as a hinge, partially restraining the fragment.

• Flexion-type fractures (1–3%) result from direct trauma to a flexed elbow; the anterior periosteum functions as a hinge and the fracture line propagates from posterior to anterior in the humerus. Coronal translation of the distal fragment may occur.

Clinical Presentation

Patients typically present with acute pain, swelling and impaired function of the elbow and forearm. The history often includes a FOOSH with immediate pain and swelling. It is critical to determine whether pain is due to the fracture itself or secondary ischaemic muscle injury (compartment syndrome) developing hours later. Inspection may reveal a swollen, tender elbow and an S-shaped deformity, particularly in displaced extension fractures. Skin puckering occurs when the proximal fragment cuts through brachialis and tethers skin and soft tissues. Open fractures may show a visible wound tract or bleeding. With suspected vascular injury, assess radial and ulnar pulses and perfusion signs (colour, temperature, capillary refill, oxygen saturation). Absent pulse alone does not always equal poor perfusion if the hand is warm and pink. A thorough neurological examination is essential to identify nerve injuries, which are relatively frequent in supracondylar fractures.

Vascular Status

• Approximately 10–20% of displaced supracondylar fractures have concomitant vascular compromise.

• Palpate both radial and ulnar pulses. If the radial pulse is absent, evaluate other parameters to exclude critical ischaemia: hand colour (pink vs pale), temperature (warm vs cool), capillary refill (<2 s) and oxygen saturation.

• With normal perfusion but absent pulse, an arterial kink or compression may resolve after reduction.

• Persistent perfusion problems require urgent surgical evaluation.

Neurological Status

• Neurological injury occurs in 6.5–19% and most often represents neurapraxia, typically improving within 2–3 months.

• Test median, radial and ulnar nerve function.

• Median/AIN injury is associated with posterolateral displacement; radial nerve injury with posteromedial displacement; ulnar nerve injury is most common with flexion-type fractures.

Clinical signs:

• Median/AIN—weak “OK sign” (pincer grip)

• Radial—weak wrist dorsiflexion; reduced dorsal hand sensation

• Ulnar—sensory loss in the little finger; intrinsic hand weakness

Compartment Syndrome

• A serious complication following fracture or massive swelling.

• Signs: severe pain, tense swelling, skin puckering, reduced capillary refill.

• Suspected cases require pressure measurement and urgent surgical assessment to prevent permanent damage.

Diagnostic Procedures

• Radiographs (AP and lateral) of the humerus and elbow are essential.

• Minimally displaced fractures may be subtle; a fat pad (“sail”) sign may be the only finding.

• On the lateral view, the anterior humeral line should pass through the middle third of the capitellum; in extension-type fractures the capitellum lies posterior to this line, and in flexion-type it lies anterior.

• The AP view helps assess displacement direction and varus/valgus malalignment.

• Baumann’s angle (humerus–capitellum angle; normal 64–82°) indicates varus deformity risk; the ulnohumeral angle more precisely quantifies varus/valgus.

• These measures guide treatment planning and the need for reduction.

Classification of Supracondylar Fracture

The most widely used system is the modified Gartland classification.

• Type I: Stable, non-displaced fracture; anterior humeral line intact.• Type II: Partially displaced fracture; posterior cortex intact.• Type III: Unstable fracture with no cortical contact; often significant soft-tissue injury.• Type IV: Rare, multidirectional instability due to complete periosteal disruption around the fracture.

Classification informs treatment strategy and complication risk.

Complications of Supracondylar Humerus Fracture

Immediate complications

• Neurovascular injury is the key acute risk.

• Vascular insufficiency (“pink pulseless hand”) is common in Type II–III fractures, often from posterolateral displacement compressing the brachial artery; the hand may be warm and pink yet pulseless—requires close monitoring.

• Compartment syndrome occurs in 0.1–0.3%; risk increases with associated forearm fractures or immobilisation in >90° flexion.

• Recommended immobilisation: 30° flexion acutely and 60–70° post-operatively to reduce risk.

• Neurological injury in 10–20%, especially Type III; neurapraxia predominates.

• Open fractures and concomitant forearm fractures can worsen complications.

Long-term complications

• Cubitus varus (“gunstock”) from malunion—can lead to tardy ulnar neuropathy, posterolateral rotatory instability (PLRI), medial triceps dislocation and higher refracture risk.

• Modern closed reduction and percutaneous pinning has reduced deformity rates from 58% to 3% in children; corrective humeral osteotomy may be indicated if needed.

• Volkmann ischaemic contracture is a severe consequence of untreated compartment syndrome, causing fixed deformity (elbow/wrist flexion, forearm pronation, finger hyperextension).

Treatment and Medical Measures

Based on modified Gartland classification:

Type I (non-displaced):

• Immobilise in a long-arm cast or splint with elbow flexion up to 80–90° and neutral pronation/supination.

• Avoid flexion >90° due to compartment risk.

• Radiographic review at 1 and 2 weeks.

Type II (partially displaced):

• Closed reduction and percutaneous pinning preferred; immobilisation alone carries a high malalignment risk.

• Remove pins at ~3 weeks.

Type III–IV (displaced, unstable):

• Closed reduction and percutaneous pinning is the gold standard.

• Open reduction if closed reduction fails, there is soft-tissue interposition (muscle, median nerve, brachial artery) or persistent poor perfusion (cold hand) after closed reduction.

• Anterior approach preferred when vascular repair is required; lateral approach carries radial nerve risk; bilaterotricipital posterior approach is not recommended (stiffness, scarring, trochlear osteonecrosis).

Physiotherapy and Rehabilitation

Role and goals

• Promote healing and optimal function, though benefit is debated in uncomplicated paediatric fractures.

• Goals: restore pain-free elbow ROM, strengthen musculature and improve overall function.

• Outcome measures: pain (NPRS or Faces Pain Scale), ROM (goniometry), strength (MMT) and function (ASK-p).

Evidence base

• Schmale et al., 2014 (RCT): six PT sessions over five weeks did not improve motion or function after casting or pinning.⁹

• 2018 study: children immobilised for three weeks regained full ROM and function within 12 weeks without PT.¹⁰

• Children’s inherent activity and self-directed movement likely drive recovery.

• PT remains important for more severe injuries with neurovascular involvement or in adults.

Principles of progression

• Optimal loading: avoid painful activities that may impair healing and cause lasting damage.

• Encourage active use and play; avoid passive mobilisation and stretching early.

• Avoid lifting and carrying initially; introduce graded strengthening when healing allows.

Exercises during immobilisation

• Keep shoulder, wrist and fingers active.

• Do not load the elbow; use the sling appropriately.

• Introduce postural training (upright sitting, relaxed shoulders, active scapular retraction).

1–2 weeks after cast removal

• Heat packs may ease stiffness.

• Light massage and active-assisted ROM with a dowel within pain-free limits.

• Isometric exercises may begin.

• Encourage daily activities (eating, dressing, writing).

• Continue to avoid heavy activities and carrying.

After 2 weeks post–cast removal

• Progress active, functional exercises (e.g., ball play, dressing).

• Strengthening tailored to the child’s level and pain tolerance.

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Conclusion

Supracondylar humerus fracture is the most common fracture in children, peaking at ages five to eight and typically caused by a FOOSH. Neurovascular assessment is essential pre- and post-operatively. Closed reduction with percutaneous pinning is standard for displaced fractures without neurovascular injury. In children, active play and use are preferred over passive treatment to support natural healing.

References:

1. Gray H. Anatomy of the human body. Lea & Febiger; 1878.

2. Kumar V, Singh A. Fracture supracondylar humerus: A review. Journal of clinical and diagnostic research: JCDR. 2016 Dec;10(12):RE01.

3. 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.

4. 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.

5. Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med 2008;1:190-196.

6. Gjennomgått - Trukket

7. Alton TB, Werner SE, Gee AO. Classifications in brief: the Gartland classification of supracondylar humerus fractures.

8. 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.

9. 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.

10. 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.