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ORIF Supracondylar Fracture Humerus - Paediatric

Surgical technique guide for ORIF Supracondylar Fracture Humerus - Paediatric - FRCS exam preparation

Core Procedure
intermediate
By OrthoVellum Medical Education Team

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High-yield overview

Closed reduction and percutaneous pinning is the standard; open reduction reserved for irreducible, open or vascular cases | high

Critical Danger Structures

Danger 1

Brachial artery. Location: Anterior to distal humerus, medial to median nerve. Protection: Assess pulse pre/post reduction, reduce flexion if pulse lost, have vascular on standby.

Danger 2

Median nerve. Location: Anterior, medial to brachial artery at antecubital fossa. Protection: Avoid excessive anterior dissection, gentle reduction technique.

Danger 3

Radial nerve. Location: Lateral distal humerus, 7-10cm proximal to lateral epicondyle. Protection: Limit proximal/lateral dissection, identify if extending approach.

Danger 4

Ulnar nerve. Location: Cubital tunnel, 10-20mm medial to olecranon tip. Protection: Identify before medial pin, flex elbow maximally, palpate during insertion.

Danger 5

Anterior Interosseous Nerve (AIN). Location: Branch of median nerve, proximal forearm. Protection: Document OK sign pre-op, most palsies from injury not surgery.

Mnemonic

G-A-R-T-L-A-N-DGARTLAND Classification

Mnemonic

P-I-N-SPIN Configuration Decisions

Positioning and Preparation

Patient Position: Supine on a radiolucent table with the affected limb on a radiolucent arm board or hand table. The C-arm is brought in either from the head or from the side, and is used as the operating surface so the elbow can be imaged in AP and lateral without moving the limb.

Primary Procedure (gold standard): Closed reduction and percutaneous pinning (CRPP). No incision is made for reduction; pins are introduced through stab incisions over the lateral (and, if needed, medial) epicondyle.

Open Reduction (only if indicated): If the fracture is irreducible, open, or the hand remains white/cold after closed reduction, convert to open reduction. For typical extension-type fractures the anterior approach (transverse antecubital crease incision) is preferred because the displaced metaphyseal spike and any interposed brachialis, brachial artery and median nerve all lie anteriorly and are addressed directly. A medial approach is an alternative. The posterior triceps-splitting approach is generally avoided for extension fractures because it divides the one structure - the posterior periosteum - that is usually still intact, and risks the tenuous distal-fragment blood supply.

Gartland Classification and Management Algorithm

GradeDescriptionPosterior CortexManagement
IUndisplaced or minimally displacedIntactAbove-elbow cast, 3 weeks
IIADisplaced, angulatedIntact, acts as hingeClosed reduction + percutaneous pinning
IIBDisplaced, rotatedIntactClosed reduction + pinning (may need open)
IIICompletely displacedDisruptedClosed reduction + pinning (open if irreducible)

Key Points:

  • Anterior humeral line should pass through middle third of capitellum (lateral view)
  • Baumann angle 65-75° on AP (compare to contralateral)
  • Rotational malreduction = most common cause of cubitus varus

Operative Technique

Step 1: Patient Positioning and Preparation

Position supine with the affected arm on a radiolucent arm board or hand table, using the C-arm as the working surface so AP and lateral images are obtained by rotating only the shoulder and forearm, not by moving the elbow. A tourniquet is usually NOT applied for routine CRPP and must be avoided when there is any vascular concern. Prep and drape the entire upper limb from shoulder to fingertips. Confirm the contralateral elbow is available (clinically or radiographically) as the reduction reference.

Clinical Pearl

Technical Tip: EXAM KEY: This is fundamentally a CLOSED procedure. Set up so you can get a clean lateral by externally rotating the shoulder rather than flexing/extending the fracture. AVOID a tourniquet in any case with suspected vascular injury. Have vascular surgery contactable if the pulse is absent pre-operatively.

Dangers at this step

  • Positioning nerve injury (ulnar nerve at elbow, brachial plexus stretch)
  • Inadequate C-arm access limiting intraoperative imaging
  • Tourniquet use risking ischaemia in an already compromised limb

Step 2: Closed Reduction Manoeuvre

With the patient anaesthetised and muscles relaxed, perform closed reduction in sequence: (1) apply longitudinal traction with the elbow in slight extension to disimpact; (2) correct medial/lateral translation and any rotation by direct pressure on the distal fragment; (3) for the typical extension fracture, with the thumb pushing the olecranon anteriorly, flex the elbow past 90-120 degrees to lock the reduction against the intact anterior periosteal hinge while pronating the forearm (corrects the common posteromedial displacement). Hold the reduced position by maintaining flexion and pronation.

Clinical Pearl

Technical Tip: EXAM KEY: The ANTERIOR periosteum is the hinge in an extension fracture - flexion and pronation tension it and stabilise the reduction. Posteromedial displacement (most common) is reduced with the forearm PRONATED; posterolateral displacement is reduced supinated. Reduction is judged on fluoroscopy, NOT by feel.

Dangers at this step

  • Repeated forceful manipulation increasing soft-tissue swelling and compartment syndrome risk
  • Hyperflexion compromising an already tenuous brachial artery (re-check perfusion after flexing)
  • Converting a reducible fracture into an unstable one by over-manipulation

Step 3: Confirm Closed Reduction (and Decide on Open Reduction)

Assess reduction on fluoroscopy: anterior humeral line through the middle third of the capitellum on a true lateral, restored Baumann angle on AP, and aligned medial and lateral columns. If reduction is anatomical, proceed to pinning. If the fracture is IRREDUCIBLE after one or two gentle attempts (suggesting interposed soft tissue - usually brachialis anteriorly, sometimes the brachial artery or median nerve), OR the hand is white/cold, OR the fracture is open, then convert to OPEN reduction through an anterior (or medial) approach to extract the interposed tissue and inspect the neurovascular bundle directly.

Clinical Pearl

Technical Tip: EXAM KEY: INTERPOSED SOFT TISSUE (commonly brachialis, "pucker sign" with skin dimpling anteriorly) is the usual reason for an irreducible fracture - do not keep manipulating, OPEN it. Use an ANTERIOR approach for an extension fracture: the spike, brachialis, brachial artery and median nerve are all anterior and addressed directly, and the intact posterior periosteum is preserved. Avoid the posterior triceps-splitting approach for these injuries.

Dangers at this step

  • Accepting a malreduction to avoid opening (causes cubitus varus)
  • Failing to recognise true irreducibility (soft-tissue interposition) and persisting with closed attempts
  • Brachial artery or median nerve injury if open dissection is performed without identifying structures first

Step 4: Lateral-Entry Pin Placement

With the reduction held (elbow flexed and forearm pronated), insert smooth K-wires (1.6mm in small children, 2.0mm in larger children) through the lateral epicondyle/capitellum via stab incisions. Pass each wire across the fracture to engage the opposite (medial) cortex with bicortical purchase. Maximise pin SPREAD at the fracture line and ensure both medial and lateral columns are engaged proximally. Two divergent lateral pins suffice for most fractures; add a third lateral pin if there is any concern about stability or pin position.

Clinical Pearl

Technical Tip: EXAM KEY: The four Skaggs technical points for reliable lateral-entry fixation are (1) maximise pin SEPARATION at the fracture site, (2) engage BOTH columns proximally, (3) get adequate bone in proximal and distal fragments, (4) keep a low threshold for a third lateral pin. Lateral-only fixation avoids the ulnar nerve entirely and, when these points are respected, maintains reduction even in unstable (Gartland III/IV) patterns.

Dangers at this step

  • Pins too close together (poor rotational control, loss of reduction)
  • Unicortical purchase - leads to secondary displacement
  • Lateral pin straying anteromedially risking the radial/posterior interosseous nerve or brachial artery

Step 5: Medial Pin (Only If Additional Stability Required)

If a medial pin is needed for stability (e.g. very unstable medial column or comminution), use a meticulous technique: make a small medial incision down to the medial epicondyle so the entry point is seen, flex the elbow LESS once the lateral pins are in (hyperflexion drives the ulnar nerve anteriorly toward the pin), palpate or directly visualise the ulnar nerve, and direct the pin proximally and slightly anteriorly away from the nerve. Confirm there is no nerve irritation. Default to lateral-only fixation when adequate, as it removes ulnar nerve risk.

Clinical Pearl

Technical Tip: EXAM KEY: The ulnar nerve subluxes ANTERIORLY over the medial epicondyle in up to a fifth of children, especially in hyperflexion - this is why a "blind" percutaneous medial pin in a maximally flexed elbow is dangerous. If a medial pin is used, do it with the elbow LESS flexed and ideally through a mini-open incision. A meta-analysis of paediatric supracondylar pinning shows adding a medial pin significantly increases iatrogenic ulnar nerve injury versus lateral-only fixation.

Dangers at this step

  • Iatrogenic ulnar nerve injury from medial pin (higher than lateral-only fixation)
  • Hyperflexing the elbow during medial pin insertion (drives ulnar nerve toward the pin)
  • Inadequate pin purchase causing loss of reduction

Step 6: Fluoroscopic Confirmation of Reduction and Fixation

Fluoroscopic Confirmation of Reduction and Fixation: Obtain AP, lateral, and both oblique views with C-arm. Assess: 1) Baumann's angle 65-75° (AP view), 2) Anterior humeral line through middle third capitellum (lateral), 3) No coronal or sagittal plane angulation, 4) Medial/lateral columns aligned, 5) Pins engage both cortices proximally, 6) No intra-articular pin penetration. Compare to contralateral elbow if uncertain.

Clinical Pearl

Technical Tip: EXAM KEY: ANTERIOR HUMERAL LINE is critical on lateral view - should pass through MIDDLE THIRD of capitellum. If anterior, you have extension malreduction. BAUMANN'S ANGLE compared to contralateral limb best assesses rotation - difference >5 degrees indicates rotational malreduction. Ensure ZERO medial/lateral translation on AP view.

Dangers at this step

  • Accepting malreduction (most common cause of cubitus varus)
  • Missing intra-articular pin placement causing chondral injury
  • Inadequate fixation allowing secondary displacement

Step 7: Pin Bend, Cut, and Secure

Pin Bend, Cut, and Secure: Once position confirmed perfect, advance pins until just engaging far cortex (avoid prominent sharp tips). Bend pins 90 degrees at skin level to prevent migration. Cut pins leaving 1cm proud of skin for easy removal at 3-4 weeks in clinic. Some surgeons bury pins beneath skin if compliant family for removal under brief sedation later.

Clinical Pearl

Technical Tip: EXAM KEY: PIN MIGRATION is prevented by bending at skin. Buried pins reduce infection risk (debated) but require second anesthetic for removal - NOT necessary in most cases. Left-out pins removed easily in clinic at 3-4 weeks without sedation (quick pull). Dress pins with Betadine gauze and splint to prevent snagging.

Dangers at this step

  • Pin track infection (2-5% incidence)
  • Pin migration causing neurovascular injury
  • Lost pins if cut too short and fall into soft tissues

Step 8: Assessment of Elbow Stability and Range of Motion

Assessment of Elbow Stability and Range of Motion: Release tourniquet if used. Assess elbow stability through gentle flexion/extension range (avoid forced motion causing fracture displacement or compartment syndrome). Should be stable throughout arc. Check mediolateral stability - no opening. Palpate radial pulse - should be present and strong. Check capillary refill <2 seconds. Assess median, radial, ulnar nerve function if patient cooperative.

Clinical Pearl

Technical Tip: EXAM KEY: POST-REDUCTION VASCULAR ASSESSMENT is mandatory. Pink, pulsatile limb essential. If pulse absent: 1) Reduce elbow flexion angle (kinked artery), 2) Remove any constricting dressings, 3) Consider brachial artery exploration if no pulse after reduction. NERVE examination may be limited by cooperation but attempt anterior interosseous (median), PIN (radial), and ulnar motor/sensory.

Dangers at this step

  • Brachial artery kink from excessive elbow flexion post-reduction
  • Missed compartment syndrome (perform fasciotomy liberally if concern)
  • Missed nerve injury that was iatrogenic vs pre-existing

Step 9: Wound Care (and Closure If Opened)

For routine CRPP there is no wound to close - the pins exit through small stab incisions. If an open reduction was performed, close the anterior (or medial) incision in layers with absorbable subcutaneous suture and a subcuticular skin closure; the brachialis is not formally repaired and the posterior periosteal hinge is left undisturbed. Dress the pin sites with antiseptic gauze.

Clinical Pearl

Technical Tip: EXAM KEY: A standard supracondylar CRPP leaves only pin-site stab wounds - there is NO triceps to repair, which is one reason CRPP is preferred over a posterior open approach. If you did open the fracture anteriorly, simply close skin and subcutaneous tissue; do not attempt to repair brachialis or strip more periosteum.

Dangers at this step

  • Pin-site soft-tissue tethering if skin is bunched against a pin
  • Haematoma under a tightly closed open-reduction wound
  • Suture knots causing skin irritation

Step 10: Splint or Cast Application

Dress the pin sites with antiseptic gauze and apply a well-padded above-elbow backslab or split cast. Critically, immobilise the elbow at only 60-90 degrees of flexion in this swollen, freshly reduced limb - the fracture is held by the pins, NOT by extreme flexion. Position the forearm in the rotation that held the reduction (usually neutral to mid-pronation). Avoid a circumferential, tight cast in the acute setting.

Clinical Pearl

Technical Tip: EXAM KEY: Once the fracture is pinned, stability comes from the wires, so there is NO need to splint in hyperflexion. Elbow flexion beyond 90 degrees kinks the brachial artery and raises forearm compartment pressure - immobilise at 60-90 degrees and never circumferentially tight on day one. Counsel parents on warning signs: severe pain, numbness, white/blue fingers, inability to move fingers.

Dangers at this step

  • Compartment syndrome from tight splint or excessive flexion (most feared complication)
  • Volkmann's ischemic contracture from missed compartment syndrome
  • Pin site infection from inadequate dressing

Step 11: Post-operative Neurovascular Monitoring

Post-operative Neurovascular Monitoring: Admit overnight for neurovascular observation. Hourly checks: radial pulse, capillary refill, finger motion/sensation, pain assessment. If any concern for compartment syndrome (pain out of proportion, tense forearm, pain with passive finger extension, progressive neurological deficit), REMOVE SPLINT immediately and reassess. Low threshold for return to OR for fasciotomy.

Clinical Pearl

Technical Tip: EXAM KEY: COMPARTMENT SYNDROME is the most devastating complication of pediatric supracondylar fractures - leads to Volkmann's contracture (permanent disability). CLINICAL DIAGNOSIS - do not wait for compartment pressure measurement. Pain out of proportion to injury and pain with passive finger/thumb extension are earliest signs. Missed diagnosis = medicolegal catastrophe. Maintain HIGH index of suspicion.

Dangers at this step

  • Volkmann's ischemic contracture from missed compartment syndrome
  • Permanent nerve palsy (AIN most commonly affected)
  • Delayed diagnosis causing irreversible muscle necrosis

Step 12: Post-operative Radiographs and Mobilization Plan

Post-operative Radiographs and Mobilization Plan: Obtain AP and lateral elbow radiographs in recovery to document maintained reduction. Check weekly for first 2-3 weeks to ensure no loss of reduction. Pins removed at 3-4 weeks in clinic (fracture healed by this time in children). Gentle active ROM started after pin removal - children regain motion quickly. Expect full ROM by 6-8 weeks. No contact sports for 8-12 weeks.

Clinical Pearl

Technical Tip: EXAM KEY: PEDIATRIC BONE HEALS RAPIDLY - 3 weeks adequate for union in supracondylar fracture. REMODELING POTENTIAL excellent in children for residual angulation (NOT rotation - cannot remodel). Encourage early ROM after pin removal to prevent stiffness. Physical therapy rarely needed - children self-mobilize through play. Parents reassured full recovery expected in uncomplicated cases.

Dangers at this step

  • Loss of reduction in first 2 weeks (weekly X-rays detect)
  • Residual stiffness from prolonged immobilization (rare)
  • Cubitus varus from malreduction (cosmetic deformity, no functional impact typically)

Complications

Complications: Recognition, Prevention and Management

Post-operative Care

Above-elbow posterior splint 60-90° flexion. Overnight neurovascular monitoring (hourly checks). Weekly radiographs x 3 weeks to ensure maintained reduction. Pin removal 3-4 weeks in clinic. Active ROM started after pin removal. Expect full motion by 6-8 weeks. No contact sports x 8-12 weeks.

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 6-year-old presents with a displaced supracondylar fracture and an absent radial pulse but pink, warm fingers. How do you manage this?"

PRACTICAL APPROACH
This is a 'pulseless pink hand' scenario - one of the most debated situations in paediatric trauma. My systematic approach: First, I would complete the clinical assessment including documenting pulse status, capillary refill (should be less than 2 seconds if perfusion adequate), digital color and temperature, and detailed neurological examination focusing on median nerve (especially AIN - OK sign), radial nerve (PIN - finger extension), and ulnar nerve. I would classify the fracture using Gartland classification and obtain AP and lateral radiographs. Management approach: This child needs urgent closed reduction and percutaneous pinning in theatre. After anatomical reduction with elbow at 60-70 degrees flexion (not greater than 90 degrees), I would reassess the pulse. In many cases, pulse returns after reduction as the artery was simply kinked or in spasm. If pulse remains absent but the hand is still pink with good capillary refill (less than 2 seconds), there is controversy. Traditional teaching allows close observation as collateral circulation is adequate. However, emerging evidence suggests these children may benefit from brachial artery exploration to prevent late complications. I would discuss with vascular surgery, admit for overnight hourly neurovascular monitoring, and have a low threshold for exploration if any deterioration occurs. If the hand is white, cold, or has poor capillary refill at any point, this mandates immediate brachial artery exploration.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"Describe your pin configuration for a Gartland III supracondylar fracture. What are the pros and cons of different configurations?"

PRACTICAL APPROACH
I would discuss the three main pinning configurations for supracondylar fractures. Configuration 1 - Crossed pins (medial and lateral): This provides maximum biomechanical stability with rotational control from pins engaging both columns. However, the medial pin carries 10-20% risk of ulnar nerve injury if not meticulously placed. Technique for safe medial pin: place the lateral pins first then REDUCE elbow flexion before inserting the medial pin (hyperflexion subluxes the ulnar nerve anteriorly onto the pin path - a common misconception is that maximal flexion protects the nerve), make a small open incision to see the medial epicondyle, palpate or visualise the nerve throughout insertion, and direct the pin proximally away from it. Configuration 2 - Two lateral divergent pins: Good stability with virtually zero ulnar nerve risk. Slightly less rotational control than crossed pins but acceptable for most fractures. Technique: enter at lateral epicondyle, diverge pins to engage both cortices of both columns, ensure adequate spread between pins. Configuration 3 - Three lateral pins: Reserved for highly unstable or comminuted fractures where maximum stability needed without ulnar nerve risk. My preference and rationale: For most Gartland III fractures, I use two lateral divergent pins as they provide adequate stability with negligible nerve risk. I reserve crossed pins for highly unstable patterns, comminuted fractures, or larger children where remodeling potential is less reliable. The key technical points regardless of configuration are: pins must engage both cortices, provide adequate spread to control rotation, and be confirmed on all four fluoroscopic views.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"Post-operatively, the parents call concerned that their child is in increasing pain and can't move their fingers. What is your approach?"

PRACTICAL APPROACH
This presentation raises immediate concern for compartment syndrome - the most feared complication of paediatric supracondylar fractures leading to Volkmann's ischemic contracture. My approach: Phone assessment: I would ask about the specific nature of pain (constant vs movement-related), pain medication effectiveness, ability to move fingers actively, sensation in fingers, finger color, and how long symptoms have been present. This is a clinical emergency - I would tell parents to bring the child to Emergency immediately or call an ambulance. Clinical assessment on arrival: I would remove all dressings and splint immediately before any other examination. Then assess the forearm for tenseness of compartments, pain with passive finger and thumb extension (earliest and most reliable sign), active finger movement, sensation (assess web spaces), and capillary refill. Importantly, I would NOT measure compartment pressures - this is a CLINICAL diagnosis in children. The 5 Ps (pain, pallor, pulselessness, paralysis, paraesthesia) are LATE signs - by then irreversible damage may have occurred. Management decision: If clinical suspicion is high (tense forearm, pain with passive stretch, progressive symptoms), I would proceed directly to emergent forearm fasciotomy. This includes both volar (Henry approach) and dorsal compartments. I would not delay for pressure measurements or imaging. Early fasciotomy has negligible downside compared to missed compartment syndrome which causes permanent devastating disability (Volkmann's contracture). If clinical picture is equivocal, I would admit for hourly observations and have an extremely low threshold for fasciotomy.

ORIF Supracondylar Fracture Humerus - Paediatric - Exam Summary

Clinical summary

Key Evidence

Lateral-entry pin fixation in the management of supracondylar fractures in children

Level IV
Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM • J Bone Joint Surg Am
Clinical Implication: Lateral-only pin fixation is sufficient even for unstable fractures when technique is sound, and avoids the ulnar nerve - this underpins lateral-entry as the default modern configuration.
Verify on PubMed (PMID 15069133)

Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis

Level IV
Babal JC, Mehlman CT, Klein G • J Pediatr Orthop
Clinical Implication: Quantifies that adding a medial pin increases iatrogenic ulnar nerve injury, supporting a lateral-first strategy and meticulous technique if a medial pin is used.
Verify on PubMed (PMID 20357592)

Treatment of multidirectionally unstable supracondylar humeral fractures in children: a modified Gartland type-IV fracture

Level IV
Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL • J Bone Joint Surg Am
Clinical Implication: Even multidirectionally unstable (type IV) fractures can usually be managed closed with pinning - reinforcing that open reduction is reserved for the irreducible, open or vascular fracture.
Verify on PubMed (PMID 16651572)

Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up

Level IV
Blakey CM, Biant LC, Birch R • J Bone Joint Surg Br
Clinical Implication: A persistently pulseless hand after reduction - especially with worsening pain or nerve signs - should prompt brachial artery exploration rather than prolonged observation.
Verify on PubMed (PMID 19880895)

AAOS Clinical Practice Guideline: The Treatment of Pediatric Supracondylar Humerus Fractures

Guideline
American Academy of Orthopaedic Surgeons • AAOS Clinical Practice Guideline
Clinical Implication: Named-society guidance converges on CRPP with lateral-entry pinning as standard, with open reduction confined to specific indications.

References

  1. Skaggs DL, Flynn JM. Supracondylar fractures of the distal humerus. In: Rockwood and Wilkins' Fractures in Children. 8th ed. 2015.

  2. Leitch KK, Kay RM, Femino JD, et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children: A modified Gartland type-IV fracture classification. J Bone Joint Surg Am. 2006;88(5):980-985. PMID: 16651572.

  3. 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;86(4):702-707. PMID: 15069133.

  4. Slobogean BL, Jackman H, Engel C, et al. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: Number needed to harm, a systematic review. J Pediatr Orthop. 2010;30(5):430-436.

  5. Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg Br. 2009;91(11):1487-1492. PMID: 19880895.

  6. Brauer CA, Lee BM, Bae DS, et al. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27(2):181-186.

  7. Mazzini JP, Rodriguez-Martin J, Andres-Esteban EM. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review. J Child Orthop. 2010;4(2):143-152.

  8. Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre. J Bone Joint Surg Br. 2006;88(1):90-94.

  9. Mapes RC, Hennrikus WL. The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children. J Pediatr Orthop. 1998;18(4):441-444.

  10. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90(5):1121-1132.