ORIF Supracondylar Fracture Humerus - Paediatric

Indication. A displaced extension-type supracondylar humerus fracture in a child - Gartland IIB or III - that cannot be managed in a cast alone. Gartland I (undisplaced) is treated non-operatively in an above-elbow cast for three weeks; Gartland IIA/B and III are treated by closed reduction and percutaneous pinning (CRPP), which is the gold-standard operation. Open reduction is the exception, reserved for specific situations below. Other operative indications include a failed closed reduction (a Gartland IIA that will not hold), a fracture needing vascular exploration, an open fracture requiring debridement, and the floating elbow (an ipsilateral forearm fracture) that needs both injuries stabilised. Assess the limb before the operation. Document a detailed neurovascular examination on arrival and again after any manipulation: the radial pulse, capillary refill (less than 2 seconds), and the three nerves at risk - the median nerve (test the anterior interosseous branch with the OK sign - thumb IP plus index DIP flexion), the radial nerve (finger and thumb extension, the posterior interosseous branch) and the ulnar nerve (finger abduction and adduction, intrinsic function, and sensation). The anterior interosseous nerve is the one most often injured by the fracture itself, not by surgery. Obtain AP and lateral radiographs and classify the fracture by Gartland. The one decision that matters. Every displaced fracture begins with an attempt at closed reduction and percutaneous pinning. The only real choice is when to abandon it and open:

Avoid the posterior approach for a typical extension fracture: it divides the one structure - the posterior periosteum - that is usually still intact as the reduction hinge, and it strips the tenuous distal-fragment blood supply, increasing the risk of osteonecrosis and stiffness. The pulseless hand - decide before you operate. After a gentle closed reduction with the elbow at 60 to 70 degrees of flexion, reassess perfusion. The action depends on the hand's colour and warmth, not on the pulse alone:

The goal is to reduce the fracture closed, hold it with percutaneous K-wires that engage both columns with bicortical purchase, confirm reduction on four fluoroscopic views, and immobilise at modest flexion while protecting the brachial artery and the three nerves at risk. The exposure for the rare open case is the anterior approach, laid out inline as the early steps below - this is the heart of the operation.

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Five structures at risk - know the location and the protection strategy for each:

Rehabilitation | Phase | Timing | Immobilisation | Activity | |-------|--------|----------------|----------| | 1 | 0 to 2 weeks | Above-elbow backslab or split cast at 60 to 90 degrees flexion; overnight hourly neurovascular monitoring | Finger active ROM only | | 2 | 2 to 3 weeks | Well-padded splint; weekly radiographs to confirm maintained reduction | Gentle finger and wrist motion | | 3 | 3 to 4 weeks | Pin removal in clinic; splint for comfort | Begin gentle active elbow ROM | | 4 | 4 to 8 weeks | Splint off | Progressive ROM; children self-mobilise through play | | 5 | 8 to 12 weeks | Return to full activity | No contact sports until 8 to 12 weeks | Most children regain full motion by 6 to 8 weeks without formal therapy - they self-mobilise through play. Pins come out at 3 to 4 weeks (paediatric bone unites by three weeks). Residual angulation remodels; rotation does not. Complications

Pathoanatomy. A paediatric supracondylar fracture is most often an extension injury from a fall onto the outstretched hand with the elbow hyperextended - the olecranon levers the distal fragment posteriorly. In the typical extension fracture the posterior periosteum remains intact and acts as the reduction hinge (tensioned by flexion and pronation), while the anterior periosteum and brachialis are torn; the distal fragment displaces posteriorly and proximally, dragging the neurovascular bundle across the sharp anterior metaphyseal spike - which is why the brachial artery and the median and AIN nerves are the structures injured. The rarer flexion-type injury is the mirror image: the anterior periosteum is intact and the ulnar nerve is the one most at risk. The modified Gartland classification drives every management decision:

Key radiographic parameters. On the lateral view, the anterior humeral line should pass through the middle third of the capitellum; if it passes anterior to the capitellum there is extension (posterior tilt) malreduction, and posterior to it, flexion malreduction (rare). On the AP view, Baumann angle - the angle between the humeral shaft and the capitellar physis - is 65 to 75 degrees; compare with the contralateral limb, where a difference greater than 5 degrees indicates rotational malreduction. The normal carrying angle is 5 to 15 degrees of valgus. Intra-operatively, obtain all four views (AP, lateral, medial oblique and lateral oblique), confirm the pins engage both cortices, and exclude intra-articular pin placement. Rotational malreduction is the most common cause of cubitus varus - and rotation cannot remodel, which is why a meticulous reduction matters more than the pin configuration.