Back to Operative Surgery
Paediatrics

Paediatric Supracondylar Humerus Fracture - Closed Reduction and Percutaneous Pinning (CRPP)

Comprehensive surgical technique guide for paediatric supracondylar humerus fracture CRPP with neurovascular assessment, reduction manoeuvres, and pulseless hand management for FRCS exam preparation

Core Procedure
intermediate
By OrthoVellum Medical Education Team

Reviewed by OrthoVellum Editorial Team

Editorial maintenance, source checking, and correction workflow • Published by OrthoVellum Medical Education Team

Editorial boardMethodologyReview policyReport a correction
High-yield overview

Core Paediatric Trauma Procedure | Emergency

Mnemonic

GARTLANDGARTLAND - Classification Simplified

Mnemonic

PULSELESSPULSELESS - Vascular Assessment Protocol

Critical Danger Structures - Distal Humerus

Brachial Artery

Lies anterior to distal humerus, directly at fracture level. Most commonly injured vessel in extension-type fractures (posteromedial spike). Can be kinked, tethered by fascial bands, entrapped, or lacerated. PULSELESS WHITE = critical ischaemia, explore if reduction fails to restore perfusion. PULSELESS PINK = perfused by collaterals - reduce and pin first; a hand that stays perfused but pulseless still warrants admission and close monitoring, because the brachial artery is frequently injured (White et al: documented arterial injury in 70% of pulseless-perfused cases).

Anterior Interosseous Nerve (AIN)

Pure motor branch of median nerve - most commonly injured nerve (10-15%). Tests: FPL (thumb IP flexion) + FDP index finger flexion = 'OK sign'. No sensory component so easily missed. Often neurapraxia - observe for recovery over 3-6 months before surgical exploration.

Ulnar Nerve

Lies posterior to medial epicondyle in cubital tunnel. At high risk (10-15% injury) with percutaneous medial pin placement. Subluxes anteriorly with elbow flexion in some children. Protection: mini-open technique with direct visualisation if medial pin needed.

Median Nerve

Runs with brachial artery anterior to fracture. Can be entrapped in fracture during reduction, especially if fracture spike buttonholes through brachialis. Tests: APB strength (thumb abduction), sensation thenar eminence and radial 3.5 digits. Post-reduction motor loss = possible entrapment, may require open exploration.

Gartland Classification and Management

Type I - Non-displaced:

  • Anterior humeral line through middle 1/3 of capitellum
  • Treatment: Long arm cast 3-4 weeks, 70-80° flexion
  • No surgery required

Type IIA - Displaced, Angulated Only:

  • Posterior cortex intact, hinge present
  • Angulation but NO rotation
  • Treatment: Closed reduction and casting may suffice
  • Operate if reduction lost or unable to maintain

Type IIB - Displaced with Rotation:

  • Rotational malalignment present
  • More unstable than IIA
  • Treatment: CRPP - closed reduction and pinning

Type III - Completely Displaced:

  • No cortical contact, periosteal sleeve disrupted
  • Highest neurovascular risk (up to 20% nerve injury)
  • Treatment: Urgent CRPP

Type IV (Wilkins modification):

  • Unstable in both flexion AND extension
  • Periosteal disruption circumferentially
  • Treatment: CRPP, may require open reduction

Subtypes by Displacement Direction

Extension Type (95%):

  • Falls on outstretched hand
  • Distal fragment displaced posteriorly
  • Apex anterior angulation

Flexion Type (5%):

  • Falls on flexed elbow
  • Distal fragment displaced anteriorly
  • Higher risk of ulnar nerve injury
  • Reduction technique opposite (extend, push posteriorly)

Equipment and Setup

Equipment Checklist

Patient Positioning:

  • Supine on radiolucent table
  • Arm on radiolucent arm board OR across chest (surgeon preference)
  • Image intensifier from opposite side, perpendicular to arm
  • Ensure true AP and lateral views achievable before draping

Instrumentation:

  • K-wires: 1.6mm or 2.0mm (size appropriate for age/bone)
  • Power driver with chuck for K-wires
  • Wire cutters
  • Wire bender
  • Smooth trocar for pin introduction
  • Mini-open set if medial pin planned (small retractors, blade)

Sterile Preparation:

  • Prep arm circumferentially from shoulder to fingertips
  • Drape free to allow manipulation
  • C-arm draped or positioned for sterile technique

Personnel:

  • Anaesthetist for GA
  • Surgeon
  • Assistant essential for reduction manoeuvres (counter-traction)
  • Radiographer to operate C-arm

C-arm Positioning

Position C-arm perpendicular to arm. Test views BEFORE draping:

  • True AP: olecranon sits in trochlear notch, medial/lateral epicondyles symmetric
  • True lateral: capitellum and trochlea superimposed

Operative Technique

Step 1: Neurovascular Documentation and Induction

Document pre-operative neurovascular status on anaesthetic chart. Induce general anaesthesia. Position supine with arm on radiolucent arm board. Prep and drape circumferentially. Confirm C-arm can obtain adequate AP and lateral views before starting.

Clinical Pearl

Technical Tip: Always document neurovascular status BEFORE induction. Any post-operative deficit needs comparison to baseline. If AIN or other nerve already injured pre-op, parents are reassured injury was from fracture not surgery.

Step 2: Initial Traction - Disimpaction

With elbow in EXTENSION, apply longitudinal traction for 2-3 minutes. Assistant provides counter-traction at upper arm. This allows muscle relaxation and disimpacts the fracture. Feel for 'give' as the fracture disengages. DO NOT flex initially as this locks the proximal spike into distal fragment.

Reduction Sequence is Critical

SEQUENCE: (1) Traction in extension to disimpact (2) Correct coronal translation (3) Correct rotation (4) Flex elbow with olecranon push. Flexing too early traps the fracture. Extension-type reduction fails if sequence wrong.

Step 3: Correct Translation and Rotation

While maintaining traction, correct coronal plane translation (usually posteromedial in extension-type). Push the distal fragment to align with proximal humeral shaft. Correct rotation by aligning medial and lateral columns - compare to forearm rotation and contralateral side. Rotation is the most commonly missed malreduction component.

Clinical Pearl

Technical Tip: Rotation malreduction causes functional deformity. Check rotation by comparing medial and lateral epicondyle orientation to the forearm. If unsure, obtain true lateral and look for 'teardrop' appearance of olecranon fossa.

Step 4: Flexion with Anterior Olecranon Push

This is the KEY reduction manoeuvre for extension-type fractures. While maintaining traction and column alignment, FLEX the elbow. Simultaneously push anteriorly on the olecranon (or posterior distal humerus) to push the distal fragment anterior. This corrects the apex anterior angulation.

Flex to 100-120 degrees if vascular status allows. Pronate the forearm - this reduces the typical posterolateral rotation.

Don't Hyperflex if Pulseless

If the hand was pulseless pre-operatively, do NOT hyperflex beyond 90 degrees until pulse checked. Hyperflexion can kink an already compromised brachial artery. Check pulse as you flex - if pulse diminishes, extend slightly.

Step 5: Fluoroscopic Assessment of Reduction

Obtain AP and lateral views with elbow flexed:

Lateral View:

  • Anterior humeral line should pass through MIDDLE 1/3 of capitellum
  • Acceptable: anterior 1/3 (slight residual extension)
  • Unacceptable: anterior to capitellum (malreduction)

AP View:

  • Baumann's angle: 70-80 degrees (compare to contralateral within 5 degrees)
  • Medial and lateral columns aligned
  • No coronal plane rotation

Clinical Pearl

Technical Tip: BAUMANN'S ANGLE is the gold standard. Take contralateral comparison X-ray pre-op if possible. Loss of Baumann's angle (more vertical) predicts cubitus varus deformity. Don't accept this - re-reduce.

Step 6: First Lateral Pin Placement

Entry point: LATERAL EPICONDYLE (palpable ossification centre). Under fluoroscopy, introduce 1.6-2.0mm K-wire through stab incision. Aim across the fracture into the MEDIAL COLUMN, engaging the far (medial) cortex. Trajectory should be slightly posterior to optimally cross the fracture.

Start with wire parallel to C-arm beam to visualise entry, then advance under intermittent fluoroscopy. Confirm wire crosses fracture line and engages medial cortex but does NOT penetrate through.

Pin Trajectory Matters

Pin too anterior misses the medial cortex and provides poor purchase. Pin that penetrates through medial cortex risks ulnar nerve or brachial artery injury. Engage but don't traverse the far cortex.

Step 7: Second Lateral Pin - Divergence Critical

Entry point: LATERAL COLUMN above the epicondyle (lateral supracondylar ridge). This pin must DIVERGE greater than 30 degrees from the first pin on AP view. This divergence is CRITICAL for rotational stability.

Both pins should:

  • Cross the fracture line
  • Engage the medial cortex
  • Be divergent more than 30 degrees at the fracture

Clinical Pearl

Technical Tip: Biomechanical studies confirm 2 LATERAL DIVERGENT pins (greater than 30 degrees apart) provide equivalent rotational stability to crossed pins. This configuration AVOIDS ulnar nerve risk. Pins less than 30 degrees apart = poor rotational control.

Step 8: Assess Stability and Decision on Third Pin

Range the elbow through flexion-extension under fluoroscopy. The fracture should remain reduced. Assess stability:

Stable with 2 lateral pins:

  • Fracture holds reduction through ROM
  • Proceed to completion

Unstable / Consider 3rd pin if:

  • Fracture shifts with elbow motion
  • Medial column comminution
  • Type III with significant displacement

Third pin options:

  • Third LATERAL pin (if bone stock allows)
  • MEDIAL pin (if lateral fixation inadequate) - use mini-open technique

Medial Pin Decision

Percutaneous medial pinning has 10-15% ulnar nerve injury rate. If medial pin is required for stability, ALWAYS use mini-open technique with direct nerve visualisation. This reduces nerve injury to less than 1%.

Step 9: Medial Pin Placement (If Required) - Mini-Open Technique

Make 1-2cm incision over medial epicondyle. Blunt dissection through subcutaneous tissue. IDENTIFY the ulnar nerve - palpable cord posterior to medial epicondyle. Protect nerve with small retractor (nerve may sublux anteriorly with flexion in children).

Under direct vision, place K-wire through medial epicondyle, crossing fracture into lateral cortex. Confirm position on fluoroscopy. The pin should cross the fracture and engage lateral cortex.

Clinical Pearl

Technical Tip: Mini-open technique for medial pin is the FRCS examiner-expected answer. Never describe percutaneous medial pinning without acknowledging ulnar nerve risk and the mini-open alternative.

Step 10: Final Fluoroscopy and Pin Fixation

Obtain final AP and lateral images confirming:

  • Adequate reduction (anterior humeral line, Baumann's angle)
  • Pins cross fracture appropriately
  • No joint penetration
  • Divergence maintained

Bend pins 90 degrees at skin level to prevent migration. Cut pins leaving 1cm outside skin for later removal. Cover pin sites with sterile dressing.

Step 11: Immobilisation and Vascular Check

Apply long arm backslab or bivalved cast:

  • Elbow at 70-80 degrees flexion (NOT hyperflexed)
  • Forearm in pronation
  • Allow for swelling - not circumferential initially

Immediate post-procedure vascular check:

  • Radial pulse - compare to pre-op
  • Capillary refill
  • Hand colour and perfusion

Cast Position Critical

DO NOT immobilise elbow above 90 degrees flexion. Hyperflexion can kink the brachial artery, especially in swollen or previously pulseless limbs. 70-80 degrees is optimal and safe.

Step 12: Post-Procedure Documentation

Document in operative note:

  • Pre-operative neurovascular status
  • Gartland type and reduction achieved
  • Pin configuration (2 lateral divergent, or crossed with mini-open)
  • Fluoroscopy findings - anterior humeral line position, Baumann's angle
  • Post-operative neurovascular status
  • Immobilisation method

Managing the Pulseless Hand

Pulseless Hand Algorithm

This is a common FRCS viva scenario. Your answer should be structured:

PULSELESS PINK Hand:

  1. Hand perfused despite absent pulse (collateral circulation maintaining viability)
  2. URGENT reduction and pinning in theatre (within hours) - this is the first intervention
  3. Re-check perfusion and pulse after reduction - pulse returns in many cases as kinking/tethering is relieved
  4. If pulse returns: admit, neuro-obs and perfusion checks q1-2h
  5. If remains pulseless but PINK and well perfused: the brachial artery is frequently injured in this group (White et al: 70% had a documented arterial injury), so management is debated - admit for close monitoring with a low threshold for vascular surgical involvement and exploration; some units image (duplex/CT angiography) or explore selectively rather than watchful waiting alone
  6. Serial checks - immediate exploration if perfusion deteriorates (becomes WHITE, cold, or painful)

PULSELESS WHITE Hand:

  1. Critical ischaemia - limb-threatening
  2. EMERGENCY reduction in theatre immediately
  3. Check pulse after reduction
  4. If pulse returns and hand pinks up: observe closely
  5. If remains pulseless WHITE: immediate vascular exploration
  6. Brachial artery exploration - may need vessel repair or thrombectomy
  7. Fasciotomy if prolonged ischaemia (greater than 6 hours) or compartment syndrome suspected

Intraoperative Vascular Concerns:

If reduction restores pulse: proceed with pinning, observe

If pulse returns but weak/intermittent: may be vasospasm - warm limb, observe

If remains pulseless after adequate reduction:

  • Extend skin incision anteriorly
  • Explore brachial artery at fracture level
  • May find: kinking, fascial band tethering, intimal injury, thrombosis
  • Vascular surgery input if repair needed

Complications

Supracondylar Fracture Complications - Recognition and Management

Post-operative Protocol

Immediate Post-operative (Day 0)

Neurovascular Observations:

  • Check pulse, cap refill, hand colour q2h for first 24 hours
  • Document motor function all nerves (AIN, median, radial, ulnar)
  • Pain assessment - severe pain may indicate compartment syndrome

Limb Elevation:

  • Elevate arm on pillows
  • Ice to elbow (if accessible through cast)

Ward Stay (Days 1-2)

  • Continue neuro-obs if vascular concerns
  • Check cast not too tight - bivalve if swelling
  • X-ray before discharge to confirm reduction maintained
  • Pain control with simple analgesia

Discharge (Day 1-2)

  • Sling for comfort
  • Cast care instructions for parents
  • Pin site care - keep dry, watch for infection signs
  • Return immediately if: increasing pain, swelling, numbness, colour change

Outpatient Follow-up

1 Week:

  • Wound check
  • X-ray to confirm reduction maintained
  • Assess swelling - may convert to full cast if settling

3-4 Weeks:

  • Pin removal (office procedure under Entonox or local)
  • Remove cast
  • Begin gentle ROM exercises
  • X-ray to confirm healing

6 Weeks:

  • Check ROM - expect stiffness initially
  • X-ray to confirm consolidation
  • May need physiotherapy if stiff

3 Months:

  • Final check - ROM should be returning
  • Compare to contralateral
  • Assess carrying angle (Baumann's angle equivalent clinically)

Expected Recovery

  • Full ROM typically returns by 6-12 months
  • Paediatric bone remodels well in plane of joint motion
  • Rotational malreduction does NOT remodel - must get this right
  • Cubitus varus does NOT remodel - cosmetic issue, consider late osteotomy

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 6-year-old boy falls off monkey bars onto an outstretched hand. He presents with a swollen elbow held in flexion. X-rays show a Gartland Type III supracondylar fracture. His hand is pulseless but pink and warm. How do you manage this?"

PRACTICAL APPROACH
This is a Gartland Type III supracondylar fracture with a pulseless pink hand - a common FRCS exam scenario. My priorities are airway breathing circulation, then managing this as an urgent orthopaedic emergency with vascular concerns. First, I would complete my neurovascular assessment documenting radial pulse status (pulseless), capillary refill (if normal, around 2 seconds, this confirms adequate collateral circulation), hand colour (pink indicating perfusion), and temperature. I would specifically test each nerve: AIN with the 'OK' sign (FPL and FDP index), median nerve (APB, sensation), radial nerve (wrist extension, first webspace sensation), and ulnar nerve (FDI, little finger sensation). A pulseless PINK hand indicates the brachial artery is compromised but collateral circulation is maintaining perfusion. This is an urgent but not emergency situation. My management would be: analgesia and splinting, keep patient nil by mouth, urgent theatre for closed reduction and percutaneous pinning - ideally within 2-4 hours on the next available emergency list. In theatre, I would perform closed reduction using the standard technique: traction in extension to disimpact, correct translation and rotation, then flex elbow with anterior push on the olecranon. I would check the pulse after reduction - in 80-90% of cases, the pulse returns after reduction as the kinking or tethering is relieved. If the pulse returns, I would complete fixation with two lateral divergent K-wires more than 30 degrees apart, confirming reduction with anterior humeral line through middle third of capitellum and Baumann's angle 70-80 degrees compared to contralateral. Post-operatively, the child would be admitted for neurovascular observations every 2 hours. If the pulse did NOT return after reduction but the hand remained pink with good capillary refill, I would complete fixation and admit the child for close in-patient monitoring with hourly perfusion checks. I would emphasise that traditional 'watchful waiting' has been challenged: the systematic review by White et al found a documented brachial artery injury in around 70% of pulseless-but-perfused hands, so I would involve the vascular team early, have a low threshold for duplex or CT angiography and exploration, and not rely on the assumption that a pulse will simply reappear as swelling settles. If the pulse did not return AND the hand became pale or perfusion deteriorated, this would be a critical ischaemia scenario requiring immediate brachial artery exploration at the fracture level, potentially with vascular surgery.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"You are the registrar on call. A 5-year-old girl had CRPP for a Gartland III supracondylar fracture 4 hours ago. The nurse calls you because the child is in severe pain and the morphine is not helping. What do you do?"

PRACTICAL APPROACH
Severe pain not responding to opioids after supracondylar fracture fixation is COMPARTMENT SYNDROME until proven otherwise. This is an orthopaedic emergency requiring immediate assessment and potentially emergency fasciotomy. I would attend immediately and assess the child. My examination would focus on the 6 Ps, remembering that pain is the earliest and most reliable sign: Pain - severe, out of proportion, and specifically pain with PASSIVE finger extension (stretches flexor compartment); Pressure - palpate the forearm compartments, are they tense and swollen?; Paraesthesia - ask about numbness in fingers (late sign); Paralysis - weakness of finger movement (late sign); Pallor and Pulselessness - these are LATE signs, don't wait for them. I would examine the cast - if circumferential, I would immediately bivalve it completely including the padding and cotton wool down to skin. This alone can reduce compartment pressures. I would check the neurovascular status: pulse, capillary refill, motor function of fingers. If pain persists after cast release and clinical examination suggests compartment syndrome (pain with passive finger extension, tense forearm), I would NOT wait for compartment pressure measurements in a child - the clinical diagnosis is sufficient and time is critical. I would inform my consultant, book an emergency theatre, and take the child for forearm fasciotomy. Fasciotomy technique: volar approach is essential - extended volar Henry incision from mobile wad to palm, releasing flexor compartments and carpal tunnel. Consider dorsal fasciotomy if dorsal compartment involved. Leave wounds open, dress with wet gauze, plan for delayed closure or skin grafting at 48-72 hours. The consequences of missed compartment syndrome - Volkmann's ischaemic contracture - are devastating and indefensible medicolegally. I would rather perform an 'unnecessary' fasciotomy than miss compartment syndrome.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"In your supracondylar fracture viva, the examiner shows you a lateral X-ray after closed reduction and asks if this reduction is acceptable. The anterior humeral line passes through the anterior third of the capitellum. What is your response?"

PRACTICAL APPROACH
Looking at this lateral radiograph, I can assess the reduction using the anterior humeral line - a line drawn along the anterior cortex of the distal humerus should pass through the middle third of the capitellum in an anatomically reduced supracondylar fracture. In this image, the anterior humeral line passes through the ANTERIOR third of the capitellum, which indicates some residual extension deformity - the distal fragment has not been adequately flexed anteriorly. This represents a near-anatomic reduction rather than an anatomic reduction. Whether this is acceptable depends on several factors. In my opinion, this reduction is BORDERLINE. The anterior humeral line should ideally pass through the middle third. However, I need to consider: First, the child's age and remodelling potential. In a young child under 5, there is significant remodelling potential in the sagittal plane (plane of elbow motion), and some extension malreduction may correct over time. In an older child approaching skeletal maturity, remodelling is limited and I would aim for anatomic reduction. Second, I would check the AP view for Baumann's angle. The Baumann's angle is the more critical measurement - loss of Baumann's angle predicts cubitus varus, which does NOT remodel. If Baumann's angle is anatomic (70-80 degrees, matching contralateral), I might accept the slight extension malreduction shown. Third, I would assess rotation clinically and radiographically. Rotational malreduction does NOT remodel and causes functional problems. My recommendation would be: if this is a young child with anatomic Baumann's angle and no rotation, I might accept this. However, if this were my case, I would likely attempt one more reduction manoeuvre to improve the anterior humeral line position before pinning. Pushing more anteriorly on the olecranon during flexion should correct this. An anterior humeral line through the middle third is the goal.

Paediatric Supracondylar Fracture CRPP - Exam Summary

Clinical summary

Evidence Base

Key technique and outcome claims on this page are anchored to the following verified studies. Across major societies the principles are concordant: the AAOS Appropriate Use Criteria (US), BOA/BSCOS (UK) and EFORT/European paediatric guidance all support closed reduction with percutaneous pinning for displaced fractures, lateral-entry pinning as the default safe construct, and urgent exploration of the truly ischaemic limb - with differences lying mainly in how aggressively the perfused-but-pulseless hand is investigated.

A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus

Level III
Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS • Journal of Pediatric Orthopaedics (2007)
Clinical Implication: Lateral-entry pinning is the default: it avoids the dominant iatrogenic risk (ulnar nerve) while giving acceptable stability. If a medial pin is genuinely needed, use a mini-open technique.
Verify on PubMed (PMID 17314643)

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

Level IV
Babal JC, Mehlman CT, Klein G • Journal of Pediatric Orthopaedics (2010)
Clinical Implication: Test the AIN ('OK' sign) in every extension-type fracture and the ulnar nerve carefully in flexion-type; most traumatic neurapraxias are observed and recover over 3-6 months.
Verify on PubMed (PMID 20357592)

Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire

Level IV
White L, Mehlman CT, Crawford AH • Journal of Pediatric Orthopaedics (2010)
Clinical Implication: Absent pulse signals arterial injury even when the hand is pink. Reduce and pin first, but a persistently pulseless hand warrants admission, close monitoring and a low threshold for vascular exploration rather than passive watchful waiting.
Verify on PubMed (PMID 20502231)

Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children

Level V
Zionts LE, McKellop HA, Hathaway R • Journal of Bone and Joint Surgery (American) (1994)
Clinical Implication: Maximise the safety/stability trade-off of lateral entry by spreading the pins widely (divergent, engaging both columns) and adding a third lateral pin for unstable or comminuted patterns rather than reaching for a medial pin.
Verify on PubMed (PMID 8113261)

Early versus delayed treatment for Gartland type III supracondylar humeral fractures in children: a systematic review and meta-analysis

Level III
Ismayl G, Kim WJ, Iqbal M, Sajid S • Indian Journal of Orthopaedics (2022)
Clinical Implication: A closed, perfused, neurologically intact displaced fracture can be safely treated on the next available list; reserve out-of-hours surgery for the ischaemic limb, open fracture, evolving compartment syndrome or floating elbow.
Verify on PubMed (PMID 36092280)

References

  1. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109(2):145-154.

  2. Skaggs DL, Flynn JM. Supracondylar fractures of the distal humerus. In: Rockwood and Wilkins' Fractures in Children. 8th ed. Wolters Kluwer; 2015:581-627.

  3. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. 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.

  4. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30(3):253-263.

  5. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30(4):328-335.

  6. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1994;76(2):253-256.

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

  8. Wilkins KE. The operative management of supracondylar fractures. Orthop Clin North Am. 1990;21(2):269-289.

  9. Mooney JF, Hosseinzadeh P. Compartment syndrome of the upper extremity in children and adolescents. J Am Acad Orthop Surg. 2020;28(23):e1017-e1027.

  10. Louahem D, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B. 2006;15(1):51-57.