High Yield Overview

SUPRACONDYLAR HUMERUS FRACTURE

Extension Type | Pulseless Pink Hand | Gartland Classification

97%Extension type

BrachialArtery at risk

AIN/MedianNerve at risk

K-wiresStandard fixation

Gartland Classification (Extension)

Type I

PatternUndisplaced

TreatmentCast in 90° flexion

Type II

PatternDisplaced, posterior cortex intact

TreatmentClosed reduction, K-wires

Type III

PatternDisplaced, no cortex contact

TreatmentUrgent closed reduction, K-wires

Critical Must-Knows

Most common elbow fracture in children (peak age 5-7)
Extension type (97%): FOOSH with hyperextension
Brachial artery at risk (pulseless with pink/white hand)
AIN most common nerve injured (extension type)
Gartland III = surgical emergency

Examiner's Pearls

"
Pink pulseless hand: Reduce urgently, reassess perfusion
"
If pink and perfused post-reduction: May observe
"
If white/non-perfused post-reduction: Explore brachial artery
"
Cubitus varus (gunstock deformity) = malunion complication

Clinical Imaging

Imaging Gallery

supracondylar-humerus-fracture imaging 1 — Clinical imaging for supracondylar-humerus-fractureCredit: James Heilman, MD via Wikimedia Commons (CC-BY-SA 3.0)

supracondylar-humerus-fracture imaging 2 — Clinical imaging for supracondylar-humerus-fractureCredit: Benoudina Samir via Wikimedia Commons (CC-BY-SA 4.0)

supracondylar-humerus-fracture imaging 3 — Clinical imaging for supracondylar-humerus-fractureCredit: Tracy Kilborn, Halvani Moodley, Stewart Mears; Mikael Häggström (annotations) via Wikimedia Commons (CC-BY-SA 4.0)

supracondylar-humerus-fracture imaging 4 — Clinical imaging for supracondylar-humerus-fractureCredit: Benoudina Samir via Wikimedia Commons (CC-BY-SA 4.0)

Elbow X-ray showing supracondylar fracture in a child with labeled anatomy — Supracondylar Humerus Fracture: Lateral elbow radiograph of a young child demonstrating a displaced supracondylar fracture. H = Humerus, R = Radius, U = Ulna. Arrow indicates fracture line. This is the most common elbow fracture in children (peak age 5-7 years).Credit: OrthoVellum

Critical Supracondylar Fracture Exam Points

Vascular

Brachial artery at risk. Pink pulseless hand: artery kinked but collateral perfusion. White pulseless hand: True ischemia = emergency. Reduce urgently then reassess.

Nerve

Extension type: AIN (anterior interosseous nerve) most common - test OK sign. Median nerve next. Flexion type: Ulnar nerve at risk. Most recover spontaneously.

Gartland III

Posterolateral or posteromedial displacement. Posterolateral more common (AIN at risk). Posteromedial (radial nerve at risk). Surgical emergency.

Fixation

Crossed K-wires (lateral and medial) or lateral only. Medial wire risks ulnar nerve. Flex elbow minimally to protect ulnar nerve when placing medial wire.

At a Glance

Supracondylar humerus fractures are the most common elbow fracture in children (peak age 5-7 years). Extension type (97%) results from FOOSH with hyperextension; flexion type (3%) from direct blow. The Gartland classification guides management: Type I (undisplaced - cast), Type II (hinged on posterior cortex - K-wires), Type III (complete displacement - surgical emergency). Critical assessment: the 3Ps - Pulse, Perfusion, Paralysis. Brachial artery is at risk; pink pulseless hand indicates artery kinked but collaterals perfusing - reduce urgently and reassess. AIN is the most commonly injured nerve (test OK sign). Fixation with crossed or lateral-only K-wires; medial wire placement risks ulnar nerve.

Mnemonic

3PsSupracondylar Assessment

PULSE

Check brachial/radial pulse

PERFUSION

Pink or white hand?

PARALYSIS

Nerve function (AIN, median, radial, ulnar)

Memory Hook:3Ps = Pulse, Perfusion, Paralysis - check all immediately!

Mnemonic

OK SignAIN Function Test

OK sign

Make circle with thumb and index

FPL

Thumb IP flexion

FDP to index

Index DIP flexion

Memory Hook:AIN = OK sign (FPL + FDP to index)!

Overview and Classification

Supracondylar humerus fracture is the most common elbow fracture in children. Peak age 5-7 years.

Mechanism

Extension Type (97%): FOOSH (fall on outstretched hand) with elbow hyperextension. Distal fragment displaces posteriorly.

Flexion Type (3%): Direct blow to posterior elbow. Distal fragment displaces anteriorly.

Gartland Classification (Extension Type)

Type I: Undisplaced or minimally displaced. Posterior cortex intact. Fat pad sign may be only clue.

Type II: Displaced with posterior cortex intact (hinged). May be angulated.

Type IIa: Extension angulation only. Type IIb: Rotation or translation (more unstable).

Type III: Completely displaced, no cortical contact.

Type IIIa: Posteromedial displacement. Type IIIb: Posterolateral displacement (more common).

Elbow Anatomy in Children

Distal Humerus Anatomy

Ossification Centers:

CRITOE mnemonic: Capitellum (1), Radial head (3), Internal (medial) epicondyle (5), Trochlea (7), Olecranon (9), External (lateral) epicondyle (11)
Ages approximate - useful for identifying fracture patterns

Supracondylar Region:

Thin bone above condyles - weak point for fracture
Anterior humeral line normally passes through middle third of capitellum
Baumann angle (shaft to capitellar physis): 70-75° normal

Neurovascular Relationships

Structure	Location	Risk with Displacement
Brachial artery	Anterior, crosses fracture site	Posterolateral (extension) displacement
Median nerve / AIN	Anterior, with artery	Posterolateral (extension) displacement
Radial nerve	Lateral, near lateral column	Posteromedial displacement
Ulnar nerve	Medial, posterior to epicondyle	Flexion type, medial wire insertion

Classification

Gartland Classification (Extension Type)

Type I:

Undisplaced or minimally displaced
Posterior cortex intact
May see fat pad sign only
Treatment: Above-elbow cast, 90° flexion

Type II:

Displaced with posterior cortex hinge
IIa: Angulated only
IIb: Rotated/translated (less stable)

Type III:

Completely displaced, no cortical contact
IIIa: Posteromedial (radial nerve risk)
IIIb: Posterolateral (AIN/median risk, more common)

Gartland Classification

Type	Displacement	Treatment
I	Undisplaced	Cast, 90° flexion, 3-4 weeks
IIa	Angulated only	Closed reduction + K-wires
IIb	Rotated/translated	Closed reduction + K-wires
III	Complete, no cortex	Urgent closed reduction + K-wires

Clinical Assessment

Neurovascular Examination

CRITICAL: Assess before any manipulation.

Vascular:

Brachial pulse, radial pulse
Capillary refill
Hand color (pink or white)

Nerve Function:

AIN: OK sign (FPL, FDP to index)
Median: Thenar power, sensation
Radial: Wrist/finger extension, sensation
Ulnar: Interossei, little finger sensation

Pulseless Hand Algorithm

Pink pulseless hand: Reduce fracture urgently. If perfusion improves → observe. Remain pink without pulse → may observe with close monitoring.

White pulseless hand: True ischemia. Reduce urgently. If still white → explore brachial artery (may be trapped, kinked, or injured).

Investigations

Radiographic Assessment

Standard Views:

AP elbow
True lateral elbow (essential for classification)

Key Radiographic Features:

Fat pad sign: Posterior fat pad always abnormal; anterior fat pad displaced ("sail sign") suggests effusion/occult fracture
Anterior humeral line: Should pass through middle third of capitellum
Baumann angle: Shaft to capitellar physis angle (70-75° normal)

Lateral elbow radiograph demonstrating the anterior humeral line passing through the capitellum — Anterior Humeral Line: Lateral elbow radiograph of a normal 4-year-old child. The anterior humeral line (black line) should pass through the middle third of the capitellum (green area). If this line passes anterior to the capitellum, it indicates posterior displacement of the distal fragment - a key sign of supracondylar fracture.Credit: OrthoVellum

Elbow radiograph demonstrating Baumann's angle measurement — Baumann's Angle: Radiographic measurement of the angle between the humeral shaft axis and the capitellar physeal line. Normal angle is 70-75 degrees. Should be compared to the contralateral side to assess reduction quality and detect varus malposition.Credit: OrthoVellum

Radiographic Landmarks

Finding	Normal	Abnormal
Anterior humeral line	Through middle 1/3 capitellum	Anterior to capitellum (extension)
Baumann angle	70-75°	Compare to opposite side
Posterior fat pad	Not visible	Visible = occult fracture
Anterior fat pad	Small, close to bone	Displaced = sail sign

Management

Undisplaced fracture.

Treatment: Long arm cast in 90° flexion. Avoid hyperflexion (compromises circulation).

Duration: 3-4 weeks.

Follow-up: X-ray at 1 week to confirm no displacement.

Surgical Technique

Closed Reduction and K-Wire Fixation

Reduction Sequence (Extension Type):

Longitudinal traction with elbow extended
Correct medial/lateral displacement
Correct rotation (pronation for posteromedial, supination for posterolateral)
Flex elbow while milking distal fragment anteriorly
Apply varus/valgus correction as needed
Check reduction on fluoroscopy

K-Wire Options:

2 Lateral divergent: Safer (avoids ulnar nerve), biomechanically adequate for most
Crossed wires (lateral + medial): More stable, but medial wire risks ulnar nerve
If medial wire: Flex elbow minimally (20-30°), palpate nerve, small stab incision

K-Wire Configuration

Configuration	Advantages	Disadvantages
2 Lateral divergent	Avoids ulnar nerve	Less rotational stability
Crossed wires	Maximum stability	Ulnar nerve risk (2-5%)
3 lateral wires	Good stability, no nerve risk	More wires, more time

Complications

Early

Vascular injury (brachial artery)
Nerve injury (AIN most common in extension type)
Compartment syndrome
Volkmann's ischemic contracture (missed ischemia)

Late

Cubitus varus (gunstock deformity): Most common complication. Malunion with varus tilt. Cosmetic deformity. May need late supracondylar osteotomy.
Stiffness: Usually temporary. Avoid aggressive physiotherapy.
Myositis ossificans: Rare in children.

Postoperative Care

Immediate Postoperative

Immobilization:

Above-elbow backslab or cast
Elbow at 60-80° flexion (not hyperflexed - risks circulation)
Forearm neutral or slight pronation
Elevate limb

Monitoring:

Hourly neurovascular checks for first 24 hours
Monitor for compartment syndrome (pain with passive finger extension)
Check cast not too tight

Postoperative Checklist

Parameter	Target	Action if Abnormal
Pulse	Present	Urgent review, check cast
Capillary refill	Less than 2 seconds	Loosen cast, elevate
Pain	Controlled	If severe - compartment syndrome?
Finger movement	Active	Document, reassure if nerve injury

Outcomes

Expected Outcomes

Good Outcomes:

Most children achieve excellent results
Full ROM typically restored within 6-12 weeks
Nerve injuries usually recover (90%+ neurapraxias)
Low malunion rate with anatomic reduction

Complications:

Cubitus varus (5-15% with malreduction)
Stiffness (usually temporary)
Nerve palsy (5-10%, most recover)
Volkmann's contracture (rare but devastating)

Outcomes Summary

Outcome	Rate	Key Factor
Full ROM	90%+	Anatomic reduction, no aggressive PT
Cubitus varus	5-15%	Malreduction (rotation, varus tilt)
Nerve recovery	90%+	Most are neurapraxias
Volkmann's	Rare	Missed compartment syndrome

Evidence Base

Key Evidence

Gartland Classification (1959):

Original three-type classification
Foundation for current management
Modified by Wilkins (Type IV added)

Lateral vs Crossed Wires:

Multiple studies show no significant difference in stability for most fractures
Lateral-only avoids ulnar nerve injury (0% vs 2-5%)
Crossed preferred for very unstable (Type IV) fractures

Key Studies

Topic	Finding	Evidence Level
Lateral vs crossed	Similar outcomes, lateral safer	Level II (meta-analyses)
Timing of surgery	Within 8 hours if possible	Level IV
Pink pulseless hand	Reduce first, most perfuse	Level IV

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Supracondylar Fracture with Pulseless Hand

EXAMINER

"A 6-year-old presents with a displaced supracondylar fracture and a pink but pulseless hand. How do you manage?"

EXCEPTIONAL ANSWER

This is a Gartland Type III supracondylar humerus fracture with vascular compromise. A pink pulseless hand indicates the brachial artery is kinked or trapped but collateral circulation is maintaining perfusion. My immediate priorities are to assess the 3Ps: Pulse, Perfusion, and Paralysis. I would document the neurovascular status carefully - checking AIN function (OK sign), median, radial, and ulnar nerve function. This is a surgical emergency. I would take the child to theatre urgently for closed reduction and K-wire fixation. Under general anaesthesia and fluoroscopy, I would perform gentle traction, correct any rotation, then flex the elbow while milking the distal fragment anteriorly to restore alignment. I would confirm reduction on AP (Baumann angle) and lateral (anterior humeral line through middle third of capitellum). I would fix with two divergent lateral K-wires (avoids ulnar nerve risk). Post-reduction, I would immediately reassess the pulse and perfusion. If the hand is pink and well-perfused post-reduction, even without a palpable pulse, I would observe closely with hourly neurovascular checks. Pulse often returns within hours. If the hand remains white and poorly perfused after reduction, I would explore the brachial artery - it may be trapped in the fracture site, kinked, or have an intimal injury. I would counsel the parents about the risk of Volkmann's contracture if ischemia is prolonged and the need for close observation.

KEY POINTS TO SCORE

Pink pulseless = collateral perfusion, urgent surgery

Reduce fracture and reassess

Pink post-reduction = may observe

White post-reduction = explore artery

COMMON TRAPS

✗Not knowing vascular algorithm

✗Exploring all pulseless hands (only white)

✗Not knowing AIN test (OK sign)

LIKELY FOLLOW-UPS

"What if the hand remains white after reduction?"

"What nerve is most commonly injured in extension type?"

VIVA SCENARIOChallenging

Scenario 2: Failed Closed Reduction - Pucker Sign

EXAMINER

"You are managing a 7-year-old with a Gartland Type III posterolateral supracondylar fracture. In theatre under general anesthesia, you notice a skin dimple (pucker sign) in the antecubital fossa. After two attempts at closed reduction, you cannot achieve adequate alignment - the distal fragment keeps subluxating posteriorly. Fluoroscopy shows persistent posterior displacement with the anterior humeral line passing anterior to the capitellum. The hand is pink and well perfused. What is your next step and how would you proceed?"

EXCEPTIONAL ANSWER

The pucker sign in the antecubital fossa is a critical finding that indicates the proximal fragment has buttonholed through the brachialis muscle fascia. This sign, combined with failed closed reduction after two attempts, strongly suggests soft tissue interposition preventing reduction. The most common structures that can be trapped include the brachialis muscle belly itself, the brachial artery, and occasionally the median nerve. Multiple aggressive closed reduction attempts should be avoided as they risk further neurovascular injury and soft tissue damage. My decision at this point is to convert to open reduction via an anterior approach. I would explain to the parents that this is necessary to safely achieve and maintain reduction. For the anterior approach, I would make a longitudinal or transverse incision over the antecubital fossa, centered over the fracture site. I would carefully identify and protect the neurovascular structures - the brachial artery, median nerve, and any venae comitantes. The lacertus fibrosus (bicipital aponeurosis) would be divided, and I would split the brachialis muscle longitudinally in line with its fibers. Upon exposing the fracture, I would carefully identify and extricate any interposed soft tissue. Most commonly, I find a portion of brachialis muscle that has been drawn into the fracture site. Less commonly but more concerning, the brachial artery or median nerve may be trapped between the fracture fragments. Once the soft tissues are freed, the fracture typically reduces easily. I would hold the reduction with a pointed reduction clamp and proceed with K-wire fixation. Given that I have already opened the fracture anteriorly, I would use crossed K-wires (one lateral, one medial) for optimal stability, though I would be particularly careful with the medial wire to avoid iatrogenic ulnar nerve injury. I would insert the lateral wire first with the elbow in 20-30 degrees of flexion, then insert the medial wire with minimal additional flexion, palpating the ulnar nerve throughout. After fixation, I would meticulously check the reduction on both AP and lateral fluoroscopy (Baumann angle should match the contralateral side, anterior humeral line through middle third of capitellum). Post-operatively, I would place the arm in a well-padded above-elbow backslab in safe position (not hyperflexed as this can compromise perfusion), elevate, and perform hourly neurovascular observations for the first 24 hours given the soft tissue injury and anterior dissection. I would counsel the parents that while open reduction carries a slightly higher risk of stiffness and heterotopic ossification compared to closed reduction, it was necessary for safety and to achieve an acceptable reduction. The functional outcome should still be excellent with appropriate therapy. Wires would typically be removed at 3-4 weeks and gentle range of motion initiated, avoiding aggressive physiotherapy which can cause myositis ossificans in children.

KEY POINTS TO SCORE

Pucker sign = proximal fragment buttonholed through brachialis, soft tissue interposition

Failed closed reduction (after 2 attempts) = convert to open reduction

Anterior approach: Identify/protect neurovascular structures, extricate interposed tissue (brachialis, artery, nerve)

Open reduction: Crossed wires acceptable for stability, careful medial wire placement

Post-op: Backslab not hyperflexed, hourly neurovascular checks, counsel about stiffness risk

COMMON TRAPS

✗Multiple aggressive closed reduction attempts - risks neurovascular injury

✗Not recognizing pucker sign significance

✗Using posterior approach - cannot visualize neurovascular structures

✗Hyperflexing elbow post-operatively - can compromise perfusion

LIKELY FOLLOW-UPS

"What is the difference between brachialis and biceps anatomy at this level?"

"How would you manage if you found the brachial artery damaged during open reduction?"

"What is myositis ossificans and why is it more common after open reduction?"

VIVA SCENARIOCritical

Scenario 3: Iatrogenic Ulnar Nerve Palsy - Post-Operative Complication

EXAMINER

"You performed closed reduction and crossed K-wire fixation (one lateral, one medial wire) for a Gartland Type III supracondylar fracture in a 5-year-old girl last night. The fracture was perfectly reduced with good wire position on post-operative X-rays. This morning on ward rounds, the mother reports the child cannot spread her fingers apart and has numbness in the little finger. Pre-operatively, all nerve function was documented as intact. On examination, you confirm ulnar nerve palsy with weak interossei, inability to abduct/adduct fingers, and diminished sensation in the ulnar distribution. What is your assessment and management?"

EXCEPTIONAL ANSWER

This is an iatrogenic ulnar nerve injury following medial pin placement for a supracondylar fracture fixation. Iatrogenic ulnar nerve injury is a well-recognized complication of medial pin insertion, occurring in approximately 2-5% of cases when a medial wire is used. The ulnar nerve is at particular risk because it courses posterior to the medial epicondyle in the cubital tunnel, very close to the typical trajectory of the medial K-wire, especially when the elbow is flexed during wire insertion. The mechanism of injury can be either direct penetration of the nerve by the wire, tethering of the nerve against the wire, or stretching of the nerve from elbow flexion during wire placement. My first step is to confirm that this is truly a new deficit by reviewing the pre-operative documentation. Assuming pre-operative function was intact as documented, this is a post-operative iatrogenic injury. The critical decision is whether this requires immediate surgical exploration or can be managed with observation. The literature and current consensus support immediate removal of the medial wire and conversion to lateral-only fixation. While there is debate about whether to formally explore the nerve, the general approach is to remove the offending wire urgently and reassess. My management would be to take the child back to theatre on the same day. Under general anesthesia and using image intensification to maintain the reduction, I would remove the medial K-wire. I would assess the stability with only the lateral wire - if the reduction is maintained with one lateral wire, I would leave it. If the reduction becomes unstable after removing the medial wire, I would insert a second lateral K-wire in a divergent configuration (two lateral wires can provide adequate stability, though biomechanically slightly weaker than crossed wires). At this point, there is controversy about nerve exploration. If the nerve deficit persists after wire removal and I suspect the nerve may be transected or severely damaged (which would be unusual with K-wire injury), I could consider exploring via a small medial incision. However, most iatrogenic ulnar nerve injuries from medial pins are neurapraxias or axonotmeses (stretch or compression injuries) rather than complete transections, and these typically recover with observation. The weight of evidence suggests that immediate exploration is not mandatory if the wire is removed promptly. I would therefore remove the wire, convert to lateral-only or two lateral wires, and observe. I would counsel the parents that most iatrogenic ulnar nerve injuries recover spontaneously within 3-6 months. I would arrange follow-up at 6 weeks, 3 months, and 6 months to assess recovery. If there is no recovery by 3-4 months (suggesting axonotmesis), I would consider electrodiagnostic studies (EMG/NCS) to differentiate neurapraxia from axonotmesis and guide prognosis. If there is still no recovery by 6 months, nerve exploration and possible neurolysis or reconstruction would be considered, though this is rarely necessary. Importantly, I would document this complication thoroughly, discuss it openly with the family, and report it for clinical governance. This is a recognized complication of the procedure, but the decision to use a medial wire carries this risk, and in hindsight, lateral-only wires may have been safer for this patient. Going forward, this experience reinforces the importance of: (1) minimizing elbow flexion when placing medial wires, (2) palpating the ulnar nerve before insertion, (3) using a small stab incision to protect the nerve, and (4) considering whether lateral-only fixation is sufficient in many cases to avoid this risk entirely.

KEY POINTS TO SCORE

Iatrogenic ulnar nerve injury: 2-5% with medial pin, caused by penetration/tethering/stretch

Management: Immediate removal of medial wire, convert to lateral-only or two lateral wires

Exploration controversial - most are neurapraxias that recover spontaneously in 3-6 months

Follow-up: 6 weeks, 3 months, 6 months; EMG at 3-4 months if no recovery

Prevention: Minimal elbow flexion, palpate nerve, small incision, consider lateral-only fixation

COMMON TRAPS

✗Leaving medial wire in situ and observing - should remove urgently

✗Routine nerve exploration - not indicated for most cases

✗Not counseling family about expected recovery timeline

✗Not documenting complication and discussing openly with family

LIKELY FOLLOW-UPS

"What is the difference between neurapraxia, axonotmesis, and neurotmesis?"

"What are the biomechanical differences between crossed wires and lateral-only fixation?"

"At what elbow flexion angle does the ulnar nerve risk increase for medial pin placement?"

MCQ Practice Points

Exam Pearl

Q: What is the most common mechanism and displacement pattern for pediatric supracondylar fractures?

A: Extension-type (95-97%): Fall on outstretched hand with elbow extended and hyperextended. Distal fragment displaces posteriorly. Flexion-type (3-5%): Fall on flexed elbow or direct blow; distal fragment displaces anteriorly - higher rate of ulnar nerve injury. Extension type further classified by displacement direction: Posteromedial (most common in extension type) - radial nerve at risk; Posterolateral - median/AIN at risk. Understanding displacement pattern predicts neurovascular injury risk.

Exam Pearl

Q: How do you assess reduction quality using radiographic parameters in supracondylar fractures?

A: Baumann's angle (AP view): Angle between humeral shaft axis and physeal line of capitellum; normal 70-75 degrees; should match opposite side. Anterior humeral line (lateral view): Line along anterior humeral cortex should pass through middle third of capitellum; if anterior to capitellum, extension malreduction. Coronoid line: Line along anterior coronoid should not pass posterior to anterior humeral cortex. Rotation: On lateral, assess teardrop of lateral column for symmetry. Intraoperative fluoroscopy essential to confirm reduction.

Exam Pearl

Q: What are the indications for open reduction in pediatric supracondylar fractures?

A: Open fractures - require debridement and stabilization. Vascular compromise not corrected by closed reduction - explore brachial artery. Irreducible fractures - soft tissue interposition (brachialis muscle, median nerve, brachial artery can become entrapped; "pucker sign" on skin indicates buttonholed structures). Neurological deficit worsening after reduction - nerve may be trapped. Open reduction via anterior approach allows visualization of neurovascular structures. Delayed presentation (greater than 5-7 days) with significant swelling may require open approach.

Exam Pearl

Q: What is the "pucker sign" and its clinical significance in supracondylar fractures?

A: The pucker sign is skin dimpling or puckering at the antecubital fossa indicating that the proximal fragment has buttonholed through the brachialis fascia. Structures at risk of entrapment: Brachialis muscle, brachial artery, median nerve. Significance: Suggests closed reduction may be impossible - the entrapped soft tissues block reduction. If pucker sign persists after reduction attempt, suspect soft tissue interposition and consider open reduction via anterior approach. Associated with higher rates of neurovascular injury.

Exam Pearl

Q: What is Volkmann's ischemic contracture and how does it develop after supracondylar fractures?

A: Volkmann's ischemic contracture is the devastating end-result of missed forearm compartment syndrome. Pathophysiology: Vascular injury or swelling leads to elevated compartment pressure, causing muscle ischemia and necrosis. As muscles fibrose, they shorten, causing flexion contracture of wrist and fingers (worse with elbow extension, MCP extension). Classic position: Flexed wrist, extended MCP, flexed IP joints. Prevention: Recognize compartment syndrome early (6 P's: Pain with passive stretch, Pallor, Pulselessness, Paresthesias, Paralysis, Pressure). Emergent fasciotomy if suspected.

Australian Context

Australian Practice

Common Presentation:

Peak incidence: 5-7 years
Common presentation to paediatric emergency departments
Often from playground falls or trampolines

Healthcare Pathway:

Tertiary paediatric centres for Gartland II/III
Regional hospitals may treat Type I
Transfer for vascular compromise is time-critical

Australian Resources

Resource	Application	Notes
PREDICT network	Paediatric ED guidelines	Evidence-based protocols
Retrieval services	Transfer from regional	Time-critical for vascular injury
Paediatric ortho subspecialty	Complex cases	Major centres

SUPRACONDYLAR HUMERUS FRACTURE

High-Yield Exam Summary

Gartland Classification

•I: Undisplaced - cast
•II: Hinged on posterior cortex
•III: Complete displacement - emergency

Neurovascular

•Brachial artery at risk
•AIN most common nerve (extension)
•Check OK sign (FPL, FDP index)
•3Ps: Pulse, Perfusion, Paralysis

Pink Pulseless Algorithm

•Reduce urgently
•Pink post-reduction: Observe
•White post-reduction: Explore artery

Fixation

•Lateral K-wires (2 divergent) - safer
•Crossed wires - stronger, ulnar nerve risk
•Avoid hyperflexion in cast

Structure

Location

Risk with Displacement

Brachial artery

Anterior, crosses fracture site

Posterolateral (extension) displacement

Median nerve / AIN

Anterior, with artery

Posterolateral (extension) displacement

Radial nerve

Lateral, near lateral column

Posteromedial displacement

Ulnar nerve

Medial, posterior to epicondyle

Flexion type, medial wire insertion

Type

Displacement

Treatment

Undisplaced

Cast, 90° flexion, 3-4 weeks

IIa

Angulated only

Closed reduction + K-wires

IIb

Rotated/translated

Closed reduction + K-wires

III

Complete, no cortex

Urgent closed reduction + K-wires

Finding

Normal

Abnormal

Anterior humeral line

Through middle 1/3 capitellum

Anterior to capitellum (extension)

Baumann angle

70-75°

Compare to opposite side

Posterior fat pad

Not visible

Visible = occult fracture

Anterior fat pad

Small, close to bone

Displaced = sail sign

Configuration

Advantages

Disadvantages

2 Lateral divergent

Avoids ulnar nerve

Less rotational stability

Crossed wires

Maximum stability

Ulnar nerve risk (2-5%)

3 lateral wires

Good stability, no nerve risk

More wires, more time

Parameter

Target

Action if Abnormal

Pulse

Present

Urgent review, check cast

Capillary refill

Less than 2 seconds

Loosen cast, elevate

Pain

Controlled

If severe - compartment syndrome?

Finger movement

Active

Document, reassure if nerve injury

Outcome

Rate

Key Factor

Full ROM

90%+

Anatomic reduction, no aggressive PT

Cubitus varus

5-15%

Malreduction (rotation, varus tilt)

Nerve recovery

90%+

Most are neurapraxias

Volkmann's

Rare

Missed compartment syndrome

Topic

Finding

Evidence Level

Lateral vs crossed

Similar outcomes, lateral safer

Level II (meta-analyses)

Timing of surgery

Within 8 hours if possible

Level IV

Pink pulseless hand

Reduce first, most perfuse

Level IV

Exam Pearl

Q: What is the most common mechanism and displacement pattern for pediatric supracondylar fractures?

Exam Pearl

Q: How do you assess reduction quality using radiographic parameters in supracondylar fractures?

Exam Pearl

Q: What are the indications for open reduction in pediatric supracondylar fractures?

Exam Pearl

Q: What is the "pucker sign" and its clinical significance in supracondylar fractures?

Exam Pearl

Q: What is Volkmann's ischemic contracture and how does it develop after supracondylar fractures?

Resource

Application

Notes

PREDICT network

Paediatric ED guidelines

Evidence-based protocols

Retrieval services

Transfer from regional

Time-critical for vascular injury

Paediatric ortho subspecialty

Complex cases

Major centres

Supracondylar Humerus Fracture

Supracondylar Humerus Fracture

SUPRACONDYLAR HUMERUS FRACTURE

Gartland Classification (Extension)

Critical Must-Knows

Examiner's Pearls

Clinical Imaging

Imaging Gallery

Critical Supracondylar Fracture Exam Points

Vascular

Nerve

Gartland III

Fixation

At a Glance

3PsSupracondylar Assessment

OK SignAIN Function Test

Overview and Classification

Mechanism

Gartland Classification (Extension Type)

Elbow Anatomy in Children

Distal Humerus Anatomy

Neurovascular Relationships

Carrying Angle and Vascular Anatomy

Classification

Gartland Classification (Extension Type)

Gartland Classification

Wilkins Modification and Flexion Type

Clinical Assessment

Neurovascular Examination

Pulseless Hand Algorithm

Investigations

Radiographic Assessment

Radiographic Landmarks

Reduction Assessment

Management

Surgical Technique

Closed Reduction and K-Wire Fixation

K-Wire Configuration

Wire Placement Technique

Complications

Early

Late

Postoperative Care

Immediate Postoperative

Postoperative Checklist

Follow-up Protocol

Outcomes

Expected Outcomes

Outcomes Summary

Cubitus Varus (Gunstock Deformity)

Evidence Base

Key Evidence

Key Studies

Vascular Injury Evidence

Exam Viva Scenarios

Scenario 1: Supracondylar Fracture with Pulseless Hand

Scenario 2: Failed Closed Reduction - Pucker Sign

Scenario 3: Iatrogenic Ulnar Nerve Palsy - Post-Operative Complication

MCQ Practice Points

Australian Context

Australian Practice

Australian Resources

MBS and Training

SUPRACONDYLAR HUMERUS FRACTURE

Gartland Classification

Neurovascular

Pink Pulseless Algorithm

Fixation

Supracondylar Humerus Fracture

Supracondylar Humerus Fracture

SUPRACONDYLAR HUMERUS FRACTURE

Gartland Classification (Extension)

Critical Must-Knows

Examiner's Pearls

Clinical Imaging

Imaging Gallery

Critical Supracondylar Fracture Exam Points

Vascular

Nerve

Gartland III