Supracondylar fracture in children

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Children's distal humerus is thin and surrounded by structures at risk. Establish hand dominance, mechanism and time, but prioritise skin and perfusion. Ask the child to perform simple gestures and record what was actually observed; fear and pain may make a complete examination impossible, which should be stated rather than recorded as normal. Compare both hands for warmth, colour and refill and repeat after analgesia and realignment.

Radiographs are interpreted with developing ossification centres. An extension-type displaced fracture disrupts the anterior humeral line and may alter Baumann angle. Treatment depends on displacement, rotation, medial-column integrity, skin and neurovascular status. Stable undisplaced injuries can be casted with early review; displaced injuries usually need same-day or urgent theatre fixation. Aftercare monitors cast pressure, pin sites, alignment, nerve recovery and range of movement.

Gartland classification communicates extension-fracture displacement. Type I is undisplaced; type II retains a posterior cortical hinge but may have rotation or medial-column instability; type III is completely displaced; type IV is unstable in flexion and extension. The label cannot replace documentation of skin, perfusion and nerve function. A rotated or medial-column-deficient type II pattern may behave unstably and require fixation. Flexion-type injuries need separate recognition because the distal fragment and ulnar-nerve risk differ from the usual extension mechanism.

Before theatre, keep the child and carers informed, administer age-appropriate analgesia and record fasting status without delaying emergency care. Immobilise in a position that preserves perfusion and does not force the swollen elbow. Percutaneous crossed or divergent wire configurations are chosen to maintain columns while avoiding nerve injury; the operating team checks stability and perfusion after fixation. If the hand remains poorly perfused after reduction, immediate exploration is required. A warm pulseless hand needs consultant-led observation or exploration criteria recorded explicitly rather than vague reassurance.

Compartment syndrome may present as increasing anxiety, escalating analgesic requirement or reluctance to move fingers before a child describes passive-stretch pain. Remove constrictive layers, place the limb at heart level and obtain immediate senior review. Do not wait for pulselessness, which is late. Associated median or anterior interosseous palsy often recovers after reduction, but serial gestures and sensation must be charted. A nerve deficit discovered only after surgery needs prompt reassessment of pin position, swelling and possible iatrogenic injury.

After discharge, parents need a direct route back for uncontrolled pain, increasing swelling, pale or blue fingers, new numbness, inability to move digits, wet or damaged cast and fever or pin-site discharge. Review radiographic alignment and remove wires according to the operative pathway. Formal physiotherapy is not routinely required for every uncomplicated child because movement often returns spontaneously, but persistent stiffness, deformity or nerve deficit merits specialist rehabilitation. Cubitus varus is principally a malunion problem and is not prevented by simply waiting longer in a cast.

Analgesia should improve comfort without erasing a worsening pattern. Prescribe paracetamol and, when suitable for the child, ibuprofen according to current weight-based guidance; document concentration and maximum frequency for carers. Stronger analgesia may be needed before reduction but increasing requirements after splintage require repeat examination. Avoid routine regional techniques that obscure evolving compartment findings unless the service has a defined monitoring protocol. Keep the child warm, hydrated and supported, and explain procedures in age-appropriate language to reduce distress that could otherwise be misread as pain deterioration.

Every handover should carry the vascular narrative: findings before reduction, immediate response, pulse or Doppler status, capillary refill, temperature and the exact monitoring frequency. Similarly, list each nerve test rather than stating that neurology is unchanged. Postoperative radiographs confirm wire position and reduction, but they cannot prove a safe cast or perfused hand. At transfer or discharge, responsibility for repeat imaging, wire removal, nerve review and suspected safeguarding concerns must be explicit, with interpreters used for consent and safety instructions when needed.

Key points

Supracondylar fracture is common around ages 5 to 8 after a fall on an outstretched hand and is usually extension type.
Inspect swelling, bruising, skin puckering and wounds and remove rings or constricting items promptly.
Document hand colour, temperature, capillary refill, radial pulse and Doppler when needed, not only whether a pulse is palpable.
Test anterior interosseous function with an OK sign, median with thumb opposition, radial with wrist or finger extension and ulnar with finger abduction.
Obtain AP and true lateral elbow radiographs including distal humerus; review anterior humeral line, Baumann angle and radiocapitellar alignment.
Splint near a safe comfortable angle without forcing flexion in a swollen or poorly perfused limb and repeat the examination after splintage.
Displaced Gartland II or III injuries generally require urgent reduction and percutaneous-wire stabilisation by an experienced paediatric team.
A pale pulseless hand requires immediate reduction; a persistently perfused pulseless hand follows a closely monitored senior vascular decision pathway.
Provide parent instructions for escalating pain, tight cast, colour change, numbness, fever or inability to move fingers.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Fall on outstretched hand

Hyperextension transmits force through the olecranon to the thin supracondylar region, causing the typical extension-type fracture in childhood.

Direct flexed-elbow impact

A rarer flexion mechanism drives the distal fragment anteriorly and carries different ulnar-nerve and reduction considerations.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Distal fragment displacement
In extension injury the distal segment moves posteriorly while the sharp proximal fragment can injure anterior muscle, brachial artery and median nerve.
2
Nerve-pattern association
Anterior interosseous or median injury often accompanies posterolateral displacement, radial injury posteromedial displacement and ulnar injury flexion-type fracture.
3
Perfusion versus pulse
Collateral circulation can keep a hand pink despite absent radial pulse, so temperature, refill, colour, waveform and trend guide limb risk.
4
Compartment ischaemia
Arterial injury, swelling or excessive elbow flexion raises forearm pressure and can cause Volkmann contracture if untreated.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Extension fractureRed flag

Pain, swelling and S-shaped elbow deformity follow a fall on the outstretched hand.

Pale pulseless handRed flag

Cool pallor, delayed refill and absent pulse indicates critical perfusion and mandates emergency reduction.

Pink pulseless handRed flag

Warm colour and refill with no palpable pulse implies collateral flow but still needs urgent monitored specialist care.

Anterior interosseous palsyRed flag

Inability to flex thumb interphalangeal and index distal joints prevents a round OK sign.

Compartment warningRed flag

Increasing pain, passive finger stretch pain and progressive motor or sensory change requires immediate escalation.

Red flags requiring action

A pale cool pulseless hand requires emergency reduction and vascular assessment; prolonged diagnostic delay is unsafe.
A pink pulseless hand still needs urgent senior management, repeated objective perfusion review and a documented exploration threshold.
Escalating pain, anxiety, analgesic requirement, pain on passive finger stretch or progressive deficit suggests compartment syndrome.
Skin puckering, anterior bruising, open injury or gross displacement indicates severe soft-tissue tethering and urgent theatre care.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
AP and true lateral elbow radiographsFirst step
Why
Define displacement, rotation, columns and alignment while excluding other paediatric elbow fracture.
Interpretation and limitations
On a true lateral, the anterior humeral line should intersect the capitellum; age and positioning affect interpretation.
02
Serial perfusion assessment
Why
Track colour, temperature, refill, pulse and Doppler response before and after reduction.
Interpretation and limitations
A warm hand without pulse is not equivalent to a normal vascular examination and requires a defined monitoring plan.
03
Named motor and sensory examination
Why
Identify median, anterior interosseous, radial and ulnar injury and establish timing.
Interpretation and limitations
Use child-friendly gestures and document untestable components honestly.
04
Vascular imaging when specifically indicated
Why
Support planning in selected persistent vascular abnormalities after urgent reduction.
Interpretation and limitations
Do not let routine angiography delay reduction of a deformed poorly perfused limb.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Lateral condyle fracture

Focal lateral tenderness and a subtle fracture line may be unstable despite less deformity and requires paediatric orthopaedic follow-up.

Elbow dislocation

Rare in younger children and can be confused with displaced fracture; radiographic alignment and ossification centres guide diagnosis.

Radial neck fracture

Lateral elbow pain and painful forearm rotation with preserved supracondylar alignment suggests radial-neck injury rather than distal humeral disruption.

Pulled elbow

A toddler after traction holds the arm still but lacks swelling, bruising and bony deformity typical of fracture.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Emergency assessmentDocument and protect the handFirst stepA child presents with a swollen painful elbow after a fall.

1Give age-appropriate analgesia, inspect skin and remove external constriction.
2Record colour, warmth, refill, pulse and four named nerve functions before splintage.
3Obtain radiographs, splint safely, keep fasting and call paediatric orthopaedics for displaced or abnormal-perfusion injury.

02Perfusion threatReduce before prolonged testingThe hand is pale, cool or otherwise poorly perfused.

1Activate emergency theatre and senior anaesthetic and orthopaedic support immediately.
2Perform urgent fracture reduction and stabilisation, then reassess objective hand perfusion and nerve function.
3Explore the artery when perfusion does not recover or the agreed vascular criteria are met.

03Definitive and follow-upMaintain reduction and detect pressureDefinitiveThe fracture is casted or fixed and the hand is perfused.

1Confirm alignment and repeat neurovascular documentation after cast or pin placement.
2Give parents immediate return advice for pain, swelling, colour, sensation and finger movement.
3Review radiographic position, pin sites, nerve recovery and later elbow motion according to the paediatric pathway.

Key medicines and prescribing safety1 treatment · regimens, roles and cautions

Provides baseline analgesia before examination, splintage and postoperative care.

Paracetamol for a child with fracture pain

For children, prescribe the current BNF for Children weight- or age-based paracetamol dose and interval, recording weight and avoiding duplicate combination products.

This is not an adult regimen; verify the child's weight, product concentration, maximum daily doses and hepatic risk.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Neurovascular injury

Median, anterior interosseous, radial, ulnar or brachial-artery damage may present initially or change after reduction and fixation.

Compartment syndrome

Missed forearm ischaemia causes muscle necrosis, nerve damage and Volkmann flexion contracture of wrist and fingers.

Cubitus varus

Coronal malunion produces a visible gunstock deformity, altered elbow mechanics and possible later instability despite acceptable flexion and extension.

Pin-site or fixation problem

Infection, loss of reduction, iatrogenic ulnar injury or migration can complicate percutaneous fixation and requires surveillance.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Repeat colour, temperature, refill, pulse and Doppler status after every intervention.
Recheck named nerve gestures when pain and cooperation improve.
Ask about increasing analgesic need and passive-stretch pain beneath the cast.
Inspect pin sites and radiographic alignment at the defined review.
Track elbow motion after healing without forceful early physiotherapy unless the specialist plan directs it.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Pulse and perfusion differ

A warm pink hand can receive collateral flow despite arterial disruption, so absent pulse still requires senior surveillance.

The OK sign is motor

A flat pinch rather than a round fingertip circle identifies anterior interosseous weakness without relying on sensation.

Flexion can obstruct flow

Forcing a swollen elbow into marked flexion can kink vessels and increase compartment pressure.

Children cannot be charted by assumption

If pain prevents a nerve test, record it as untestable and repeat rather than writing normal.

11Common pitfallsFrequent interpretation and management errors.

01
Recording only the radial pulse and omitting colour, warmth, refill and named nerve tests.
02
Delaying reduction of a pale pulseless hand for routine vascular imaging.
03
Forcing a swollen elbow into excessive flexion to hold reduction.
04
Misreading a rotated lateral radiograph and ignoring paediatric ossification centres.
05
Discharging parents without explicit cast-pressure and perfusion warning signs.