Supracondylar Fracture of the Humerus: A Pediatric Orthopedic Challenge

 It was around 12 am, and in the dead silence, my cellphone rang. I had received a call from the emergency department for a 3-year-old baby who had fallen from a chair and presented with deformity, pain, and bluish discoloration at his elbow joint. I was sure of the outcome, but after checking the pulse over the affected side and looking at the deformity, I asked for an X-ray. It confirmed my diagnosis: a supracondylar fracture of the humerus.

(Spracondylar fracture of Humerus)

Introduction

Supracondylar fractures of the humerus are among the most common fractures in children, accounting for approximately 16% of all pediatric fractures and 60% of elbow fractures in this age group (Fracture SupracondylarHumerus: A Review). These fractures occur just above the elbow joint and are most frequently seen in children aged 5-7 years, typically resulting from a fall on an outstretched hand. This article explores the causes, epidemiology, treatment methods, outcomes, and specific considerations for the Indian population, with a focus on why these fractures are prevalent among children.

Definition and Classification

A supracondylar fracture is a break in the distal humerus, just proximal to the elbow joint. It is classified using the Gartland system, which guides treatment decisions based on the degree of displacement:

• Type I: Non-displaced or minimally displaced (<2 mm).
• Type II: Partially displaced with an intact posterior cortex.
• Type III: Completely displaced with no cortical contact.
• Type IV: Multi-directional instability, unstable in both flexion and extension.

The Gartland classification is critical for determining whether conservative or surgical intervention is appropriate (SupracondylarHumerus Fractures).

Causes

The primary cause of supracondylar fractures is a fall on an outstretched hand, leading to an extension-type injury in 95-98% of cases. Less commonly, a fall on a flexed elbow results in a flexion-type fracture, which is more frequent in older children. The mechanism involves the olecranon acting as a fulcrum, causing the humerus to fracture anteriorly and then posteriorly (Radiopaedia). Additional factors include:

• Higher incidence in males (1.5:1 ratio).
• Frequent involvement of the non-dominant extremity (65% of cases).
• Up to 30% of cases may present as open fractures.

Why Common in Children?

Supracondylar fractures are prevalent in children due to several factors:

• Mechanism of Injury: Children frequently fall on an outstretched hand as a protective reflex during play, transmitting force to the elbow.
• Anatomical Factors: The distal humerus in children has a thinner cortex and is structurally weaker, making it more susceptible to fracture. The presence of growth plates further increases vulnerability.
• Activity Level: Children’s active lifestyles, including climbing and playing on structures like monkey bars or rooftops, increase the risk of falls (Supracondylar Fractures in Children).

Epidemiology

Globally, supracondylar fractures account for 16% of pediatric fractures and 55-80% of elbow fractures in children, with a peak incidence at 5-7 years. They are more common in boys, though recent studies suggest gender differences may be narrowing (Radiopaedia).

Epidemiology in India

In India, supracondylar fractures are a significant pediatric orthopedic concern, particularly in rural settings. A prospective study of 263 cases in a rural teaching hospital reported:

• Age: Mean age of 7.9 years, with a peak at 5-8 years.
• Gender: 59.7% males (157/263), 40.3% females (106/263), a 1.5:1 ratio.
• Laterality: Non-dominant extremity involved in 65% of cases, with the left side more frequently affected.
• Presentation: 39.9% presented within 48 hours, 24% between 48 hours and 1 week, and 36.1% after 1 week, often due to initial treatment by traditional bonesetters.
• Fracture Types: Gartland Type III (54.4%), Type I (24%), Type II (21.7%).
• Complications: Nerve injuries in 4.9% (median nerve most common), vascular injuries in 0.76%, open fractures in 3.4%, and associated injuries in 4.9% (Epidemiologic Pattern Study).

The study highlighted that falls from rooftops or stairs were a predominant cause, suggesting that installing railings could prevent nearly one-fourth of these injuries.

Treatment Methods

Treatment is tailored to the fracture type and severity, guided by the Gartland classification and American Academy of Orthopaedic Surgeons (AAOS) guidelines (AAOS Pediatric Supracondylar Humerus Fractures).

(Closed Reduction and Percutaneous Pinning)

Gartland Type	Treatment	Details
Type I	Non-surgical immobilization	Above-elbow splint or long arm cast at 60-90° flexion for 3 weeks. Avoid circumferential casting to prevent vascular compromise.
Type II	Closed reduction with or without pinning	Reduction followed by casting at 90° or percutaneous pinning if stability requires >90° flexion.
Type III/IV	Closed reduction and percutaneous pinning; open reduction if necessary	Preferred within 24 hours for neurovascular compromise. Open reduction for open fractures, significant swelling, or unstable reduction.

Surgical Techniques

• Closed Reduction and Percutaneous Pinning (CRPP): The standard for displaced fractures, using two or three lateral pins to minimize ulnar nerve injury (0.53% risk vs. 6% with medial pins).
• Open Reduction: Indicated for irreducible fractures, neurovascular compromise, or open fractures. The anterior approach is preferred for extension-type fractures, while the medial approach suits flexion-type fractures.
• Post-treatment: Pins are removed at 3-4 weeks, followed by active range-of-motion exercises. Physical therapy may be needed for persistent contractures (Fracture Supracondylar Humerus: A Review).

AAOS Guidelines

The AAOS recommends:

• Nonsurgical immobilization for non-displaced fractures (Moderate evidence).
• Closed reduction with pin fixation for displaced fractures (Moderate evidence).
• Use of lateral pins to reduce ulnar nerve injury risk (Limited evidence).

Outcomes

With timely treatment, outcomes are generally excellent, particularly for Type I fractures. However, complications can occur:

• Vascular Insufficiency: Radial pulse absent in 6-20% of cases, with brachial artery injury common in Type II/III fractures. Pulse returns in 51% after CRPP, but 97% of persistent cases show artery injury on exploration.
• Neurologic Deficit: Occurs in 10-20% of cases, up to 49% in Type III, mostly neuropraxias resolving in 2-3 months. Median nerve is most affected in posterolateral displacement.
• Compartment Syndrome: Can lead to Volkmann’s ischemic contracture if untreated within 12-24 hours.
• Malunion: Cubitus varus (“gunstock” deformity) is common but reduced from 58% to 3% with modern techniques. It may require humeral osteotomy for correction (Supracondylar Humerus Fractures).

In India, delayed presentation increases complication rates. The rural study noted complications like gangrene and compartment syndrome linked to late treatment, emphasizing the need for public education on avoiding traditional bonesetters (Epidemiologic Pattern Study). Public awareness campaigns are needed to discourage reliance on traditional healers and promote prompt medical care.