Supracondylar humerus fractures are the most common elbow fracture in children, accounting for >50% of all pediatric elbow fractures, with peak incidence at ages 5–7 years. The vast majority (95–99%) are extension-type injuries from a fall on an outstretched hand (FOOSH). [1-3] This is a high-stakes ED diagnosis due to the risk of neurovascular injury and compartment syndrome.
1. History
- Mechanism: Fall on outstretched hand with elbow in extension (most common); direct fall onto flexed elbow (flexion-type, ~5%) [2-3]
- Symptom characterization: Acute elbow pain, swelling, inability to move the arm; child typically holds arm in extension and refuses to flex
- Timing: Acute onset after fall — playground equipment, trampolines, monkey bars are classic settings
- Associated symptoms: Ask about numbness/tingling in fingers (nerve injury), hand color changes (vascular compromise), wrist pain (ipsilateral distal radius fracture in up to 5%) [1]
- Important negatives: Ability to wiggle fingers, hand warmth and color, prior elbow injuries, metabolic bone disease
2. Alarm Features
- White, cold, pulseless hand (Class 3 vascular injury) — surgical emergency requiring immediate closed reduction [2]
- Pink, pulseless hand (Class 2) — urgent reduction with close monitoring; may evolve into Class 3 [2]
- Compartment syndrome: Increasing pain out of proportion, pain with passive finger extension, tense forearm swelling — most devastating complication [2]
- Open fracture (~1% of cases) — requires urgent surgical treatment [2]
- Nerve deficit — especially anterior interosseous nerve (AIN): inability to make "OK" sign, weak thumb IP and index DIP flexion [4-5]
- Ecchymosis of the antecubital fossa (pucker sign) — suggests brachial artery entrapment
3. Medications
- Acute pain management: Weight-based ibuprofen, acetaminophen; intranasal fentanyl for severe pain in the ED
- Procedural sedation: Ketamine or propofol for closed reduction in the ED or OR
- Avoid: Tight circumferential casting in the acute setting (risk of compartment syndrome); aspirin in pediatric patients
- Post-op: Acetaminophen/ibuprofen alternating; opioids rarely needed beyond 24–48 hours
4. Diet
- NPO if surgical intervention anticipated (displaced fractures likely going to OR)
- Adequate calcium and vitamin D for bone healing in the recovery phase
- Hydration important perioperatively
5. Review of Systems
- Neurologic: Numbness, tingling, weakness in hand/fingers — screen all three major nerves (median/AIN, radial, ulnar)
- Vascular: Hand color, warmth, capillary refill
- MSK: Wrist pain (ipsilateral distal radius fracture), shoulder pain (assess for additional injuries)
- Constitutional: Fever (concern for pathologic fracture if atraumatic), weight loss
- Skin: Open wound near elbow (open fracture)
6. Collateral History and Family History
- Witnessed mechanism of injury — important for non-accidental trauma (NAT) screening
- Non-accidental trauma: Inconsistent history, delay in presentation, multiple fractures in various stages of healing, age <18 months with supracondylar fracture should raise suspicion
- Family history of osteogenesis imperfecta or metabolic bone disease
- Social context: Caregiver reliability for follow-up and cast care
7. Risk Factors
- Age 5–7 years (peak incidence due to ligamentous laxity and thin olecranon fossa) [1-2]
- High-energy falls (playground equipment, trampolines)
- Generalized ligamentous laxity / joint hypermobility
- Prior elbow fracture
- No significant gender difference in most studies [2]
8. Differential Diagnosis
- Lateral condyle fracture — tenderness more lateral, different radiographic appearance; important because it requires surgical fixation if displaced >2 mm and has risk of nonunion
- Medial epicondyle fracture — ulnar nerve symptoms, medial tenderness
- Elbow dislocation — obvious deformity, olecranon prominent posteriorly
- Radial head/neck fracture — lateral elbow tenderness, pain with forearm rotation
- Olecranon fracture — posterior tenderness, inability to extend against gravity
- Occult fracture (fat pad sign only) — treat as nondisplaced supracondylar fracture [6]
- Nursemaid's elbow (radial head subluxation) — typically younger children (<5), no swelling, history of traction on arm
- Pathologic fracture — consider if minimal trauma or underlying bone lesion
9. Past Medical History
- Prior elbow fractures or dislocations
- Osteogenesis imperfecta, rickets, or other metabolic bone disease
- Neuromuscular conditions affecting bone density
- Bleeding disorders (relevant for surgical planning)
- Previous surgeries on the affected limb
10. Physical Exam
- Inspection: Swelling, ecchymosis, deformity (S-shaped deformity of the arm), skin integrity (open fracture), antecubital pucker sign
- Vital signs: Tachycardia may indicate pain or blood loss
- Vascular exam (critical):
- Radial and ulnar pulses
- Capillary refill time (<2 seconds normal)
- Hand color and temperature
- Pulse oximetry on affected hand [4]
- Classify as Class 1 (pink, pulsed), Class 2 (pink, pulseless), or Class 3 (white, pulseless) [2]
- Neurologic exam (document before any intervention):
- AIN (branch of median): "OK" sign, thumb IP flexion, index DIP flexion [4]
- Median nerve: Thenar opposition, sensation over palmar thumb/index
- Radial nerve: Wrist/finger extension, sensation dorsal first web space
- Ulnar nerve: Finger abduction/adduction, sensation over small finger
- Palpation: Point tenderness at distal humerus; assess ipsilateral wrist for concomitant distal radius fracture [1]
- Compartment assessment: Forearm firmness, pain with passive finger extension
11. Lab Studies
- Routine labs are generally not indicated for isolated supracondylar fractures
- Pre-operative labs (CBC, type and screen) if surgical intervention planned and per institutional protocol
- Consider CRP/ESR only if concern for pathologic fracture or infection
- Coagulation studies if bleeding disorder suspected
12. Imaging
- First-line: AP and lateral elbow radiographs [3][7]
- Key radiographic findings:
- Posterior fat pad sign: Any visible posterior fat pad on lateral view is pathologic and indicates intra-articular effusion — 76% of children with this sign and no visible fracture have an occult fracture [6]
- Anterior humeral line (AHL): A line drawn along the anterior cortex of the humerus should intersect the middle third of the capitellum; if it passes anterior to the capitellum, posterior displacement is present [7-9]
- Baumann angle: Angle between the humeral shaft and the physis of the lateral condyle on AP view (normal ~72°) [7]
- Fracture line, cortical disruption, displacement pattern (posterolateral vs posteromedial)
- When imaging is unnecessary: If clinical exam is clearly consistent with nursemaid's elbow and successfully reduced
- CT/MRI: Rarely needed; consider if occult fracture suspected and management would change
- Doppler ultrasound: If vascular status uncertain after reduction [4]
The following lateral elbow radiograph demonstrates the classic posterior fat pad sign — any visualization of the posterior fat pad is pathologic and should prompt evaluation for occult fracture: [6][10]
13. Special Tests
- Gartland ClassificationCochrane + 1[2][7]
- Vascular classification (Omid system): [2]
- Class 1: Pink, pulsed → normal
- Class 2: Pink, pulseless → compensated; urgent reduction
- Class 3: White, pulseless → emergent reduction
- Point-of-care ultrasound: Can assess for effusion and vascular flow
- Pulse oximetry on affected hand as adjunct vascular assessment [4]
The following figure illustrates the correlation between Gartland fracture type and vascular complications, with 88% of vascular injuries occurring in Type IV fractures: [4]
14. ECG
- Not routinely indicated for isolated supracondylar fractures
- Obtain if procedural sedation planned (per institutional sedation protocol)
- Consider if polytrauma or hemodynamic instability
15. Assessment
Supracondylar humerus fractures represent a spectrum from benign nondisplaced injuries to limb-threatening emergencies. Key assessment points:
- Severity stratification is driven by the Gartland classification and neurovascular status [2][7]
- Neurovascular injury rates: 5–15% nerve injury and 5–31% vascular injury in displaced fractures. The anterior interosseous nerve is most commonly injured in extension-type fractures (34% of neurapraxias); ulnar nerve predominates in flexion-type injuries (91%) [2][5]
- Nerve injuries resolve spontaneously in the vast majority of cases (mean recovery ~122 days), though 2% may require nerve grafting [4][13]
- Posterolateral displacement → median nerve and brachial artery injury; posteromedial displacement → radial nerve injury [14-15]
- Complications overall ~1%, with compartment syndrome being the most devastating [3]
- Overall functional outcomes are good; physical therapy is generally not necessary [3]
The following treatment algorithm provides a practical decision framework for managing vascular compromise in supracondylar fractures: [16]
16. Treatment Plan
Initial stabilization (ED):
- Immobilize in a well-padded posterior long arm splint at 60–90° of flexion — avoid hyperflexion (risk of vascular compromise) [2][12]
- Ice, elevation, analgesia
- Serial neurovascular checks every 30–60 minutes
- If vascular compromise (Class 2 or 3): immediate gentle closed reduction with inline traction before any imaging delays [1]
Definitive management by Gartland type:
- Type I: Long arm cast or splint for 3–5 weeks; orthopedic follow-up within 1 week [2][7]
- Type IIA (angulation only, no rotation): Nonoperative management with close radiographic follow-up is reasonable (~90% success rate); casting in 60–90° flexion [11]
- Type IIB–IV: Closed reduction and percutaneous K-wire pinning (CRPP) is the gold standard [7][12][17]
- Lateral divergent pins reduce ulnar nerve injury risk (vs crossed pins) but have slightly higher loss-of-fixation rate [7][12]
- K-wires removed at 3–6 weeks after radiographic consolidation [7]
- Type III fractures: surgery recommended within 12–18 hours [1]
Vascular compromise management: [1][18]
- Class 3 (white, pulseless): Surgical emergency — immediate closed reduction in OR
- Class 2 (pink, pulseless): Urgent closed reduction → if pulse returns, observe; if hand remains pink but pulseless after reduction, close monitoring is acceptable
- Persistent ischemia after reduction → open exploration of brachial artery in antecubital fossa
17. Disposition
- Admit (orthopedic consultation):
- All displaced fractures (Gartland II with rotation, III, IV) [1]
- Any neurovascular compromise [1]
- Open fractures
- Significant swelling with concern for evolving compartment syndrome
- Inability to obtain timely orthopedic follow-up
- Concern for non-accidental trauma
- Discharge (with orthopedic follow-up):
- Gartland Type I fractures with intact neurovascular exam, adequate splinting, and reliable caregivers
- Type IIA fractures after successful reduction and splinting with close follow-up arranged within 5–7 days [11]
- Outpatient surgery: Type 3M fractures (with metaphyseal contact) may behave like Type II injuries and can be considered for outpatient surgical management [19]
18. Follow Up / Return Precautions
- Follow-up timing:
- Type I: Orthopedic follow-up within 5–7 days for repeat radiographs
- Post-operative: Follow-up at 3 weeks for radiographic assessment of reduction; K-wire removal at 3–6 weeks [7]
- Post-mobilization: Early discharge from clinic is feasible for uncomplicated fractures if no stiffness or functional deficit at cast removal [20]
- Return precautions (counsel families):
- Increasing pain, especially with passive finger extension (compartment syndrome)
- Color change of hand/fingers — pallor, cyanosis, or mottling
- Numbness or tingling in fingers, new weakness
- Swelling that worsens or causes the cast/splint to feel too tight
- Fever, drainage, or foul smell from cast (infection)
- Cast damage or loosening
- Expected recovery: 3–6 weeks immobilization → gentle return to activity → 2–3 months for full functional recovery; formal physical therapy is generally not necessary [2-3]
- Long-term considerations: Monitor for cubitus varus (gunstock deformity), which is the most common late complication from malunion [2]
References
1. Best Practices In The Management Of Orthopaedic Trauma. — Matthew L. Davis MD FACS, Gregory J. Della Rocca MD PhD FACS, Megan Brenner MD MS RPVI FACS, et al American College of Surgeons (2015). 2015.
2. Best Practices In The Management Of Orthopaedic Trauma. — Matthew L. Davis MD FACS, Gregory J. Della Rocca MD PhD FACS, Megan Brenner MD MS RPVI FACS, et al American College of Surgeons (2015). 2015.
3. Best Practices In The Management Of Orthopaedic Trauma. — Matthew L. Davis MD FACS, Gregory J. Della Rocca MD PhD FACS, Megan Brenner MD MS RPVI FACS, et al American College of Surgeons (2015). 2015.
4. Interventions for Treating Supracondylar Elbow Fractures in Children. — Marson BA, Ikram A, Craxford S, et al. The Cochrane Database of Systematic Reviews. 2022.
5. Interventions for Treating Supracondylar Elbow Fractures in Children. — Marson BA, Ikram A, Craxford S, et al. The Cochrane Database of Systematic Reviews. 2022.
6. Supracondylar Humeral Fractures in Children: Current Concepts for Management and Prognosis. — Zorrilla S de Neira J, Prada-Cañizares A, Marti-Ciruelos R, Pretell-Mazzini J. International Orthopaedics. 2015.
7. Supracondylar Humeral Fractures in Children: Current Concepts for Management and Prognosis. — Zorrilla S de Neira J, Prada-Cañizares A, Marti-Ciruelos R, Pretell-Mazzini J. International Orthopaedics. 2015.
8. Analysis of Early Neurovascular Complications of Pediatric Supracondylar Humerus Fractures: A Long‐Term Observation. — Tomaszewski R, Wozowicz A, Wysocka-Wojakiewicz P. BioMed Research International. 2016.
9. Analysis of Early Neurovascular Complications of Pediatric Supracondylar Humerus Fractures: A Long‐Term Observation. — Tomaszewski R, Wozowicz A, Wysocka-Wojakiewicz P. BioMed Research International. 2016.
10. Nerve Injuries Associated With Pediatric Supracondylar Humeral Fractures: A Meta-Analysis. — Babal JC, Mehlman CT, Klein G. Journal of Pediatric Orthopedics. 2010.
11. Nerve Injuries Associated With Pediatric Supracondylar Humeral Fractures: A Meta-Analysis. — Babal JC, Mehlman CT, Klein G. Journal of Pediatric Orthopedics. 2010.
12. The Posterior Fat Pad Sign in Association With Occult Fracture of the Elbow in Children. — Skaggs DL, Mirzayan R. The Journal of Bone and Joint Surgery. American Volume. 1999.
13. The Posterior Fat Pad Sign in Association With Occult Fracture of the Elbow in Children. — Skaggs DL, Mirzayan R. The Journal of Bone and Joint Surgery. American Volume. 1999.
14. Pinning of Supracondylar Fractures in Children - Strategies to Avoid Complications. — Rupp M, Schäfer C, Heiss C, Alt V. Injury. 2019.
15. Pinning of Supracondylar Fractures in Children - Strategies to Avoid Complications. — Rupp M, Schäfer C, Heiss C, Alt V. Injury. 2019.
16. Plastic Bowing, Torus and Greenstick Supracondylar Fractures of the Humerus: Radiographic Clues to Obscure Fractures of the Elbow in Children. — Rogers LF, Malave S, White H, Tachdjian MO. Radiology. 1978.
17. Plastic Bowing, Torus and Greenstick Supracondylar Fractures of the Humerus: Radiographic Clues to Obscure Fractures of the Elbow in Children. — Rogers LF, Malave S, White H, Tachdjian MO. Radiology. 1978.
18. Clinical Significance of Anterior Humeral Line in Supracondylar Humeral Fractures in Children. — Kao HK, Lee WC, Yang WE, Chang CH. Injury. 2016.
19. Clinical Significance of Anterior Humeral Line in Supracondylar Humeral Fractures in Children. — Kao HK, Lee WC, Yang WE, Chang CH. Injury. 2016.
20. — Voio Voio Radiology Database.
21. — Voio Voio Radiology Database.
22. Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients. — Sanders JS, Ouillette RJ, Howard R, et al. Journal of Pediatric Orthopedics. 2023.
23. Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients. — Sanders JS, Ouillette RJ, Howard R, et al. Journal of Pediatric Orthopedics. 2023.
24. The Treatment of Displaced Supracondylar Humerus Fractures: Evidence-Based Guideline. — Mulpuri K, Wilkins K. Journal of Pediatric Orthopedics. 2012.
25. The Treatment of Displaced Supracondylar Humerus Fractures: Evidence-Based Guideline. — Mulpuri K, Wilkins K. Journal of Pediatric Orthopedics. 2012.
26. Nerve Injury Severity and Outcomes: An Analysis of Supracondylar Humeral Fractures. — Balogun OT, Anthony A, Dealy J, et al. JB & JS Open Access. 2025.
27. Nerve Injury Severity and Outcomes: An Analysis of Supracondylar Humeral Fractures. — Balogun OT, Anthony A, Dealy J, et al. JB & JS Open Access. 2025.
28. Neurovascular Injuries in Type III Humeral Supracondylar Fractures in Children. — Lyons ST, Quinn M, Stanitski CL. Clinical Orthopaedics and Related Research. 2000.
29. Neurovascular Injuries in Type III Humeral Supracondylar Fractures in Children. — Lyons ST, Quinn M, Stanitski CL. Clinical Orthopaedics and Related Research. 2000.
30. Neurovascular Injury and Displacement in Type III Supracondylar Humerus Fractures. — Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Journal of Pediatric Orthopedics. 1995.
31. Neurovascular Injury and Displacement in Type III Supracondylar Humerus Fractures. — Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Journal of Pediatric Orthopedics. 1995.
32. Supracondylar Humerus Fractures. — Ravi Brar, David Skaggs, Sanjeev Sabharwal Evidence‐Based Orthopedics, 2nd Edition. 2021.
33. Supracondylar Humerus Fractures. — Ravi Brar, David Skaggs, Sanjeev Sabharwal Evidence‐Based Orthopedics, 2nd Edition. 2021.
34. The Treatment of Pediatric Supracondylar Humerus Fractures. — Howard A, Mulpuri K, Abel MF, et al. The Journal of the American Academy of Orthopaedic Surgeons. 2012.
35. The Treatment of Pediatric Supracondylar Humerus Fractures. — Howard A, Mulpuri K, Abel MF, et al. The Journal of the American Academy of Orthopaedic Surgeons. 2012.
36. Acute Ischemia and Pink Pulseless Hand in 68 of 404 Gartland Type III Supracondylar Humeral Fractures in Children: Urgent Management and Therapeutic Consensus. — Louahem D, Cottalorda J. Injury. 2016.
37. Acute Ischemia and Pink Pulseless Hand in 68 of 404 Gartland Type III Supracondylar Humeral Fractures in Children: Urgent Management and Therapeutic Consensus. — Louahem D, Cottalorda J. Injury. 2016.
38. Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery. — Hockensmith LH, Muffly BT, Wattles MR, et al. Journal of Pediatric Orthopedics. 2021.
39. Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery. — Hockensmith LH, Muffly BT, Wattles MR, et al. Journal of Pediatric Orthopedics. 2021.
40. Pediatric Supracondylar Humerus Fractures: The Utility of Post-Mobilization Follow-Up. — Tung WS, Muñoz T, Tan LYT, et al. Journal of Pediatric Orthopedics. 2025.
41. Pediatric Supracondylar Humerus Fractures: The Utility of Post-Mobilization Follow-Up. — Tung WS, Muñoz T, Tan LYT, et al. Journal of Pediatric Orthopedics. 2025.