›Elbow flexion 60 to 90 degrees
›Forearm in neutral rotation
›Duration 3 to 5 weeks
›Avoid circumferential cast in acute swelling phase
›Risk of compartment syndrome
›Bivalve or splint until swelling resolves
›Collar-and-cuff alternative
›Appropriate for minimally displaced fractures
›Gravity assists in maintenance of reduction
Closed reduction and percutaneous pinning (CRPP)
›CRPP indications
›Gartland Type IIB, III, and IV fractures
›Standard of care for displaced supracondylar fractures
›Cochrane SR: CRPP superior to casting for displaced injuries
›Technique principles
›Fluoroscopy-guided reduction in OR
›General anesthesia typically used in children
›Reduction maintained with percutaneous Kirschner wires
›Pin configuration options
›Lateral-only divergent pins
›Reduces ulnar nerve injury risk compared to crossed pins
›Slightly higher loss-of-fixation rate than crossed configuration
›Preferred technique in many centers
›Crossed pins (lateral plus medial)
›Greater rotational stability
›Ulnar nerve injury risk with medial pin
›Medial mini-incision reduces but does not eliminate ulnar nerve risk
›K-wire removal
›3 to 6 weeks after radiographic consolidation
›Clinic or office procedure under local anesthesia
Open reduction indications
›Open reduction triggers
›Irreducible fracture after attempted closed reduction
›Soft tissue interposition — muscle or brachialis tendon
›Pucker sign predicts need for open approach
›Vascular injury requiring exploration
›Persistent ischemia after reduction
›Brachial artery repair or vascular bypass
›Open fracture
›Wound irrigation and debridement
›Antibiotic coverage with cefazolin 50 mg/kg IV
Vascular injury management
›Class 2 (pink, pulseless) management
›Urgent closed reduction in OR
›If pulse returns and hand remains pink — observe closely
›Post-reduction Doppler assessment of brachial artery
›If pink, pulseless but perfused after reduction
›Close monitoring is acceptable per expert consensus
›Louahem and Cottalorda, Injury 2016
›Class 3 (white, pulseless) management
›Surgical emergency — immediate OR
›Reduction performed first
›Persistent ischemia after reduction — open brachial artery exploration
›Vascular surgery involvement for repair
›Vein graft if arterial damage extensive
›Open fracture prophylaxis
›Cefazolin IV
›50 mg/kg IV every 8 hours (max 2 g per dose)
›First generation cephalosporin for gram-positive coverage
›Initiated in ED and continued perioperatively
›Cefazolin allergy — clindamycin IV
›10 mg/kg IV every 8 hours (max 600 mg per dose)
›Duration: 24 hours post wound closure for most cases