Supracondylar fracture (pediatric and adult)MANAGEMENT

ARM & ELBOW · 12 SECTIONS

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605 items

☷ Legend

01Approach to the Critical Patient/attcp53

Immediate priorities

›Immediate priorities

›Limb threat screen

›Pulseless or poorly perfused hand

›If absent pulse with cool or pale hand, immediate reduction and splinting

›Severe pain out of proportion

›If escalating pain despite immobilization and analgesia, compartment syndrome pathway

›Neurovascular documentation checkpoints

›Pre-splint baseline

›Radial pulse

›Capillary refill

›Hand temperature and color

›Median nerve sensation

›Ulnar nerve sensation

›Radial nerve sensation

›Anterior interosseous nerve motor

›Ulnar motor

›Radial motor

›Post-splint reassessment

›Same neurovascular set repeated

›Consultation and escalation triggers

›Pulseless limb after reduction

›Immediate orthopedics and vascular surgery

›Open fracture

›Antibiotics and tetanus pathway

›Urgent orthopedics

›Skin tenting or threatened skin

›Urgent reduction

›Evolving neurologic deficit

›Urgent orthopedics

Limb threat framework

›Limb threat framework

›Vascular injury risk focus

›Brachial artery tethering risk in pediatric extension type

›High suspicion with absent pulse or cool hand

›Collateral flow possibility

›Pink pulseless hand as collateral perfusion scenario

›Compartment syndrome risk

›Forearm compartment syndrome association

›Increased risk with vascular compromise and swelling

›Volkmann ischemic contracture risk

›Prolonged ischemia and reperfusion injury

Open fracture pathway

›Open fracture pathway

›Open injury recognition

›Any wound near elbow treated as open until proven otherwise

›Puncture wound

›Bleeding at deformity apex

›Immediate contamination control

›Sterile saline moistened dressing

›No probing in ED

›Antibiotics and tetanus timing

›Antibiotics as early as feasible

›Target within 60 minutes when possible

›Transfer logic

›If pediatric pinning or vascular capability unavailable, transfer early

02History/hx57

Mechanism and trajectory

›Mechanism and trajectory

›Injury pattern mapping

›Pediatric FOOSH with elbow extension

›Extension type supracondylar most common

›Direct blow or flexion mechanism

›Flexion type less common

›Adult high energy trauma

›MVC

›Fall from height

›Osteoporotic low energy fall

›Time factors

›Time since injury

›Swelling trajectory

›Prior reduction attempt

›Bystander manipulation

›Outside facility splinting

›Functional baseline

›Hand dominance

›Work and sport demands

›Baseline elbow ROM limitations

›Prior injury or arthritis

Symptoms and red flags

›Symptoms and red flags

›Neurovascular symptoms

›Hand numbness or tingling

›Median distribution

›Ulnar distribution

›Radial distribution

›Hand weakness

›Pinch weakness

›Finger extension weakness

›Ischemia and compartment risk symptoms

›Increasing pain despite immobilization

›Pain with passive finger extension

›Increasing tightness or swelling

›Forearm pressure sensation

›Cool or pale hand

›Delayed cap refill report

›Open fracture indicators

›Wound, bleeding, or puncture at elbow

›Contamination context

Patient factors

›Patient factors

›Bleeding and perioperative risk

›Anticoagulants

›DOAC timing last dose

›Warfarin and INR context

›Bleeding disorder history

›Hemophilia

›Bone health and healing risk

›Osteoporosis or fragility fracture history

›Prior low energy fractures

›Chronic steroid use

›Dose and duration

›Pediatric safeguarding

›Nonaccidental trauma concern

›Inconsistent mechanism

›Delay to presentation

›Additional injuries history

03Physical Exam/exam61

General and local exam

›General and local exam

›Global assessment

›Pain control adequacy

›Agitation limiting exam

›Hemodynamic stability in high energy trauma

›Polytrauma screening

›Elbow and limb inspection

›Deformity pattern

›S shaped elbow contour

›Swelling and ecchymosis

›Rapidly expanding swelling

›Skin integrity

›Tenting and blanching

›Fracture blisters

›Wound consistent with open fracture

›Palpation focus

›Supracondylar tenderness

›Medial column tenderness

›Lateral column tenderness

›Forearm compartment firmness

›Volar compartment

›Dorsal compartment

Neurovascular exam

›Neurovascular exam

›Vascular

›Radial pulse

›Palpable vs Doppler only

›Capillary refill

›Greater than 2 seconds concern

›Hand color and temperature

›Pale and cool concern

›Pink warm but pulseless scenario

›Motor

›Anterior interosseous nerve

›Thumb IP flexion

›Index DIP flexion

›Median nerve

›Thumb opposition

›Ulnar nerve

›Finger abduction and adduction

›Radial nerve

›Wrist extension

›Finger MCP extension

›Sensory

›Median

›Volar index finger

›Ulnar

›Volar small finger

›Radial

›Dorsal first web space

›Documentation timing

›Before analgesia and splinting when possible

›Baseline deficits flagged as pre-existing vs evolving

›After reduction and immobilization

›Any change triggers escalation

PITFALLS

›PITFALLS

›Pain and swelling masking evolving ischemia

›Frequent reassessment within ED stay

›Sedation or opioids blunting compartment syndrome symptoms

›Maintain suspicion with worsening swelling and pain with passive stretch

›Missed ipsilateral forearm fractures

›Floating elbow pattern in pediatrics

04Differential Diagnosis/ddx38

Primary and mimics

›Primary and mimics

›Supracondylar fracture of humerus

›Pediatric extension type

›Pediatric flexion type

›Adult extra-articular distal humerus fracture

›Elbow dislocation

›Posterior dislocation

›Fracture dislocation complex

›Lateral condyle fracture in pediatrics

›Salter-Harris involvement possibility

›Medial epicondyle avulsion in pediatrics

›Associated with dislocation

›Radial head or neck fracture

›Occult fracture with fat pad sign

›Olecranon fracture

›Triceps mechanism involvement

Threatening associated injuries

›Threatening associated injuries

›Brachial artery injury

›Thrombosis

›Intimal tear

›Transection

›Nerve injury

›Anterior interosseous neuropraxia

›Median neuropraxia

›Radial neuropraxia

›Ulnar neuropraxia

›Compartment syndrome

›Forearm compartments

›Polytrauma conditions in adults

›Head injury

›Thoracoabdominal injury

Coding alignment

›Coding alignment

›ICD-10-CM

›S42.4 fracture of lower end of humerus category

›Laterality and encounter type coding required

›SNOMED CT

›Supracondylar fracture of humerus concept

›Pediatric vs adult context specified in documentation

05Laboratory Tests/lt27

Routine labs

›Routine labs

›No routine labs in isolated closed stable fracture

›Exception for procedural sedation pathway

›Procedural sedation baseline tests

›Point of care glucose if altered mental status risk

›Hypoglycemia exclusion

›Pregnancy test when relevant

›Imaging and medication planning

Trauma and operative pathway labs

›Trauma and operative pathway labs

›Open fracture or planned OR

›Complete blood count

›Baseline hemoglobin for bleeding risk

›Electrolytes and creatinine

›Renal function for medication selection

›Anticoagulation context

›INR for warfarin

›Reversal planning if urgent surgery

›Rhabdomyolysis or crush concern

›Creatine kinase

›Trend if prolonged ischemia concern

›Potassium

›Reperfusion risk

Limitations and interpretation

›Limitations and interpretation

›Normal labs do not exclude vascular injury

›Clinical perfusion exam remains primary

›Creatine kinase lag early in ischemia

›Clinical compartment signs prioritized

06Diagnostic Tests/dt58

Scoring Systems

›Scoring systems

›Pediatric Gartland classification

›Type I

›Nondisplaced

›Typically nonoperative immobilization

›Type II

›Displaced with intact posterior cortex hinge

›Often operative fixation depending on stability and alignment

›Type III

›Completely displaced

›Operative fixation typical

›Type IV

›Multidirectional instability

›Operative fixation typical

›Adult fracture classification

›AO OTA distal humerus extra-articular patterns

›Surgical planning framework

›Higher operative rate in displaced patterns

Radiographs

›Radiographs

›Initial imaging views

›Elbow AP

›Distal humerus alignment

›Elbow lateral

›Anterior humeral line assessment

›Oblique views when needed

›Column involvement clarification

›Alignment and key signs

›Anterior humeral line

›Should intersect middle third of capitellum in many children

›Anterior intersection suggests extension type displacement

›Baumann angle on AP

›Varus risk assessment

›Fat pad sign on lateral

›Posterior fat pad suggests intra-articular effusion and occult fracture

›Post-reduction films

›Required after any manipulation

›Alignment confirmation

›Hardware position if pinned

MRI

›MRI

›Indications

›Persistent clinical suspicion with negative radiographs

›Occult fracture evaluation

›Suspected ligamentous injury without clear fracture

›Adult elbow instability assessment

›Limitations

›Limited acute availability in ED

›Not first-line for typical supracondylar fracture

›Need for sedation in younger children

›Risk-benefit consideration

›CT

›Indications

›Adult complex distal humerus fracture suspicion

›Articular extension evaluation

›Preoperative planning in markedly displaced adult patterns

›Fragment mapping

›Limitations

›Not required for typical pediatric supracondylar pattern

›Radiographs usually sufficient

07Disposition/dispo37

Consult, admit, transfer

›Consult, admit, transfer

›Immediate orthopedics

›Gartland II with instability features

›Poor alignment after splinting

›Rotation or translation concerns

›Gartland III or IV

›Operative fixation typical

›Adult displaced supracondylar distal humerus fracture

›Operative management common

›Emergent escalation

›Pulseless limb

›Immediate reduction and orthopedics

›Persistent ischemia after reduction

›Vascular surgery involvement

›Compartment syndrome concern

›Emergent surgical evaluation

›Transfer criteria

›Pediatric operative capability not available

›Transfer prior to repeated reduction attempts

›Vascular repair capability not available

›Transfer after initial stabilization and splinting

Discharge and follow-up

›Discharge and follow-up

›Discharge criteria

›Gartland I pediatric

›Neurovascularly intact

›Pain controlled

›Reliable follow-up

›Adult nondisplaced stable pattern

›Neurovascularly intact

›Splinted with clear plan

›Follow-up timing

›Pediatric Gartland I

›Ortho follow-up within 5 to 7 days

›Any reduced fracture

›Ortho follow-up within 24 to 72 hours based on local practice

›Adult displaced pattern

›Ortho follow-up within 24 to 72 hours or admission for OR

08Treatment/t130

Immediate life-saving interventions

›Immediate life-saving interventions

›Limb perfusion restoration

›If pulseless or poorly perfused hand, immediate gentle reduction attempt

›Traction with countertraction

›Avoid forceful repeated attempts

›Constriction relief

›Ring and jewelry removal

›Prevent venous congestion

›Vascular compromise monitoring

›If perfusion concern, continuous reassessment while awaiting orthopedics

›Cap refill trend

›Doppler pulse trend

Immobilization and Splinting

›Immobilization and splinting

›Splint selection

›Posterior long arm splint

›Most common initial immobilization for supracondylar fractures

›Sugar tong alternative in selected patterns

›When forearm rotation control needed

›Positioning principles

›Elbow flexion degree individualized to perfusion and swelling

›Avoid excessive flexion if vascular status tenuous

›Forearm neutral rotation

›Comfort and nerve protection

›Post-immobilization checks

›Neurovascular reassessment documented

›Motor and sensory

›Pulse and cap refill

›Swelling-phase casting caution

›No circumferential cast in acute swelling phase

›Compartment risk mitigation

Reduction

›Reduction

›Indications

›Neurovascular compromise

›Absent pulse

›Poor perfusion

›Threatened skin

›Tenting or blanching

›Marked displacement

›Deformity interfering with splinting and perfusion checks

›Contraindications or caution triggers

›Suspected vascular injury requiring immediate specialist involvement

›Expanding hematoma at antecubital fossa

›Open fracture

›Antibiotics and tetanus pathway prioritized when feasible

›Pediatric physeal concern

›Gentle technique

›Analgesia and anesthesia options

›Non-opioid baseline

›Acetaminophen PO 15 mg/kg

›Maximum 1000 mg per dose

›Ibuprofen PO 10 mg/kg

›Maximum 600 mg per dose

›Opioid titration

›Morphine IV 0.05 mg/kg

›Repeat every 10 minutes to effect

›Typical single dose cap 0.1 mg/kg

›Fentanyl IV 1 mcg/kg

›Repeat 0.5 to 1 mcg/kg every 5 to 10 minutes to effect

›Procedural sedation

›Ketamine IV 1 to 2 mg/kg

›Additional 0.5 mg/kg every 5 to 10 minutes as needed

›Continuous cardiorespiratory monitoring

›Propofol IV 0.5 to 1 mg/kg

›Additional 0.25 to 0.5 mg/kg every 1 to 3 minutes as needed

›Airway capable team and resuscitation readiness

›Nitrous oxide where available

›Suitable for cooperative older child or adult

›Avoid if significant injury complexity or aspiration risk

›Regional anesthesia

›Hematoma block generally not favored for supracondylar region

›Neurovascular risk considerations

›Reduction technique principles

›Traction and countertraction

›Gentle sustained longitudinal traction

›Deformity exaggeration when needed

›Disengagement of fragments before correction

›Reverse mechanism

›Extension type

›Flexion type

›Attempt limits

›Avoid repeated forceful attempts

›If unsuccessful, urgent orthopedics

›Post-reduction requirements

›Immediate neurovascular reassessment

›Document any change from baseline

›Immobilization in stable position

›Avoid excessive flexion if swelling

›Post-reduction radiographs

›Alignment confirmation

›Failed reduction pathway

›Persistent deficit

›Immediate orthopedics

›Persistent ischemia

›Vascular surgery and urgent operative pathway

›Worsening pain and tense compartments

›Compartment syndrome escalation

Open fracture medications and timing

›Open fracture medications and timing

›Antibiotics

›Cefazolin IV 30 mg/kg

›Maximum 2000 mg per dose

›Typical interval every 8 hours

›If severe beta-lactam allergy, clindamycin IV 10 mg/kg

›Maximum 900 mg per dose

›Typical interval every 8 hours

›If heavy contamination or farm injury, add gram negative coverage per local protocol

›Early ortho discussion

›Tetanus prophylaxis

›Immunization up to date and clean minor wound

›No booster if within 10 years

›Dirty wound or open fracture

›Booster if more than 5 years since last dose

›Unknown or incomplete immunization

›Tetanus immune globulin plus vaccine series

›Wound care

›Saline irrigation as feasible without delaying OR

›No aggressive debridement in ED

›Sterile dressing and splinting

›Hemorrhage control

DVT prophylaxis when relevant

›DVT prophylaxis when relevant

›Typical risk profile

›Upper extremity immobilization alone usually low risk

›Pharmacologic prophylaxis usually not indicated

›Consider prophylaxis in high risk adult contexts

›Prolonged immobilization and reduced mobility

›Multiple trauma

›Prior venous thromboembolism

›Hematology or internal medicine guidance

›Documentation

›Rationale for prophylaxis decision

›Bleeding risk context

09Special Populations/sp42

Pregnancy

›Pregnancy

›Imaging considerations

›Plain radiographs low fetal dose with shielding

›Maternal stabilization prioritized

›CT only if needed for complex adult injury planning

›Dose minimization strategy

›Analgesia and sedation

›Acetaminophen preferred baseline

›NSAID trimester considerations per local guidance

›Opioid minimal effective dosing

›Maternal respiratory monitoring

›Disposition threshold

›Lower threshold for observation with trauma

›Abdominal symptoms or high energy mechanism triggers obstetric involvement

Geriatric

›Geriatric

›Mechanism context

›Fragility fracture possibility

›Fall from standing

›Osteoporosis and bone quality

›Higher displacement risk

›Pain and delirium risk

›Opioid sensitivity

›Start low and titrate

›Delirium prevention

›Avoid polypharmacy when possible

›Operative risk and planning

›Displaced distal humerus patterns often operative

›Early ortho involvement

Pediatrics

›Pediatrics

›Neurovascular injury patterns

›Anterior interosseous neuropraxia common association

›Pinch motor testing emphasized

›Brachial artery compromise risk

›Perfusion exam repeated after splinting

›Remodeling and alignment

›Malunion risk

›Cubitus varus as functional and cosmetic complication

›Displaced patterns often require pinning

›Time sensitive operative planning

›Safeguarding

›Nonaccidental trauma consideration in atypical context

›Documentation of mechanism consistency

10Background/b47

Epidemiology

›Epidemiology

›Pediatric incidence context

›Common elbow fracture in children

›Peak in school age range

›Mechanism distribution

›Extension type predominance

›FOOSH mechanism common

›Adult distribution

›Less common than pediatric

›Higher association with high energy trauma

Pathophysiology

›Pathophysiology

›Anatomy and vulnerability

›Distal humerus supracondylar region thin cortex in children

›Fracture through metaphyseal bone

›Brachial artery proximity

›Anterior tethering with extension displacement

›Median and anterior interosseous nerve proximity

›Neuropraxia risk with displacement

›Injury mechanics

›Extension type

›Distal fragment posterior displacement tendency

›Flexion type

›Distal fragment anterior displacement tendency

›Complications mechanism

›Malunion

›Varus deformity from medial column collapse

›Ischemia and reperfusion

›Volkmann contracture pathway

Therapeutic Considerations

›Therapeutic considerations

›Immobilization rationale

›Pain control and soft tissue protection

›Swelling accommodation in splint

›Reduction rationale

›Perfusion restoration

›Brachial artery decompression and alignment

›Skin protection

›Relieve tenting and prevent necrosis

›Operative rationale

›Pediatric displaced patterns

›Percutaneous pinning reduces malunion risk

›Adult displaced patterns

›ORIF for alignment and elbow function restoration

›Evidence framing

›Pediatric Gartland III and IV commonly treated with closed reduction and percutaneous pinning

›Standard orthopedic practice consensus

›Pink pulseless hand management variable

›Perfusion based decision making with specialist involvement

11Patient Discharge Instructions/pdi41

copy discharge instructions

›copy discharge instructions

›Splint care

›Keep splint clean and dry

›Cover for bathing

›Do not insert objects inside splint

›Skin injury risk

›Swelling control

›Elevation above heart level

›First 48 hours emphasized

›Ice over splint if permitted

›15 to 20 minutes at a time

›Activity restrictions

›No lifting with injured arm

›Keep in sling as instructed

›Finger motion encouraged if allowed

›Prevent stiffness and swelling

›Pain plan

›Acetaminophen as directed

›Do not exceed daily maximum

›Ibuprofen as directed if safe

›Avoid if contraindicated

›Opioid only if prescribed

›No driving or alcohol

›Return to ED now

›Increasing pain not relieved by medication

›Especially pain with finger movement

›New numbness or weakness in hand

›Trouble moving fingers

›Fingers becoming pale, blue, or cold

›Cap refill slowing

›Increasing tightness or swelling in forearm or hand

›Splint feeling too tight

›Wet, damaged, or slipping splint

›Loss of support

›Fever or wound drainage

›Open injury concern

›Follow-up

›Orthopedics appointment as directed

›Bring copies of imaging if applicable

›If no appointment arranged, contact orthopedics within 1 to 2 business days

›Pediatric displaced injuries require urgent follow-up

12References/r14

Clinical guidelines and evidence sources

›Clinical guidelines and evidence sources

›AAOS clinical practice guidance relevant to pediatric elbow fractures when available

›Operative indications aligned with displacement and neurovascular status

›Pediatric orthopedic society resources

›POSNA educational guidance for supracondylar humerus fracture management

›Procedural sedation guidance

›ACEP procedural sedation policy for ED sedation safety and monitoring

›Trauma framework

›ATLS principles for high energy injury and associated trauma evaluation

›Evidence and outcomes themes

›Displaced pediatric supracondylar fractures commonly managed with closed reduction and percutaneous pinning to reduce malunion

›Consensus and broad observational evidence base in pediatric orthopedics

›File reference

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Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

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