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Paediatric Orthopaedic Pathways
Paediatric Orthopaedic Pathways

Supracondylar fractures

ED Management | Outpatient/Fracture Clinic Management | Operative Management


Type 2 supracondylar fracture pathway pilot
Consent to treatment form

ED Management

The following information is for use by medical practitioners and trainees in the Emergency Department  

1.   Treatment Pathway  
2.   What are likely findings on history?
3.   What specific information from the patient history should be documented?
4.   What are likely findings on clinical exam?
5.   What specific findings on the physical exam are important to document?
6.   What X-rays should be ordered?
7.   What specific features are found on X-ray?
8.   How should this fracture be treated in the emergency department?
9.   Should this patient be referred urgently to the nearest orthopaedic surgery service on call?
10. Where should this patient be seen for follow-up care?
11. What discharge prescriptions and instructions should be provided?
12. What potential complications could result from this injury or its management?

1. Treatment Pathway

Fracture type 

ED management

Follow-up care

Type 1

  • Analgesia
  • No reduction needed
  • Long-arm backslab with the elbow flexed to 90° and broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Provide SickKids Parent Information sheets- Supracondylar humerus fracture without displacement (PDF) and Cast Care: Arm or Leg (PDF)

 

  • Follow up in Fracture Clinic in 1 week
  • No repeat X-rays needed
  • Remove backslab at home at 3 weeks and begin gentle range of motion exercises
  • Avoid high-risk activities for 12 weeks following injury

Type 2, 3, and Flexion

     

  • Analgesia
  • Long-arm backslab to splint elbow in position of comfort
  • Keep NPO
  • Urgent referral to nearest orthopaedic surgeon on call for closed reduction and percutaneous pinning
  • To be determined by treating orthopaedic surgeon

 

2. What are likely findings on history?

Mechanism of injury is usually a fall onto an outstretched hand. Monkeybars are common culprits.  Though not often provided on history, hyperextension of the arm during the injury is common.

3. What specific information from the patient history should be documented?

    • Document the date and time of injury
    • Document the time of the last oral intake (all patients should be kept fasting until a decision has been made regarding the need and timing of orthopaedic intervention)

4. What are likely findings on clinical exam?

    • Pain and swelling at the elbow. It is always important to use the uninjured arm as a comparison as swelling around the elbow can be subtle in undisplaced fractures
    • Severely displaced fractures can have:
      • Bruising or skin tenting anteriorly
      • Marked extension deformity at the elbow
      • In-to-out puncture wounds anteriorly
      • Anterior Interosseous nerve, Median nerve proper, radial or ulna nerve palsies
      • Absent radial pulse and cool hand
      • Symptoms of compartment syndrome

5. What specific findings on the physical exam are important to document?

    • The presence of skin tenting or fracture blisters
    • The presence of an open fracture (splints placed at outside institutions should be taken down if there is any suspicion of an open fracture to allow adequate inspection of the overlying skin)
    • The presence of a peripheral nerve injury using the SickKids Peripheral Neurovascular Checklist (PDF)
    • The presence of an arterial injury or limb ischemia using the SickKids Peripheral Neurovascular Checklist (PDF)
    • The presence of signs or symptoms of compartment syndrome
    • The presence of an injury to the joints or bones above and below the injury (two-level injuries are at increased risk of developing compartment syndrome)

6. What X-rays should be ordered?

After splinting the elbow and providing analgesia, AP and lateral elbow x-rays should be ordered. If there are concerns of adjacent injuries above or below the elbow, additional radiographs may be warranted.   

7. What specific features are found on X-rays?

If you are unfamiliar with interpreting elbow radiographs, or need a refresher, click here.

Supracondylar humerus fractures can be classified using the Gartland Classification. Using a lateral radiograph, this classification system uses the relationship of the anterior humeral line and the capitellum to assign severity. A true lateral radiograph must be used.

 

 

In type 1 fractures, the anterior humeral line passes through the middle third of the capitellum on the lateral radiograph. An undisplaced fracture line through the distal humerus and/or a posterior fat pad sign may be present. A faint fracture line can sometimes be appreciated on the AP radiograph. 


 

 

 

In type 2 fractures, the anterior humeral line passes anterior to the middle third of the capitellum on the lateral radiograph or may even miss the capitellum completely. However, there is still a posterior hinge present. A distinct fracture line is seen on the AP radiograph.


 

 

 

In type 3 fractures, the anterior humeral line misses the capitellum completely and there is 100 per cent displacement on the lateral radiograph,. The distal fragment can be superimposed on the proximal fragment on the AP radiograph.


 

 

In type 4 or flexion type fractures, the anterior humeral line passes posterior to the middle third of the capitellum on the lateral radiographs.

8. How should this fracture be treated in the emergency department?

    • Type 1:
      • Analgesia:  
        • Oral: Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine(0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
        • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
      • Does not need a reduction in the ED
      • Place in long-arm backslab with the elbow flexed to 90 degrees and broad arm sling
    • Type 2, 3 and Flexion types:
      • Analgesia:  
        • Oral: Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed.
        • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
      • Place in long-arm backslab to splint elbow in position of comfort
      •  A formal closed reduction in the ED is NOT advised
      • Keep NPO
      • Urgent referral to nearest orthopaedic surgeon on call for closed reduction and percutaneous pinning

9. Should this patient be referred urgently to the nearest orthopaedic surgery service on call?

Indications for emergent (within 1 hour) referral to the nearest orthopaedic surgeon on call include:

    • Loss of radial pulse or a cool, white hand
    • Signs or symptoms of compartment syndrome

Indications for urgent (within 4 hours) referral to the nearest orthopaedic surgeon on call include:

    • Type 2, 3 and Flexion fractures
    • Associated nerve injuries
    • Open fracture
    • Impending open fracture (e.g. large anterior bruise or skin tenting)
    • Adjacent injuries to the forearm or wrist

Patients awaiting orthopaedic assessment in the emergency department should be kept nil per os (NPO) until a decision about surgery is made.

For open fractures, tetanus immunization status should be assessed and appropriate IV antibiotics provided.

 10. Where should this patient be seen for follow-up care?

Type 1:

    • Follow up in Fracture Clinic in 1 week (no repeat X-rays needed)

Type 2, 3 and Flexion types:

    • To be arranged by treating orthopaedic surgeon

11. What discharge prescriptions and instructions should be provided?

Type 1:

    • Ibuprofen (10 mg/kg, max. 600 mg) every 6 hours as needed is as effective as morphine in children with non-operative upper extremity fractures.
    • Provide SickKids Parent Information Sheet- Supracondylar humerus fracture without displacement (PDF) and cast care: arm or leg (PDF).

Type 2, 3, and Flexion types:

    • To be arranged by treating orthopaedic surgeon.
    • Provide SickKids Parent Information Sheet-  Supracondylar humerus fracture with displacement (PDF) and cast care: arm or leg (PDF).

12. What potential complications could result from this injury or its management? 

    • Malunion
    • Cubitus varus or gunstock deformity
    • Nerve Palsies
      • Rare in Type 1 and 2 fractures, more commonly seen in Type 3 and Flexion fractures.
      • Most commonly the anterior interosseous nerve.
      • Most nerve palsies resolve within three months from injury with no need for intervention.
    • Arterial injury
      • Rare in Type 1 and 2 fractures, more commonly seen in Type 3 and Flexion fractures.
      • The brachial artery can be injured which can present with a pale cool hand. It can ultimately lead to compartment syndrome and Volkmann’s ischaemic contracture of the forerarm.
    • Compartment Syndrome
      • Rare in Type 1 and 2 fractures, although can develop in the presence of an injury to the joints or bones above and below a Type 1 or 2 fracture. More commonly seen in Type 3 and Flexion fractures.

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Outpatient/Fracture Clinic Management

The following information is for use by medical practitioners and trainees in Fracture clinics or Outpatient clinics.

1. When should this patient be seen in fracture clinic/outpatient clinic?
2. What should be reviewed at each clinic visit?
3. What are common reasons to deviate from the treatment pathway?
4. Does this patient require long-term follow-up?
5. Instructions for parents and SickKids Parent Information Sheets  

1. When should this patient be seen in fracture clinic/outpatient clinic?

Type 1 Fractures

Follow-up in Fracture clinic in 1 week

    • No repeat X-rays needed
    • Show parents how to remove backslab safely at home in 3 weeks

Subsequent Follow-up

    • No further follow up usually needed
    • Parents to remove backslab at home at 3 weeks and begin gentle range of motion exercises
    • Avoid high-risk activities for 12 weeks following injury

Type 2, 3, and Flexion type Fractures

Follow-up in Orthopaedic Surgeon's clinic 3 weeks post closed-reduction and percutaneous pinning with:

    1. Removal of backslab and K-wires
    2. Radiographs of elbow out of backslab
    3. Clinical Review
    4. Begin gentle range of motion exercises
    5. Avoid high-risk activities for 12 weeks following injury

Subsequent Follow-Up

    • At 3 months
    • No repeat X-rays needed routinely
    • Examine for coronal alignment and range of motion
    • Return for further follow up if any subsequent concern regarding deformity
    • Likely to have prolonged period (months) of inability to fully extend elbow (This does not cause functional disability and should not be treated with physiotherapy)

2. What should be reviewed at each clinic visit?

At first clinic visit:

        • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
        • Review radiographs
        • If k-wires removed at this appointment- examine insertion sites

At 3 month appointment (Type 2, 3, and Flexion type):

        • Perform and document peripheral neurovascular examination
        • Assess range of motion
        • Assess coronal alignment

3. What are common reasons to deviate from the treatment pathway?

Common reasons to deviate from the treatment pathway include:

        • Angulation or displacement beyond acceptable limits for continued closed management  
          • May require more frequent follow-up, additional investigations or referral to subspecialist
        • Patient underwent treatment in the operating room
          • These patients should be followed up by their treating surgeon
          • The treating surgeon may want to deviate from the pathway due to patient, fracture or surgeon factors
        • Established neurovascular injury
          • May require more frequent follow-up, additional investigations or referral to subspecialist
            • In supracondylar fractures:  
              • Most common nerve palsy is that of the anterior interosseous nerve
              • Most nerve palsies resolve within 3 months from injury with no need for intervention
        • Malunion
          • Malunion in the coronal plane commonly results in cubitus varus and may require referral to a pediatric orthopaedic surgeon for consideration of corrective osteotomy
        • Stiffness/Limited motion
          • A decrease in range of motion is most often the result of a malunion in the sagittal plane which can slowly remodel over years and is not usually improved with physiotherapy
        • Delayed or Nonunion
          • May require evaluation by a pediatric orthopaedic surgeon or, if close to skeletal maturity, an adult orthopaedic surgeon

4. Does this patient require long-term follow-up?

Patients with malunion, significant elbow stiffness, unresolved nerve palsies or complications from arterial injuries warrant long-term follow-up provided by a pediatric orthopaedic surgeon
 

A patient can be discharged from future follow up when they have met the  following criteria:

        • clinical and radiological evidence of union
        • no tenderness at the fracture site
        • painless ROM from 30 to ≥130 degrees elbow flexion
        • coronal alignment is symmetrical

5. Instructions for parents and SickKids Parent Information Sheets

Patients with supracondylar fractures will often have prolonged period (months) of inability to fully extend their elbow. This does not cause functional disability and should not be treated with physiotherapy.

        • SickKids Parent Information Sheet- Supracondylar humerus fracture without displacement (PDF)
        • SickKids Parent Information Sheet- Supracondylar humerus fracture with displacement (PDF)
        • SickKids Parent Information Sheet- Cast care: arm or leg (PDF)

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Operative Management

The following information is for use by Orthopaedic Surgeons and trainees in the Operating Room.

1. What are the indications for operative management?
2. Should this patient be referred to a paediatric orthopaedic surgeon for management?
3. What particular risks should be brought up during the consent discussion?
4. How urgently does this fracture need to be surgically managed?
5. What operative equipment is required?
6. How should the operating theatre be setup?
7. What are the general surgical techniques and goals of managing this fracture?
8. How should this fracture be managed post-operatively?
9. What are the expected outcomes and potential complications specific to this fracture?

1. What are the indications for operative management?

We recommend using the American Academy of Orthopaedic Surgeons Paediatric Supracondylar Humerus Fractures Appropriate Use Criteria for surgical indications

    • Fracture type:
      • Type 2 - extension type with cortical continuity of posterior cortex
      • Type 3
      • Flexion Type
    • Soft Tissue Envelope:
      • Open fractures
        • Splint should be taken down to assess 360 degree soft tissue envelope to rule out an open fracture
      • Skin puckering
    • Degree of swelling
      • Concerns of compartment syndrome
    • Associate nerve injury
    • Vascular compromise
      • Non-perfused hand (cool, white, diminished capillary refill >3 sec) without palpable radial pulse
      • Perfused hand (warm, pink, capillary refill <3 sec) without palpable radial pulse
    • Ipsilateral radius and/or ulna fracture

2. Should this fracture be referred to a paediatric orthopaedic surgeon for management?

  • Not necessarily, the surgical management and follow up of these injuries is within the skill set of a general orthopaedic surgeon.
  • Associated vascular compromise may require the availability of a vascular surgeon or plastic surgeon.

 

3. What specific risks or complications should be brought up during the consent discussion with the parents?

    • Risks of injury with or without surgical management
      • Compartment syndrome
        • Volkmann contracture
    • Risks of non-operative treatment
      • Malunion
        • Cubitus varus
          • Cosmetic
          • Increased risk of lateral condyle fracture
          • Tardy posterolateral rotatory instability
        • Gunstock deformity (varus, medial rotation, extension) with associated block to range of motion
    • Benefits of surgical management
      • Reduced risk of malunion
      • Reduced risk of limited range of motion
    • Risks of surgical management
      • Iatrogenic nerve injury
      • Iatrogenic artery injury
      • Pin tract infection
        • Osteomyelitis
        • Septic arthritis
      • Surgical site infection (if open reduction required)

4. How urgently does this fracture need to be managed?

We recommend using the American Academy of Orthopaedic Surgeons Paediatric Supracondylar Humerus Fractures Appropriate Use Criteria for surgical timing

    • Indications for emergent surgical management (SickKids Priority 1):
      • Non-perfused hand (cool, white, diminished capillary refill >3 sec) without palpable radial pulse
      • Compartment syndrome
    • Indications for urgent surgical management (SickKids Priority 2):
      • Perfused hand (warm, pink, capillary refill <3 sec) without palpable radial pulse
      • Ipsilateral radius and/or ulna fracture (associated forearm fracture puts the child at higher risk of compartment syndrome then an isolated supracondylar fracture)
      • Skin puckering
      • Unreliable examination for compartment syndrome
        • Very young children
        • Cognitive disability
        • Complete median nerve palsy

Pearl: A vascular surgeon or plastic surgeon should be given advanced warning prior to taking a child with a poorly perfused extremity to the operating room

 

5. What operative equipment needs to be available in the operating room?

    • Regular operating table with radiolucent arm table
    • Intraoperative fluoroscopy
    • Kirschner wire set with wire driver
      • Pearl: A good rule of thumb for wire size- if child >20kg use 2mm Kirschner wires, if child <20kg 1.6mm use Kirschner wires
    • Basic orthopaedic set up*
    • Bone reduction forceps*
    • Diathermy available*
    • Sterile tourniquet*
    • Vessel loops*

* To be opened only if open reduction or neurovascular exploration required

 

6. How should the operating room be setup?

The patient should be brought down the operating table so that his head is level with the arm table. This will ensure that the patients head does not inadvertently roll off the side of the operating table during the traction, manipulation and reduction of the fracture.

For unstable fracture patterns it is helpful to bring the C-arm in parallel to the operating table. This will allow a lateral image to be obtained by rotating the C-arm as opposed to rotating the extremity.

 

7. What are the general goals and surgical techniques of managing this fracture?

Goals: Obtain and maintain an anatomic reduction until union

  • AP view: Restoration of Baumann angle
  • Lateral view: Anterior humeral line passing through the middle 1/3 of the capitellum

Pearl: Include shoulder in sterile field- this will aid in visualizing the direction of the wires

 

Surgical Technique:

    • Obtaining a closed reduction:
      • Apply longitudinal traction to restore length
        • Assistant to provide counter traction holding the proximal humerus
        • Elbow in extension with the forearm in supination
        • In severely displaced fractures, the brachialis may need to be “milked” out of the fracture site
        • Obtain AP image to confirm fracture is out to length
      • Correct coronal plane malalignment (varus/valgus) and translation
        • Obtain AP image to confirm that outline of olecranon fossa has been restored
      • Correct sagittal plane malalignment (extension) and translation by gently flexing elbow while maintaining traction and countertraction 
        • The surgeon’s right hand can be used to maintain traction at the forearm while applying pressure with their left thumb over the patient’s olecranon and simultaneously flexing the elbow.
        • Pearl: Gentle reduction avoids conversion of a type III fracture to a multidirectionally unstable fracture with a loss of the intact posterior periosteum
        • Pearl: Posteromedially displaced fracture are reduced with elbow flexion and pronation of the forearm, placing the intact medial periosteum on tension. Posterolaterally displaced fracture are reduced with elbow flexion and supination of the forearm, placing the intact lateral periosteum in tension
      • Once the elbow is flexed, obtain a shoot through AP view of the elbow to assess the coronal plane reduction. Next, by externally rotating the extremity through the shoulder, obtain a lateral view of the elbow to assess the sagittal plane reduction.

Pearl: For Flexion type or Multi-directionally unstable fractures consider placing lateral and medial K-wires into the distal fragment to use as joysticks prior to commencing with reduction. Rotate the fluoroscopy unit to the lateral view rather than moving the arm. 

 

      • Maintaining a closed reduction:
        • To minimize iatrogenic ulna nerve injuries, lateral wiring techniques are recommended except with:
          • Reverse obliquity fractures (where the fracture line is from distal lateral to proximal medial)
          • Very distal fracture patterns
        • In general Type 2 fractures require 2 lateral wires and Type 3 fractures and Flexion type fractures require 3 lateral wires
        • Wires should penetrate both cortices
        • On the AP view both the medial and lateral columns should be secured with divergent wires spanning at least 1/3 of the fracture line
        • Perfusion of the hand is checked after fracture stabilization
        • Wires should be bent 90 degrees without stressing the fracture fixation, cut 1cm proximally to make removal easier
        • The surgeon should ensure that the wires are not causing excessive skin tension
        • Sterile dressings are then placed over the wires and the elbow is immobilized in a posterior splint with the elbow in no more than 80 degrees of flexion
        • Reassess perfusion

Type 2 fracture reduction maintained with 2 divergent lateral wires spanning at least 1/3 of the fracture line


 

Type 3 fracture reduction maintained with 3 divergent wires spanning at least 1/3 of fracture site and penetrating both cortices


 

Reverse obliquity fracture pattern requiring medial wire

Pearl: To reduce risk of an iatrogenic ulna nerve injury when placing a medial wire consider a mini open approach and insert the wire with the elbow in slight extension


 

Indications for open reduction:

      • Vascular compromise
        • Anterior approach
      • Irreducible fracture by closed means
        • Approach from direction of metaphyseal spike
      • Open fracture
    • Non-perfused hand (vascular compromise) prior to closed reduction
      • Closed reduction of the fracture usually restores perfusion
      • No benefit of pre-reduction angiography
      • Persistent vascular compromise following reduction: Open vascular exploration through anterior approach in combination with vascular or plastic surgery colleagues
    • Non-perfused hand following closed reduction
      • Extend arm and reassess
      • Assume brachial artery is entrapped in the fracture site
      • Requires open exploration and re-reduction in combination with vascular or plastic surgery colleagues

8. How should this fracture be managed post-operatively?

    • Immediate post-operative management:
      • Elevate limb
      • Neurovascular observations every 2 hours
      • If no elevated risk of compartment syndrome, may discharge home after 12 hours.

Pearl: Cases with medial nerve injury need particular monitoring as pain suggestive of compartment syndrome will not be felt in the volar compartment.

 

    • Follow up appointments for uncomplicated fractures (complicated fractures may require individualized follow up schedules):

    3 weeks post-operative closed reduction and percutaneous pinning with:

  1. Removal of backslab and K-wires
  2. Radiographs of elbow out of backslab
  3. Clinical Review
  4. Begin gentle range of motion exercises
  5. Avoid high-risk activities for 12 weeks post-injury

    At 3 months. No repeat x-rays needed routinely. Examine for coronal alignment and range of motion.

    • Return for further follow up if any subsequent concern regarding deformity and range of motion
    • Likely to have prolonged period (months) of inability to fully extend elbow. This does not cause functional disability and should not be treated with physiotherapy

9. What are the expected outcomes and potential complications specific to this fracture?

    • Expected outcomes: Near full range of motion at 3 months
    • Complications:
      • Compartment syndrome
        • Volkmann contracture
      • Malunion
        • Cubitus varus or gunstock deformity
      • Nerve injury – refer to peripheral nerve surgeon if nerve has not recovered 3 months following injury

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References

  1. Azbug JM, Herman MJ. Management of supracondylar humerus fractures in children: Current concepts. J Am Acad Ortho Surg. 2012; 20(2): 69-77.
  2. Cuomo AV, Howard A, Hsueh S, Boutis K. Gartland type I supracondylar humerus fractures in children: is splint immobilization enough? Pediatric emergency care. 2012;28 (11):1150-3.
  3. Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2012; 20(5):328-30.
  4. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence-based guideline. Journal of pediatric orthopedics. 2012; 32 Suppl 2:S143-52.
  5. Poonai et al. Oral administration of morphine versus ibuprofen to manage post fracture pain in children: a randomized trial. CMAJ 2014 vol. 186 no. 18 1358-1363.
  6. Rang M, Pring, ME, Wenger DR. Rang’s Children’s Fractures. 3rd ed. Philadelphia. Lippincott Williams & Wilkins; c2005. Chapter 8, Elbow-Distal Humerus
  7. Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Fractures, [Internet, cited January 1, 2015], Available from: http://www.rch.org.au/clinicalguide/index.cfm
  8. Kasser JR, Beaty JH. Rockwood and Wilkins' Fractures in Children, 6thed. Philadelphia. Lippincott Williams & Wilkins; c2006. Chapter 14, Supracondylar fractures of the distal humerus; p. 543-590.
  9. Skaggs DL, Flynn JM. Staying out of trouble in Pediatric Orthopaedics. Philadelphia. Lippincott Williams & Wilkins; c2006. Chapter 4, Trauma about the Elbow 1: Overview, Supracondylar, and Transphyseal Fractures; p 50-64.
  10. Omid et al. Supracondylar Humeral Fractures in Children. J Bone Joint Surg Am. 2008;90:1121-1132
  11. Leitch KK et al. Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 2006;88:980-5
  12. Zaltz et al. Ulnar nerve instability in children. J Pediatric Orthop. 1996; 16:567-9
  13. Lee et al. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440-3
  14. Larson et al. Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures. J Pediatric Orthop. 2006;26:573-8
  15. Sankar et al. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am. 2007;89:713-7
  16. Davids JR. Lateral condylar fracture of the humerus following posttraumatic cubitus varus. J Pediatr Orthop. 1994 Jul-Aug;14(4):466- 70
  17. Mehlman CT et al. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joine Surg Am 2001;83(3):323-327
  18. Dennis R. Wenger, Maya E. Pring. Rang’s Children’s Fractures Third Edition. 2005
  19. Karim MA, Crossed wires versus two lateral wires in management of supracondylar fracture of the humerus in Children in the Hands of Junior Trainees. J Orthop Trauma 2015;
  20. Schlechter JA, Dempewolf M. The utility of radiographs prior to pin removal after operative treatment of supracondylar humerus fractures in children. J Child Orthop 2015;9(4):303-306

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Content developed by Dr. Rekha Ganeshalingam and Dr. Mark Camp and approved by the SKPOP Committee on May 1st 2015. Content updated on April 1st 2016.
To provide feedback, please email mark.camp@sickkids.ca