Updated: 8/12/2018

Supracondylar Humerus Fx Open Reduction and Internal Fixation

Preoperative Patient Care


Intermediate Evaluation and Management


Recognize vascular, nerve or other associated injuries

  • document neurovascular status
  • document radial and ulnar pulses along with median, radial, and ulnar nerve function
  • AIN neuropraxia (test A-OK sign) most common followed by radial nerve (thumb/wrist extension) palsy and ulnar nerve (hand intrinsics) depending on fracture pattern
  • vascular insufficiency at presentation 5-17% of cases and emergent surgical intervention typically necessary
  • differentiate anterior interosseous nerve versus complete median nerve palsy


Appropriately interprets basic imaging studies and recognizes fracture patterns

  • interpret radiographs of the elbow


Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention


Splints or casts fracture appropriately

  • flexion less than 90 degrees
  • accommodates for swelling potential


Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • change splint/cast and continue non-weight bearing
  • check radiographs
  • diagnose and management of early complications
  • postop: 4-6 week postoperative visit
  • check xrays for callus formation out of splint/cast
  • can remove kwires with heavy needle driver in clinic
  • begin range of motion exercises to wrist, hand, and elbow
  • return to activity at ~8 wks


Capable of diagnosis and early management of complications

  • compartment syndrome
  • pin tract infection
  • cast problems

Advanced Evaluation and Management


Recognizes factors that could predict difficult reduction and post-operative complication risk

  • abnormal vascular examination
  • neurological deficits
  • brachialis sign or severe soft tissue swelling
  • associated forearm fracture


Appropriately orders and interprets advanced imaging studies


Completes comprehensive pre-operative planning with alternatives

  • recognizes fracture patterns that may preclude lateral entry only pinning or necessitate ORIF


Modifies and adjusts post-operative treatment plan as needed

  • recognize deviations from typical postoperative course

Preoperative H & P


Obtains history and performs basic physical exam

  • injury mechanism
  • radial and ulnar pulse assessment
  • identify medical co-morbidities that might impact surgical treatment


Order basic imaging studies

  • AP and lateral elbow radiographs
  • oblique views if concern for condylar component


Prescribe nonoperative treatments

  • long arm cast for garland type I fractures


Perform operative consent

  • describe complications of surgery including
  • pin site infection
  • pin site migration
  • cubitus varus deformity
  • neurovascular injury
  • AIN palsy
  • delayed union
  • nonunion

Operative Techniques


Preoperative Plan


Template fracture

  • identify fracture pattern (extension vs. flexion), displacement (Gartland classification), comminution, angulation, and rotation based on initial xrays
  • gartland III and IV completely displaced fractures may have interposed brachialis muscle (skin puckering anteriorly on exam) requiring ORIF
  • evaluate anterior humeral line (should traverse capitellum) and integrity of posterior cortex on Lat xray, coronal angulation and rotation on AP
  • critical to determine if lateral condyle vs. medial condyle vs. supracondylar fracture is present as these can be confused with each other
  • determine if posteromedial or posterolateral fragment present as this will affect reduction and potential nerve injury
  • take radiographs of forearm to evaluate for possible forearm fractures (“floating elbow”)


Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them

Room Preparation


Surgical instrumentation

  • smooth k-wires: .062 or .08


Room setup and equipment

  • setup OR with standard operating table
  • turn table 90° so that operative extremity points away from Anesthesia machines
  • c-arm in from foot of bed
  • monitor in surgeon direct line of site on opposite side of OR table


Patient positioning

  • arm board centered at level of patient’s shoulder
  • take care not to pull arm into full extension when prepping and draping
  • after draping, apply sterile tourniquet

Anterior Incision


depending on surgeon preference, inflate tourniquet (vs only inflate after exposing if needed for significant bleeding)


Make an anterior incision

  • make a transverse incision over the antecubital fossa
  • this can be extended if needed either proximally or distally

Deep Dissection


Perform blunt dissection

  • perform blunt dissection through the subcutaneous and fatty tissue
  • be aware of the neurovascular structures as they might not be in the normal anatomic position
  • dissect down until the metaphyseal spike is identified
  • it is often buttonholed through the brachialis
  • once spike is encountered remove periosteum that may interfere with reduction


Identify neurovascular structures (brachial artery and median nerve)

  • Retract neurovascular structures to allow visualization and reduction of the fracture

Fracture Reduction


Define the outline of the distal fragment

  • this can be one of the most challenging aspects of the procedure
  • it is posterior and lateral with the periosteum folded over its surface


Perform the reduction

  • reach the fracture site with a hemostat to get a hold of the cut edge of the periosteum
  • extend the cut edge with scissors to increase the size of the buttonhole and to help free up the distal fragment
  • bring the distal fragment anteriorly and reduce the shaft fragment
  • maneuver the shaft fragment back through the buttonhole into its resting position posterior to the brachialis
  • another option for reduction is to use your thumb on the proximal fragment and push downward while an assistant applies traction to the forearm with the elbow flexed at 90 degrees



After fracture reduced, check on AP/Lat fluoro (rotate C-arm instead of arm if gross fracture instability)

  • smooth .062” kwires (if patient <20 kg) placed from lateral condyle in superomedial direction x2
  • consider .045" kwires if age <2 years, .08" kwires if patient >20 kg
  • want divergent pins spaced ~1.5-2cm apart with elbow flexed
  • first pin (more medial of 2 pins) enters through capitellum for bicortical fixation and goes from anterior to posterior for more fixation


Check first kwire placement, needs to be in center of humeral canal on lateral xray, second wire divergent on AP

  • if crossed medial and lateral pins used they need to cross above fracture site for increased stability, not below or at fracture site
  • higher risk of ulnar nerve injury if medial pin placed with elbow in flexion or hyperflexion
  • pins need to be bicortical


In highly unstable fractures place a 3rd kwire lateral

  • need to watch out for ulnar nerve if using medial kwire


Bend kwires at base using pliers, use fraiser tip suction to bend kwires, then cut with 2cm exposed

  • cover bent k wire tips

Confirm Hardware Position Recheck Clinical Exam


Check dynamic live exam then final AP/oblique/lat radiographs

  • Check carrying angle compared to contralateral side
  • Check forearm compartments and pulses

Wound Closure


Irrigation and Hemostasis

  • irrigate pin sites
  • close skin with absorbable sutures


Dressing and Immediate immobilization

  • xeroform around base of kwires
  • padded gauze around base of kwires
  • long-arm postmold splint for immobilization at 75°or use uni- or bi-valved cast to reduce swelling
  • sling for comfort

Postoperative Patient Care


Perioperative Inpatient Management


Discharge patient appropriately

  • pain meds
  • cast care
  • non weightbearing
  • manage swelling
  • monitor neurological and vascular status
  • schedule follow up in 2 weeks

Complex Patient Care


Develops unique, complex post-operative management plans


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