Pediatric Supracondylar Fracture, ABOS Oral Boards Preparation

This is a 6-year-old right-hand-dominant girl brought to the emergency department by her parents after falling approximately 4 feet from a playground slide, landing on her outstretched left arm. She was crying and holding her left elbow. No medical history, no prior fractures.

On exam, the left elbow was swollen with a visible S-shaped deformity and ecchymosis in the antecubital fossa. In a child this age, I need a reliable neurovascular exam before any intervention. She could make an OK sign, testing the anterior interosseous nerve. She could extend her fingers and wrist, testing the posterior interosseous nerve. She had intact sensation in the median, ulnar, and radial distributions. Radial pulse was palpable with brisk capillary refill. Forearm compartments were soft. The neurovascular exam was intact.

AP and lateral radiographs showed a completely displaced extension-type supracondylar humerus fracture, Gartland type III. The distal fragment was displaced posteriorly and medially. The anterior humeral line did not intersect the capitellum, confirming the extension pattern and displacement. The Baumann angle was altered, suggesting varus malalignment. No associated condylar fracture.

A Gartland III supracondylar fracture with complete displacement requires operative fixation. Non-operative management is not an option, these fractures are unstable and malunion in varus or extension is unacceptable. I discussed the surgery with her parents, explaining the procedure, the need for pins through the skin, and the risks, including nerve injury, compartment syndrome, and the possibility of needing an open reduction.

I took her to the operating room under general anesthesia within four hours of presentation. I performed closed reduction and percutaneous pinning with three laterally based divergent K-wires. Fluoroscopy confirmed anatomic reduction and satisfactory pin position.

Post-operatively, the arm was placed in a well-padded long arm posterior splint at 60 degrees of flexion, not more, because excessive flexion in a swollen elbow can compromise the brachial artery. I checked her pulse and capillary refill after splint application. I counseled the family on neurovascular monitoring, specifically to watch for increasing pain, loss of finger motion, or color changes, and on pin site care.

At one week, she was comfortable and neurovascularly intact. At four weeks, X-rays showed early healing with maintained alignment. I removed the pins in clinic, a quick procedure that children tolerate well. She started progressive range of motion. At three months, she had near-full elbow motion and was back to all normal activities. There was no cubitus varus on clinical exam.

Her parents were satisfied and she was back to being an active kid with no limitations. Looking back, I would have had a more detailed conversation with the family about the signs of compartment syndrome before discharge. I provided written instructions, but in the moment, with anxious parents and a crying child, I think a more deliberate, structured discharge discussion with teach-back would have been more effective. She did not develop any vascular or neurologic complications, and her carrying angle remained symmetric on follow-up. I watched for growth disturbance at subsequent visits and she had no evidence of physeal arrest.