Injury, Int. J.

Care Injured 34 (2003) 267273

Neurovascular complications and functional outcome in displaced

supracondylar fractures of the humerus in children
Taco Gosens a, , Karst J. Bongers b
a Atrium Medical Centre, Heerlen, P.O. Box 4446, 6401 CX Heerlen, The Netherlands
b Department of Surgery, Isala Clinics, Sophia Hospital, Zwolle, The Netherlands

Accepted 9 September 2002

Abstract
We retrospectively studied the complications associated with a displaced supracondylar fracture of the humerus in children and its
treatment. Between 1978 and 1997, 200 displaced fractures were treated by operative means. In 190 cases closed reduction and percuta-
neous pinning was performed. In 10 cases vascular impairment or unsatisfactory reduction necessitated open exploration. Functional and
cosmetic success was achieved in 90% of all operated children. In 33 (16.5%) of all cases we found neurological impairment. All recovered
without sequelae, except for one case with persistent radial nerve palsy which recovered after a sural nerve interposition graft. Transient
neurological problems are common in this fracture. A mini-open procedure is recommended for the ulnar Kirschner wire (K-wire) to
prevent iatrogenic ulnar nerve injury.
2002 Elsevier Science Ltd. All rights reserved.

1. Introduction
The supracondylar fracture of the humerus in children is
a common childhood injury accounting for 37% of all frac-
tures [17] and the majority (5580%) of all elbow fractures
in children [3,18]. The commonest type is the extension frac-
ture, in which the condylar complex shifts posteromedially
or posterolaterally after a fall on the outstretched arm, but in
2% the condylar complex shifts anterolaterally: the flexion
type fracture [9,16].
Primary lesions of the brachial artery and the median and
radial nerve can occur from stretching, entrapping or dis-
rupting the neurovascular structures on the sharp proximal
humeral fragment. In extension type fractures, posterolateral
displacement fractures have a predilection of injury to the
median nerve and/or the brachial artery and posteromedial
displacement fractures are more likely to injure the radial
nerve. The ulnar nerve is more frequently damaged in a flex-
ion type fracture [14,16,36,37]. Secondary lesions can also
occur in various ways: first, during manipulation of the frac-
ture the nerves and/or vessels can be stretched or entrapped
between the fracture ends; second, treatment in hyperflexion
position (used when only closed reduction is performed) can
compromise the vascularity of the forearm, eventually result-
ing in a Volkmanns contracture. Dysfunction of nerves can
also exist because of swelling of the tissues around the elbow
irrespective of the treatment. Although it can be difficult to
quantify disturbances in sensory and motor function preop-
eratively, especially in the younger child for whom this is a
very painful and stressful event, it is important to carry out
the preoperative assessment of neurovascular status in these
patients, and for medicolegal reasons the inability to perform
a complete neurovascular assessment should be documented.
The reported rate of primary nerve injury in displaced
supracondylar fractures is up to 20% [5,11,3537]. The rate
of iatrogenic nerve injury has been reported to be 23% [29].
The radial pulse is reported to be absent before reduction
in 712% [5,9,15,16,28] of all fractures and up to 19% in
displaced fractures. After reduction the pulse is restored in
80% of the cases.
The aim of this study is to report the incidence of neu-
rovascular injuries associated with displaced supracondylar
fractures of the humerus and their treatment in children. We
also report the functional results of operative treatment of
these fractures.
2. Patients and methods
2.1. Philosophy of treatment

Corresponding author. Tel.: +31-45-5766740; fax: +31-45-5766742. We classified the amount of displacement according to
E-mail address: tacogosens@hetnet.nl (T. Gosens). Felsenreich, but the mostly used classification in literature

0020-1383/02/$ see front matter 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 3 1 2 - 1
268 T. Gosens, K.J. Bongers / Injury, Int. J. Care Injured 34 (2003) 267273

Fig. 1. (AD) Supracondylar fracture of the humerus, Felsenreich III, before and after closed reduction and percutaneous pinning with two crossed K-wires.

is Gartlands classification. It is almost identical, but a dis-
tinction is made between stable class II (IIA) and unstable
II (IIB) fractures [10,13]. Group I: no displacement, incom-
plete fracture; group II: axial deviation with displacement,
fracture ends are still in contact; and group III: no contact.
We treated all group I fractures conservatively by immo-
bilisation in a plaster cast. Group II fractures were treated
by closed reduction and a plaster cast if the reduction was
judged to be stable. Unstable groups II and III fractures
were treated by closed reduction and percutaneous fixation
with Kirschner wires (Fig. 1AD). Open reduction and
Kirschner wire fixation were carried out for cases associ-
ated with neurovascular injuries and for fractures which
were not satisfactorily reduced. Neurological injuries were
 T. Gosens, K.J. Bongers / Injury, Int. J. Care Injured 34 (2003) 267273
assessed in the emergency room and after the operation by
routine physical examination. EMG studies were not used
in the diagnosis, but only if after 4 months neurological in-
juries had not disappeared. Vascular injuries were assessed
in the emergency room and after immediate reduction by
routine physical examination and Doppler sonography. If
after immediate reduction no pulse was palpated patients
were explored. Vascular reconstruction procedures were
monitored at the out patient clinic by routine physical
examination.
2.2. Inclusion and exclusion of patients
We included all patients seen at the emergency de-
partment of the Isala Hospital, location Sophia in Zwolle
between 1978 and 1997 with a displaced supracondylar
fracture of the humerus with an age below 16. We excluded
condylar fractures and avulsion fractures of the epicondyle.
Also fractures involving the physic were excluded.
2.3. Surgical procedure
Surgery was performed as soon as possible to minimise
swelling of the soft tissues. Under general anaesthesia and
image intensifier fractures with no neurovascular problems
were reduced by traction and flexion and percutaneously
pinned with smooth Kirschner wires (up to 1.4 mm, depend-
ing upon the size of the patient) from the lateral and me-
dial epicondyles. The tip of the wire was pierced into the
bone before the onset of the drilling in order to minimise
the possibility of the ulnar nerve wrapping around the wire.
Both wires pierced the medial and lateral humeral cortices.
The wires were cut subcutaneously without bending the end.
The skin was closed over the wire. The elbow was immo-
bilised at less than 90 for 4 weeks after which the wires
were usually removed in the out patient clinic under local
anaesthesia.
2.4. Assessment of final result
The final outcome was reviewed by or under supervi-
sion of the senior author by measuring range of motion,
varusvalgus deformity and the distal neurovascular status
at their last visit to the out patient clinic by comparing these
parameters with the contralateral side.
Table 1
Numbers of patients and the treatment chosen
Classification Patients
Felsenreich I Gartland I 407
Felsenreich II Gartland IIA 10
Felsenreich II and III Gartland IIB and III 190
Felsenreich III Gartland III 6 Open reduction and pinning
Felsenreich III Gartland III 4 Open reduction and pinning
617
269
3. Results
Between 1978 and 1997 we treated 617 children with
a mean age of 7.7 (216) years and a male:female ratio
of 0.96:1, with a supracondylar fracture of the humerus
(Table 1). In 190 patients we performed closed reduction and
percutaneous pinning for an unstable group II or III fracture.
Three of these patients had a dislocated flexion type fracture.
Ten patients underwent open exploration and cross-pinning,
six patients because of vascular compromise of the forearm
(cold hand and absent pulses), three of which had an open
fracture, and four patients because of an unsatisfactory at-
tempt to closed reduction and percutaneous pinning. The re-
maining patients (417 patients) had an undisplaced fracture
and were treated conservatively (407 patients) or a minimally
displaced fracture which could be treated with closed reduc-
tion and immobilisation in a plaster cast (10 patients). There
were no neurovascular complications in this last two groups.
One patient died as a result of accompanying injuries.
We therefore reviewed 189 patients with closed manipula-
tion and pinning and 10 patients with open reduction and
pinning.
3.1. Neurological complications (Table 2)
There were 34 nerve injuries in 33 patients. In two ulnar
nerve injuries we were unable to discern between primary
or secondary lesions, because of lack of information in the
earlier years of the period of study. In two children it was
impossible to gain information about additional neurologic
damage because they were unconscious prior to surgery.
Postoperatively, after the patients regained consciousness,
we found a radial and a median nerve palsy in one patient
with accompanying vascular damage and a median nerve
palsy in the other patient.
In 10 cases there was a radial nerve dysfunction, in seven
cases this was diagnosed before operation. One radial nerve
lesion was caused by a preoperative transsection of the nerve
during an exploration for vascular injury. In two cases, in-
cluding one unconscious child, insufficient preoperative data
were available.
There were 11 cases of median nerve damage. In seven
cases the median nerve lesion was diagnosed before oper-
ation, in two unconscious children insufficient preoperative
data was available, in two cases the median nerve was
Treatment Reason
Plaster cast No dislocation
Closed reduction and plaster cast Stable after closed reduction
Closed reduction and percutaneous pinning Unstable after closed reduction
Vascular compromise
Unsatisfactory closed reduction
270 T. Gosens, K.J. Bongers / Injury, Int. J. Care Injured 34 (2003) 267273

Table 2
Neurological complications
Case Sex Age Fracture Class Nerve Preoperative/ Concomitant vascular Remarks
type injury postoperative injury
15 M 3 Closed III Radial Unknown
100 M 10 Closed III Radial Preoperative
253 F 9 Closed III Radial Preoperative
319 M 4 Closed III Radial Preoperative
350 M 2 Closed III Radial Preoperative
418 M 2 Closed III Radial Preoperative
459 F 4 Closed III Radial Preoperative Pink hand, no pulses Spontaneous return of pulses
489 M 8 Closed III Radial Preoperative
30 F 3 Closed III Median Preoperative
112 M 6 Closed III Median Preoperative Intima lesion Open procedure
237 F 7 Closed III Median Preoperative Pink hand, no pulses Spontaneous return of pulses
476 F 6 Closed III Median Postoperative
589 F 7 Closed III Median Preoperative
125 F 10 Closed III Ulnar Postoperative
140 M 6 Closed II Ulnar Postoperative
185 M 10 Closed III Ulnar Unknown Flexion type
198 F 8 Closed III Ulnar Postoperative
213 F 12 Closed II Ulnar Unknown Flexion type
216 M 2 Closed III Ulnar Postoperative
219 M 11 Closed II Ulnar Postoperative
380 M 14 Closed III Ulnar Postoperative
392 M 11 Closed III Ulnar Postoperative
532 F 7 Closed II Ulnar Postoperative
575 F 13 Closed III Ulnar Postoperative
448 M 8 Open III Radial Postoperative Intima lesion Open procedure, preoperative transsection
of radial nerve
98 M 6 Open III Median Unknown Complete disruption Open procedure, unconscious at admission
112 M 6 Closed III Median Preoperative Intima lesion Open procedure
280 M 12 Closed III Median Preoperative Intima lesion Open procedure
333 F 9 Closed III Median Preoperative Intima lesion Open procedure
603 M 7 Closed III Median Postoperative Conversion to open procedure
59 M 10 Closed II Ulnar Preoperative Flexion type, conversion to open procedure
364 M 5 Closed III Ulnar Preoperative Conversion to open procedure
265 F 4 Open III Radial and Unknown Complete disruption Open procedure, unconscious at admission
median

damaged during the reduction of the fracture or during the
open procedure.
Ulnar nerve function was impaired in 13 cases. Two
cases were identified during preoperative examination, in
two cases not enough information was available, although
both were flexion type fractures, and in nine cases nerve
damage was diagnosed postoperatively having been normal
preoperatively.
Apart from the radial nerve transsection, all nerve palsies
were caused by contusion or stretching of the nerves, none
of the nerve injuries were complete disruptions. All of these
nerve injuries recovered spontaneously within 6 months
without premature removal of the Kirschner wires. The
radial nerve transsection however required a sural nerve
interposition graft.
In the 189 patients with closed reduction and percutaneous
pinning we found 23 nerve injuries, of which 10 (nine ulnar
nerves and one median nerve) were caused by the reduction
of the fracture or the percutaneous pinning. In two of the
nerve injuries (both ulnar) it was not clear whether they
were caused by the procedure or by the trauma itself, but
both were in flexion type fractures, suggesting traumatic
origin.
In the 10 open procedures (six for exploration of the
brachial artery and four conversions for unsatisfactory re-
duction) we found 11 nerve injuries: there was one postop-
erative radial and one postoperative median nerve lesion, in
three nerve injuries it was unknown (one radial and two me-
dian) whether they were present preoperatively or whether
they were caused by the operation and six nerve lesions were
diagnosed preoperatively.
3.2. Vascular complications (Table 3)
Six patients had vascular impairment (no pulses and a cold
hand) complicating the fracture. In all of these patients the
vascular injury was accompanied by nerve dysfunction. In
four cases only the median nerve was involved, in one case
only the radial nerve and in one case the radial and median
nerve combined.
While exploring the antecubital region in two cases the
vascular impairment appeared to be caused by complete
 T. Gosens, K.J. Bongers / Injury, Int. J. Care Injured 34 (2003) 267273 271

Table 3
Vascular complications
Case Sex Age Fracture Class Vascular injury Preoperative/ Concomitant Remarks
type postoperative nerve injury
459 F 4 Closed III Pink hand, no pulses Preoperative Radial Spontaneous return of pulses
112 M 6 Closed III Intima lesion Preoperative Median Open procedure
237 F 7 Closed III Pink hand, no pulses Preoperative Median Spontaneous return of pulses
167 M 11 Closed III Pink hand, no pulses Spontaneous return of pulses
301 M 13 Closed III Pink hand, no pulses Spontaneous return of pulses
448 M 8 Open III Intima lesion Postoperative Radial Open procedure, preoperative transsection
of radial nerve
98 M 6 Open III Complete disruption Unknown Median Open procedure, unconscious at admission
112 M 6 Closed III Intima lesion Preoperative Median Open procedure
280 M 12 Closed III Intima lesion Preoperative Median Open procedure
333 F 9 Closed III Intima lesion Preoperative Median Open procedure
265 F 4 Open III Complete disruption Unknown Radial and Open procedure, unconscious at admission
median

disruption of the brachial artery and four patients had inti-
mal lesions of the brachial artery. In the cases with complete
disruption of the brachial artery a reversed venous graft
was inserted. In the cases with intima lesions, the artery
was opened, the intimal flap was resected and a venous
widening patch was placed. In addition to these six patients
without pulses and a cold hand we saw four patients with-
out pulses, but with good capillary refill and a warm hand.
These patients were carefully observed and pulses returned
spontaneously.
3.3. Other complications
Three patients were reoperated the next day because of
inadequate reduction (Baumanns angle [2] >10 ) of the
fracture when reviewing the postoperative X-ray. Repeated
percutaneous pinning after satisfactory reduction was per-
formed. In four patients the attempt to closed reduction and
percutaneous pinning failed and the procedure was converted
to open reduction and pinning. There was one superficial
wound infection which resolved with oral antibiotics until
the wire was removed. In one case we found sclerosis of the
medial epicondyle which did not result in a cubitus varus or
functional impairment, because the patient was at the end of
his growing potential. No cases of Volkmanns contracture
or ischaemia of the forearm were seen as a result of any of
the treatments performed in this study.
3.4. Functional outcome (Table 4)
In the 417 patients treated conservatively the fracture
healed without loss of function, malalignment and/or other
complications. The functional result of the patients treated
by either closed or open pinning (n = 200), was no impair-
ment in 115 (61%) operated patients at the last visit to the out
patient clinic. In 55 (29%) patients there was a small (<10 )
impairment of flexion or extension, without causing prob-
lems to the patient. These patients all regained full function
within 1 year after surgery and were not followed up further
Table 4
Functional result in operated patients (n = 200)
Impairment Explanation Percentage
of patients
No Full ROM, no malalignment 61
Small Loss of flexion or extension <10 29
Mild Loss of flexion or extension >10 , but <20 9
Severe Cubitus varus >10 0
Unknown 1
(hence the minimal follow up of 1 month and the mean fol-
low up of 5.4 months). There was a larger (>10 ) impairment
of flexion or extension in 17 (9%) patients after a mean inter-
val of 18.8 (1260) months. None of these patients had loss
of motion of more than 20 . In 5 of these 17 patients with a
loss of motion the deficit in extension was seen together with
a cubitus varus of less than 10 . None of the patients had a
cubitus varus of more than 10 , none had a cubitus valgus
and no patient required an osteotomy for residual malalign-
ment. Their deformity remained constant over a mean obser-
vation time of 15 months and the result was accepted. In one
patient there was no information available about the func-
tional result after surgery and one patient died of accompany-
ing injuries before review (1%). At the last out patient clinic
review no muscular atrophy or loss of strength was seen, ex-
cept in the patient who required a sural nerve interposition:
he still suffered from loss of strength and atrophy of the mus-
cles supplied by the radial nerve. In the patients with vascu-
lar or neurological complications muscle power and range
of movement took more time to return than in the uncom-
plicated cases. All fractures united within 4 weeks of injury.
4. Discussion
We agree that closed reduction and percutaneous pin-
ning of unstable grades II and III dislocated supracondylar
fractures in children is the treatment method of choice [24].
Closed reduction alone requires an immobilisation in more
272 T. Gosens, K.J. Bongers / Injury, Int. J. Care Injured 34 (2003) 267273
than 90 of flexion to preserve the obtained reduction [22],
which might endanger the vascular status of the forearm.
This is called the supracondylar dilemma by McLaughlin
[21]. Moreover, this method leads to only 51% of excellent
results in a study by Pirone et al. [27] and they concluded
that closed reduction and immobilisation is not appropriate
for displaced fractures. Also skin traction [8,26] or skeletal
traction [25,38] have been recommended, particularly in
very swollen soft tissues. The incidence of cubitus varus is
higher than in percutaneous pinning and hospital costs are
increased by a longer hospital stay [28].
4.1. Neurological complications
The reported rate of primary nerve injury in displaced
supracondylar fractures is up to 20% [5,11,36,37]. The rate
of iatrogenic nerve injury has been reported to be 23% [29].
In this study an incidence of primary nerve injury in
displaced supracondylar fractures of 7.5% was found. How-
ever, including the cases in which the preoperative data were
incomplete, it would add up to 10%. An iatrogenic nerve
damage rate of 6.0% was found in this study, which is high in
comparison with the literature. However, we would empha-
sise that in this percentage 10 explorations for unsatisfying
reduction or vascular injury were included. They account for
two postoperatively diagnosed and three nerve lesions with
unknown origin. Other studies exclude these patients when
studying the results of percutaneous pinning of these frac-
tures [29]. The rate of iatrogenic nerve injury in patients with
closed reduction and percutaneous pinning is 5.2%, which
is still higher than in the literature. Others also observed a
higher incidence and doubted the incidence of iatrogenical
injury to the ulnar nerve presented in the literature [30].
In closed cross-pinning of these fractures the ulnar
nerve is in danger because of the placement of the medial
Kirschner wire near the cubital tunnel. The ulnar nerve
can be directly penetrated or constricted by the cubital tun-
nel retinaculum or a hypermobile nerve outside its groove
over the medial epicondyle can be damaged [29]. Possible
mechanisms for delayed ulnar neuropathy are nerve con-
tusion with oedema or stretching of the ulnar nerve over a
pin [30]. Late ulnar nerve palsy can exist in cubitus varus
when the triceps shifts medially pushing the ulnar nerve
anteriorly [34]. One of the methods used to avoid the ul-
nar nerve being damaged by a Kirschner wire is to use
lateral parallel pinning. The results using this method are
comparable to those with cross-pinning [12,33], although
others were not able to reproduce the diminished risk of
iatrogenic nerve injury and describe an increased rotational
instability [5,36,37]. In very young children with smaller
cross-sections of the distal humerus and children with a
comminuted medial cortex lateral pinning will not provide
enough stability. The best method of preventing ulnar nerve
injury might be an open approach to the medial epicondyle.
Brown and Zinar reported no iatrogenic ulnar nerve injuries
after using a mini incision over the medial epicondyle [4].
We now follow this procedure too. The iatrogenic ulnar
nerve injuries in our study were predominantly seen in the
earlier stage of this study, when the mini-open approach to
the medial epicondyle was not used.
In difficult fractures, fractures with neurovascular impair-
ment and unsatisfactorily reduction open reduction and pin-
ning is advised. It is said that this can be done without an
increased risk of complications [6], but in this study one
radial nerve and one median nerve palsy was found after
open reduction. In these two cases additional damage was
caused by an exploration of the cubital fossa. We think that
the altered anatomy of a dislocated fracture of the humerus
can enlarge the risk of additional complications. Like many
authors we have adopted a conservative approach towards
associated nerve palsies. We would explore the nerve when
there is no evidence of clinical or electrophysiological im-
provement by 4 months after surgery [5,7,20].
4.2. Vascular complications
The incidence of impaired circulation of the forearm af-
ter reduction of the fracture amounted 0.3%. The indication
for exploration in our clinic is a cold hand and no palpable
radial or ulnar pulse after immediate reduction. As a result
we discovered the intima lesions at the time of exploration.
It is possible that an angiogram might have revealed the in-
tima lesions earlier. When there is a warm and pink hand but
we cannot feel the pulse, we frequently check the vascular
status by routine physical examination and Doppler sonog-
raphy before we decide to do more invasive procedures such
as angiography and exploration. This policy is the same as
others described [15,31]. No vascular spasm was encoun-
tered in this series although they might have been present in
the pink pulseless hands that were carefully observed.
4.3. Functional outcome
Patients were discharged when no deficit in range of mo-
tion of more than 20 in either direction, or a varus or valgus
malunion of more than 10 was present. This explains the
rather short observation period of 5.4 (160) months. Such
a short clinical follow up can be accepted, because when
the fracture has healed, the wires removed, range of motion
is regained and the neurovascular status is normal again, no
adverse results can be expected. The cubitus varus is due to
medial tilting of the distal fragment combined with rotation
[32] and not to physical injury [12]. It does not remodel with
growth and is not progressive [1,11,23].
The 90% good or excellent functional and cosmetic result
is in concordance with reports in the literature [5,19,29]. Five
patients developed a cubitus varus of less than 10 (2.5%).
This result is in concordance with other results [27].
After reviewing the postoperative X-rays a trend was vis-
ible that less well reduced fractures (Baumanns angle [2]
>10 ) tended to lead to a functional impairment than did per-
fectly reduced fractures. This was only a trend and could not
 T. Gosens, K.J. Bongers / Injury, Int. J. Care Injured 34 (2003) 267273
be statistically proven in the 17 patients who had a subopti-
mal result. In such a case we would now either perform rema-
nipulation and closed pinning or open reduction and pinning.
A deficit of flexion associated with a residual rotational fail-
ure resulting in a ventral bone spur of the proximal fragment
of the humerus has been described in the literature [36,37].
5. Conclusion
One lesson to be learnt from this study is that transient
neurological problems are common with these fractures and
that their incidence should not be underestimated. In our
opinion the reported literature is an underestimation of pri-
mary as well as secondary neurological injury. Another les-
son to be learnt from this study and related literature is that
a mini-open procedure at the medial epicondyle is able to
prevent iatrogenic nerve injury.
Vascular injuries with a warm hand can be treated by
observation. In vascular injuries with a cold hand immediate
exploration is indicated.
We conclude that a good functional result can be obtained
in perfectly reduced fractures, but fractures that heal in mal-
rotation can give rise to a reduced function and cosmetic
appearance of the elbow.
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