Abstract
Purpose:
Supracondylar humerus (SCH) fractures are common, but they rarely present as open fractures. This study aimed to evaluate the incidence, associated injuries, and postoperative outcomes of open SCH fracture management in the pediatric population.
Methods:
Children with open SCH fractures treated at a single institution between January 2005 and January 2025 were included in this study. Electronic medical records were reviewed to collect demographic data, fracture characteristics, surgical details, and postoperative outcomes. All patients underwent wound irrigation and debridement, open-assisted reduction, and K-wire fixation under general anesthesia. Postoperative care included immobilization, follow-up for fracture healing and range of motion (ROM), and selective physical therapy. Data were analyzed using standard statistical methods, with significance set at p < 0.05.
Results:
Among 3053 SCH fractures, 1.1% were open fractures (15 males, 19 females), with a mean age of 7.7 ± 2.4 years. The nondominant left arm was affected in 82.4% of cases, and the most common mechanism of injury was a fall from height (64.7%). Extension-type modified Gartland type III fractures were observed in 91.2% of patients, and Gustilo–Anderson type II was the most frequent open fracture classification (44.1%). Associated nerve injuries occurred in 20.6% of patients, and vascular repair was required in 5.9%. The mean time to pin removal was 4.7 ± 1 weeks. Overall, 26.5% of patients underwent reoperation, 26.5% experienced ≥10° reduction in flexion-extension ROM.
Conclusion:
Open SCH fractures are rare yet serious injuries, causing peripheral nerve and vascular damage that require surgical repair.
Keywords
Introduction
Open supracondylar humerus (SCH) fractures in children are rare but serious injuries, accounting for only 1%–2% of all SCH fractures. 1 In contrast to closed supracondylar fractures, which are among the most common pediatric elbow injuries and well documented for their risk of neurovascular compromise,2–5 open fractures are associated with a higher overall risk of complications. 6
Existing literature presents conflicting findings regarding the comparative neurovascular risks of open versus closed SCH fractures. While multiple studies have demonstrated that open SCH fractures are associated with a higher risk of vascular injuries,7,8 not all studies have found a higher risk of neurologic injuries or impaired nerve recovery. 9 In addition to the primary injuries, open fractures are generally associated with an increased risk of complications such as infection or nonunion. 10 Such complications are relatively uncommon in children compared with adults, but still warrant careful management. 11 Rather than indicating a high risk of infection or nonunion, the presence of an open wound in children more often reflects a higher-energy mechanism of injury with associated soft tissue trauma. 12 Disruption of the periosteum and surrounding soft tissues may compromise fracture stability, making anatomic reduction more challenging and increasing the risk of malalignment. 13 Cubitus varus results from malunion of the distal humeral fragment rather than growth disturbance and remains one of the most clinically relevant late complications following SCH fractures.14,15
There is a paucity of literature characterizing the clinical features and injury- or management-related complications of open SCH fractures. Previous studies have either analyzed SCH fractures in the context of small sample-size case series9,16 or registry level data that lack clinically important parameters such as fracture classification, reduction accuracy, or follow-up data surgical and radiographic detail.
Our study aims to provide a comprehensive evaluation of the epidemiological characteristics, surgical parameters, complications, and associated injuries of open SCH fractures in the pediatric population. This will advance our understanding of this rare fracture type and provide data that can directly inform clinical decision-making in the management of open SCH fractures.
Methods
Study design
This retrospective study included children with open SCH fractures treated at a single institution between January 2005 and January 2025. Approval was obtained from the Institutional Review Board, and informed consent was waived due to the retrospective nature of the study. Electronic medical records were reviewed to identify patients who met the following inclusion criteria: age 2–13 years, presentation with an open SCH fracture, treatment with wound irrigation and debridement followed by reduction and internal fixation with Kirschner wires (K-wires), and a minimum postoperative follow-up of 3 months. Collected variables included age at surgery, sex, fracture laterality, mechanism of injury, fracture classification, associated fractures, pin configuration, operative time, length of hospital stay (LOS), time to pin removal, complications, and duration of follow-up.
Preoperative management
All patients received intravenous antibiotics in the emergency department or perioperatively, most commonly cefazolin (Ancef). Tetanus immunization status was verified in all cases. Combination therapy, such as cefazolin with gentamicin or penicillin, was administered in a small subset of patients, and ampicillin–sulbactam (Unasyn) was used for a single dog-bite case. Postoperative courses of antibiotics lasting 12–48 h were typical in this patient population. Preoperatively, the peripheral pulses of all patients were systematically assessed. The wound was dressed with a sterile dressing and elastic bandage, and the fracture was temporarily stabilized with a posterior splint. Preoperative anteroposterior and lateral radiographs of the elbow were obtained to confirm and classify the fracture (Figure 1). Fractures were classified according to the modified Gartland classification 17 for SCH fractures and the Gustilo-Anderson classification 18 for open fractures. Patients were admitted to the orthopedic department and taken to the next available operating room for irrigation and debridement, followed by open-assisted reduction and percutaneous pinning of the fracture.
Preoperative X-rays of an 8.9-year-old female with a modified Gartland type III and Gustilo–Anderson type I supracondylar humerus fracture of the left arm (a) AP view (b) Lateral view.
Surgical technique
Surgeries were performed under general anesthesia with a pneumatic tourniquet. The incision was planned in a patient-specific manner according to the wound resulting from the open fracture and was extended to adequately expose the fracture lines. Debridement of the fracture edges and surrounding soft tissue was performed, followed by thorough irrigation with 3–6 liters of normal saline. With direct visualization of the fracture, reduction was achieved using traction, translation, and patient-specific maneuvers, and the reduction was confirmed under C-arm fluoroscopy. Accuracy of reduction was confirmed through measurement of the Baumann angle, 19 the shaft-condylar angle (SCA), 20 and the lateral capitellohumeral angle (LCHA) 21 (Figure 2). Following fracture reduction, two lateral K-wires were inserted in all patients and fracture stability was assessed. If instability persisted after lateral pinning, a single medial K-wire was added through a small incision over the medial epicondyle, with protection of the ulnar nerve, and stability was re-evaluated. If stability was already achieved with two lateral pins, a third lateral pin was added if needed to complete the procedure. If the radial pulse remained absent despite adequate reduction and fixation, the brachial artery was routinely explored in all such patients, even in the presence of a well-perfused hand. When a vascular injury was identified, a vascular surgeon was involved in the management. Doppler ultrasonography was used after vascular repair to confirm restoration of circulation. After deflating the tourniquet, hemostasis was achieved with electrocoagulation. In most cases, the wound was closed and a sterile dressing applied; a few patients underwent staged closure after a second irrigation due to contamination. Pins were cut and bent outside the skin, and a posterior splint or long-arm cast (70°–90° flexion) was applied. Casts were routinely split or bivalved to allow for swelling and vascular assessment.
Fluoroscopic images after reduction and fixation showing the measurement of angles (a) Baumann angle (b) SCA (c) LCHA.
Postoperative care
Patients were seen in the outpatient clinic within 2 weeks of initial treatment for wound assessment and suture removal. Assessment of the healing site was performed after removal of the cast or splint. If inspection alone was sufficient, the cast was modified by creating a window or bivalve to facilitate assessment. Once healing was considered adequate, casts were replaced with a removable splint, passive and active motion was initiated immediately, even while pins remained in situ. Splints were temporarily removed, reapplied, or adjusted as needed during this process.
Patients were additionally seen for follow-up at the fourth or fifth postoperative week for evaluation of fracture union and K-wire removal, followed by monthly assessment of elbow range of motion (ROM). Physical therapy was prescribed at the discretion of the treating surgeon based on patient stiffness, strength, and ROM. We pragmatically determined a threshold of approximately 65% of the expected recovery in elbow flexion, extension, supination, and pronation based on our clinical experience. This threshold was estimated as roughly two-thirds of the anticipated ROM. Patients who did not reach this threshold by approximately 3 months postoperatively were considered for targeted physiotherapy. Final follow-up radiographs were obtained to assess fracture remodeling (Figure 3), and the carrying angle was measured on AP images along the axes of the humerus and ulna, as previously described, 22 to evaluate residual angular deformity (Figure 4). During the same visit, ROM was assessed by the attending physician via comparison with the contralateral limb, and decreased ROM was defined as a limitation of more than 15° in elbow flexion-extension relative to the unaffected elbow.
Three-month follow-up X-rays demonstrating fracture union and remodeling (a) AP view (b) Lateral view.
X-ray demonstrating the measurement of the carrying angle.
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics 25 (IBM Corp., Armonk, NY, USA). Quantitative data were summarized as mean, standard deviation, and range, and compared using the independent-samples t-test or Mann–Whitney U test as appropriate. Qualitative data were expressed as numbers and percentages and analyzed using the Chi-square test. A p-value of <0.05 was considered statistically significant.
Results
Throughout the study period, a total of 3053 patients underwent surgical treatment for SCH fractures. Thirty-four (1.1%) of these patients presented with open fractures and were included in this study (15 males, 19 females). The mean age was 7.7 ± 2.4 years (range, 2.2–12.4). In all patients, the left arm was the nondominant side and was fractured more frequently than the right (82.4% vs. 17.6%, respectively). The most common mode of injury was a fall from height (n = 22, 64.7%). Thirty-one fractures (91.2%) were classified as extension-type modified Gartland type III fractures. The most common Gustilo–Anderson type was type II, observed in 15 (44.1%) patients. Two (5.9%) patients had a history of a previous closed SCH fracture on the same side, treated with closed reduction and percutaneous pinning. Five (14.7%) patients had ipsilateral forearm fractures that had undergone closed reduction. Associated nerve injuries were present in 7 (20.6%) patients (Table 1).
Demographics and baseline characteristics of the included patients.
SCH: Supracondylar humerus; SD: Standard deviation.
Anterior interosseous nerve injury was the most common neurological finding (four patients, 11.8%). Median, ulnar, and radial nerve injuries were each observed in one patient (2.9%). All nerve injuries were identified at initial presentation during preoperative assessment. Distal pulses were systematically evaluated preoperatively. Vascular involvement included absent radial pulse with intact brachial artery in four patients (11.8%) and brachial artery injury requiring repair in two patients (5.9%). None of the patients with an absent radial pulse had additional nerve injuries. If the radial pulse remained absent intraoperatively despite adequate reduction and fixation, the brachial artery was explored. One of these patients had a complete brachial artery transection with a 5 cm gap retraction, requiring vascular repair using a saphenous vein bypass graft and fasciotomy of the forearm. The other patient had a brachial artery laceration that required vascular repair using a cephalic vein graft and forearm fasciotomy. Circulation was restored in both patients as confirmed by Doppler ultrasonography, and secondary fasciotomy wound closure was performed 2 days postoperatively (Table 2).
Associated neurological and vascular injuries.
No significant association was found between the incidence of neurologic or vascular injuries and baseline factors, including age, gender, fracture side, Gustilo–Anderson classification, or the presence of ipsilateral forearm fractures (Table 3).
Baseline demographics and injury correlations.
SD: Standard deviation.
Among the 34 study patients, the mean operative time was 81.4 ± 66.8 min, and the mean LOS was 2.2 ± 1.4 days. Postoperatively, the mean Baumann angle was 74.7 ± 4.3°, the mean SCA was 38.1 ± 6.1°, and the mean LCHA was 49.4 ± 7.1°. The average time to pin removal was 4.7 ± 1.1 weeks, and the mean time to fracture union was 4.8 ± 1.1 weeks. A total of 11 patients (32.3%) required reoperation. Of these, two patients (5.9%) underwent wound irrigation and debridement due to wound-related concerns. Revision open reduction and repeat K-wire fixation were required in two patients (5.9%) because of loss of reduction or fixation instability. Pin removal in the operating room was performed in two patients (5.9%) after the K-wire tips were cut short and became subcutaneous. In addition, two patients (5.9%) who initially underwent fasciotomy required reoperation for wound management and delayed closure, and three patients (8.8%) underwent secondary wound closure as part of staged soft-tissue management. The mean carrying angle was 10.3° ± 5.1°. Regarding malunion, cubitus varus was observed in three patients (8.8%). Fasciotomy was performed in two patients (5.9%), and decreased ROM was observed in nine patients (26.5%) (Table 4). The mean follow-up duration in patients with decreased ROM was 6.38 months (5–9 months).
Operative, postoperative parameters and complications.
SCA: Shaft-condylar angle; ROM: Range of motion; SD: Standard deviation; LCHA: Lateral capitellohumeral angle.
The anterior interosseous nerve was injured in four patients; three recovered, with an average recovery time of 2 months. The median nerve and radial nerve were each injured in one patient, with complete recovery in each case at 7.5 and 6 months, respectively. One patient sustained an ulnar nerve injury, which did not recover (Table 5).
Nerve injuries and recovery in study patients.
Discussion
SCH fractures are among the most common pediatric fractures, but open fractures remain rare. In our study, open SCH fractures accounted for 1.1% of all pediatric SCH fractures, consistent with large database studies. 1 Closed SCH fractures typically occur following simple falls, whereas open fractures are generally associated with higher-energy trauma. 23 However, we found that falls from height, even if not considered high-energy trauma, can also lead to open SCH fractures. This finding highlights that even minor falls can result in severe injuries. Furthermore, our findings indicate that motor vehicle accidents represent an important high-risk mechanism for open SCH fractures.
The mean age of children with open SCH fractures in our study was 7.7 years, which supports previous reports.6,8 Fletcher et al. 24 reported the incidence of open SCH fractures in children older than 8 years to be 3.8%, which was significantly higher than in children younger than 8 years (1.3%). Additionally, a nationwide epidemiologic database study reported a mean patient age of 9.1 years, which was significantly higher than that of children with closed fractures. 7
In our cohort, all patients were right-hand dominant, with injuries most frequently involving the left, nondominant arm (82.4%). This aligns with previous literature, and as proposed by Herdea et al., 25 this phenomenon may be due to the tendency among children to protect their dominant arm by falling on their nondominant one. Alternatively, Farnsworth et al. 26 suggested that children playing on structures such as monkey bars tend to fall on their nondominant arm because the dominant arm is able to maintain grip longer.
In our cohort, 14.7% of patients had associated ipsilateral forearm fractures, supporting Armstrong et al. 6 and highlighting the association of open SCH fractures with high-energy trauma and related injuries. 27 Given that nerve injuries following high-energy trauma often result from compression between fracture ends and may take several months to recover, careful documentation and regular follow-up are essential to monitor progress and guide management.28,29 Peripheral nerve palsies were observed in 20.6% of our cohort, with the anterior interosseous nerve being the most commonly affected, in line with previous reports.8,9 In our study, most peripheral nerve deficits recovered within 1 to 7.5 months. However, one anterior interosseous nerve palsy and one ulnar nerve palsy did not fully recover by final follow-up, further emphasizing the importance of careful documentation and ongoing follow-up.
Distal pulse assessment by both palpation and Doppler ultrasonography is critical, as pulse loss is a well-recognized complication of open fractures. 30 Nordin et al. 1 reported a vascular injury incidence of 3.48% in open fractures, which was significantly higher than that observed in closed fractures. Similarly, Cambon-Binder et al. 31 demonstrated that a pulseless hand and the need for vascular repair were more commonly associated with open fractures. In patients without detectable pulses, urgent fracture reduction and fixation are required; if perfusion remains inadequate, vascular exploration and potential repair may be necessary. 32 In the present cohort, six patients (17.6%) presented without distal pulses, and two of which required brachial artery repair. Although the small sample size limits direct comparison with previous reports, we believe reporting these cases highlights the potential severity of open SCH fractures and the need for careful vascular assessment.
Preventing infection is an important goal when treating open fractures. 33 In children with open SCH fractures, infection is generally rare, likely due to the rich blood supply around the elbow and careful perioperative care. 34 In our study, all patients received intravenous antibiotics in the emergency department or perioperatively, and no infections were observed. Our findings align with Lewine et al., 9 who reported that timely wound and fracture management in children with open supracondylar fractures resulted in outcomes similar to those with closed fractures, with minimal increased risk of infection. Beyond infection, children with open SCH fractures often present with complex injury patterns that may necessitate repeated surgical intervention. 35 Among our patients, 14.7% underwent subsequent surgery, and 14.7% returned to the operating room for pin removal.
Historically, cubitus varus was much more common after SCH fractures, but with modern surgical reduction and appropriate fixation, the rate has decreased to 5%–10%.36–38 In our series, cubitus varus developed in 8.8% of patients, representing a clinically relevant complication of open fractures. However, even with anatomic reduction, cubitus varus can still occur, as reported by Eren et al., 39 due to initial compression of the medial column or physeal injury, highlighting the importance of careful follow-up to monitor functional recovery and residual deformity.
Management of SCH fractures is generally urgent. Timing to surgical treatment has been extensively studied, and although various thresholds have been evaluated, delayed surgery within these time frames has not been associated with increased complication rates.40–42 In our series, the average time from admission to surgery was 6.0 ± 4.0 h, which is consistent with the reported literature. Although delays in treatment have not been shown to result in high complication rates, they are significantly associated with decreased ROM.43,44 Data on elbow ROM after open fractures are limited, but Lewine et al. 9 reported reduced ROM in patients with open fractures compared to closed fractures. Similarly, 26.5% of patients included here demonstrated decreased ROM at final follow-up, indicating that limitations in motion can occur even in the absence of treatment delay.
This study has several limitations, including its retrospective design and the lack of a control group. Although the number of patients was limited, the data remain meaningful given the rarity of open SCH fractures and the relatively small sample sizes reported in previous studies. Despite these limitations, the findings provide valuable clinical insights to inform the management of open SCH fractures in children.
As a conclusion, open SCH fractures in children are uncommon but can involve neurovascular compromise and associated ipsilateral forearm injuries. Satisfactory outcomes for fracture union and recovery of neurovascular function can generally be expected; however, surgeons should perform careful assessment, provide timely management, and monitor for cubitus varus as well as potential limitations in ROM.
Supplemental Material
sj-pdf-1-cho-10.1177_18632521261435431 – Supplemental material for Open supracondylar humerus fractures in children: Associated injuries and clinical outcomes
Supplemental material, sj-pdf-1-cho-10.1177_18632521261435431 for Open supracondylar humerus fractures in children: Associated injuries and clinical outcomes by Abdulsamet Emet, Grace Armet, Connor Luck, Taha Aksoy, Stephen A. Mendelson and Ozgur Dede in Journal of Children's Orthopaedics
Footnotes
Acknowledgements
The authors would like to sincerely thank the staff of the Emergency and Orthopedic Surgery Departments, as well as the operating room team, for their invaluable support in patient care. We also extend our gratitude to the radiology team.
Author contributions
A.E., S.A.M., and O.D. served as guarantors of the integrity of the entire study and provided supervision. A.E. drafted the manuscript. C.L. and G.A. contributed to manuscript writing and data collection. A.E., S.A.M., and O.D. were involved in manuscript editing. All authors reviewed and approved the final version of the manuscript.
Availability of data and materials
The data used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethics approval
Approval of the Institutional Review Board (IRB), University of Pittsburgh, Study20060200, has been obtained.
References
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