See also:  Supracondylar fracture of the humerus - Emergency Department

1. How often should these fractures be followed up in fracture clinics?
2. What should I review at each appointment?
3. What are the potential complications associated with this injury?
4. When should I refer for an orthopaedic consultant opinion?
5. What are the indications for discharge?
6. Parent information fact sheet

1. How often should these fractures be followed up in fracture clinics?

Table 1: Recommended follow-up schedule for supracondylar fractures of the humerus.

Fracture type	First appointment	Subsequent review appointments	Discharge advice to parents
	At 7 days post-injury with x-ray of distal humerus in backslab Check for any loss of position	At 3 weeks post-injury. Removal of backslab and x-ray out of backslab. Check for adequate callus. Allow gentle ROM. At 6 weeks post-injury with x-ray. If there is any concern about the change in the carrying angle of the elbow (cubitus varus), longer follow-up may be required.	Return if any subsequent concern re 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
	At 3 weeks post-operative reduction Removal of backslab and K-wires X-ray of distal humerus out of backslab	At 6 weeks post-operative with x-ray. Examine for coronal and axial alignment	As above Modify activities to avoid heavy arm use (e.g. climbing) for one month post-removal of cast

2. What should I review at each appointment?

See above.

3. What are the potential complications associated with this injury?

1. Malunion
   The typical deformity is a varus malalignment (cubitus varus or gunstock deformity). This is seen as a reverse of the normal carrying angle of the arm (Figure 1) with an unsightly prominence of the lateral aspect of the elbow. Functional deficit is minimal but the cosmetic effect can be considerable.
   
   
   
   
   Figure 1: Cubitus varus (red arrow) deformity (or gunstock deformity) of the elbow can result from malunion of a supracondylar humeral fracture. The normal carrying angle of the arm is reversed and the forearm deviates to the midline when the elbow is extended.
   
   
2. Malalignment
   Malalignment in the sagittal plane (i.e. flexion or extension) is usually not a cosmetic or functional problem because of the large ROM in the elbow and compensation through shoulder movement.
   
   
3. Stiffness/limited motion
   A lack of full elbow extension is common. This can occur through sagittal malalignment. It can slowly remodel over years and is not improved with physiotherapy.
   
   
4. Neurological injury
   The most common is anterior interosseus nerve palsy, followed by median nerve, ulnar nerve, and less commonly radial nerve palsy. The majority will resolve. If neurological injury occurs after surgical reduction then a full evaluation should be performed immediately, including return to theatre. Persistent neurological injury should be investigated with nerve conduction studies if still unchanged three months after injury.
   
   
5. Volkmann's ischaemic contracture
   Occurs through vascular compromise at the time of injury, causing the death and ultimately fibrous contraction of the affected muscle. Typically the fingers, thumb and wrist become fixed in flexion.
   
   
6. Infection
   May occur in operative cases with percutaneous K-wires. To reduce the risk, avoid skin tension around the K-wires, use sterile dressings and remove K-wires three weeks post-operatively.

4. When should I refer for an orthopaedic consultant opinion?

Indications for a consultant orthopaedic surgeon opinion are:

• loss of position
• complications as per above list

5. What are the indications for discharge?

A patient can be discharged when they have met the following criteria:

• clinical and radiological evidence of union
• no tenderness at the fracture site
• painless ROM from 30 to ≥90 degrees elbow flexion

6.  Parent information fact sheet

  Supracondylar fracture (with displacement)

References (Outpatient setting)

Skaggs DL, Flynn JM. Supracondylar fractures of the distal humerus. In Rockwood and Wilkins' Fractures in Children, 7^th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.487-532.

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