Pediatric Supracondylar Humerus Fracture Repair with Mini-Open Assisted Reduction and Percutaneous Pinning

Abstract

Supracondylar humerus (SCH) fractures are the most common elbow fractures in children and represent a significant source of morbidity in low- and middle-income countries (LMICs), where delayed presentation and limited surgical capacity frequently lead to poor outcomes. Closed reduction and percutaneous pinning (CRPP) is the gold-standard treatment for displaced SCH fractures and is particularly well-suited to resource-limited settings given its reliance on minimal, low-cost implants.

This case describes a 9-year-old male who presented to Mzuzu Central Hospital in Malawi with a completely displaced Gartland Type III SCH fracture following a fall. Surgical intervention was delayed three days due to unavailability of intraoperative fluoroscopic imaging. Neurovascular examination was intact on presentation. The procedure was performed under general anesthesia. Reduction was first attempted with longitudinal traction to unlock the distal fragment, followed by thumb pressure on the olecranon and elbow flexion. As the distal fragment remained incompletely reduced in the sagittal plane, a small posterior incision was made and the Kapandji maneuver was performed to achieve satisfactory reduction, confirmed fluoroscopically. Three smooth Kirschner wires (K-wires) were introduced in retrograde fashion from the lateral condyle under fluoroscopic guidance. One of the three K-wires was intramedullary and became loose prior to case conclusion, so it was removed before the remaining pins were cut and bent outside the skin, and a posterior back slab was applied with the elbow at 90 degrees of flexion. The remaining K-wires were removed at 4 weeks, and range-of-motion exercises were initiated thereafter.

This case demonstrates that percutaneous pinning, with mini-open assistance where closed reduction cannot be achieved, can be performed safely in resource-limited settings and illustrates the real-world intraoperative challenges, including limited C-arm resolution, use of non-orthopaedic drills with insufficient power, and bent K-wires, that afflict much of the developing world.

Keywords

Fracture fixation; bone wires; humeral fractures; orthopaedic procedures; global health; children.

Case Overview

Background

Supracondylar humerus fractures (SCH) are the most common elbow fractures in children, accounting for approximately 55–75% of all pediatric elbow fractures and causing significant morbidity in low- and middle-income countries (LMICs).¹ In sub-Saharan Africa, delayed presentation is common due to barriers including distance from care, cost, and reliance on traditional bonesetter treatment, which can result in malunion, neurovascular compromise, and permanent functional loss.^2-4

Supracondylar fractures are classified by the modified Gartland system into four types based on displacement (Figure 1): Type I (non-displaced), Type II (displaced with intact posterior cortex), Type III (completely displaced), and Type IV (multidirectional instability).^5,6 Types III and IV fractures typically require surgical intervention, while Type II fractures are more controversial, as some are amenable to non-operative treatment. Closed reduction and percutaneous pinning (CRPP) is the gold-standard treatment for displaced SCH in children, offering reliable fracture stabilization with low complication rates while avoiding the risks associated with open reduction.⁷ In resource-limited settings, timely CRPP is critical to preventing neurovascular injury, compartment syndrome, and malunion.^8,9

Figure 1. Gartland Classification of Supracondylar Humeral Fractures.

Focused History of the Patient

A 9-year-old male patient presented to Mzuzu Central Hospital in Malawi with left elbow pain and inability to use the arm following a fall earlier that day. He had no significant past medical or surgical history. Surgical intervention was delayed 3 days due to unavailability of intraoperative C-arm imaging.

Physical Exam

The patient presented with swelling, tenderness, and deformity about the left elbow. There was no overlying skin compromise or open wound. Neurovascular examination was intact, with palpable radial pulse, brisk capillary refill, and preserved sensation and motor function throughout the hand and digits. Specifically, anterior interosseous nerve function was intact as evidenced by preserved flexion of the distal interphalangeal joint of the index finger (“OK” sign), and radial nerve function was intact with preserved wrist and thumb extension.

In Gartland type III supracondylar fractures, the neurovascular exam is a critical component of the initial assessment. The anterior interosseous nerve is the most commonly injured structure, followed by the radial nerve.¹⁰ The brachial artery is also at risk in significantly displaced fractures, and a "pulseless but well-perfused" hand warrants close monitoring even in the absence of hard signs of vascular injury.⁷

Imaging

Anteroposterior (AP) and lateral radiographs of the left elbow were obtained and are sufficient for diagnosis and surgical planning in the majority of SCH fractures (Figure 2). In this case, preoperative radiographs demonstrated a significantly displaced SCH consistent with Gartland Type III, with loss of contact between the proximal and distal fragments including loss of posterior hinge and significant posterior displacement of the distal fragment. The anterior humeral line, a line drawn along the anterior cortex of the humerus on the lateral view, did not intersect the middle third of the capitellum, consistent with significant posterior displacement of the distal fragment.⁵ The Baumann angle was approximately 60 degrees in our patient, as measured on the AP view as the angle between the physeal line of the lateral condyle and a line perpendicular to the humeral shaft, normally measuring between 70–75 degrees and serving as a reliable proxy for the carrying angle of the elbow.⁵ Both measurements are essential for preoperative diagnosis and for intraoperative confirmation of adequate reduction, and should be compared to the contralateral elbow where possible.

Advanced imaging such as CT or MRI is not routinely indicated for isolated supracondylar fractures and was not obtained in this case.

Figure 2. AP and lateral preoperative radiographs of the left elbow demonstrating a Gartland type III supracondylar humerus fracture.

Natural History

SCH in children, if left untreated or inadequately managed, can result in significant short- and long-term complications. In the acute setting, the greatest risk is neurovascular injury. Brachial artery compromise can lead to Volkmann ischemic contracture, a devastating and largely irreversible condition characterized by forearm and hand contracture resulting from compartment syndrome.¹¹ Nerve injuries, most commonly to the anterior interosseous nerve, radial nerve, or median nerve, may also occur at the time of injury or as a result of delayed treatment.

While pediatric patients generally have strong remodeling potential, the distal humerus in particular is less capable of remodeling, especially coronal and rotational deformities,¹² with subsequent risk of long-term growth disturbance and elbow stiffness. In the chronic setting, malunion is the most common complication of inadequately treated or neglected supracondylar fractures. Malunion in the coronal plane results in a cubitus varus deformity (decreased Baumann angle), colloquially termed "gunstock deformity," which, while often functionally tolerable, carries cosmetic consequences and a risk of subsequent lateral condyle fracture.^1,12,13 In resource-limited settings where delayed presentation is common, malunion and its sequelae represent a significant burden,⁸ often requiring complex corrective osteotomy that demands greater surgical expertise and resources than the index procedure.

Options for Treatment

Management of SCH depends on the degree of displacement. Type I fractures are treated conservatively with cast immobilization alone.⁹ Type II fractures may be managed with either cast immobilization or CRPP depending on the degree of angulation and surgeon preference. Type III fractures, such as in this case, universally require surgical intervention.

Three broad surgical options exist for displaced SCH: CRPP, open reduction and percutaneous pinning (ORPP), and open reduction and internal fixation (ORIF).⁷ CRPP is preferred when closed reduction can be achieved, offering reliable stabilization with minimal soft tissue disruption, low infection risk, and excellent functional outcomes. Open reduction is reserved for cases where closed reduction fails, where there is an open injury, or where neurovascular structures are entrapped within the fracture site requiring exploration. ORIF is rarely indicated in pediatric SCH.

In LMICs, treatment should be matched to the resources of the treating hospital (Table 1).¹⁴ CRPP remains preferred wherever it can be performed safely, as it requires minimal implants and no specialized instrumentation.^2,8 Many LMIC hospitals, however, have no fluoroscope at all.¹⁴ Where a surgeon trained in the procedure is available, open reduction followed by percutaneous K-wire fixation is preferable to blind pinning, which carries a high risk of neurovascular injury. The approach should be chosen according to the fracture pattern and the surgeon’s experience. Lateral, medial, anterior, and posterior approaches have all been described, with lateral and posterior most commonly used where fluoroscopy is unavailable.^1,15 For open fractures, the traumatic wound can be extended to reach the fracture site. Wires are then placed using anatomic landmarks and tactile feedback through the incision, and postoperative AP and lateral radiographs are used to confirm reduction and fixation. Where safe operative capability is also absent, the child should be immobilized and referred. When referral is not possible, and no alternative exists, traction and manipulation without fluoroscopy is the remaining option.¹⁴ In a Malawian district hospital series of 119 children, this pathway was associated with high rates of functional impairment, particularly for Gartland Type III fractures.⁸ It should be understood as a last resort rather than an equivalent option.

Table 1. Suggested management of a completely displaced supracondylar humerus fracture, stratified by the resources available at the treating hospital.

Traction and manipulation without fluoroscopy pathway involves straight arm traction until the swelling settles, followed by closed reduction under anesthesia, and placement of a long arm posterior slab.

Rationale for Treatment

The goals of surgical treatment in this patient were to achieve and maintain anatomic or near-anatomic reduction of the distal humerus, restore normal coronal and sagittal alignment, and provide stable fixation to allow early mobilization and minimize the risk of stiffness, malunion, and neurovascular compromise.

CRPP was planned given the completely displaced Gartland Type III fracture pattern, the patient's skeletal immaturity, and the absence of indications for open reduction such as failed closed reduction, open fracture, or neurovascular entrapment. Closed reduction alone did not fully correct the sagittal plane in this case, and a posterior mini-incision was therefore used to complete the reduction.

Fluoroscopic guidance was essential to confirm adequate reduction intraoperatively and to ensure safe pin placement, particularly to confirm that the lateral pins achieved adequate spread at the fracture site and purchase in the far cortex.

Special Considerations

CRPP is most beneficial in skeletally immature patients with Gartland Type II and III SCH who have sufficient bone for K-wire purchase and no contraindications to general anesthesia. Adequate reduction is essential as the pediatric distal humerus has lesser remodeling potential, especially with coronal and rotational deformities. CRPP, however, is contraindicated in open injuries or when closed reduction cannot be achieved. A poorly perfused hand after attempted reduction is an indication for vascular exploration and should not be managed with pinning alone.

K-wires are low-cost, widely available, and do not require specialized instrumentation, making CRPP particularly well-suited to resource-limited settings. However, the procedure is highly technique dependent, and fluoroscopic confirmation of reduction and pin placement should not be foregone, as the risk of neurovascular injury outweighs the benefit of earlier fixation. 

Postoperative follow-up presents unique challenges in settings where patients may travel long distances to access care. Clear counseling regarding pin site care, signs of infection, and the importance of timely return for pin removal is critical to achieving good outcomes.

Discussion

This case presents a 9-year-old male with a Gartland Type III SCH managed successfully with a posterior mini-incision and percutaneous pinning at Mzuzu Central Hospital in Malawi (Figure 2). Three lateral-entry pins were placed, one of which was removed at the conclusion of the case. The case demonstrates the safe, effective surgical management of a completely displaced pediatric SCH in a resource-limited setting, and illustrates resource-related challenges that are common but rarely described in surgical literature. Because reduction of this fracture required a small posterior incision, we describe the procedure as mini-open assisted reduction with percutaneous pinning rather than CRPP.

Surgical Technique

The patient was placed supine on the operating table under general anesthesia. The affected extremity was prepped and draped in standard sterile fashion. Initial fluoroscopic images were obtained to confirm fracture configuration prior to reduction.

Closed reduction was attempted by first applying longitudinal traction to the forearm to unlock the posteriorly displaced distal fragment, followed by thumb pressure on the olecranon and elbow flexion to translate the distal fragment anteriorly. Fluoroscopic assessment confirmed improvement in the anterior humeral line, though the distal fragment remained incompletely reduced in the sagittal plane. A small posterior incision was therefore made, and a hemostat was used to dissect down to the fracture site. The Kapandji maneuver was then performed, using an instrument as a lever to flex the distal fragment more anteriorly, achieving satisfactory reduction confirmed fluoroscopically with the anterior humeral line intersecting the capitellum (Figure 3). Coronal alignment was additionally assessed on the AP view before pinning. Coronal malalignment remodels poorly and is the principal determinant of long-term cubitus varus, so coronal correction takes priority over sagittal correction when the two compete.¹²

In this case, coronal alignment was acceptable after closed manipulation, and thus the residual sagittal plane deformity was addressed.

Figure 3. Lateral intraoperative radiograph of the left elbow demonstrating the Kapandji maneuver to push the distal fragment anterior.

Three smooth K-wires were introduced in retrograde fashion from the lateral condyle into the proximal humerus under fluoroscopic guidance. Maximal divergence of the pins at the fracture site is a critical technical point, as pin spread maximizes rotational stability of the construct. Final fluoroscopic images confirmed satisfactory reduction and pin placement in both AP and lateral planes (Figure 4). One of the three wires was intramedullary rather than crossing the fracture plane obliquely and had lost purchase, so it was removed before the remaining pins were cut and bent outside the skin. A posterior back slab was applied with the elbow at 90 degrees of flexion.

Figure 4. Lateral intraoperative radiograph of the left elbow after satisfactory placement of the three retrograde wires.

Postoperative radiographs confirmed satisfactory reduction with restoration of the anterior humeral line (Figure 5). The patient was seen for wound and pin site check at two weeks. The remaining K-wires were removed at 4 weeks, at which point range of motion was initiated.

Figure 5. Lateral postoperative radiographs of the left elbow after mini-open assisted reduction and percutaneous pinning for a Gartland type III supracondylar humerus fracture.

Intraoperative challenges included limited C-arm image resolution, use of non-orthopaedic drills with poor power, and bent K-wires, all of which are representative of equipment limitations commonly encountered in resource-limited settings. Reduction after closed manipulation may well have been acceptable without the mini-open step. The decision to proceed was made intraoperatively based on limited C-arm image quality with the trade-off being additional soft tissue dissection and operative time. Additionally, where possible, the C-arm should be moved to obtain the lateral view rather than rotating the injured elbow, which risks losing the reduction. The monitor should also sit in the surgeon’s direct line of sight rather than behind them, so that wire trajectory can be adjusted without turning away from the field. In this case, the operating room layout prevented ideal C-arm positioning.

Pin Configuration: Evidence and Rationale

The choice of lateral-entry-only pinning in this case reflects both the current evidence base and the practical considerations of the operative setting. While crossed medial-lateral pinning has historically been favored for its rotational stability, a landmark randomized controlled trial by Kocher et al. and subsequent meta-analyses have demonstrated equivalent stability and clinical outcomes between lateral-only and crossed configurations when lateral pins are appropriately placed with maximal spread at the fracture site.^16-18 Critically, lateral-entry pinning eliminates the risk of iatrogenic ulnar nerve injury associated with the medial pin, reported at up to 6% in some series. In resource-limited settings where postoperative neurological monitoring and management of nerve injury may be challenging, this risk avoidance is particularly valuable.

Outcomes

At 3 weeks post-op, the patient was doing well with no signs of pin-site infection and reported intermittent pain with activity. The patient had not yet returned to school at this time and reported some difficulties with self-care and participation in usual activities. He had begun physiotherapy near his home. Follow-up radiographs demonstrated stable alignment and pin position, with a Baumann angle of approximately 70 degrees, within the normal range (Figure 6). Follow-up beyond 3 weeks was not available at the time of writing, so the final radiographic and functional result is not known. Loss to follow-up is common in this setting, where families often travel long distances to reach care.

Figure 6. Lateral and AP radiographs of the left elbow 3 weeks after mini-open assisted reduction and percutaneous pinning for a Gartland type III supracondylar humerus fracture.

LMIC Context

This case illustrates both the feasibility and the constraints of performing percutaneous pinning in sub-Saharan Africa. The technical steps described here are standard, and the contribution of this case lies in the setting and subsequent surgical decision-making rather than the technique.

SCH are common pediatric injuries globally, yet in LMICs they are disproportionately subject to delays in care, equipment limitations, and postoperative follow-up challenges. The 3-day surgical delay experienced in this case due to C-arm unavailability is representative of a systemic issue across many hospitals in the region, where fluoroscopic equipment may be shared across departments, frequently out of service, or absent entirely.^2,19 While this delay did not result in adverse outcomes in the present case, longer delays carry increasing risk of neurovascular compromise, soft tissue swelling that complicates reduction, and early callus formation that may render closed reduction impossible.²⁰

Beyond fluoroscopy, operative challenges in this case included the use of a non-orthopaedic power drill with insufficient power output and bent K-wires. This reflects a broader pattern in resource-limited settings where equipment may be available but not built for the procedure being performed, or may be damaged, with implications for operative efficiency.

K-wires remain among the most accessible and affordable implants available in LMIC settings, and CRPP requires no specialized instrumentation beyond a standard wire driver and fluoroscope. However, in LMIC settings, fluoroscopy and operative capability are less common, and thus treatment should be tailored to the resources of the treating hospital, as described earlier in Table 1.

Equipment

A C-arm fluoroscope, a wire driver or power drill, and smooth Kirschner wires were used. No implants beyond the K-wires were required. Well-functioning versions of each are essential for optimal reduction and fixation, and limitations in all three are described above.

Disclosures

Kiran J. Agarwal‑Harding serves as a Section Editor at JOMI for Orthopaedic Surgery and has not been involved in the editorial processing of this article in any capacity other than as an author.
The Mzuzu Orthopaedic Support and Training program was funded by the Foundation for Orthopaedic Trauma.

Artificial intelligence was used to enhance some of the figures, and all enhanced figures were manually reviewed and verified for accuracy.

We report no other conflicts of interest, financial relationships, sponsorship, equipment support, or other relationships that could be perceived to influence the content of this article.

Statement of Consent

The legal representative of the patient referred to in this video article has given informed consent for the child to be filmed and is aware that information and images will be published online.

Acknowledgments

We would like to acknowledge the team from the Mzuzu Orthopedic Support and Training program, including the local operating room staff (nurses, transport staff, anesthesia clinical officers), local orthopedic surgery team (Dr. Bitiel Banda and orthopedic clinical officers), program staff (Gomezgani Jenda), and the Foundation for Orthopaedic Trauma who funded this program. We would also like to sincerely thank the patient, who agreed to allow for filming and dissemination of this procedure and its details.