The typical deformity for an "off-ended" Gartland III injury is an S-shaped deformity. Any bleeding around the elbow may point towards an open fracture and needs to be assessed. The arm may be swollen, bruised, and deformed. The affected limb must be thoroughly assessed for the integrity of the soft tissue envelope and the distal neurovascular status. Any other injuries must also be carefully evaluated and documented. Young children may be reluctant to use the affected limb. The child or carer may give a history of pain, swelling, or deformity of the affected limb. There may be a history of a fall on an outstretched arm, causing an extension-type fracture or a fall on a flexed elbow. Although rare, a non-accidental injury must be excluded, accounting for <0.5% of the fractures. On the other hand, posterolateral displacement tends to rupture the medial periosteum, and the reduction is therefore performed in supination. Due to this, the reduction is performed in pronation which tensions the medial periosteum and prevents varus malalignment. In posteromedial displacement of the distal fragment, the medial periosteum is intact. The mechanism of injury and the resultant displacement of the fracture also guides the reduction maneuver performed. Flexion-type fractures occur with a fall on a flexed elbow but are much less common. This is the mechanism of injury for extension-type fractures, which account for up to 95% of supracondylar fractures. The posterior cortex and periosteum may be intact. The bone fractures at the weakest point, and the anterior humeral cortex fails in tension. The olecranon process engages the olecranon fossa producing an extensive force on the distal humerus. Most fractures occur when the child falls on an outstretched arm causing hyperextension of the elbow. In the axial plane, it is dumbbell shaped owing to the thin plate of the bone in the middle, at the site of the olecranon fossa and coronoid fossa. The shape of the distal humerus is roughly triangular in the coronal plane, with the base composed of the lateral epicondyle, capitellum, trochlea, and medial epicondyle. The incidence of open supracondylar fractures is around 1%. These injuries often occur in the non-dominant upper extremity. Flexion-type fractures are more prevalent in older children. Also, it has been reported that these fractures are more common on weekends and during summer. Ligamentous laxity in the pediatric age group causes hyper-extension of the elbow and contributes to causing extension-type fractures. Extension-type fractures are much more common than flexion-type fractures and occur as a result of a fall on an outstretched hand. However, a recent epidemiological study found no significant difference between the genders. Some studies describe an increased prevalence among males than females, while others describe a higher prevalence in females. The median age is approximately six years, and the incidence gradually decreases with age. They most frequently occur in children aged 5 to 7 years. The supracondylar region of the distal humerus is the most commonly fractured area around the elbow in children. On the other hand, some patients who develop a malunion may have a satisfactory function in the long term. Inadequate reduction and fixation can also lead to malunion and deformity. These injuries can be significant due to the risks of neurological damage, vascular injury, and compartment syndrome. The modified Gartland classification is often used to describe fracture patterns and guide treatment. Despite evolutions in the evaluation and treatment over the years, these fractures still pose considerable challenges to orthopedic surgeons. Gartland described that even expert trauma surgeons are anxious and apprehensive while managing supracondylar humerus fractures. Supracondylar fractures of the humerus account for up to 18% of pediatric fractures and 60% of elbow fractures. Children often utilize an outstretched arm as a protective mechanism when falling, creating a high incidence of fractures about the elbow. Elbow fractures are more common in the pediatric population than in the adult population.
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