Journal of Children's Orthopaedics - 2026-07-10 - Journal Article
Fracture morphology and multidirectional instability in failed closed reduction of pediatric supracondylar humerus fractures.
Darilmaz MF, Bulut M
Topics
Key Takeaway
Flexion-type supracondylar humerus fractures had an 80% open reduction rate, and Gartland Type IV instability carried an OR of 5.21 for failed closed reduction in a cohort of 318 children.
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Summary
This study identified preoperative and intraoperative predictors of failed closed reduction in Gartland Type III and IV supracondylar humerus fractures in children aged 2–12. Multivariable logistic regression on 318 consecutive cases showed flexion-type morphology (80% open reduction rate) and Gartland Type IV instability (OR 5.21, 95% CI 2.69–10.53) were the strongest independent predictors of conversion to open reduction. Older age and longer time from injury to surgery were additional significant factors.
Key Limitation
Intraoperative classification of Gartland Type IV instability lacks a standardized, reproducible definition, making this key predictor variable susceptible to inter-surgeon variability and limiting external validity.
Original Abstract
PURPOSE
To evaluate clinical and fracture-related factors associated with failed closed reduction in high-risk pediatric supracondylar humerus fractures (SCHF), with emphasis on fracture morphology and intraoperative multidirectional instability.
METHODS
This retrospective cohort study included 318 consecutive children aged 2-12 years who underwent surgery for Gartland type III SCHF or intraoperatively confirmed Gartland type IV instability between 2015 and 2025. Fractures were classified as typical extension-type, medial oblique, lateral oblique, or flexion-type. Univariable and multivariable logistic regression analyses were performed.
RESULTS
Closed reduction was successful in 192 patients, whereas 126 required conversion to open reduction. Flexion-type fractures had the highest open reduction rate (80.0%; p < 0.001). In the full multivariable model, Gartland type IV instability was strongly associated with open reduction (odds ratio 5.21, 95% confidence interval 2.69 to 10.53; p < 0.001). Compared with flexion-type fractures, typical, medial oblique, and lateral oblique patterns had significantly lower adjusted odds. Older age and longer time from injury to surgery were also associated with open reduction.
CONCLUSIONS
Flexion-type morphology and intraoperatively confirmed Gartland type IV instability were strongly associated with failed closed reduction. These findings may help surgeons anticipate reduction difficulty and plan operative resources in high-risk pediatric SCHF.
SIGNIFICANCE OF STUDY
Recognizing fracture morphology and intraoperative multidirectional instability may help surgeons anticipate failed closed reduction in high-risk pediatric SCHF.
LEVEL OF EVIDENCE
III.