Original article 1
Fracture obliquity is a predictor for loss of reduction in
supracondylar humeral fractures in older children
David Segala,b, Leah Cobba and Kevin J. Littlea
Supracondylar humeral fractures in older children have
different biomechanical characteristics and surgical
outcomes when compared to the same fractures in younger
children. We aimed to analyze the fracture’s architecture in a
large group of older children and investigate the correlation
between patients’ variables, fracture patterns, fixation
techniques and the rate of loss of reduction (LOR). A
retrospective review study was conducted. We collected the
records of 240 consecutive patients aged 8–14 years that
sustained Gartland type 2/3 supracondylar humeral
fractures between 2004 and 2014 and were operated at our
hospital. We excluded patients with intra-articular or
pathological fractures. Following the radiographical analysis
and chart review, we conducted a multivariable regression
analysis. Fracture obliquity on the sagittal plane (>20°)
occurred in 33% of the cases and was found to be the only
factor related to LOR (P = 0.01). Gartland type 3 fractures
and more than two lateral pin configuration did not correlate
to fixation failure (P = 0.69 and 0.14, respectively). The
incidence of flexion-type fractures (5.8%) was found to be
higher than in the total pediatric population. The sagittal
oblique supracondylar humeral fracture is common and is
Introduction
Supracondylar humeral fractures (SCHFs) are the most
common elbow fractures in children and account for 3–18%
of all pediatric fractures [1,2]. The predictable ossification
rate of the distal humerus along with increased participation
in activities lead to a peak incidence of these fractures
between 5 and 6 years of age [3–6]. As fractures occurring in
older patients (defined as > 8 years old, 2SD above the
mean age of SCHF patients [7]) are more likely to be
caused by high-energy mechanisms [7], and the fractured
bone is more ossified and closer to skeletal maturity, the
biomechanical structure and potential complications might
differ from younger children. These include residual stiff-
ness after bone union [7] and loss of reduction (LOR) after
surgical fixation, also referred to as ‘redisplacement.’ Several
studies were carried out to investigate the risk factors
associated with LOR of which incidence was estimated to
be 0–33% [8,9]. Some of these studies identified Gartland
classification, rotational extent, medial comminution, the
time between injury and treatment, mechanism of injury
(high vs. low energy), treatment method (open vs. closed
reduction), pinning configuration, surgical technique, and
obesity as potential risk factors [10–14]. Inconsistent con-
clusions with regard to the causes of LOR were reported in
these papers. For example, Pennock et al. [14] concluded
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related to fixation instability and LOR. This pattern needs to
be considered when investigating different pin
configurations, complication rates, and biomechanical
properties. Subclassifying Gartland type 2/3 supracondylar
humeral fractures as ‘oblique’ or ‘transverse’ might offer
more comprehensive information about the anticipated
operative results, lead to applying more stable pin
constructs to these fractures and allow improved outcomes
following surgical fixation. J Pediatr Orthop B 00:000–000
Copyright © 2019 Wolters Kluwer Health, Inc. All rights
reserved.
Journal of Pediatric Orthopaedics B 2019, 00:000–000
Keywords: elbow, fracture, humerus, loss of reduction, stability,
supracondylar
a
Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center,
Affiliated with Cincinnati University, Cincinnati, Ohio, USA and bDepartment of
Orthopaedic Surgery, Meir Medical Center, Affiliated with Tel Aviv University, Kfar
Saba, Israel
Correspondence to David Segal, MD, Orthopaedic Surgery Division, Cincinnati
Children’s Medical Center, 3333 Burnet Avenue, Cincinnati, 45229 OH, USA
Tel: + 1 513 387 9545; fax: + 1 747 1746 9972; e-mail: dudisegal@gmail.com
that Gartland classification was not a predictive factor in
LOR but both Sangkomkamhang et al. [12] and Sun et al.
[13] found that Gartland type-III fractures were associated
with a higher incidence of redisplacement. This lack of
consensus makes it difficult to apply evidence-based data to
accurately identify unstable SCHFs preoperatively and
intraoperatively, where appropriate treatment could ame-
liorate some of these risks.
In the present study, we seek to examine the afore-
mentioned factors and determine whether there are any
other factors that may be associated with LOR and
therefore the need for reintervention of supracondylar
fractures in older pediatric patients.
Patients and methods
A retrospective record review was conducted following
Institutional Review Board committee approval. Using
billing records we identified 341 consecutive patients
aged 8–18 years that were operated for SCHFs between
February 2004 and September 2014. SCHFs and opera-
tive repair were defined in accordance with the ICD 9
codes 812.4 and 812.51, and the current procedural ter-
minology codes 24535, 24545, and 24538. Following the
exclusion of patients with condylar, intercondylar, or
T fractures (n = 66), insufficient radiographic records (n = 22),
DOI: 10.1097/BPB.0000000000000636
 2 Journal of Pediatric Orthopaedics B 2019, Vol 00 No 00

and patients with a pre-existing elbow or bone pathologies
(n = 6) we were left with 240 (220 extension-type and 20
flexion-type fractures) patients for analysis. The patients with
flexion-type SCHFs, which differ in their biomechanics [15],
were analyzed separately.
The medical record was used to collect data regarding
patient’s demographics, history, physical examination
findings, complications, and surgical record documenta-
tion. We used the timing of the first radiograph and the
initiation of surgery for ‘time to surgery’ measurements,
and signified the shift at which the surgery was con-
ducted (day: 07:01–15:30, evening: 15:31–23:00, night:
23:01–07:00).
For fracture analysis, we used the presentation radiographs
and operative fluoroscopy. We used all relevant images
available in order to properly define the Wilkins’ modified
Gartland’s type [16,17], to measure the distal fragment dis-
placement extent, to detect comminution (general or medial
[18]), and to classify the fractures according to the character-
ization system offered by Bahk et al. [19] (Table 1), who also
defined 20° as a fracture obliquity cutoff. To measure the later
we drew a line between the posterior and anterior fracture
edges on the proximal fragment and measured its angulation
with a line perpendicular to the humeral shaft (Fig. 1). We
used previously published guidelines to state whether the
anterior–posterior and lateral radiographs were technically
acceptable [4]. In some instances, the fractures’ rotational
component had limited our ability to use the radius and ulna
properties to define an exact orthogonal arm position. As we
evaluated all available imaging studies that were obtained
both preoperatively and intraoperatively, and compared them
when a classification uncertainty occurred, we did not have
cases in which the arm position on radiograph had affected our
ability to classify the fractures for obliquity.
For LOR assessment, we compared the intraoperative fluoro-
scopy studies with the follow-up radiographies. We aimed for
the 30–60 postoperative day radiographs but used earlier or
later if these were not available (mean: 39.9 days, SE: 0.9,
range: 12–79). On the anterior–posterior radiographs, we
measured the Baumann’s angle (BA; Table 1) [20]. When the
capitellar physis was not apparent because of closure (four
patients), the distal humeral articular angle [21,22], as reflected
on the coronal plane radiographs, was used instead of the BA
[22]. On the lateral radiographs, we measured the anterior
angulation of the articular surface of the distal humerus
[22–24] [will be called here the ‘Lateral Humero-Capitellar
Tilt Angle’ (LHCTA) [23]]. We also documented whether
the anterior humeral line (AHL) crossed the anterior, middle,
or posterior thirds of the capitellum [25]. For the characterizing
the fixation constructs, we documented the pin number,
direction, unicolumnar or bicolumnar fixation and the pin
separation. The latter was presented as a ratio and was cal-
culated as the fraction of the distance between the most lateral
and medial pin at the fracture site and distance between the
medial and lateral ends of the fracture line on the coronal
plane. The existence of forearm fractures was documented. As
these vary significantly, only fractures that were internally
fixated were regarded as possible risk factors. The decision to
operate on forearm fractures is based on the current literature
and is elaborated elsewhere [26].
LOR was previously defined either clinically [27], or
radiographically as a loss of 5° [11], 10° [14], or 12° [28] of
BA and/or LHCTA or a shift of the capitellar ossification
center in respect to the AHL [25,29], relying mainly on
what would have been considered by previous authors as
a significant displacement of the original reduction.
When defining LOR for this study, we took into con-
sideration the above, the arm position effect on the BA
(6° change for every 10° rotation) [30], and the expected

Table 1 Variables used to describe supracondylar humeral fractures

Variables Value Description

Gartland classification
Coronal pattern a
Sagittal patterna
Displacement directiona
Displacement extent
2 or 3 A type-II fracture is extended but not translated, with the posterior cortex intact and the capitellum posterior to its
normal intersection with the anterior humeral line. A type-III fracture is displaced with none of the cortex intact.
Typical transverse The fractures’ enter and exit points are close to the epicondyles, obliquity <10°
High transverse The fractures’ enter and exit points are close or above the proximal margin of the olecranon fossa, obliquity <10°
High medial The angle between the longitudinal humeral axis and the fracture line is ≥ 10°, medial side higher
High lateral The angle between the longitudinal humeral axis and the fracture line is ≥ 10°, lateral side higher.
Low The angle between the longitudinal humeral axis and the fracture line is <20°
High (oblique) The angle between the longitudinal humeral axis and the fracture line is ≥ 20°
Posterior Pure posterior displacement as reflected on the coronal plane
Posteromedial Posterior–medial displacement as reflected on the coronal plane
Posterolateral Posterior–lateral displacement as reflected on the coronal plane
Three groups 0–50%, 51–100%, ≥ 100.1%

Anterior humeral line Anterior The distal extension of the AHL crosses the anterior third of the capitellar ossification center
Middle The distal extension of the AHL crosses the middle third of the capitellar ossification center
Posterior The distal extension of the AHL crosses the posterior third of the capitellar ossification center
Baumann’s angle Continuous The angle between the longitudinal humeral axis and the lateral condylar physis as reflected in the AP radiograph
LCHTA The angle between the longitudinal humeral axis and the capitellar axis as reflected in the lateral radiograph
Comminution All planes Comminution was defined when the fracture was composed of more than two bone fragments. A separate
analysis was conducted for only medial comminution.

AHL, anterior humeral line; AP, anterior–posterior; LCHTA lateral caitellohumeral tilt angle.
a
Fracture classification as presented by Bahk et al. [19].

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 Oblique supracondylar humeral fractures Segal et al. 3

Fig. 1

(a) (b) (c)

>20°

(d) (e) (f)

A 9-year-old boy with a Gartland type 3 sagittal oblique supracondylar humeral fracture that has lost reduction despite two lateral pin fixations. The
difference in the pin orientation between (b,c) implies either that the radiographic beam angle might have been set in a different angle or that the pins
moved with the distal fragment. This uncertainty mandates a subjective evaluation of the x ray images on top of objective measurement analysis. (a,d)
Preoperative x-ray images. (b,e) Intra-operative fluoroscopy studies. (c,f) Follow-up x-ray images the sagittal obliquity measurement is demonstrated (a).

7° measurement normal error [20,22]. Thus, we used a
change in the BA or LHCTA of 12° or greater to be
significant. BA values were corrected according to the
radioulnar overlap as suggested by Pace et al. [31]. All
cases that showed a change of more than 12° in the BA or
the LHCTA, or a shift in AHL were further evaluated by
the primary (D.S.) and senior (K.J.L.) authors to assure
that the difference reflected a true change in the distal
fragment’s position as compared with a false reading
because of radiographic projection. Only if agreed were
they regarded as LORs. The LOR cases were analyzed
for possible failure causes.
All measurements and evaluations were carried out twice by
the primary author (D.S.), at least 2 weeks apart. The senior
author evaluated 60 radiographs for quality assessment
2 weeks apart. After accepting excellent inter-rater and
intrarater reliability evaluations for Baumann’s angle, HCTL,
and AHL (similar for all, ICC: 0.81, P < 0.001, ICC: 0.88,
P < 0.001, respectively) we used the average of the two first
consecutive measurements as the values for analysis. In cases
where any of the categorical variables were different between
the two assessments, a third evaluation was conducted by the
two raters to establish the correct definition.
Statistical analysis
The data analysis was carried out with SPSS 25 (IBM,
New York City, New York, USA). Following descriptive
statistics, a binominal multivariable logistic regression
model was applied to ascertain the effect different factors
have on the likelihood for LOR. P values less than 0.05
were regarded as statistically significant. LOR was
defined as the dependent variable. For independent
variables, we assessed age, sex, side, fractures character-
istics, and treatment features (Table 1). A preliminary
analysis revealed a correlation between coronal and

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 4 Journal of Pediatric Orthopaedics B 2019, Vol 00 No 00
Table 2 The correlation between supracondylar humeral fracture characteristics
Sagittal obliquity
O L
Gartland classification
2a 7 44
2b 1 12
3 62 91
P < 0.001 0.163 < 0.001
Displacement direction
PS 20 67
PM 21 31
PL 29 49
P 0.53 < 0.001
Coronal pattern
LTV 38 121
HTV 2 5
HM 6 3
HL 24 18
P < 0.001
Frequencies are presented in absolute numbers, Pearson’s χ2-test in P values.
HL, high lateral; HM, high medial; HTV, high transverse; L, low; LTV, low transverse; O, oblique; PL, posterolateral; PM, posteromedial; PS, posterior.
sagittal patterns (P < 0.001) and between coronal obliquity
and nonpure posterior (posterolateral or posteromedial)
displacement (P < 0.001; Table 2). For all mentioned the
variance inflation factor (VIF) was lower than 2.15, which
allowed their introduction to the model. (The VIF mea-
sures the inflation in the variances of the parameter esti-
mates due to multicollinearity potential. VIFs lower than 5
are generally acceptable for analysis inclusion) [32]. The
correlation between the two categorical variables was tes-
ted using the χ2-test. Both height and weight levels were
available for only 91 patients. To not damage the power of
the study, the BMI percentile was not included in the
multivariate model, and its correlation with the incidence
of LOR was analyzed separately (P = 0.18).
Results
Among the extension-type group: 131 (59.5%) boys, 168
(75%) left side, a median age of 9 years in the range of
8–14 years, mean BMI percentile 53.46% (SD: 32%, BMI
data were available for only 91 patients). All patients were
operated by one of 13 attending fellowship-trained
pediatric orthopedic surgeons. The decision for treat-
ment approach and pin configuration were individualized
on the basis of fracture characteristics and the surgeon’s
preference [2]. Forty-four percent were fixated by more
than two lateral pins, 39% by two lateral pins, and 17% by
crossed pins. When closed reduction was achieved, an
open reduction was conducted (n = 10). Open fractures
were irrigated and debrided in the operating room before
stabilization. An evaluation under anesthesia was con-
ducted following fixation to assure stability. All fractures
were immobilized postoperatively in a long arm cast for at
least 3 weeks.
Of 220 extension-type SCHF patients, 34 (15.5%)
developed LOR (Table 3). In a multivariable analysis
fracture obliquity on the sagittal plane was found as the
only statistically significant factor related to the
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Coronal pattern Displacement direction
LTV HTV HM HL PS PM PL
45 1 1 4 41 6 4
10 0 0 3 5 2 6
104 6 8 35 41 44 68
76 3 0 8
37 2 9 4
46 2 0 30
occurrence of LOR (P = 0.01, Table 4). Patients who
sustained sagittal oblique fractures had 2.9 times the risk
of developing LOR (95% confidence interval: 1.19–7.96).
It was found that the higher oblique side on the coronal
plane was related to the displacement direction.
Posteromedial displacement correlated with high medial
fractures and vice versa (P < 0.001). The Gartland clas-
sification was found to correlate with sagittal plane obli-
quity (P < 0.001) but was statistically insignificant when
tested as an indicator for LOR even after the exclusion of
the obliquity criteria from the statistical model (P = 0.81).
The subdivisions of Gartland 2 fractures (2a and 2b,
according to rotation percentage) were not found to be
related to either coronal or sagittal obliquity (P = 0.413
and 0.557), nor was it related with the incidence of LOR
(P = 0.565). The fixation stability was not affected by any
other patient, fracture or treatment-related variables. One
(12.5%) of the eight Gartland type 2 fractures with
sagittal obliquity developed LOR.
Twenty flexion-type SCHFs composed 5.8% of the
preliminary cohort, of them three patients developed
LOR (15%; Table 5). Two of the three patients who
developed LOR were above 10 years of age. Sagittal
obliquity did not correlate with LOR (P =0.168). Because
of the small sample size, we found it inadequate to pro-
ceed with a multivariable analysis for this group [33].
Discussion
The stability of supracondylar humeral fractures among
older children was found to be related with the oblique
fracture pattern on the sagittal plane, independent of the
preoperative Gartland classification. Although the influ-
ence of the fracture pattern on the fixation stability is
intuitive, conflicting reports were published in that
regard [7,9–11,14,19,27–29,34–37]. Our ability to rely on
the existing literature was limited to the fact that studies
on SCHF in older children as a specific subgroup of
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Table 3 Patients that developed loss of reduction of supracondylar humeral fracture fixation
Sagittal Coronal Forearm Pin
Numbers Gd plane pattern Dislocation comminution fixation configuration Radiographic LOR Reason for LOR Clinical notes

1 3 Oblique HL PL No No 2 Lateral Extension No technical error 10 months after surgery lacks 10° of both flexion and extension.
2 3 Oblique HL PL Yes Yes 2 Lateral Extension Insufficient reduction 4 months after surgery lacks 10° of flexion
3 3 Oblique HL PL No yes 3 Lateral Extension and valgus Not sufficient pin separation 12 months after surgery no clinical deficit
4 3 Oblique HL PS Yes No 3 Lateral Extension Not sufficient pin separation No follow-up records available
5 3 Oblique HM PM No No 4 Lateral Extension Improper fixation 5 months after surgery has 10° varus and lacks 10° of flexion, but
does not feel it.
6 3 Oblique HM PM Yes Yes 2 Lateral Varus Improper fixation 1 year after surgery lacks 10° of flexion. No mention of other
2 Medial complications
1 Transverse
7 3 Oblique HTV PM No No 3 Lateral Extension Not sufficient pin separation No follow-up records available
8 2 oblique LTV PM No No 2 Lateral Extension The pins are not divergent No follow-up records available
9 3 Oblique LTV PM No No 3 Lateral Extension No technical error Two years after surgery went through an osteotomy for cubitus varus
10 2 Oblique LTV PL No No 2 Lateral Extension Not sufficient separation and too No follow-up records available
small pins
11 3 Oblique LTV PL No No 3 Lateral Extension No technical error No follow-up records available
12 3 Oblique LTV PM No No 3 Lateral Extension and varus No technical error 10 months after surgery ROM is 5°–100°
13 3 Oblique LTV PL Yes No 2 Lateral Extension No technical error 12 months after surgery has cubitus valgus and lacks 10° of flexion
1 Medial
14 3 Oblique LTV PS No No 3 Lateral Extension No technical error No follow-up records available
15 3 Oblique LTV PS No No 3 Lateral Extension Not sufficient pin separation No follow-up records available
16 3 Oblique LTV PM No No 3 Lateral Extension Inadequate reduction 2 months after surgery lacks 5° of flexion and extension
17 3 Oblique LTV PL No No 2 Lateral Extension No technical error 1 month after surgery no deficits
1 Medial
18 3 Oblique LTV PS No No 2 Lateral Extension No technical error No follow-up records available
19 3 Oblique HL PS No No 2 Lateral Extension Insufficient pin separation 3 years after surgery no clinical deficits
20 3 Oblique HL PL No No 3 Lateral Varus No lateral column fixation No follow-up records available
21 3 Not LTV PL Yes No 2 Lateral Extension No technical error No follow-up records available
oblique 1 Medial
22 3 Not LTV PM No No 2 Lateral Extension Medial column pin did not reach Pink pulseless hand that resolved after the reduction in the OR.
oblique the proximal fragment 3 months after surgery the ROM is 10°–140°

Oblique supracondylar humeral fractures Segal et al. 5

23 2 Not LTV PS No No 2 Lateral Extension No technical error No follow-up records available
oblique
24 2 Not LTV PM No No 2 Lateral Extension No technical error No follow-up records available
oblique
25 2 Not LTV PL No No 2 Lateral Extension Should have used larger pins 1 month after surgery lacks 10° of extension
oblique
26 3 Not LTV PM Yes Yes 3 Lateral Extension Pins were not divergent No follow-up records available
oblique
27 3 Not LTV PL No No 3 Lateral Extension and valgus No technical error No follow-up records available
oblique
28 3 Not LTV PL No No 2 Lateral Extension and varus No sufficient pin separation No follow-up records available
oblique
29 3 Not LTV PS No No 2 Lateral Extension Improper fixation No follow-up records available
oblique
30 3 Not LTV PM Yes No 2 Lateral Varus and a little Improper fixation 3 months after surgery lacks 15° of extension
oblique 1 Medial extension
31 2 Not LTV PM No No 2 Lateral Extension Not sufficient pin separation No follow-up records available
oblique 1 Medial
32 3 Not LTV PS No No 3 Lateral Extension The most lateral pin did not grab 3 months after surgery lacks 3° of flexion
oblique the distal fragment
33 3 Not LTV PM No No 2 Lateral Extension One of the two pins goes through No follow-up records available
oblique the fracture site
 6 Journal of Pediatric Orthopaedics B 2019, Vol 00 No 00

patients were not available. Nevertheless, some authors

Gd, Wilkins modified Gartland classification; HL, hight lateral; HM, high medial; HT, high transverse; LTV, low transverse; PM, posteromedial; OR, Operating room; PL, posterolateral; PS, posterior; ROM, range of motion.
have presented significant findings that affect the way we
understand this topic and their notions might be applic-
able to older children. In a previous article by Bahk et al.
[19] that analyzed 203 young patients (mean age:
6.05 years, SD = 2.39 years), fracture obliquity in the
sagittal or coronal planes was found to have a negative
2 months after surgery no clinical deficits impact on the fixation stability and was more frequently
accompanied by additional injuries. A later study by
Balakumar and Madhuri [9] on 77 patients in the mean
No follow-up records available

No follow-up records available

No follow-up records available

age of 7.8 years (range: 10 months to 15 years) reached an

opposite conclusion. However, this study placed all
nonlow transverse fractures under the same ‘unstable’
group as oblique fractures, while solely analyzing the
Clinical notes

differences between ‘stable’ and ‘unstable’ groups with-

out specifically categorizing oblique fractures separately.
Unfortunately, most other investigators did not analyze
obliquity when assessing SCHF fixation stability (Table 6).
Medial comminution was also investigated as a potential
Should have used a larger pin

risk factor for fracture instability, mainly as its collapse

Insufficient pin separation

Insufficient pin separation

might lead to a cubitus varus deformity [18], but despite its

biomechanical logic, the correlation with LOR could not be
No technical error
Reason for LOR

proven [14,18].
The negative impact of the oblique fractures patterns on
fixation stability is a widely accepted concept in adult
orthopedics [38], although this concept has not been
related to SCHF fixation until recently. A fixated SCHF
Extension and valgus

should stand against compressive, bending, and rotational

configuration Radiographic LOR

hyperflexion to
Varus and slight

Extension (from

forces. When applying compressive forces on a transver-

extension

sely fractured long bone, these forces compress the

normal)
Extension

fracture. In contrast, when applying the same forces on an

oblique fracture, they translate into shear forces that are
not stabilized with most pin constructs and allow for
subsequent fracture displacement. When bending forces
2 Lateral

2 Lateral

2 Lateral

3 Lateral

are applied on an oblique fracture (in this case the pos-

Pin

terior pull of the triceps on the olecranon, and through

that on the distal fragment), the posterior tip of the
Forearm
Dislocation comminution fixation

fracture acts as a pivot. The higher, and thus more

No

No

No

No

proximal, the pivot is, the more effect a given change in

the angulation will have on the posterior displacement
distance (Figs 1–2). Although oblique fractures, which
are the less stable type, encompass 33.2% of SCHFs in
No

No

No

No

the current study, and 39.4% in Bahk’s [19] cohort, this

pattern was hardly respected in previous relevant bio-
mechanical studies [39–43], where different pin config-
PS

AS

AS

AS

urations were evaluated on simple transverse fractures.

Coronal
pattern

The reliability of the Gartland classification and its utility

LTV

LTV

LTV

LTV

in guiding operative decision making with regard to

fixation construct has been previously evaluated. The
Oblique
oblique

oblique

oblique
Sagittal

classification into three types (1/2/3) was found to be

plane

Not

Flexion Not

Flexion Not

Flexion Not
Table 3 (continued)

reproducible and applicable [44,45], although the agree-

ment about types 1 and 2 was found inferior compared
2

with type 3 [46]. Although the correlation of this classi-

Numbers Gd

fication with neurovascular complications was well

established [2], its ability to predict fixation instability is
34

36
35

37

unsubstantiated (Table 6). Furthermore, in a recent

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 Oblique supracondylar humeral fractures Segal et al. 7

Table 4 Loss of reduction of supracondylar humeral fractures in 8–18-year-old pediatric population: patient, fracture, and treatment
characteristics
LOR (%) Non-LOR (%) P

Patients
Age (mean ± SD) (years) 9.59 ± 1.51 9.38 ± 1.51 0.57
Sex (male) 16.8 13.5 0.94
Fracture
Comminution 20.6 11.8 0.12
Side (right) 29.4 24.2 0.58
Gartland classification (3) 82.4 69.4 0.69
Displacement extent (< 50, 51–100, > 100%) 11.8, 44.1, 44.1 25.5, 32.1, 42.4 0.21
Sagittal obliquity 52.9 29.6 0.01
Coronal obliquity (LTV, HTV, HM, HL) 73.5, 2.9, 5.9, 17.6 72.6, 3.2, 3.8, 20.4 0.61
Displacement direction 35.3, 38.2, 26.5 36, 21, 43 0.25
Open fracture 2.9 3.8 0.43
Either sagittal or coronal high medial obliquitya 52.9 31.7 0.064 (0.017 in univariate analysis)
Treatment
Weekend surgery 23.5 27.4 0.46
Shift differences 61.8, 23.5, 14.7 65.5, 22, 12.4 0.79
Concomitant forearm fracture fixation 11.8 5.9 0.69
Pin separation (continuous variable) 0.41 ± 0.16 0.41 ± 0.11 0.89
Time to operation (< 8, 8–24 h, > 24 h) 29.4, 67.6, 2.9 21.5, 63.4, 15.1 0.32
Number of pins (> two lateral) 58.8 61.8 0.19
Bicolumnar fixation 50 61.8 0.14
Open reduction 5.9 4.3 0.35

HL, high lateral; HM, high medial; HTV, high transverse; LOR, loss of reduction; LTV, low transverse.
a
Nonsignificant, both when included in a model with or without other coronal or sagittal pattern variables.

Table 5 High lateral: flexion-type supracondylar humeral fractures in older children

Coronal Forearm Lateral/bicolumn
Number Age Sagittal plane pattern Dislocation Comminution fixation Pin configuration fixation Radiographic LOR

1 9.5 Oblique LTV Flexion No No 3 Lateral 1 No

2 8 Oblique LTV Flexion No No 2 Lateral 2 No
1 Medial
3 8.6 Oblique HM Flexion No No 3 Lateral 1 No
4 8 Oblique LTV Flexion Yes No 3 Lateral 1 No
5 9 Oblique HM Lateral flexion Yes No 3 Lateral 2 No
6 13 Oblique LTV Flexion No No 2 Lateral 1 No
7 8.6 Oblique LTV Flexion No No 3 Lateral 2 No
8 10.4 Anterior LTV Flexion Yes No 3 Lateral 2 No
oblique
9 12.2 Not oblique LTV Flexion No No 2 Lateral 2 No
10 8 Not oblique LTV Flexion No No 2 Lateral 2 No
11 8.4 Anterior LTV Flexion No No 2 Lateral 1 No
oblique
12 9.5 Not oblique LTV Flexion No No 3 Lateral 2 No
13 8.8 Not oblique LTV Flexion No No 3 Lateral 2 No
14 8.9 Not oblique LTV Flexion No No 2 Lateral 1 No
15 9.5 Not oblique LTV Flexion No No 3 Lateral 1 No
16 8.7 Not oblique LTV Flexion No No 2 Lateral 1 No
17 8.9 Not oblique HM Flexion No No 2 Lateral 2 No
1 Medial
18 10 Not oblique LTV Flexion No No 3 Lateral 2 Extension
19 12.4 Not oblique LTV Flexion No No 2 Lateral Unclear Extension and
valgus
20 8.5 Not oblique LTV Flexion No No 3 Lateral 2 Extension

HL, hight lateral, HM, high medial; HT, high transverse; LTV, low transverse; PL, posterolateral; PS, posterior.

study by Leung et al. [47], a concern was raised about the
utility and the reliability of the subdivision of Gartland
type 2 fractures to 2a and 2b with regard to surgical
decision making. They found it to be of poor to moderate
interobserver and intraobserver agreements. They also
revealed that while attending surgeons and residents
decided to operate on 99% of the 2b fractures, they also
chose to operate 27% of 2a fractures, and in too many
instances did not agree upon the subclassification itself,
which made it inapplicable. This investigation took place
while the AAOS guidelines, preceding the Leung’s
study, dictated surgical treatment for all type 2 fractures
[48]. These inconsistencies might explain why the sub-
classification was hardly used in published studies
(Table 6), and might reflect on the extent of its clinical
use. As type 2 fractures are known to be widely variable
in stability, complications, and treatment [49], a clear
preoperative differentiation of this group of fractures, that

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Copyright r 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

8 Journal of Pediatric Orthopaedics B 2019, Vol 00 No 00

Table 6 Studies that evaluated the stability of supracondylar humeral fracture fixation
Cohort size, age (year, month)
and fracture types included
References (Gartland) LOR definition Findings and conclusions Gartland classification Sagittal obliquity

Bahk et al. [19] 203, 6.05 ± 2.39, 2–3 Loss of maintenance of the AHL Sagittal obliquity was significant, medial obliquity showed a Was found not related with Was found to be a risk
trend but was not significant LOR factor for LOR
Gordon et al. [10] 138, 6.2 (1.3–13.2), 2–3 Not defined. Changes in angles were No difference between different pin configurations. A medial Accounted as less stable, Was not evaluated as a
compared pin was advised when the intraoperative stress test is although not statistically confounder
positive after two pin fixation, only for type 3 fractures. significant
Fletcher et al. [7] 158, Not mentioned, 3 Not defined Age was not related with LOR Was not evaluated as a Was not evaluated as a
confounder confounder
Kocher et al. [34] 52, Only 3–10 were primarily A change in Baumann’s angle of > 6° Medial pin fixation was not found to be related to a lower Not relevant Was not evaluated as a
included: 6.1 (3.6–8.1), 3 (minor) or > 12° (major) incidence of LOR confounder
Skaggs et al. [28] 124, 4 (0.8–14), 2–3 A change in Baumann’s angle of Pin configuration was the only relevant factor associated with Was found not related with Was not evaluated as a
> 12° (major) or a change in AHL LOR, although no comparison with non-LOR configuration LOR confounder
faults
Mehlman et al. [35] 198, 6.3 (1.4–14.4), 2–3 Reoperations were evaluated When no specific indication for emergent surgery exist, Evaluated as a discrete Was not evaluated as a
operation timing (before or after 8 h) had no influence on variable and was found as confounder
the complication rate, reoperation for LOR among them not influential
Lucas et al. [11] 29, 4.5, > 10° displaced type 2 > 5° Change from the initial Type 2 displaced fractures were found highly unstable, with Not relevant Was not evaluated as a
reduction 71% LOR confounder
Skankar et al. [27] 279, Not mentioned, 2–3 Change in Baumann’s angle, AHL or Technical errors appeared in all LORs. LOR appeared in only LOR happened only in type 3 Was not evaluated as a
rotation percentage, and clinical type 3 fractures fixated with either 2 lateral or crossed pins fractures confounder
evaluation
Gaston et al. [36] 104, 6, 3 A change of 6° in Baumann’s angle Crossed pins technique was not superior compared with 2 Not relevant Was not evaluated as a
and 10° in LHCA lateral pins confounder
Pennock et al. [14] 192, 5.7 ± 2.3, 2–3 A change of > 10° in either AP or Pin spread was the most important factor related to LOR Was found not related with Was not evaluated as a
lateral alignment LOR confounder
Karamitopoulos et al. 643, 6.1 (1.1–16), 2–3 Subjective assessment The need for postoperative radiography was evaluated. Was found not related with Was not evaluated as a
[37] Although only type 3 fractures had postoperative fracture LOR confounder
translation, this was not statistically significant (P = 0.58).
Madhuri et al. [9] 77, 7.8 (0.1–15), 2–3 A change in Baumann’s angle of > 6° The surgical technique was the only significant factor related Was found not related with Was not evaluated as a
(minor) or >12° (major) to LOR LOR single variable

Most investigators could not prove a correlation between Gartland’s classification and LOR, and did not evaluate sagittal obliquity.
AHL, anterior humeral line; LHCA, lateral humeral capitellar angle; LOR, loss of reduction.
 Oblique supracondylar humeral fractures Segal et al. 9

Fig. 2 is based on stability and anticipated outcome, is of the

(a) Sagittal oblique (b) Transverse
essence for appropriate treatment planning.
fracture fracture Sagittal oblique fractures are involved with specific sur-
gical pitfalls. The common pin insertion direction is
distal-to-proximal [2], which is parallel to the oblique

Posterior
Posterior

fracture pattern. Accordingly, the risk of inserting a pin

Anterior

Anterior
α fractures where shear forces cannot be neutralized with
α standard pin constructs. As the goal in these specific
Y X
A graphical illustration of a transverse (b) and a sagittal oblique (a)
supracondylar humeral fractures. When the fracture is dislocated
posteriorly the posterior edge of the fracture acts as a pivot. When this
edge is higher (more proximal), the distal fragment shifts a longer
distance for the same angulation.
along the fracture plane instead of crossing it is greater
when operating on fractures with sagittal obliquity
(Figs 3–4). This is of greater importance in oblique
patterns is to neutralize the shear forces and the unstable
posterior high hinge point, the surgeon should consider
alternative pin constructs, such as crossed pins or greater
than 2 pins for fracture fixation. The surgeon should
place the pins as divergent as possible both on the cor-
onal and on the sagittal plane and attempt to place then
pins as perpendicular to the fracture plane as possible by
starting posteriorly and exiting anteriorly. There should
be a low threshold for an open reduction and internal
fixation with a posterolateral buttress plate when the pins
are judged to be insufficient under live fluoroscopy. As
surgical technical errors were repeatedly found to be the

Fig. 3

An 8-year-old girl with a Gartland type 3 oblique (unstable) supracondylar humeral fracture. The lateral pins were placed parallel, and did not properly
capture both fragments. (a,d) Preoperative x-ray images. (b,e) Intra-operative fluoroscopy studies. (c,f) Follow-up x-ray images.

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 10 Journal of Pediatric Orthopaedics B 2019, Vol 00 No 00

Fig. 4

An 11-year-old boy with a Gartland type 3 oblique (unstable) fracture. A combination of an unstable fracture pattern and an insufficient pin separation
had led to a loss of reduction. (a,c) Iintra-operative fluoroscopy studies. (b,d) Follow up x-ray images.

most important factor related to LORs [14,27,28] a pre-
operative recognition of the oblique pattern can aid in
decreasing inadequate surgical fixation by noticing spe-
cific pitfalls.
In this study, no correlation was found between pin
separation, configuration, or columnar fixation and the
occurrence of LOR, which might contradict the surgical
principle of the need for maximal separation between the
pins and proper medial and lateral cortex grip. However,
previous studies [27,28] have shown that these were
potential risk factors for LOR and should be carefully
evaluated during surgical fixation, especially in older
children with higher-energy injuries [7]. In our study,
many of the patients that developed LOR did not have
an adequate fixation and lost reduction accordingly
(Table 2). The existing data regarding technique con-
cepts, strategy, and execution [9,14,27,28,34,50–52] act as
important guidelines in both clinical and biomechanical
tests. Challenging these educational pearls mandates a
specifically designated prospective study rather than
relying on retrospective findings.
Flexion-type fractures composed 5.8% of the preliminary
study group and 8.33% of nonintercondylar or patholo-
gical fractures – higher than the rate of 1–3% that was
previously reported [15]. This finding correlates with a
previous report of nine flexion-type fractures in which

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the median age was found to be 9.8, and raise the sus-
picion that this type is more common among older chil-
dren. The LOR rate of 15% in this group was comparable
to the 14% in the extension-type group.
The effect that sagittal obliquity had on fixation stability
and the easy interpretation of this feature might offer a
useful tool for presurgical planning of displaced SCHFs
in older children. Although the Gartland classification
offers significant data regarding possible neurovascular
complications, the rotation percentage represents the
malposition of the distal fragment, and the medial com-
minution encompasses a risk for cubitus varus, the frac-
ture pattern was the only factor that offered data
regarding the fracture’s stability once reduction and
fixation have been performed. The ability to generalize
our conclusions to younger children is limited. A pro-
spective study that includes the entire pediatric age scale
and evaluates the use of sagittal obliquity in surgical
decision making, with standardized and controlled
follow-up examinations needs to be conducted to better
establish the role of fracture pattern in pin configuration
decisions and perhaps the actual need for surgical inter-
vention in type 2 fractures.
This study has the basic limitations of a retrospective
record review research. Even though the multi-
collinearity between the variables was ruled out, there
was still a sense that coronal and sagittal obliquities cor-
relate, as they are two-dimensional radiographic projec-
tions that represent a three-dimensional injury. Long-
term follow-up examinations were not always available
and were conducted by multiple examiners, which did
not allow us to properly correlate the radiographic find-
ings with clinical outcomes. As a consequence, the clin-
ical significance of LOR that did not lead to reoperation
is yet to be understood. However, as the distal humeral
physis has limited remodeling potential, especially in
older children, LOR will likely lead to long-term defor-
mity in these children, which may have functional
effects. As the investigators had no control over the
treatment technique, we could not genuinely asses the
possible effect of different treatment modalities (pin
configuration for example) on LOR. In our study, a large
population of a specific age group and physis closure
status was included, offering significant power. All
flexion-type fractures and intercondylar fracture were
excluded from the main analysis, allowing a relatively
homogenous group of fractures to be analyzed.
Consecutive radiographic measurements with reliability
assessments were conducted, and positive values were
followed by a subjective interpretation of the images – all
of which raised the diagnostic specificity.
Conclusion
The sagittal oblique SCHF is common and correlates well
to fixation instability and subsequent LOR. Accordingly, it
needs to be considered when investigating the stability of
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Oblique supracondylar humeral fractures Segal et al. 11
different pin configurations, complication rates and bio-
mechanical properties of SCHFs. Subclassifying displaced
SCHFs as ‘oblique’ or ‘transverse’ might offer more com-
prehensive information about the anticipated operative
results and lead to improved outcomes following surgical
fixation.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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