TECHNIQUE

The Use of a Transolecranon Pin in the Treatment of

Pediatric Flexion-type Supracondylar Humerus Fractures
Brandon M. Green, DO,* Joseph D. Stone, MD,w
Robert W. Bruce, Jr, MD,* and Nicholas D. Fletcher, MD*

Background: Flexion-type supracondylar humerus fractures are

much more uncommon than their extension-type counterparts.
Instability in elbow flexion renders traditional closed techniques
inadequate and often results in the need for open reduction. We
present a simple technique for closed reduction using a trans-
olecranon pin for temporary stability.
Methods: A retrospective review of 9 patients treated with a
transolecranon pin technique for a flexion-type supracondylar
humerus fracture was performed. Operative time, need for open
reduction, postoperative range of motion, final radiographic
alignment using Baumann angle, and the intersection of the
anterior humeral line with the capitellum was evaluated.
Results: All 9 patients were treated with closed reduction using a
temporary transolecranon pin technique. Total surgical time
averaged 38 ± 15 minutes and was longer for type III than type
II flexion-type fractures. All fractures healed by first follow-up
at 1 month. There was 1 preoperative ulnar nerve deficit that
resolved by the first postoperative visit. Average Baumann angle
at radiographic healing was 71.2 ± 3.3 degrees and all cases
showed restoration of the normal anterior humeral line:-
capitellar relationship. Average postoperative flexion at final
follow-up was 125 degrees and extension was 5 degrees. One
patient had a flexion contracture of 10 degrees.
Discussion: Use of a temporary transolecranon pin allowed for
closed reduction of all flexion-type fractures with no radio-
graphic malunion. This technique is technically simple and
avoids the need for open reduction or multiple fluoroscopy
views.
Level of Evidence: Level IV—case series.
Key Words: flexion type, supracondylar humerus fracture,
transolecranon
(J Pediatr Orthop 2016;00:000–000)
S upracondylar fractures of the humerus account for
50% to 70% of elbow fractures in children and typi-
cally occur between 3 and 10 years of age.1 The majority
(95% to 98%) of supracondylar humerus fractures occur
due to elbow hyperextension with the olecranon acting as
a fulcrum over which the distal humerus fractures oc-
cur.2–4 Traditional reduction techniques for these fractures
include hyperflexion in addition to correction of coronal
and rotational deformity.1,5,6 This hyperflexion is easily
permitted on a flat-topped surface during surgery, such as
an arm board or the flat surface of the fluoroscopy ma-
chine. Approximately 1% to 10% of supracondylar frac-
tures occur from a direct fall on the olecranon, resulting in
a flexion-type fracture (Figs. 1, 2).7–9 Operative fixation of
flexion-type fractures is technically difficult because the
traditional reduction technique involving hyperflexion of
the elbow results in further displacement. The literature
supports the fact that flexion-type supracondylar humerus
fractures are particularly difficult to reduce, and often
require open reduction to obtain near-anatomic align-
ment.7,10,11 No widespread reproducible means of closed
reduction has been described in the orthopaedic literature.

From the *Department of Orthopaedics, Emory University; and

wPediatric Orthopaedic Associates, Atlanta, GA.
No internal or external support was received for this study.
There was no funding used for this study from the NIH, HHMI, or other
sources.
The authors declare no conflicts of interest.
Reprints: Nicholas D. Fletcher, MD, Department of Orthopaedics,
Emory University, 59 Executive Park South NE, Atlanta, GA 30329.
E-mail: nicholas.d.fletcher@emory.edu. FIGURE 1. Preoperative lateral radiograph of a flexion-type
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Green et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2016

classification in 1990 accounted for the flexion-type variant

with severity based on amount of displacement as in the
extension type. Type 1 fractures are nondisplaced, type 2
fractures are moderately displaced with an intact anterior
cortex, and type 3 fractures are severely displaced with both
the anterior and posterior cortex disrupted.3
Clinical preoperative neurological and vascular as-
sessment was obtained from the emergency department
orthopaedic consultation record. Initial radiographs were
reviewed to confirm fracture type. Radiographic evaluation
including postoperative Bauman angle and location of the
anterior humeral line with regards to the capitellum as seen
on the lateral radiograph was performed at final follow-up.
Clinical documentation of range of motion and motor
function was noted in the clinical chart when available.
Technique
First, a 2-mm Steinman pin is inserted in a trans-
olecranon manner across the olecranon and directed up
the shaft of the humerus with the elbow reduced in the
sagittal plane on the lateral image (Figs. 3, 4). No sig-
nificant attention is given to the coronal or rotational
deformity at this time other than to ensure relative re-
approximation of the 2 fracture ends. Minimizing the

FIGURE 2. Preoperative anteroposterior radiograph of a

flexion-type supracondylar humerus fracture.

Here we describe a technique for closed reduction of

flexion-type supracondylar fractures using a trans-
olecranon pin.

METHODS
This study was approved by the Institutional Review
Board of our hospital. All demographic and intraoperative
data were retrieved on patients undergoing a fixation of a
flexion-type supracondylar humerus fracture using a
transolecranon technique by the authors from 2011 to 2015. FIGURE 3. Intraoperative anteroposterior fluoroscopic image
The original Gartland classification did not account for showing a transolecranon pin placed centrally up the humeral
flexion-type fractures.12,13 Wilkins’ modification of this canal.

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
FIGURE 4. Lateral intraoperative fluoroscopic image showing
the transolecranon pin holding the sagittal alignment. This
step is required such that subsequent correction of coronal,
angular, and rotational deformity can occur. This sequence
occurs in the opposite order from traditional reduction of an
extension-type fracture where sagittal deformity is corrected
last.
coronal translation makes subsequent reduction of the
angular deformity easier. The alignment is held gently in
place on the lateral view as opposed to a more forceful
reduction as is typical in an extension-type fracture. The
transolecranon pin is then advanced up the humeral canal
similar to an intramedullary nail. In essence, this techni-
que works in the opposite order of that used in reducing
an extension-type fracture where the sagittal deformity is
corrected last. Once this pin placement has been con-
firmed on the lateral view, the elbow is brought back to
the anteroposterior view and the humerus is gently lifted
off of the table at the shoulder by placing the surgeon’s
hand under the proximal humerus to allow the x-ray
beam to be directed perpendicular to the elbow despite
being secured in 90 degrees of flexion by the trans-
olecranon pin (Fig. 5). At this point the surgeon may
correct the rotational and coronal angular deformity
through rotation and translation of the distal segment.
The transolecranon pin typically does not interfere with
this correction as long as it is not too stout a pin (> 2 mm
in diameter). Of note, if the surgeon needs to obtain a
lateral radiograph before the definitive lateral pins are
placed, it is imperative that the humerus is externally
rotated manually to match the forearm to minimize ro-
tational deformity. Failure to do so will result in sig-
nificant external rotational deformity of the distal
segment (Fig. 6).
Once appropriate alignment is achieved, 2 to 3 lat-
erally based 0.062 Kirshner wires are placed in a divergent
manner to complete the fixation and the transolecranon
pin is removed (Figs. 7, 8). The lateral pins are then cut
short and bent over sterile felt padding. The patient is
placed into a well-padded, well-molded, long-arm splint
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Flexion-type Supracondylar Humerus Fractures
FIGURE 5. An anteroposterior view can be obtained by gently
lifting up on the proximal humerus (arrow) while allowing the
elbow to be held at 90 degrees.
or bivalved cast at 70 degrees of flexion, with the forearm
in neutral or slight pronation to lock in the periosteum.
Each patient was scheduled to follow-up at the senior
author’s clinic at an average of 4 weeks following repair
for orthopaedic and radiographic evaluation. At the first
follow-up visit, the cast was removed and AP and lateral
elbow radiographs were taken to assess whether an ac-
ceptable overall alignment and union was achieved
(Figs. 9, 10).
RESULTS
We retrospectively reviewed the medical records of
the 100 patients who underwent treatment of a supra-
condylar humerus fracture from August 2011 to De-
cember 2015 by the senior author. Of these fractures, we
further classified these as either flexion type or extension
type. There were 9 patients with recognized flexion-type
supracondylar humerus injury (9%). The mean age of
each patient was 7.1 years (range, 4 to 12 y). Two of the
patients were male and 7 were female. Four of the su-
pracondylar humerus fractures were right sided and 5
were left sided. Five patients had type II fractures and 4
had type III fractures. One patient (11%) with a type II
fracture had a preoperative ulnar nerve palsy that re-
solved by the first postoperative visit. Average surgical
time was 38 ± 15 minutes, including cast placement.
Operative time was significantly longer in type III frac-
tures (47.5 ± 13.5 vs. 30.8 ± 10.4 min, P = 0.04).
Each of the radiographs were reviewed by the lead
surgeon and an upper level orthopaedic resident/fellow,
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Green et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2016

FIGURE 6. External rotation of the elbow for assessing sagittal

pin trajectory will result in rotational malalignment unless the
proximal humerus is manually externally rotated (arrow).

with the lateral humerocapitellar line measurement and FIGURE 8. Fluoroscopic image showing the transolecranon
Baumann angle recorded for each patient (refer to the pin and 1 laterally based Steinman pin.
chart and preoperative/postoperative radiographs). On
postoperative lateral radiographs, the anterior humeral
line intersected the middle 1/3 of the capitellum in all
cases. On the postoperative AP film, the average
Baumann angle was found to be 71.2 ± 3.3 degrees with
no difference between patients with type II and III frac-
tures. Union was achieved in all patients at average of

FIGURE 9. Lateral radiograph at final healing showing the

anterior humeral line intersecting the central 1/3 of the cap-
FIGURE 7. Addition of the first laterally based Steinman pin. itellum.

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
FIGURE 10. Final healed anteroposterior radiograph after pin
removal.
4 weeks based on the presence of bridging callus at the
fracture site and triangular periosteal bone formation
along the medial and lateral column of the distal humerus
on the AP radiograph. At this point of time, the pins were
removed and the patient was allowed to move the elbow
with no restrictions.
The range of motion was evaluated in the post-
operative setting 1 month following pin removal. One
patient did not have postoperative range of motion
documented at the time of follow-up. The average ex-
tension/flexion of the remaining 8 patients was 5 degrees /
125 degrees, respectively. One patient had loss of ex-
tension >10 degrees at most recent follow-up. The
average pronation/supination was 76 degrees/82 degrees
at final follow-up. There was no difference in range of
motion between patients with type II and III fractures.
There were no occurrences of malunion, loss of reduction,
cubitus varus, hyperextension, nerve palsy, pin tract in-
fection, iatrogenic nerve injury, pin migration, or com-
partment syndrome in our study.
DISCUSSION
In the pediatric population, displaced supracondylar
humerus fractures are an extremely common injury. It has
been well documented in the orthopaedic literature that
flexion-type supracondylar humerus fractures may require
open reduction to obtain an anatomic alignment. Although
some fractures may be converted to an extension-type injury
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Flexion-type Supracondylar Humerus Fractures
through hyperextension of the fracture, this is not always
possible and may lead to significant multidirectional in-
stability. Mahan et al7 evaluated 58 patients with a flexion-
type supracondylar humerus fracture and noted that 31%
required open reduction. Turgut et al14 described 43 patients
with a 14% rate of open reduction. Conversely, De Boeck
described treatment of 22 patients with flexion-type injuries
with no patient requiring open reduction. The author sug-
gested that closed reduction was challenging, however, and
noted that a skilled assistant is needed to hold the reduction
during fixation due to the instability of these fractures in
rotation.10 Novais and colleagues more recently described 30
patients with flexion-type fractures within a larger cohort of
384 total supracondylar fractures. Fifty percent of the
flexion-type fractures required open reduction in this series
and flexion-type fractures had a 34.1-fold increased relative
risk of open reduction when compared with extension-type
fractures.11 We were able to reduce all fractures without
open reduction, although the technique is certainly more
straightforward in type II fractures as evidenced by a sig-
nificantly shorter operative time.
Prior techniques have been described for management
of this fracture. Novais and colleagues have described a
technique whereby the distal segment is used as a joystick
and pins are placed before reduction. We have found this
challenging at times in unstable (type III) fractures, especially
in smaller extremities with large amounts of subcutaneous
fat.15 Leitch et al16 recently described a technique for closed
manipulation and percutaneous pinning in fractures that are
unstable in flexion and extension, which requires a fluo-
roscopist to alternate between AP and lateral views while the
reduction is held. Although this technique can work well, it
does require a reasonably skilled radiology technician, and
our experience has been that pinning can be difficult due to
the lack of ability to adequately visualize the distal humerus
on the AP view while the elbow is flexed to 90 degrees.
Chukwunyerenwa and colleagues described a “push-pull”
method that uses a rolled towel fulcrum as a reduction aid
under the fracture. Although we do not have personal ex-
perience with this method, it should be noted that it also
requires maintaining a reduction while the fluoroscope is
moved around the arm.17 We feel that the benefit of the
presented technique is that the transolecranon pin allows for
manipulation of the humerus without significant risk for loss
of reduction. This enables the surgeon to determine the
proper pin trajectory on the AP view. External rotation of
the proximal fragment by manually grabbing and rotating
the humerus allows the surgeon to obtain an adequate lateral
view. It is our practice to reduce and pin all of the fractures
using the base of the C-arm as a table. Use of a trans-
olecranon pin allows for this same setup to be used regard-
less of fracture type. Finally, the transolecranon pin frees up
the surgeon’s hands and permits reduction and pinning of a
fracture when a skilled assistant is not available.
The small number of patients and the lack of a con-
trol group are major limitations of this study; however, we
feel that this work has described a new technique that may
simplify the reduction of, what is often, a very challenging
fracture pattern. As this was a single surgeon’s experience
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Green et al
over 4 years, we hope that future work can expand on these
data once larger numbers of patients are available.
In summary, our retrospective review revealed that all
9 patients who underwent closed reduction percutaneous
pinning of a flexion-type supracondylar humerus fracture
were reduced to a near-anatomic position without need for
an open reduction approach. None of these children re-
quired any additional form of revision surgery. This is a case
series documenting a specific technique that we feel is helpful
in the management of these challenging fractures. Our results
suggest that this may obviate the need for open reduction.
As is the case with many orthopaedic interventions, there are
likely multiple surgical techniques that may suffice and we
are not trying to claim that this technique is superior to any
of them. Given these promising results, we feel that closed
reduction of a flexion-type supracondylar humerus fracture
with the aid of a transolecranon Steinman pin is a viable
treatment option for this complicated fracture.
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