ORIGINAL ARTICLE
Soft Tissue Injury Severity is Associated With
Neurovascular Injury in Pediatric
Supracondylar Humerus Fractures
Christine A. Ho, MD, David A. Podeszwa, MD, Anthony I. Riccio, MD,
Robert L. Wimberly, MD, and Brandon A. Ramo, MD
Background: Neurovascular injury in pediatric supracondylar
fractures (SCHFx) has been associated with fracture classi-
fication but not with soft tissue injury. The purpose of this study
is to correlate clinical soft tissue damage to neurovascular in-
juries in SCHFx.
Methods: This is an institutional review board approved pro-
spective study from January 2010 through December 2013 of
748 operatively treated pediatric SCHFx. Prospective data were
gathered both preoperatively and intraoperatively regarding
detailed neurovascular examination as well as soft tissue status,
with qualitative descriptives for swelling (mild/moderate/severe),
ecchymosis, abrasions, skin tenting, and skin puckering.
Results: A total of 7.8% of patients (41/526) had a nonpalpable
radial pulse preoperatively. Compared with those with a pal-
pable pulse, a nonpalpable pulse was associated with severe el-
bow swelling (P < 0.0001), tenting (P = 0.0085), puckering
(P = 0.0011), ecchymoses (P < 0.0001), and open fracture
(P = 0.044). Ten patients had a loss of a palpable pulse from
initial orthopaedic consult to time of surgery, and when com-
pared with the patients who did not have a loss of pulse, this was
associated with swelling severity (P = 0.0001) and ecchymosis
(P = 0.053). A total of 14% of patients (71/526) had a neuro-
logical injury preoperatively, and this was associated with severe
elbow swelling (P < 0.0001), tenting (P = 0.0008), puckering
(P = 0.0077), and ecchymoses (P < 0.0001) when compared
with patients who did not have a neurological injury. In total, 17
patients had a decline in their neurological examination from the
time of initial orthopaedic consult to the time of surgery, and
this was associated with severe elbow swelling (P = 0.0054) and
ecchymoses (P = 0.011). After multivariate logistic regression
analysis, severe swelling and ecchymoses were significantly as-
sociated with a nonpalpable pulse as well as neurological injury
(P < 0.05). No patient had compartment syndrome.
From the Department of Orthopaedic Surgery, Texas Scottish Rite
Hospital for Children and Children’s Medical Center of Dallas,
Dallas, TX.
The authors declare no conflicts of interest.
Reprints: Christine A. Ho, MD, 1935 Medical Center Dr, E2300-E2.01,
Dallas, TX 75235. E-mail: christine.ho@childrens.com.
Supplemental Digital Content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Website, www.
pedorthopaedics.com.
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
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Conclusions: Soft tissue injury, as measured by swelling, ecchymosis,
puckering, and tenting, had a clinically significant association with
neurovascular compromise in pediatric SCHFx, and assessment of
soft tissue injury is as important as the radiographic appearance
when examining these patients. The physical examination signs of
soft tissue injury may play a factor in determining urgency of surgical
treatment in these fractures.
Level of Evidence: Level II—therapeutic.
Key Words: supracondylar humerus fracture, soft tissue injury,
neurovascular injury, pediatric
(J Pediatr Orthop 2016;00:000–000)
S upracondylar humerus fractures (SCHFx) are the
most common operative fracture in children. The
morbidity of these injuries has been well documented and
is associated with greater degrees of displacement and
higher Gartland classification as modified by Wilkins.1–5
The “brachialis sign” is traditionally described as
cubital fossa ecchymosis, dimpling of the skin anteriorly
over the fracture site, and a palpable proximal fracture
fragment in the subcutaneous tissue. This typically occurs
in posterolaterally displaced fractures when the proximal
humeral metaphysis lacerates or impales the brachialis
muscle, and may indicate a higher severity of injury.6,7
Authors have noted that this entrapment of the brachialis
muscle in the humerus may block reduction and that the
neurovascular structures may be entrapped along with the
muscle.8
Although the brachialis sign can be helpful in de-
termining operative urgency, to our knowledge, in-
dividual parameters for the severity of soft tissue injury
have not been previously defined. This paucity of in-
formation leaves only the radiographic classification and
descriptors of the injury for prognosis. Although the
ability to quantify soft tissue severity may allow for better
understanding of the severity of this injury, no previous
study has attempted to correlate soft tissue severity to
associated neurovascular compromise or clinical out-
comes. The purpose of this study was to correlate clinical
soft tissue damage to neurological and vascular injuries as
well as functional outcomes in pediatric SCHFx.
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Ho et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2016

METHODS
Following institutional review board approval, all
pediatric patients with an operatively treated isolated
SCHFx at a single level 1 pediatric trauma center from
January 2010 through December 2013 were prospectively
enrolled in a database. Informed consent was obtained
from all subjects. Patients were excluded if they were
treated nonoperatively, had other orthopaedic injuries, or
sustained an intercondylar humerus fracture or adult-
pattern supracondylar fracture that was not amenable to
pin fixation. Eleven fellowship-trained pediatric ortho-
paedic attending surgeons identified eligible patients and
performed all surgeries. All patients received weight ap-
propriate dose of prophylactic antibiotics before pin
placement, and intraoperative fluoroscopy was used in all
cases. During that time period, 1094 patients (98.5%,
1094/1109) were treated with closed reductions and pin FIGURE 1. Medial skin of a posterolaterally displaced Gartland
fixation, and 15 patients (1.5%, 15/1109) were treated type III supracondylar humerus fractures. There is pronounced
with open reduction and pin fixation. A total 749 patients ecchymoses with skin abrasions and severe swelling. Although
agreed to enrollment and signed informed consent. Of there is some palpable tenting of the skin by the medial
those, 636 patients (85%, 636/748) had prospective data metaphyseal spike, there is no puckering.
forms completed to allow analysis. Because some of the
initial and intraoperative forms were incomplete, the de-
nominator differed when analyzing different groups (ie, of absence of skin tenting and skin puckering (Figs. 1 and
patients with neurological injury, patients with change in 2, Appendix B, Supplemental Digital Content 2, http://
neurologic status, patients with vascular injury, and pa- links.lww.com/BPO/A79—intraoperative). Because of
tients with a change in vascular examination) (Table 1). lack of a standardized method to quantify amount of
These differing groups were not compared with each swelling, all participating attending surgeons agreed to
other. We did not analyze and compare patients with define the term “mild” as the bottom 1/3 of severity in
incomplete data. Average length of follow-up was 73 their experience, “moderate” as the middle 1/3 of severity
days. in their experience, and “severe” as the top 1/3 of severity
Prospective data in a standardized electronic medical in their experience. If there was a difference between
record (EMR) form was gathered at the initial evaluation swelling classification between the initial examiner and the
in the Emergency Department (ED) or orthopaedic clinic attending surgeon, the attending’s assessment was used, as
by an orthopaedic resident, nurse practitioner, physician this was the clinical assessment at the immediately pre-
assistant, or attending surgeon (Appendix A, Supple- operative period.
mental Digital Content 1, http://links.lww.com/BPO/
A78—initial). These forms were separate and distinct from
the orthopaedic EMR consult note. A second evaluation
was performed in the preoperative holding area and in-
traoperatively to record neurovascular and soft tissue
status in another standardized EMR form by the attend-
ing surgeon. Particular attention was paid to qualitative
descriptors of elbow and forearm swelling (mild/moder-
ate/severe), ecchymoses, and abrasions, as well as presence

TABLE 1. Completion of Forms and Outcomes Scores

(n = 636)
% Completion [n/
Forms Completed N (%)]
Initial form only 116/636 (18)
Intraoperative form only 294/636 (46)
Initial and intraoperative form 230/636 (36)
QuickDASH 320/636 (50)
QuickDASH and initial/intraoperative form 292/636 (45) FIGURE 2. Antecubital fossa of a posteriorly displaced Gart-
Pediatric outcomes data collection instrument 390/636 (61) land type III supracondylar humerus fractures. There is puck-
Pediatric outcomes data collection instrument and 380/636 (60)
initial/intraoperative form
ering of the antecubital fossa with ecchymoses but no tenting
or skin abrasions.

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
Wilkins’ modification of the Gartland classification
was determined intraoperatively by the attending sur-
geon. All patients were treated at the discretion of the
attending surgeon without any variation in typical post-
operative care due to the study protocol. At each post-
operative clinic visit, neurovascular status and elbow
range of motion were assessed and recorded by the
treating surgeon (Appendix C, Supplemental Digital
Content 3, http://links.lww.com/BPO/A80—clinic).
Complications were defined as infection requiring
antibiotic treatment, infection requiring operative treat-
ment, unplanned-related readmission to the hospital
within 90 days of the surgery, or an unplanned-related
return to the operating room (OR) within 90 days of the
surgery.
For purpose of statistical analyses, the qualitatives
of mild/moderate/severe were assigned the quantitative
numbers 1/2/3, respectively, for each physical examina-
tion finding studied. Pearson correlation was used to
correlate severity of swelling with rate of neurovascular
injury, assuming that the numerical values for swelling
were continuous and not categorical variables. When
comparing 2 rates, the Fisher exact test was used. When
comparing 3 or more rates, w2 test was used. The 2-sample
t test, not assuming equal group variances, was used to
compare 2 means. To compare 3 or more means, the 1-
way analysis of variance with Tukey multiple comparison
methods was used. To look for combinations of variables
that had the potential to predict the probability of a
particular outcome, such as nerve injury, logistic
regression methods were used.
Because of the multiple variables examined in this
study [neurological injury, change in neurological ex-
amination, nonpalpable pulse, change in pulse examina-
tion compared with all of the multiple characteristics of
soft tissue injury (swelling, ecchymoses, puckering, tent-
ing, abrasions)], a power analysis was not performed of
each individual variable. However, a post hoc power
analysis with elbow swelling severity was conducted based
on the outcome of neurological injury. Moderate and
severe groups were combined together to allow a 1:1
study design comparison with 2 groups. Power analysis
using a 2-sided Z test with pooled variance showed that
128 patients were needed in each group (total N = 256) to
detect a difference of 10%, assuming that mild has 4%
neurological injuries. The significance level of the test was
targeted at 5%. If the number of patients who sustain
neurological injury at our institution remains constant,
prospective data would need to be collected for over
8 years.
There were no external sources of funding for this
study.
RESULTS
Forty-eight percent (304/636) of patients were male,
with 61% (388/636) left-sided injuries. Average age at the
time of surgery was 6.4 ± 2.6 years (range, 0.79 to 14.9 y).
A total of 174 SCHFx were classified as Gartland II, 320
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Soft Tissue Injury Severity in SCH Fractures
as Gartland III, 30 as flexion type, and 25 as multi-
directionally unstable. Eighty-seven patients did not have
fracture classification data identified on the form. There
were 5 open fractures.
Forty-one patients (7.8%, 41/526) had a nonpalpable
radial pulse preoperatively. When compared with patients with
a palpable pulse, a nonpalpable radial pulse was significantly
associated with Gartland III fractures (P = 0.0013). Direction
of fracture displacement was also associated with having a
nonpalpable pulse, with higher prevalence in multidirectionally
unstable fracture and posterolateral fracture patterns
(P = 0.0014) (Table 2). In addition, a nonpalpable radial pulse
was strongly associated with severe elbow swelling
(P < 0.0001), the presence of skin tenting (P = 0.0085), the
presence of puckering (P = 0.0011), the presence of ecchy-
moses (P < 0.0001), and having an open fracture (P = 0.044).
There was no association between a nonpalpable pulse and the
presence of superficial abrasions (P = 0.176) (Table 3). In-
creasing severity of swelling also correlated with increasing rate
of nonpalpable pulse (r = 0.223, P < 0.0001).
A total of 207 patients had radial pulse examina-
tions documented in both the initial and intraoperative
forms. Ten of these patients (10/207, 4.8%) had docu-
mented loss of a palpable radial pulse between the time of
initial orthopaedic assessment and the time of surgery
(average time 14.8 h; range, 3.7 to 21.7 h). This loss of
pulse was associated with severe elbow swelling
(P = 0.001), and approached significance for the presence
of ecchymoses (P = 0.053) (Table 4). Direction of frac-
ture displacement, tenting, puckering, abrasions, and
having an open fracture were not associated with a loss of
palpable radial pulse.
A total of 526 patients had a neurological exami-
nation documented in either the initial or intraoperative
form. Fourteen percent of patients (71/526) had a neu-
rological injury at initial presentation: 8.4% (44/526)
median nerve/anterior interosseous nerve (AIN), 3.2%
(17/526) ulnar nerve, 4.2% (22/526) radial nerve. There
were 12 combined nerve injuries. Sixty-six patients had
data present to allow comparisons. As expected, Gartland
III fractures were strongly associated with the presence of
a nerve injury (P < 0.0001). Fracture pattern was also
significantly associated with nerve injuries, with greater
TABLE 2. Association of Fracture Characteristics With a
Nonpalpable Radial Pulse
Nonpalpable Pulse
(Numerator)
Fracture Characteristic [n/N (%)] P
Gartland classification
II 4/174 (2) 0.0004
III 35/320 (11)
Direction of displacement
Type IV (multi-directionally 5/25 (20) 0.0014
unstable)
Posterolateral 22/142 (15)
Posteromedial 9/179 (5)
Extension 4/82 (5)
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Ho et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2016

TABLE 3. Association of Soft Tissue Injury Severity With a TABLE 5. Association of Fracture Characteristics with
Nonpalpable Radial Pulse Neurological Injury
Nonpalpable Pulse (Numerator) Neurological Injury
Soft Tissue Factor [n/N (%)] P Fracture Characteristic [n/N (%)] P
Elbow swelling severity Gartland classification
Mild 12/364 (3) < 0.0001 II 5/174 (2.9) < 0.0001
Moderate 23/220 (10) III 48/320 (15)
Severe 10/29 (34) Direction of displacement
Tenting Type IV (multi-directionally 5/25 (20) 0.036
Yes 6/26 (23) 0.0085 unstable)
No 39/585 (7) Posterolateral 22/142 (15)
Puckering Posteromedial 18/179 (10)
Yes 10/47 (21) 0.0011 Extension 4/82 (5)
No 35/566 (6)
Ecchymosis
Yes 34/222 (15) < 0.0001
No 11/392 (3)
Skin abrasion
increased elbow swelling severity (< 0.0001), tenting
Yes 3/20 (15) 0.176 (P = 0.0076), ecchymoses (P < 0.001), and open fractures
No 42/592 (7) (P = 0.042) but not puckering (P = 0.068) and superficial
Open fracture abrasions (P = 0.65). Ulnar nerve injuries were associated
Yes 3/5 (60) 0.044 with elbow swelling severity (< 0.0001), tenting (P = 0.0317),
No 42/608 (7)
puckering (P = 0.001), and ecchymoses (P = 0.0011) but not
fracture pattern (P = 0.91), superficial abrasions (P = 0.43) or
open fractures (P = 0.13). We were unable to find a statisti-
incidences in multidirectionally unstable fractures and cally significant correlation between fracture pattern or signs
Gartland III fractures with posterolateral displacement of soft tissue injury and radial nerve injuries, although swelling
(P = 0.036) (Table 5). Neurological injury was strongly severity trended toward statistical significance (P = 0.057).
associated with increased swelling severity (P < 0.0001) A total of 208 patients had neurological examina-
as well as with skin tenting (P = 0.0008), puckering tions documented in both the initial and intraoperative
(P = 0.0077), and ecchymoses (P < 0.0001), but not su- forms. Seventeen of these 208 patients (8%) had a docu-
perficial abrasions or open fractures (Table 6). Increasing mented decline in their neurological examination between
severity of swelling also correlated with increasing rate of the time of initial evaluation and the immediate pre-
neurological injury (r = 0.248, P < 0.0001). operative period. Five of these patients developed com-
Median nerve/AIN injuries were strongly associated bined neuropraxias with the distribution of neurological
with direction of fracture displacement (P = 0.0055), injury as follows: 10 median nerve/AIN, 5 ulnar nerve, 7
radial nerve. Increased swelling severity (P = 0.0054) and

TABLE 4. Association of Soft Tissue Injury Severity With Loss of

Palpable Radial Pulse Between Initial Evaluation in the TABLE 6. Association of Soft Tissue Injury Severity With
Emergency Department and Immediately Preoperatively Neurological Injury
Nonpalpable Pulse (Numerator) Neurological Injury (Numerator)
Soft Tissue Factor [n/N (%)] P Soft Tissue Factor [n/N (%)] P
Elbow swelling severity Elbow swelling severity
Mild 1/116 (1) 0.001 Mild 13/364 (4) < 0.0001
Moderate 6/79 (8) Moderate 44/220 (20)
Severe 3/12 (25) Severe 9/29 (31)
Tenting Tenting
Yes 1/10 (10) 0.39 Yes 9/26 (35) 0.0008
No 9/197 (5) No 57/585 (10)
Puckering Puckering
Yes 2/16 (13) 0.18 Yes 11/47 (23) 0.0077
No 8/191 (4) No 55/566 (10)
Ecchymosis Ecchymosis
Yes 7/82 (9) 0.053 Yes 46/222 (21) < 0.0001
No 3/125 (2) No 20/392 (5)
Skin abrasion Skin abrasion
Yes 2/11 (28) 0.09 Yes 2/20 (10) > 0.99
No 8/196 (4) No 64/609 (11)
Open fracture Open fracture
Yes 0/2 (0) > 0.99 Yes 2/5 (40) 0.09
No 10/205 (5) No 63/608 (10)

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016 Soft Tissue Injury Severity in SCH Fractures

patients had a dense median nerve palsy at presentation

TABLE 7. Association of Soft Tissue Injury Severity With
Decline in Neurological Function Between Initial Evaluation in with tenting and puckering.
the Emergency Department and Immediately Preoperatively During the study period, there were 9 patients with
Neurological Injury (Numerator)
superficial infections and 4 deep infections that required
Soft Tissue Factor [n/N (%)] P operative treatment. Of the deep infections, 3 of the pa-
tients had type II SCHFx and were treated with out-
Elbow swelling severity patient surgery, and the single type III SCHFx with a
Mild 4/154 (3) 0.0054
Moderate 9/127 (7) deep infection had only severe soft tissue swelling noted
Severe 4/17 (24) but no other soft tissue injury signs. There were 5 patients
Tenting with an unplanned return to the OR (4 patients had pins
Yes 1/16 (6) > 0.99 that migrated under the skin and 1 had a refracture after
No 16/282 (5.7)
Puckering
the pins were pulled). One patient was readmitted to the
Yes 2/22 (9) 0.36 hospital for pain control, discharged the following day,
No 15/276 (5) and had an otherwise uneventful postoperative course.
Ecchymosis There were no compartment syndromes.
Yes 12/115 (10) 0.011
No 5/183 (3)
Skin abrasion
Yes 1/13 (8) > 0.99 DISCUSSION
No 16/285 (6) Before this study, there has been very little corre-
Open fracture lation of physical examination findings to the prognosis
Yes 0/2 (0) > 0.99
No 17/279 (6)
of or possible challenges in the treatment of SCHFx. To
the authors’ knowledge, there are no other published
papers that correlate neurovascular injury to severity of
soft tissue injury other than discussion of the brachialis
ecchymoses (P = 0.011) were significantly associated with sign. In fact, a Pubmed search for “soft tissue pediatric
any change in a neurological examination (Table 7). supracondylar humerus” yields 6 results, none of which
Increasing severity of swelling also correlated with an actually discuss soft tissue injury.
increasing rate of change in the neurological examination Authors have noted that the “brachialis sign” (but-
(r = 0.173, P = 0.012). tonholing of the brachialis muscle from penetration of the
The covariates of severity of elbow swelling, tenting, proximal humeral metaphyseal fragment) may imply a
puckering, and ecchymoses for patients with neurological more challenging reduction due to entrapment of the
injury and nonpalpable pulses were analyzed using mul- brachialis muscle or interposition of neurovascular struc-
tivariate logistic regression analysis. Severe swelling tures.6–8 The “brachialis sign” is associated with poster-
(P = 0.011) and ecchymoses (P = 0.001) were significantly olaterally displaced SCHFx, and clinical signs include
associated with a nonpalpable pulse. Severe swelling antecubital ecchymosis, puckering, and a prominent pal-
(P = 0.001), and ecchymoses (P = 0.017) were also sig- pable bony proximal fragment.8 Though well reported, the
nificantly associated with neurological injury. “brachialis sign” has been the only marker of soft tissue
injury routinely described.8 Although the “brachialis sign”
has been described as a predictor for an irreducible
Complications SCHFx by closed means,6,8 no association between the
During the enrollment period, 5 patients underwent soft tissue components of this sign and neurovascular in-
open exploration of their brachial artery for lack of radial jury has been defined until now. Archibeck et al6 found
pulse and poor perfusion as documented by sluggish ca- that the brachialis muscle was the cause of 90% of irre-
pillary refill and decreased Doppler ultrasound signal. One ducible SCHFx, but that the “milking maneuver” could be
child had the brachial artery injury noted during irrigation successfully use to extricate the brachialis muscle in 15 of
and debridement of their open SCHFx. Another patient 16 patients. Although 2 of 6 children in our cohort who
underwent immediate exploration and untethering of the required open reduction did have the “brachialis sign,”
brachial artery from surrounding soft tissue due to lack of many patients with the “brachialis sign” did not require
a Doppler signal and poor perfusion on clinical exami- open reduction. We cannot, therefore, comment on the
nation. This patient did not have any forms completed utility of the “brachialis sign” in predicting the need for
regarding soft tissue injury. The other 3 patients had a open reduction.8 Only 1.5% of SCHFx treated operatively
return to the OR for vascular exploration within 24 hours during the study period required open reduction, perhaps
for lack of improvement of Doppler signal and persistent a reflection of a high volume center with fellowship-
clinical signs of poor perfusion. All 3 were noted to have trained surgeons experienced in pediatric orthopaedic
the neurovascular bundle entrapped or tethered in the trauma. Recently published rates of open reduction for
fracture site. Two of these children had a reverse saphe- type III SCHFx range from 9.2% to 16.8%.9–12
nous vein graft and 1 underwent thromboembolectomy Our institution has reported a 4% complication rate
with vein patch angioplasty. All 3 patients were noted to in Gartland type II SCHFx, with a 0.07% rate of nerve
have ecchymoses anteriorly/anteromedially, and 1 of these injuries and no compartment syndromes or vascular in-

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Ho et al
juries.13 However, Gartland type III and flexion injuries
were found to carry a 21.3% complication rate, 8.5%
incidence of nerve palsy and a 6.1% rate of pulseless
presentations.3,14 In addition, patients with a type III
SCHFx with a nonpalpable radial pulse have been dem-
onstrated to have a 3-fold higher rate of nerve palsy.14
Thus, it is clear that radiographic classification has some
prognostic ability, but the radiographic classification of
Gartland type III injuries includes a large spectrum of
severity of injury, making it a poor prognostic descriptor
in isolation. In the authors’ clinical experience, physical
examination signs of soft tissue injury such as swelling,
skin puckering, ecchymoses, tenting, and superficial
abrasions often are associated with more severe osseous
injuries and can play a factor in determining urgency of
surgical treatment when these injuries are present, and we
sought to test this hypothesis.
Our results highlight that soft tissue injury in
SCHFxs is strongly associated with neurovascular com-
promise. Clinical descriptors of soft tissue injury should
play an important role in assessing the severity of injury
in pediatric SCHFx and serve to heighten vigilance for
associated neurological or vascular compromise. In ad-
dition to the Gartland classification, direction of dis-
placement, severity of elbow swelling, tenting, puckering,
and ecchymosis should be routinely assessed and com-
municated in all patients with a SCHFx. This is a vital
part of the physical examination, and this should be
emphasized to all residents and consultants who evaluate
children with this injury.
In addition, it should be noted that the neuro-
vascular exam is not static, and that patients with signs of
soft tissue injury may be at risk for a deteriorating ex-
amination. The importance of serial examinations in these
patients awaiting surgery cannot be understated. Al-
though the mean time to surgery for patients who had
loss of radial pulse was 14.8 hours, this is consistent with
our previous published study that reported a mean time
to the OR of 16.8 hours in Gartland type III fractures
with a palpable pulse, compared with 8.4 hours for
Gartland type III fractures with a nonpalpable pulse.14
Unfortunately, some of the time to surgery is due to
transfer delay as our institution is 1 of only 2 level-1
children’s hospitals in a large state that encompasses
268,280 square miles.
Deep infection after operative treatment of SCHFx
was not associated with soft tissue injury in this cohort.
Three of the 4 deep infections presented initially to frac-
ture clinic with their untreated SCHFx and were treated
with scheduled outpatient surgery >24 hours from the
time of injury. Although it would seem intuitive that in
severe soft tissue injury, the compromised soft tissue en-
velope may predispose to infection, our low rate of deep
infection did not allow us to show that association.
One weakness of this study is the lack of stand-
ardization in quantifying severity of soft tissue injury.
Although all attending surgeons defined and agreed upon
the categories of “mild/moderate/severe,” there is of
course the very distinct possibility that the interobserver
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
and even intraobserver reliability of this classification
may be in question. However, we as a group found it was
near impossible to have 2 surgeons, let alone 11 surgeons,
available at the exact same time to examine a child’s
elbow, as soft tissue severity can also be time dependent
as the exam may change. Although photographs might be
useful to establish interobserver and intraobserver reli-
ability (and certainly more convenient!), assessment of
swelling is often tactile, and this cannot be evaluated from
a photograph.
We did not correlate soft tissue injury to outcomes,
as return of function and outcomes after nerve and vas-
cular injury are the subjects of 2 other presented abstracts
from the authors.15,16
The most obvious weakness of this study was the
incomplete data obtained for many enrolled patients.
These standardized forms in the EMR were a form sep-
arate from the orthopaedic consult note, and therefore
many times, the initial orthopaedic consultant and/or
attending surgeon simply forgot to fill out the form.
The neurovascular examination was included in the
standardized orthopaedic consult note, but as there was
no information regarding soft tissue injury accompanying
that consult note, we were unable to include those pa-
tients in our analysis. In addition, many forms were in-
completely filled out. Thus, our study results reflect a
smaller cohort than our available clinical volume and may
therefore be subject to selection bias.
CONCLUSIONS
In this cohort of pediatric SCHFx, severity of soft
tissue injury, as measured by swelling, ecchymosis,
puckering, and tenting, was strongly associated with
neurovascular compromise. Soft tissue injury has a clin-
ically significant association with neurovascular com-
promise in pediatric supracondylar humerus fractures,
and assessment of soft tissue injury is mandatory when
assessing these patients.
REFERENCES
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