Upper limb fractures become common in children soon after they become ambulatory. This is so as children use their upper limbs to project themselves when they fall. The most common fracture around the elbow is the supracondylar humeral fracture followed in frequency by the lateral condylar humeral fracture. Both have a peak incidence in first decade of life.

Elbow region fracture present with some unique problems. Due to its complex anatomy and considerable swelling which follows a fracture of this region, there are difficulties in making a clinical diagnosis. The interpretation of radiographs is difficult on account of presence of multiple ossification centres, which appear at different ages. All three major upper limb nerves as well as the brachial artery are vulnerable in their close proximity to the elbow. This is one of the favored sites for development of distal compartment syndrome and myositis ossificans. In contrast to minimal procedures required to treat other fractures in children, fracture here require aggressive management including surgery. Any errors in treatment of elbow region fracture can have serious short and long term consequences.

This is the second most common fracture in children (after the forearm fracture). According to Hanlon et al (1954), this fracture has the highest incidence of rereduction, nerve injury and poor results compared to any other pediatric age group fracture. The patient presents with a swollen elbow, which is mild in an undisplaced fracture to huge with ecchymotic and blistered skin in a widely displaced fracture. The deformity is typically S shaped when seen from the side. There is pain, tenderness and refusal to handling. A gently elicited stretch pain is definite cause for alarm and required urgent treatment.

Orthopedic management consists of radiographic fracture assessment and classification, careful evaluation of overlying skin, peripheral neurovascular status and compartment pressure. The patient is taken up for closed reduction of the fracture under anesthesia. Any residual side to side or AP displacement, which is so very obvious on radiographs, is acceptable. Any rotational and varus or valgus angulation which are subtly visible and difficult to assess on x-are grounds to rereduce or open reduce the fracture. Open reduction involves a reduction of the fracture under vision and fixation by various configurations of smooth K-wires. At times, due to severe edema or poor skin condition, or a history of massage or multiple manipulations, many surgeons choose to treat the fracture conservatively in traction and accept whatever deformity that results. This is perfectly valid, as it is preferable to electively correct the deformity at a later date by an osteotomy, thereby avoiding complications like wound dehiscence and infection and minimizing myositis and stiffness.

During the rehabilitative period, only active range of motion exercises are instituted. No attempt must be made to force the joint as it results in myositis. Unless there has been a major complication, almost total functional recovery can be expected even if reduction is suboptimal.

Stiffness is documented in 2% of all supracondylar fractures. 7% of these fractures are complicated by nerve injury, radial nerve being the most commonly involved. Vascular injury is the most feared complication of this fracture, and the outcome can result in a Volkmann's contracture with or without motor sensory loss or gangrene. Myositis ossificans is rare in western world, but is commonly seen in our clinics, the principal cause being a vigorous massage and application of irritants by local osteopaths and healers. Cubitus varus is the most common complication and results from an inadequate reduction. Very rarely, cubitus valgus may result.