Fracture morphology and multidirectional instability in failed closed reduction of pediatric supracondylar humerus fractures

Abstract

Purpose: To evaluate clinical and fracture-related factors associated with failed closed reduction in high-risk pediatric supracondylar humerus fractures (SCHF), with emphasis on fracture morphology and intraoperative multidirectional instability. Methods: This retrospective cohort study included 318 consecutive children aged 2–12 years who underwent surgery for Gartland type III SCHF or intraoperatively confirmed Gartland type IV instability between 2015 and 2025. Fractures were classified as typical extension-type, medial oblique, lateral oblique, or flexion-type. Univariable and multivariable logistic regression analyses were performed. Results: Closed reduction was successful in 192 patients, whereas 126 required conversion to open reduction. Flexion-type fractures had the highest open reduction rate (80.0%; p < 0.001). In the full multivariable model, Gartland type IV instability was strongly associated with open reduction (odds ratio 5.21, 95% confidence interval 2.69 to 10.53; p < 0.001). Compared with flexion-type fractures, typical, medial oblique, and lateral oblique patterns had significantly lower adjusted odds. Older age and longer time from injury to surgery were also associated with open reduction. Conclusions: Flexion-type morphology and intraoperatively confirmed Gartland type IV instability were strongly associated with failed closed reduction. These findings may help surgeons anticipate reduction difficulty and plan operative resources in high-risk pediatric SCHF. Significance of Study: Recognizing fracture morphology and intraoperative multidirectional instability may help surgeons anticipate failed closed reduction in high-risk pediatric SCHF. Level of evidence: III