Evaluating Surgical Outcomes of Supracondylar Humerus Fractures Through Patient and Parent Perspectives

Vedat Öztürk; Başar Burak Çakmur; Nebi Köksal Yazgan; Malik Çelik; Alkan Bayrak; Altuğ Duramaz

doi:10.4274/BMJ.galenos.2025.2025.3-3

ABSTRACT

Objective

This study aimed to evaluate the surgical outcomes of supracondylar humerus (SCH) fractures in children aged 8-18 years, focusing on patient and parental satisfaction.

Methods

A retrospective analysis was conducted on 105 pediatric patients (81 male and 24 female) treated surgically between 2018 and 2025. Data collected included demographic characteristics, fracture classification (Gartland), reduction type, surgical method, Baumann angle, capitellohumeral angle, healing time, follow-up duration, Visual Analog Scale (VAS) scores, Pediatric Quality of Life Inventory (PedsQL) scores, Client Satisfaction Questionnaire-8 (CSQ-8) scores, Flynn cosmetic and functional criteria, and complications. Subgroup analyses were performed to assess differences based on fracture classification and reduction type.

Results

The mean age of the patients was 10.16±1.9 years. Gartland type 2 fractures demonstrated significantly shorter healing times compared to type 3 fractures (p=0.05), and closed reductions were associated with shorter healing times than open reductions (p=0.04). Although PedsQL scores, were higher in Gartland type 2 fractures (95.3±8) and closed reductions (94.9±8.1) compared to type 3 fractures (93.8±8.4) and open reductions (92.4±9.1), these differences were not statistically significant. Subgroup analysis revealed significant associations between CSQ-8 scores and the presence of concomitant injuries (p=0.03) as well as the need for revision surgeries (p=0.028). Overall, surgical outcomes were satisfactory, with high PedsQL and low VAS scores across all groups.

Conclusion

Patient and parental satisfaction in SCH fracture treatment is influenced by concomitant injuries and revision surgery, despite generally favorable surgical outcomes.

Keywords:

Supracondylar humerus fractures, pediatric trauma, patient and parental satisfaction

INTRODUCTION

Supracondylar humerus (SCH) fractures are among the most common elbow injuries in the pediatric population (1). These fractures typically occur due to mechanisms such as falls, trauma, or high-energy impacts, and require careful management due to their potential to cause serious neurovascular complications (2). The primary goals in the treatment of SCH fractures are to restore fracture stability, protect neurovascular structures, and optimize functional recovery (3).

The choice of treatment is generally determined by the type and severity of the fracture. According to the Gartland classification, type 1 fractures can often be managed conservatively, whereas type 2 and type 3 fractures typically require surgical intervention. Closed reduction and percutaneous pinning are considered the gold standard for the surgical management of these fractures, while open reduction and internal fixation are reserved for more complex fractures or cases where closed reduction fails (4).

The literature has explored the relationship between different fracture types, treatment outcomes, and patient satisfaction, focusing on patient perspectives and cosmetic results (5-9). However, studies evaluating the relationship between both the surgical treatment of SCH fractures and patient and parental satisfaction, as well as cosmetic outcomes, remain limited.

This study aims to evaluate the radiological, clinical, and cosmetic outcomes of the surgical treatment of SCH fractures. Additionally, it seeks to assess treatment outcomes from the perspectives of patients and their parents, and to investigate the associations between these outcomes and variables such as fracture type and treatment method.

METHODS

Study Design and Setting

This retrospective, single-center study evaluated pediatric patients who underwent surgical treatment for SCH fractures between 2018 and 2025. Ethical approval for the study was obtained from the Clinical Research Ethics Committee of the University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital (approval no: 2021-04-12, date: 15.02.2021).

Inclusion and Exclusion Criteria

The study included pediatric patients aged 8 to 18 years who presented with SCH fractures, underwent surgical treatment, and completed a minimum follow-up of 24 months at our institution. Patients capable of completing the Pediatric Quality of Life Inventory (PedsQL) questionnaire were eligible for inclusion. Exclusion criteria were incomplete medical records, follow-up at external institutions, pre-existing upper extremity deformities, metabolic bone disorders, or pathological fractures. A total of 105 patients who met the inclusion criteria were included in the analysis.

Data Collection

Demographic data (age, sex, injured side, dominant side, and mechanism of injury) were collected directly from patients during outpatient visits and confirmed using electronic medical records. Associated injuries (vascular injury, neurological injury, compartment syndrome), mechanisms of injury, and fracture classification based on the Gartland system were documented. Surgical treatment details (open or closed reduction, fixation method) and complications during or after surgery were recorded. Radiological outcomes, including Baumann angle and capitellohumeral angle, were assessed using the most recent radiographs obtained during follow-up. Clinical outcomes such as healing time, follow-up duration, and Visual Analog Scale (VAS) scores were also evaluated.

Surgical Technique

Under general anesthesia, patients were positioned supine, and pneumatic tourniquets were applied to control blood flow and ensure optimal surgical conditions. Closed reduction and percutaneous pinning were initially attempted in all cases. In successful closed reductions, fixation was achieved using crossed K-wires inserted laterally and/or medially, depending on fracture configuration. For cases where closed reduction was unsuccessful, the pneumatic tourniquet was inflated and a lateral mini-incision was made for open reduction. Fixation was subsequently achieved using crossed K-wires, similar to the closed reduction group. At the end of the surgical procedure, a long-arm splint was applied to all patients (Figure 1).

Postoperative Care

Patients were monitored with a standard analgesia protocol during hospitalization. Depending on pain levels and soft tissue conditions, they were discharged within 24 to 48 hours postoperatively. All patients were called for a follow-up visit at the second postoperative week. For those who underwent open reduction, sutures were removed during this visit. At the fourth postoperative week, K-wires were removed, and passive and active range-of-motion exercises, as well as strengthening exercises, were initiated. Follow-up visits were scheduled at the second, third, sixth, and twelfth months postoperatively and annually thereafter. During the final follow-up visit, patient satisfaction was evaluated using PedsQL scores, and parental satisfaction was assessed using Client Satisfaction Questionnaire-8 (CSQ-8) scores. Additionally, objective cosmetic and functional outcomes were evaluated using Flynn cosmetic and functional criteria, and radiological outcomes were assessed by measuring the Baumann and capitellohumeral angles (Figure 2).

Primary and Secondary Outcomes

The primary outcomes of this study were healing time, radiological results (Baumann angle and capitellohumeral angle), patient satisfaction measured using PedsQL scores, and parental satisfaction evaluated using CSQ-8 scores. Secondary outcomes included functional and cosmetic results assessed using Flynn criteria, the occurrence of complications, the need for revision surgeries, and postoperative pain levels based on VAS scores. Additionally, correlations between CSQ-8, PedsQL, and Flynn criteria were analyzed to explore their interrelationships.

Statistical Analysis

Statistical analysis was performed using IBM SPSS 26 (Chicago, IL, USA). Descriptive statistical methods (minimum, maximum, and median values) were used to evaluate the study data. The normality of quantitative data was tested using the Kolmogorov-Smirnov test and graphical examinations. Independent sample t-tests were used to compare normally distributed quantitative variables between two groups, while the chi-square test was employed for qualitative independent data. A p-value of <0.05 was considered statistically significant.

RESULT

The demographic characteristics of the patients are summarized in Table 1. A total of 105 patients, aged 8-15 years, were included in the study (24 females and 81 males). Subgroup analyses based on fracture types and reduction methods revealed no statistically significant differences in Baumann angle, capitellohumeral angle, follow-up duration, or VAS scores among the groups (p>0.05). However, healing time was significantly shorter in Gartland type 2 fractures compared to type 3 fractures (p=0.05); and in cases treated with closed reduction compared to open reduction (p=0.04).

The mean PedsQL scores were higher in Gartland type 2 fractures (95.3±8) compared to type 3 fractures (93.8±8.4), but this difference was not statistically significant (p>0.05). Similarly, PedsQL scores were higher in cases treated with closed reduction (94.9±8.1) compared to open reduction (92.4±9.1), but the difference was not statistically significant (p>0.05) (Table 2).

According to the Flynn criteria, there were no statistically significant differences in fracture classification, reduction type, or sex (p>0.05). When CSQ-8 scores were categorized into three subgroups, no statistically significant differences were found among dominant side, mechanism of injury, Gartland classification, surgical method, or sex (p>0.05) (Table 3). However, subgroup analysis based on CSQ-8 scores revealed a statistically significant difference between the intermediate and high CSQ-8 groups in terms of the presence of associated injuries (p=0.03). Similarly, revision surgeries were significantly more common in the intermediate CSQ-8 group compared to the high CSQ-8 group (p=0.028).

Key Findings

1) Healing time was shorter in cases of Gartland type 2 fractures and in cases treated with closed reduction.

2) Mean PedsQL scores were higher in Gartland type 2 fractures and cases treated with closed reduction, although the differences were not statistically significant.

3) Patients with associated injuries were significantly more common in the intermediate CSQ-8 group compared to the high CSQ-8 group.

4) Revision surgeries were significantly more frequent in the intermediate CSQ-8 group compared to the high CSQ-8 group.

DISCUSSION

The most significant findings of this study are that Gartland type 2 fractures and cases treated with closed reduction exhibited shorter recovery times and higher PedsQL scores. Furthermore, patient and parent satisfaction, as measured by CSQ-8 scores, was significantly influenced by the presence of fracture-related injuries and the need for revision surgery.

In our study, Gartland type 2 fractures exhibited shorter recovery times compared to type 3 fractures. This finding is consistent with previous studies reporting similar recovery durations for less severe fractures (2, 10, 11). Additionally, our study indicates that closed reduction results in shorter recovery times compared to open reduction, thereby corroborating previous studies suggesting that closed techniques reduce complication rates and accelerate recovery (4, 12, 13). Prior studies have also recommended closed reduction whenever possible, as it minimizes surgical trauma and postoperative complications (13, 14).

Although PedsQL scores in our study were higher in type 2 fractures and in cases treated with closed reduction, the differences were not statistically significant. This finding aligns with another study in the literature that did not observe a significant difference in long-term satisfaction between different treatment methods for SCH fractures (10). Another possible explanation for the lack of statistical significance is the overall high level of recovery observed across all groups. This suggests that despite the observed differences, appropriate surgical treatment of SCH fractures remains highly effective across different fracture types.

Parental expectations play a crucial role in managing a child’s recovery, as they significantly influence their perception of the outcome and, consequently, their level of satisfaction (7, 10, 15, 16). In our study, we observed that parental satisfaction, as measured by CSQ-8 scores, was negatively affected in patients with associated injuries and those requiring revision surgery. Notably, in the moderate CSQ-8 satisfaction group, the need for revision surgery was more prevalent. Previous studies have highlighted the impact of surgical complications and secondary interventions on satisfaction, reporting a direct correlation between surgical complications and parental dissatisfaction (6, 15, 16). Patients who sustained additional injuries during the initial trauma were more likely to report lower satisfaction, likely due to prolonged treatment durations and increased postoperative challenges. These findings underscore the importance of comprehensive preoperative counseling and expectation management for patients and their families, particularly in cases involving complex fractures or potential complications.

In terms of functional and cosmetic outcomes, the Flynn criteria used in our study did not reveal significant differences between groups. This finding is consistent with the results of Rapp et al. (6), who reported that fracture type and surgical approach do not substantially affect the cosmetic outcomes of pediatric clavicle fractures. Similarly, the lack of significant differences in Baumann and capitellohumeral angles, between treatment methods, aligns with previous research indicating that radiological outcomes do not always correlate with perceived functional recovery or satisfaction (17). Another study in the literature suggests that, despite varying treatment approaches for different fracture types, satisfactory cosmetic and functional outcomes can be achieved with the appropriate surgical technique (18). This underscores the importance of radiological outcomes while also highlighting their limitations in fully capturing patient and parental experiences, emphasizing the need for more comprehensive satisfaction assessments.

Our study also identified a significant association between revision surgeries and lower satisfaction scores. This finding is consistent with the study by Keppler et al. (5), which reported that patients requiring multiple surgical procedures generally express lower levels of satisfaction. This highlights the importance of achieving optimal surgical outcomes to minimize the need for additional procedures. Furthermore, the challenges associated with managing fractures with concomitant injuries can significantly impact patient satisfaction (14).

One of the strengths of this study is its integration of both objective clinical measurements and subjective patient-reported outcomes, providing a comprehensive assessment of treatment success. By evaluating both radiological parameters and patient satisfaction measures, we were able to identify key factors influencing postoperative recovery from multiple perspectives. Additionally, the inclusion of parental satisfaction as an outcome measure adds a new dimension to the evaluation of pediatric fracture management (7).

Study Limitations

This study’s retrospective design and single-center nature may limit its generalizability. While follow-up periods were adequate for short- and mid-term assessments, longer-term evaluations could provide further insights into treatment durability. Additionally, satisfaction surveys are subjective and may be influenced by psychological and familial factors.

CONCLUSION

Surgical treatment of SCH fractures in children yields favorable outcomes, with shorter healing times in Gartland type 2 fractures and when using closed reductions. While functional and cosmetic results remain similar across treatment groups, patient and parental satisfaction is influenced by concomitant injuries and the need for revision surgery.

Ethics

Ethics Committee Approval: Ethical approval for the study was obtained from the Clinical Research Ethics Committee of the University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital (approval no: 2021-04-12, date: 15.02.2021).

Informed Consent: Informed consent was obtained from all individual participants and their legal guardians.

Authorship Contributions

Surgical and Medical Practices: V.Ö., B.B.Ç., N.K.Y., M.Ç., A.B., A.D., Concept: V.Ö., A.B., A.D., Design: V.Ö., A.B., A.D., Data Collection or Processing: B.B.Ç., N.K.Y., M.Ç., Analysis or Interpretation: N.K.Y., A.B., A.D., Literature Search: N.K.Y., M.Ç., Writing: V.Ö.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declare that this study received no financial support.

References

Çelik M, Kantarcı M, Sapmaz İE, Öztürk V, Baca E, Duramaz A. Characterization and mapping of upper extremity fractures in children by a tertiary hospital quarantine and post-quarantine period. Jt Dis Relat Surg. 2024;35:692-8.

CrossRef PubMed Google Scholar

Tuomilehto N, Sommarhem A, Nietosvaara AY. 9 years’ follow-up of 168 pin-fixed supracondylar humerus fractures in children. Acta Orthop. 2018;89:351-6.

CrossRef PubMed Google Scholar

Baumann AN, Anaspure O, Patel S, Shams K, Yoder RG, Mistovich RJ. Examining outcomes and complications for operative versus nonoperative treatment of pediatric type II supracondylar humerus fractures: a systematic review of comparative studies. J Pediatr Orthop. 2025;45:e1-e9.

CrossRef PubMed Google Scholar

Vajda M, Lőrincz A, Szakó L, Szabó L, Kassai T, Zahár Á, et al. The first analysis of a multicentre paediatric supracondylar humerus fracture (SCHF) registry by fracture type. Arch Orthop Trauma Surg. 2024;145:39.

Keppler L, Navarre F, Keppler AM, Ihle C, Becker J, Fürmetz J, et al. Fulfillment of expectations and patient satisfaction following surgical treatment of complex proximal tibial fractures. Arch Orthop Trauma Surg. 2024;145:87.

Rapp M, Prinz K, Kaiser MM. Elastic stable intramedullary nailing for displaced pediatric clavicle midshaft fractures: a prospective study of the results and patient satisfaction in 24 children and adolescents aged 10 to 15 years. J Pediatr Orthop. 2013;33:608-13.

CrossRef PubMed Google Scholar

Gill M, Drendel AL, Weisman SJ. Parent satisfaction with acute pediatric pain treatment at home. Clin J Pain. 2013;29:64-9.

CrossRef PubMed Google Scholar

Çelik M, Çanlıoğlu A, Tıngır M, Öztürk V, Kural C. Frequencies and lines of pediatric distal humerus fractures: where and how are the fractures? Med J Bakirkoy. 2025;21:14-8.

Çelik M, Bayrak A, Öztürk V, Kizilkaya C, Avkan MC. Functional and radiological comparison and evaluation of gustilo-anderson type 3 open tibia fractures treated with an ilizarov external fixator. Med J Bakirkoy. 2024;20:308-14.

Young S, Fevang JM, Gullaksen G, Nilsen PT, Engesæter LB. Parent and patient satisfaction after treatment for supracondylar humerus fractures in 139 children: no difference between skeletal traction and crossed pin fixation at long-term followup. Adv Orthop. 2012;2012:1-5.

CrossRef PubMed Google Scholar

Samaila EM, Auregli L, Pezzè L, Colò G, Magnan B. Medium-term clinical results in the treatment of supracondylar humeral fractures in children: does the surgical approach impact outcomes? J Orthop Traumatol. 2024;25:43.

CrossRef PubMed Google Scholar

Sinikumpu JJ, Victorzon S, Pokka T, Lindholm EL, Peljo T, Serlo W. The long-term outcome of childhood supracondylar humeral fractures: a population-based follow up study with a minimum follow up of ten years and normal matched comparisons. Bone Joint J. 2016;98-B:1410-7.

Barik S, Garg V, Sinha SK, Chaudhary S, Kandwal P, Singh V. A meta-analysis on comparison of open vs closed reduction of gartland type 3 supracondylar humerus fractures in children. Acta Chir Orthop Traumatol Cech. 2023;90:198-205.

Williams KG, Smith G, Luhmann SJ, Mao J, Gunn JD, Luhmann JD. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference. Pediatr Emerg Care. 2013;29:555-9.

Basaran SH, Ercin E, Bayrak A, Bilgili MG, Kizilkaya C, Dasar U, et al. The outcome and parents-based cosmetic satisfaction following fixation of paediatric supracondylar humerus fractures treated by closed method with or without small medial incision. Springerplus. 2016;5:1-5.

CrossRef PubMed Google Scholar

Silva M, Sadlik G, Avoian T, Ebramzadeh E. A removable long-arm soft cast to treat nondisplaced pediatric elbow fractures: a randomized, controlled trial. J Pediatr Orthop. 2018;38:223-9.

CrossRef PubMed Google Scholar

Poonai N, Myslik F, Joubert G, Fan J, Misir A, Istasy V, et al. Point-of-care Ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med. 2017;24:607-16.