Management of Distal Humerus Fractures

Initial Assessment and Treatment

The American Academy of Orthopaedic Surgeons recommends using a posterior splint for nondisplaced or minimally displaced distal humerus fractures in pediatric patients, as it provides superior pain relief in the first 2 weeks after injury 1, 2
Apply a posterior splint extending from the upper arm to the wrist with the elbow at 90 degrees for better pain control compared to collar and cuff immobilization, based on randomized controlled trial evidence showing statistically significant pain relief within the first 2 weeks 1, 2
Avoid hyperflexion positioning, as this can cause limb-threatening ischemia 1, 2

Closed reduction and percutaneous Kirschner wire pinning is the preferred treatment for displaced fractures, demonstrating superior outcomes with a number needed to treat (NNT) of 20 for preventing cubitus varus and NNT of 7 for Flynn's elbow criteria 1, 2
Surgical fixation is necessary for displaced fractures, as simple casting is inadequate and carries risk of limb-threatening complications 1, 2

Immediately assess for vascular compromise, as this is the most serious complication that can lead to permanent nerve and muscle dysfunction, and check wrist pulses and hand perfusion status 1, 2, 3
If vascular compromise persists after reduction and pinning, perform open exploration of the antecubital fossa immediately to prevent limb loss 3
The catastrophic risks of delayed treatment include limb loss, ischemic contracture, and permanent functional deficit 3

Obtain radiographic follow-up at approximately 3 weeks to confirm adequate healing 4, 5
Initiate active finger motion exercises immediately to prevent stiffness, which is the most functionally disabling complication 4, 6
Monitor for skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 4, 5, 6

Never immobilize the elbow in hyperflexion, as this can cause vascular compromise and compartment syndrome 1, 2
Do not delay reduction in cases with vascular compromise; the potential benefit of emergent manipulation outweighs transport time to specialized centers 3
Avoid prolonged immobilization beyond what is necessary for fracture stability, as this increases stiffness risk 5