Outline:
Supracondylar fracture of humerus is a fracture occurring in the juncture of the cancellous bone and the consistent bone, about 2 to 3 cm above medial and lateral condyli of the lower end of humerus. It is often found in children under 10. It may be classified into three types according to the origin and direction of the violent forces causing the fractures, extension type, flexion type and comminuted type. Extension fracture appears when one falls with his elbow extended and his palm touching the ground first, in which the force through the forearm drives the condyle of humerus backward and upward, and the gravity of the body drives the humeral shaft forward, resulting in fracture in weak part of supracondyle of humerus.

It may injure brachial artery and median nerve when there appears severe displacement of fracture. Brachial artery injury may lead to compartment syndrome of antebrachial fascia. Flexion fracture develops when one falls with his elbow flexed and the tip of elbow touching the ground first, in which the force through the olecranon drives the condyle of humerus from the postero-inferior to the anterosuperior, resulting in fracture. Comminuted fracture occurs between supracondyle and condyle of humerus, presenting T-shaped or Y-shaped fracture, so it is also called intercondylar fracture of humerus. More than 90% cases are fallen into the type of extension fracture.

Major points for diagnosis:  
1. There is an obvious traumatic history.

2. There is pain in the injured elbow with dysfunction.

3. There is marked swelling, tenderness and positive bony crepitus. Extension fracture is marked by prominence at the posterior region, presenting a deformity just like a "boot", and in the anterior cubital fossa, the proximal end with anterior displacement can be felt. The flexion fracture is characterized by flatness at the posterior cubital region but fullness at the anterior cubital region. In the case of ulnar displacement at the distal end, the elbow tip is deviated medially.

4. Corresponding signs may appear when the fracture is complicated by neurovascular injuries

5. Roentgenogram can confirm the type of fracture and the degree of displacement. For the extension fracture, the fracture line is usually oblique, going from the anteroinferior to posterosuperior, with anterior displacement of the proximal end and posterosuperior displacement of the distal end. For the flexion fracture, the fracture line is usually oblique, going from the posteroin-ferior to anterosuperior, with anterosuperior displacement of the distal end and posterior displacement of the proximal end. At the same time, there is often ulnar or rotation displacement of the distal end.
 
Treatment:
Manipulative reduction and fixation with small splints can cure most cases of fresh supracondylar fracture of humerus. But for displaced, open or old fractures with serious neurovascular injury, any manipulation should not be blindly applied, and an early surgical reduction is advisable.
    
Reduction:   
The child patient takes a supine position, and brachial plexus anesthesia or Ketamine anesthesia is commonly used. One assistant holds the diseased upper arm, and the other holds the diseased forearm, then the two assistants apply a gentle counter-traction on the condition of the forearm in the neutral position and the elbow flexed slightly so as to correct the over-lapped displacement of fracture. The operator should apply manipulation of counter pressing and squeezing with two bands, first correcting the lateral displacement, then, correcting the anteroposterior displacement.

For extension fracture, the operator pushes and presses the distal end forward with thumbs, and pulls the proximal end backward with the rest fingers. As the operator practices reduction, the assistant below is asked to flex gently the elbow joint at the angle of about 70°on the basis of traction, thus the reduction can be achieved. For flexion fracture, the operator pushes and presses the proximal end forward with thumbs, pulls the distal end backward with the rest fingers, while the operator practices reduction, the assistant below is asked to extend gently the elbow joint straight to obtain reduction.

Fixation:   
For extension fracture, after reduction, small splints are used to fix the elbow in a position bent to form the angle of 90°to110° for 3 weeks. Superiorly, the splints should be long enough to reach the middle part of deltoid muscle; inferiorly, the medial and lateral splints should reach (or surpass) the elbow joint. The anterior splint reaches the transverse cubital crease; and the distal end of the posterior splint should be made into forward-curved form, and inlaid with an aluminum nail so as to prevent the slip of the lowest string passing the elbow joint obliquely. When splintage of bark of China fir is applied, the lowest string cannot obliquely pass the elbow joint, but bind the medial and lateral splints below the elbow.
 
In order to prevent the distal end of fracture from displacement backward, a ladder pad may be used on the posterior side or the olecranon. In order to avoid cubitus varus, two pagoda-like pads may be respectively put on the lateral side of the proximal end and the medial side of the distal end. After splintage, the forearm should be suspended with a neck-wrist sling. For flexion fracture, the elbow should be fixed in a position bent to form an angle of 40° to 60° for 1 to 2 weeks.

Except that the position of the pads is just opposite to that for extension fracture, the rest procedure is just the same as that for extension fracture; and the degree of the angle gradually increases to 90° for another 1 to 2 weeks. In 2 to 3 days after fixation, close watch should be kept on the condition of blood circulation and joint movement of the diseased arm. If something abnormal happens, it should be corrected timely. Ischemic necrosis in the forearm and pressure sores of the skin due to tight bandage or local pressure should be especially avoided.

Functional exercise:  
After reduction and fixation, the patient should be encouraged to do fist-clenching exercises, but elbow exercises should be avoided. In the late stage, the active exercises and movements of the elbow joint should be performed following the removal of the fixation, but the range of motion should be progressively increased, any violent pulling or extending motion should be forbidden.

Herbal therapy:   
Internal treatment based on syndrome differentiation
1. In the early stage
Main symptoms and signs:
Swelling, pain, and ecchymoses in the injured elbow with dysfunction.

Therapeutic methods:
Promoting blood flow to remove the stasis, and removing swelling to alleviate pain.

Recipe and herbs:
Modified Huoxue Zhitong Decoction. Specifically, Danggui (Radix Angelicae Sinensis)10 g, Chishaoyao (Radix Paeniae Rubrae)10 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)10 g, Honghua (Flos Carthmi)6 g, Zhechong (Eupolyphaga seu Steleophaga)10 g, Sanqi (RadixNotoginseng)9 g, Chenpi (Peri-carpium Citri Reticulatae )10 g, Luodeda (Herba Centellae)10 g, Zhidahuang (Radix et Rhizoma Rhei Praeparata)10 g, Cheqianzi (Semen Plataginis)10 g and Gancao (Radix Glycyrrhizae)5 g.

2. In the middle stage
Main symptoms and signs: Subsided swelling and pain, and callus in its hypoporosis stage.
Therapeutic methods: Promoting blood flow and reuniting the bone.

Recipe and herbs:
Modified Zhishang'er Decoction. Specifically, Danggui (Radix Angelicae Sinensis)12 g, Chishaoyao (Radix PaeniaeRubrae)12 g, Xuduan (Radix Dipsaci )12 g, Weilingxian ( Radix Clematidis)12 g, Zhechong (Eupolyphaga seu Steteophaga)10 g, Shengyiyiren30 g, Chenpi (Pericarpium Citri Reticugatae)10 g, Wujiapi ( Cortex Acanthopanacis Gracilistyli Radicis)10 g, Sangjisheng (Ramulus Loranthi)30 g, Gusuibu (Rhizoma Drynarii)12 g and Gancao (Radix Glycyrrhizae)5 g.

3. In the late stage
Main symptoms and signs:
Contracture of muscles and tendons, functional limitation of joint.

Therapeutic methods:
Promoting blood flow, relaxing muscles and tendons and freeing joint movement.

Recipe and herbs:
Modified Huoxue Shujin Decoction. Specifically, Danggui (Radix Angelicae Sinensis)15 g, Guizhi (Ramulus Cinnamomi Cassiae)6 g, Sang-zhi (Ramulus Mori Albae)12 g, Honghua ( Flos Carthmi)6 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)10 g, Qinjiao (Radix Gentianae Macrophyllae )10 g, Weilingxian (Radix Clema tidis )10 g, Jianghuang ( Rhizoma Curcumae longae )10 g, Oianghuo (Rhizoma seu Radix Notopterygii)10 g, Niuxi (Radix Achyranthis Bidentatae)10 g and Gancao (Radix Glycyrrhizae)5g.