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

Abstract

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. 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. 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%; <i>p</i> < 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; <i>p</i> < 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. 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. Recognizing fracture morphology and intraoperative multidirectional instability may help surgeons anticipate failed closed reduction in high-risk pediatric SCHF. III.