When a supracondylar humerus fracture is severely displaced, the preoperative explanation goes something like this: we will try to realign it without making an incision on the elbow and stabilize it with Kirschner wires. However, if it is not possible to achieve or maintain a correct reduction, it may be necessary to surgically expose the fracture.
The question that inevitably follows is:
“What does it depend on?”
A study published in July 2026 in the Journal of Children’s Orthopaedics attempts to answer this by analyzing fracture morphology, instability, age, and the time elapsed before surgery [1]. The most interesting result, however, is not finding a single predictive factor. It is understanding how these elements are intertwined and how timing must be interpreted within a clinical pathway, not as a simple stopwatch.
The Study: 318 High-Risk Fractures
Darilmaz and Bulut retrospectively analyzed 318 children between 2 and 12 years old, operated on between 2015 and 2025 for Gartland III supracondylar fractures or for fractures that proved to be multidirectionally unstable during surgery and were therefore classified as Gartland IV [1].
All patients initially underwent an attempt at closed reduction and percutaneous pinning. In 192 cases, the closed procedure was successful; in 126, it was necessary to switch to an open reduction.
The conversion rate is therefore 39.6%.
This is a very high number. So high that it needs to be interpreted before it can be commented on.
This is not a representative case series of all pediatric supracondylar fractures. The study includes only displaced, high-risk fractures, with a significant proportion of Gartland IV and flexion-type fractures. The authors themselves clarify that this figure should not be read as the normal rate of open reduction in children's supracondylar fractures [1].
Furthermore, the decision to stop closed attempts and proceed to open reduction inevitably depends on the surgeon's judgment. There is no universal number of maneuvers beyond which everyone makes the same decision.
The Strongest Factor Is Not Time: It's Morphology
There were only 30 flexion-type fractures, but in 24 out of 30 cases, an open reduction was necessary: 80% [1].
This finding is consistent with previous literature. Flexion-type fractures are less common than the classic extension-type forms, but they can be much more difficult to reduce. The loss of the normal periosteal support, the different direction of displacement, and the interposition of soft tissues can render the usual maneuvers ineffective [2,3].
Gartland IV instability also carried significant weight. In the complete model, the presence of multidirectional instability was associated with odds of open reduction that were more than five times higher [1].
This does not mean that a Gartland IV must be opened by definition.
A multidirectionally unstable fracture can still be reduced and stabilized percutaneously. The classification indicates that it will be more difficult to obtain and, especially, to maintain alignment during the insertion of the wires. It is a marker of difficulty, not an automatic indication for a surgical approach.
And What About Timing? The Data Is Strong, But Not So Simple
In the study, the average time from injury to surgery was approximately 5.4 hours in children successfully treated with a closed procedure and 15.1 hours in those who underwent open reduction [1].
Even after statistical adjustment, a longer interval remained associated with a higher probability of conversion.
The article's supplement makes the data even more evident:
- within 6 hours, open reduction was necessary in 60 out of 210 cases, or 28.6%;
- between 6 and 12 hours, in 48 out of 78 cases, or 61.5%;
- after 12 hours, in 18 out of 30 cases, or 60%.
This distribution suggests that timing may matter. But it also shows the limitation of the most immediate interpretation: the risk does not continue to increase linearly between 6–12 hours and over 12 hours. The two groups have almost identical raw percentages, and the latest group contains only 30 patients.
The authors themselves urge caution. Time might reflect not only a biological effect of waiting but also the complexity of the fracture, transfer from another hospital, the condition of the soft tissues, and the priority assigned to the case [1].
In other words: it is not proven that every hour that passes inevitably makes reduction more difficult.
Why, in My Practice, Timing Remains Fundamental
In our practice, Gartland III fractures are placed on the emergency operating room schedule.
I do not consider this an organizational automatism. It means avoiding unnecessary delays, repeatedly checking vascular and neurological status, limiting the increase in edema, and addressing the fracture with a team accustomed to pediatric traumatology.
In my experience, when a Gartland III is treated with the right timing, in an emergency operating room and by an experienced team, the need to switch to an open reduction is much less probable and certainly significantly lower than what appears in this case series.
This is a clinical observation, not scientific proof. A single experience is not enough to prove that early intervention prevents open reduction.
But this is precisely where the study becomes interesting: how much of the outcome depends on the fracture, and how much on the pathway in which that fracture is treated?
Operating room availability, anesthesia, team experience, fluoroscopy quality, patient positioning, gentleness of maneuvers, and the chosen threshold for conversion are variables that are difficult to measure, but in real life, they matter.
Timing, therefore, is not just the number of hours that have passed since the trauma. It is organization of treatment.
What Previous Literature Says About Surgical Delay
The studies on timing do not provide a single answer.
Gupta and collaborators, as early as 2004, had not observed a significant increase in open reductions or complications when the treatment of supracondylar fractures was performed after the first 12 hours [4]. Bales and colleagues, in 2010, reached similar conclusions in a case series of pediatric fractures treated with delayed pinning [5].
These works helped to scale back the idea that every Gartland III with a well-perfused hand and stable neurological status must necessarily be operated on in the middle of the night, regardless of the team's condition.
A more recent meta-analysis on factors associated with open reduction, however, showed strong heterogeneity among studies: the relationship between delay and conversion varies greatly depending on patient selection, fracture severity, and the organizational models of different centers [6].
Therefore, the following two statements can both be true:
- a short delay, in a stable and properly monitored child, does not automatically lead to a worse outcome;
- avoiding unnecessary delays and treating the fracture in an emergency setting can create more favorable conditions for closed reduction.
The difference is important. “Not all Gartland III fractures must be operated on within minutes” does not mean “timing doesn’t matter.”
Other Factors That Increase the Difficulty of Reduction
The 2026 paper confirms that no single element can predict the need for an open procedure.
Older Age
Children who underwent open reduction were, on average, older. In the statistical model, each year of age was associated with an increased probability of conversion [1].
This is a plausible finding: with age, limb size, trauma force, and tissue stiffness increase, while some maneuvers become less simple compared to in a small child.
Multidirectional Instability
A Gartland IV fracture loses both the anterior and posterior periosteal support. During reduction, the distal fragment can be unstable in flexion, extension, and rotation. Even after obtaining a seemingly correct image, maintaining it while inserting the wires can be difficult [1,7].
Flexion-type Fracture
This is probably the most obvious preoperative sign. The literature associates these forms with a higher frequency of ulnar nerve injury and a higher probability of open reduction [2].
Displacement and Soft Tissue Signs
Significant coronal displacement, the presence of a medial spike, marked rotation, or the so-called pucker sign may indicate that the proximal fragment has pierced the brachialis muscle or has become engaged in the anterior tissues. In these cases, it is not just “more crooked”: there may be a real mechanical obstacle to reduction.
Obesity and Neurological Deficits
Recent studies and a 2024 meta-analysis have indicated obesity, greater displacement, and initial neurological deficits as markers of a higher probability of an open approach [3,6,8].
In the work by Darilmaz and Bulut, neurological deficit was associated with open reduction in the simple analysis but lost significance after considering age, morphology, and instability together [1]. This suggests that the deficit may primarily be a sign of a more violent and complex fracture, not necessarily the direct cause of the conversion.
Opening Does Not Mean the Surgery “Went Wrong”
This point needs to be explained well to parents.
The goal is not to finish the surgery through small skin incisions at all costs. The goal is to achieve correct alignment and stable fixation without further damaging nerves, vessels, and soft tissues.
Insisting with repeated maneuvers on an irreducible fracture can be less safe than choosing a targeted approach.
Open reduction is not necessarily a complication. It can become the correct choice when:
- a fragment is incarcerated in the soft tissues;
- rotation cannot be corrected;
- the achieved alignment cannot be maintained during fixation;
- a vascular or neurological problem persists that requires exploration;
- further closed attempts risk being traumatic and futile.
The problem is not “opening.” The problem would be accepting an inadequate reduction just to be able to say it was completed percutaneously.
What Really Changes in Practice
This article does not suggest planning an open reduction for all Gartland IV or flexion-type fractures.
It suggests anticipating the difficulty.
When faced with a flexion-type fracture, an elbow with a pucker sign, an older child, or a fracture that arrives after a prolonged transfer, it is reasonable to prepare the operating room and the family for the possibility of a surgical approach.
At the same time, the data on timing reinforces an organizational choice that I consider important: Gartland III fractures should not get lost on an elective list or suffer avoidable postponements. They must enter an emergency pathway, with neurovascular monitoring and a defined surgical window.
Not because there is a magic threshold beyond which the fracture becomes irreducible.
Because the probability of achieving a good closed reduction also depends on the conditions under which we attempt to achieve it.
Limitations of the Study
The sample size is numerically adequate, but the design remains retrospective and single-center.
The cohort is highly selected: it includes only high-risk fractures, with 41.5% being Gartland IV and almost 10% being flexion-type fractures. The open reduction rate is therefore not transferable to the general population of children with supracondylar fractures.
The time to surgery has a very skewed distribution, influenced by a few extreme delays. Moreover, the raw percentage of open procedures is almost identical between the group operated on at 6–12 hours and the one operated on after 12 hours. This weakens the idea of a linear, hour-by-hour relationship.
Finally, conversion also depends on the surgeon's threshold. Three different teams may approach the same fracture with techniques, number of attempts, and indications for an open approach that are not perfectly overlapping.
Final Comment
The most useful message is not that a delayed Gartland III must necessarily be opened.
Nor is it that timing is irrelevant because some studies found no differences after 12 hours.
The message is more realistic:
the need for an open reduction arises from the intersection of fracture morphology, instability, age, soft tissue condition, timing, and the organization of treatment.
Flexion-type and Gartland IV forms are intrinsically more difficult. A delay can add edema and complexity, but it can also simply be a sign of a case that was already more severe or transferred from afar.
In my experience, placing Gartland III fractures on an emergency operating room pathway and treating them with the right timing makes the need for an open procedure highly improbable and much less frequent than reported in this case series.
This is not a refutation of the study.
It is perhaps the most interesting question the study leaves open: how much does the fracture matter, and how much does the system in which we treat it matter?
Bibliographical References
[1] Darilmaz MF, Bulut M. Fracture morphology and multidirectional instability in failed closed reduction of pediatric supracondylar humerus fractures. Journal of Children’s Orthopaedics. Published online July 10, 2026. doi:10.1177/18632521261466892.
Link: https://journals.sagepub.com/doi/10.1177/18632521261466892
[2] Flynn K, Shah AS, Brusalis CM, et al. Flexion-type supracondylar humeral fractures: ulnar nerve injury increases risk of open reduction. Journal of Bone and Joint Surgery American Volume. 2017;99(17):1485–1487. doi:10.2106/JBJS.17.00068.
[3] Kolac UC, Oral M, Sili MV, et al. Identifying risk factors for open reduction in pediatric supracondylar humerus fractures. Journal of Pediatric Orthopaedics. 2024;44(10):573–578. doi:10.1097/BPO.0000000000002784. PMID: 39099078.
[4] Gupta N, Kay RM, Leitch K, et al. Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children. Journal of Pediatric Orthopaedics. 2004;24(3):245–248. doi:10.1097/01241398-200405000-00001.
[5] Bales JG, Spencer HT, Wong MA, et al. The effects of surgical delay on the outcome of pediatric supracondylar humeral fractures. Journal of Pediatric Orthopaedics. 2010;30(8):785–791. doi:10.1097/BPO.0b013e3181f9fc03.
[6] Transtrum MB, Sanchez D, Griffith S, et al. Predictors associated with the need for open reduction of pediatric supracondylar humerus fractures: a meta-analysis of the recent literature. JB & JS Open Access. 2024;9(3):e24.00011. PMID: 39108336.
[7] Mitchell SL, Sullivan BT, Ho CA, et al. Pediatric Gartland Type-IV supracondylar humeral fractures have substantial overlap with flexion-type fractures. Journal of Bone and Joint Surgery American Volume. 2019;101(15):1351–1356.
[8] Latario LD, Lubitz MG, Narain AS, et al. Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction? Journal of Pediatric Orthopaedics B. 2023;32(6):569–574. doi:10.1097/BPB.0000000000001042. PMID: 36454244.
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