Epidemiology, management patterns, and complication profile of pediatric supracondylar humerus fractures in Makkah: A retrospective analysis

Abstract

BACKGROUND

Supracondylar humerus fractures are common elbow injuries in children; however, epidemiological and clinical data from Saudi Arabia are limited.

AIM

To describe the epidemiology, management strategies, and early clinical outcomes of pediatric supracondylar humerus fractures treated in Makkah, Saudi Arabia.

METHODS

We retrospectively reviewed 399 children treated for supracondylar humerus fractures from January 2021 to March 2025. Data collected included age, sex, fracture laterality, Gartland classification, fixation method, length of hospital stay, timing of cast removal, rehabilitation, and complications. Logistic regression analysis was performed to identify predictors of complications, nerve injury, and prolonged hospitalization.

RESULTS

The mean age of the patients was 5.8 years, and 54.1% were male. Fractures mostly involved the left arm (63.4%) and were classified as Gartland type III (54.9%) or type II (41.9%). Lateral entry pin fixation was used in 36.8% of cases, whereas cross-pin fixation was used in 32.1%. The median duration of hospitalization was 2 days, and three-quarters of patients were discharged within 3 days. Cast removal and rehabilitation were typically started 4 weeks after treatment. Complications were rare (5.5%), with ulnar neuropathy being the most frequent complication (2.5%). Logistic regression analysis did not identify any significant predictors of complications, nerve injury, or prolonged hospitalization.

CONCLUSION

Pediatric supracondylar humerus fractures in Makkah predominantly affect young Saudi children and commonly involve the left arm, with a displaced extension-type fracture pattern. Percutaneous lateral-entry pinning provided stable fixation and was associated with low complication rates and short hospital stays. No significant predictors of adverse outcomes were identified.

Key Words: Supracondylar humerus fracture; Pediatrics; Epidemiology; Percutaneous pinning; Makkah

Core Tip: This retrospective study evaluated 399 pediatric supracondylar humerus fractures treated at Al-Noor Specialist Hospital, Makkah, from 2021 to 2025. Mean patient age was 5.8 years, with slight male predominance (54.1%). Most fractures involved the left arm (63.4%) and were classified as Gartland type III (54.9%). Surgical fixation was primarily performed using percutaneous pin fixation, particularly lateral-entry pinning. Median hospital stay was 2 days, and the overall complication rate was low (5.5%), most commonly ulnar neuropathy. No significant predictors of poor outcomes were identified. These findings support percutaneous pinning as a safe and effective treatment for displaced pediatric supracondylar humerus fractures.

INTRODUCTION

Supracondylar humerus fractures are among the most common elbow fractures in children and are classified as arising from extension-type or flexion-type injuries. Extension-type fractures account for approximately 90% to 95% of cases, whereas flexion-type fractures are considerably less common, representing 5% to 10% of cases. Falls are the primary mechanism of injury, with the fracture pattern depending on the position of the elbow at the time of the trauma. Owing to the proximity of the distal humerus to important neurovascular structures, this type of fracture may be associated with significant complications, including injury to the brachial artery and the radial nerve. Neurological injury is among the most frequently reported complications, with the median, radial, and ulnar nerves being particularly vulnerable depending on the fracture pattern and displacement[1].

Supracondylar humerus fractures account for approximately 60% of all elbow injuries in children[2]. They most commonly occur in children aged 5-8 years, with both males and females equally affected. Around 98% of these fractures are the consequence of a fall onto an outstretched hand, with the elbow fully extended and the wrist dorsiflexed[3]. Based on the mechanism of injury and fracture pattern, supracondylar fractures are generally classified into extension-type and flexion-type fractures, with extension-type fractures being more common[4]. The Gartland classification system further subdivides extension-type fractures according to the degree of displacement and stability: Type I fractures are nondisplaced or slightly displaced, type II fractures are partially displaced, and type III fractures are totally displaced[5]. Supracondylar fractures are considered serious pediatric injuries because they may be associated with significant acute and chronic long-term complications such as neurovascular injuries, compartment syndrome, Volkmann ischemic contracture, and cubitus varus deformity[6].

Although supracondylar humerus fractures have been studied extensively worldwide, data regarding their epidemiology, mechanisms of injury, and clinical outcomes in Saudi Arabia remain limited. Recognizing these patterns is essential for establishing guiding management strategies, considering preventive measures, and tailoring them to local pediatric populations. Therefore, this study aimed to evaluate the epidemiological characteristics, management approaches, and clinical outcomes of pediatric supracondylar fractures treated at Al-Noor Specialist Hospital, Makkah, one of the major trauma centers in the region.

MATERIALS AND METHODS

Study design

A retrospective analysis was conducted on pediatric patients with supracondylar humerus fractures who visited Al-Noor Specialist Hospital, Makkah, from January 2021 to March 2025.

Data collection

Data were extracted from the electronic medical records of eligible patients and recorded on paper or electronic data collection forms without revealing any personally identifiable information to ensure patient confidentiality. Each patient was assigned a unique study identification number, which was linked to the medical record numbers and patient name through an independent identification log sheet that was stored securely. After verification, the dataset was transferred to a statistical database for evaluation.

Statical analysis

Continuous variables are presented as mean ± SD for normally distributed data and median with interquartile range (IQR) for skewed distributions. Categorical variables are expressed as n (%), with 95% confidence intervals (CIs) calculated using the Wilson score method. Associations between categorical variables were assessed using Fisher’s exact test owing to sparse cell counts in some categories. All statistical tests were two-tailed, with significance set at P < 0.05. No adjustment for multiple comparisons was performed given the exploratory nature of this study.

RESULTS

Patient demographics

As shown in Table 1, a total of 399 pediatric patients with supracondylar humerus fractures were included in this retrospective analysis. The mean patient age was 5.8 ± 2.9 (range: 1-14) years, while the median age was 5.0 (IQR: 3-8) years. The sex distribution showed a slight male predominance, with males representing 54.1% of the cohort (95%CI: 49.2%-59.0%) and females accounting for 45.9% (95%CI: 41.0%-50.8%). The majority of patients were Saudi nationals (72.2%, 95%CI: 67.7%-76.4%), followed by Myanmar (6.0%), Yemeni (5.0%), Pakistani (3.8%), Egyptian (3.3%), and other nationalities (9.7%).

Table 1 Baseline demographic characteristics of pediatric patients with supracondylar humerus fractures (n = 399), n (%).

Characteristic	Frequency (%)
Age (years)
mean ± SD	5.8 ± 2.9
Median (interquartile range)	5.0 (3-8)
Range	1-14
Gender
Male	216 (54.1)
Female	183 (45.9)
Nationality
Saudi	288 (72.2)
Myanmar	24 (6.0)
Yemen	20 (5.0)
Pakistan	15 (3.8)
Egypt	13 (3.3)
Other	39 (9.7)

Annual and seasonal admission trends

As shown in Figures 1 and 2, the 5-year study period from 2021 to 2025 demonstrated relatively consistent annual admission rates, with a peak observed in 2024 (28.6%). Monthly distribution analysis revealed seasonal variation, with higher admission rates during the summer months, particularly in May, July, and August. In contrast, a noticeable decline in admission rates was observed in June.

Figure 1 Temporal trend in annual admissions for pediatric supracondylar humerus fractures from 2021 to 2025.

Figure 2 Seasonal variation in pediatric supracondylar humerus fracture admissions by month.

Length of hospital stay

As illustrated in Figure 3, the median length of hospital stay was 2 days, with 76.2% of patients discharged within 3 days. Extended hospitalization beyond 5 days was uncommon, occurring in only 3.9% of patients.

Figure 3 Distribution of hospital length of stay among pediatric patients with supracondylar humerus fractures.

Fracture characteristics and Gartland classification

As presented in Table 2, left-sided fractures were more prevalent (63.4%, 95%CI: 58.6%-68.0%) than right-sided fractures (36.6%, 95%CI: 32.0%-41.4%). According to the Gartland classification, most fractures were type III (54.9%, 95%CI: 50.0%-59.7%), indicating complete displacement requiring surgical intervention, followed by type II fractures (41.9%, 95%CI: 37.1%-46.8%). Type IV fractures were rare, representing only 3.0% of the cases.

Table 2 Fracture characteristics and fixation methods, n (%).

Characteristic	n = 399
Laterality
Left	253 (63.4)
Right	146 (36.6)
Gartland classification
Type I	1 (0.3)
Type II	167 (41.9)
Type III	219 (54.9)
Type IV	12 (3.0)
Fixation technique
2 lateral pins	147 (36.8)
2 laterals + 1 medial	128 (32.1)
1 lateral + 1 medial	91 (22.8)
3 lateral pins	19 (4.8)
Other configurations	14 (3.5)

Fixation techniques

The predominant fixation technique was lateral-entry pinning, with two lateral pins used in 36.8% of cases and three lateral pins in 4.8%. This was followed by crossed-pin configurations, including two lateral pins with one medial pin in 32.1% of cases and one lateral pin with one medial pin in 22.8%.

Postoperative management and follow-up

As demonstrated in Table 3, cast removal occurred at a median of 4 weeks postoperatively (IQR: 3-4 weeks), with 84.2% of patients having casts removed between weeks 3 and 4 after surgery. Rehabilitation was initiated at a median of 4 weeks, with initiation times ranging from 2 weeks to 20 weeks. The median follow-up duration was 8 (IQR: 6-12) weeks, although 24.3% of patients required extended follow-up beyond 12 weeks, primarily those who experienced complications or had concerning clinical findings.

Table 3 Postoperative timeline and follow-up characteristics.

Variable	n = 399
Time to cast removal
3 weeks	168 (42.1)
4 weeks	168 (42.1)
> 4 weeks	63 (15.8)
Rehabilitation initiation
Median (range)	4 (2-20)
Follow-up duration
≤ 6 weeks	120 (30.1)
7-12 weeks	182 (45.6)
> 12 weeks	97 (24.3)

Predictors of postoperative outcomes

Tables 4, 5, and 6 summarizes the multivariate logistic regression analyses performed to identify predictors of postoperative complications, nerve injury, and extended hospital stay among the study cohort. In model 1, none of the evaluated variables, including age, sex, fracture severity classified as Gartland type III/IV, and medial pin use, demonstrated a statistically significant association with the occurrence of any postoperative complication.

Table 4 Multivariate logistic regression models for the predictors of complications and extended hospital stay - model 1.

Variable	Odds ratio	95% confidence interval		P value
		Lower	Upper
Age	1.077	0.92	1.26	0.36
Male gender	1.693	0.66	4.32	0.271
Severe fracture	0.805	0.32	2.05	0.65
Medial pin used	2.018	0.72	5.64	0.181

Model 1: Predictors of any complication.

Table 5 Multivariate logistic regression models for the predictors of complications and extended hospital stay - model 2.

Variable	Odds ratio	95% confidence interval		P value
		Lower	Upper
Age	1.047	0.85	1.28	0.658
Male gender	1.762	0.52	5.96	0.362
Severe fracture	0.741	0.22	2.45	0.623
Medial pin used	4.367	0.89	21.38	0.069

Model 2: Predictors of nerve injury.

Table 6 Multivariate logistic regression models for the predictors of complications and extended hospital stay - model 3.

Variable	Odds ratio	95% confidence interval		P value
		Lower	Upper
Age	1.011	0.93	1.10	0.784
Male gender	1.071	0.70	1.65	0.754
Severe fracture	1.512	0.98	2.33	0.061
Any complication	0.745	0.28	1.97	0.553

Model 3: Predictors of extended hospital stay (> 2 days).

In model 2, medial pin use was associated with increased odds of nerve injury (odds ratio = 4.37), although this association did not reach statistical significance (P = 0.069). Other variables, including age, sex, and fracture severity, were not significant predictors of nerve injury.

In model 3, severe fracture patterns, classified as Gartland type III/IV, showed a trend toward an association with prolonged hospitalization (< 2 days; odds ratio = 1.51, P = 0.061), although this association did not meet the threshold for statistical significance. No other variables were significantly associated with length of hospital stay. Overall, although certain trends were observed, none of the examined clinical or management-related factors were statistically significant predictors of postoperative complications, nerve injury, or extended hospital stay in this cohort.

DISCUSSION

This retrospective study assessed the epidemiology, management patterns, and clinical outcomes of pediatric supracondylar humerus fractures treated at the main regional pediatric orthopedics referral center in Makkah over 5 years. Supracondylar humerus fractures remain the most common cause of elbow injuries in children and are a frequent reason for emergency department visits worldwide. Consistent with previous epidemiological data reporting a higher incidence in boys than in girls[7,8], our series showed a slight male predominance (54.1%). The mean age of the study population was 5.8 years, which is in agreement with the typical age range reported in the literature and likely reflects a period of increased physical activity and increased risk of falls from a height.

Most fractures in our series involved the left arm (63.4%), consistent with previous reports. Bijyal et al[9] reported left-sided involvement in 61.59% of cases, whereas Santos et al[10] observed left-sided fractures in 51.8% of patients. Analysis of admission patterns revealed peaks in May (10.5%), January (10.3%), and July (10.0%). A significant association was observed between the year and month of admission (P < 0.001), suggesting temporal and seasonal variation in fracture occurrence. The increased incidence during summer is consistent with the findings of Bhat et al[11], who reported that 75% of pediatric elbow fractures occurred during summer, with a peak in June. Similarly, Santos et al[10] identified increased fracture incidence during summer and school vacation periods.

Extension-type injuries accounted for most cases in our cohort (98%), whereas flexion-type injuries comprised only 1.8% of the cases. This distribution is consistent with findings from the study by Wu et al[12], who reported that 98.3% of supracondylar humerus fractures were extension-type and only 1.7% were flexion-type, while Vajda et al[13] reported similar proportions, highlighting the rarity of flexion-type fractures compared with extension-type fractures. Regarding fracture severity, the majority of our cohort sustained Gartland type III fractures (54.9%), followed by type II fractures (41.9%). This pattern differs somewhat from the findings of Aparicio Martínez et al[14], who reported Gartland type I and type III fractures as the most frequent fracture patterns, accounting for 40% and 39.3% of cases, respectively.

Regarding fixation methods, the most frequently used construct in our cohort was two lateral-entry pins (36.8%), followed by crossed-pin fixation (32.1%). Many surgeons favored the lateral-only technique to reduce the risk of neurovascular injury, although crossed-pin configurations remained valuable in rotationally unstable fractures. These findings are consistent with the ongoing debate in the literature regarding the optimal pin configuration for displaced pediatric supracondylar humerus fractures. Although crossed-pin fixation provides stronger biomechanical stability, it is associated with a higher risk of iatrogenic injury to the ulnar nerve.

Neurological complications remain a significant concern in the management of pediatric supracondylar humerus fractures. In a meta-analysis involving more than 5000 patients, Babal et al[15] reported an overall nerve injury rate of 11.3%, most commonly involving the anterior interosseous nerve in extension fractures and the ulnar nerve in flexion fractures. In comparison, our study demonstrated a lower overall complication rate of 5.5%. Ulnar neuropathy was the most frequently observed complication, accounting for 2.5% of cases, and occurred in extensiontype injuries, likely related to surgical fixation. These findings highlight the need for precision and experience in pin application, especially in cases requiring medial pin placement. The low complication rate observed in our study further supports the safety and effectiveness of percutaneous pin fixation when performed using appropriate surgical principles.

Our findings emphasize the role of percutaneous pinning as the gold standard of care for displaced supracondylar humerus fractures, particularly Gartland type III injuries. Our multivariate logistic regression analysis (Tables 4, 5, and 6) sought to identify predictors of postoperative complications, nerve injury, and extended hospital stay in this cohort. Although none of the examined variables reached statistical significance, several clinically relevant trends emerged. Use of a medial pin was associated with a more than four-fold increase in the odds of nerve injury, albeit without statistical significance (P = 0.069). This observation aligns with previous meta-analyses demonstrating that crossed-pin fixation carries a higher risk of iatrogenic ulnar nerve injury compared with lateral-entry pinning techniques[16]. Conversely, technical modifications such as the mini-open medial approach have been shown to minimize ulnar neuropraxia, with only transient sensory deficits reported[17].

Severe fracture patterns (Gartland type III/IV) also exhibited a non-significant trend toward prolonged hospitalization (> 2 days) in our cohort. Previous studies of displaced supracondylar humerus fractures treated with cross-pinning have demonstrated average hospital stays of approximately 2 (range: 1-3) days and support the feasibility of early discharge when postoperative neurovascular status is stable[18]. Neither age nor sex was significantly associated with postoperative complications, nerve injury, or length of hospital stay, consistent with studies indicating that neurological deficits are primarily related to fracture morphology and the presence of long, sharp bone spikes rather than patient demographics[19]. Given the relatively low frequency of adverse outcomes in our cohort, larger prospective, adequately powered studies are needed to confirm these associations and identify additional risk factors.

This study has several limitations that should be acknowledged. First, its retrospective design may introduce selection bias. Second, as this is a single-center study conducted at a tertiary referral hospital, the data may not fully represent the region and may not yield generalizable outcomes. Further prospective research is needed with standardized follow-up protocols to provide more robust evidence regarding long-term functional outcomes and complication rates.

CONCLUSION

Pediatric supracondylar humerus fractures in Makkah predominantly affect young Saudi children and commonly involve the left arm, with a displaced extension-type fracture pattern. Percutaneous lateral-entry pinning provided stable fixation and was associated with low complication rates and short hospital stays. No significant predictors of adverse outcomes were identified. Larger prospective studies are needed to validate these findings and further optimize treatment strategies.

ACKNOWLEDGEMENTS

The authors would like to thank the clinical and medical records staff at Al-Noor Specialist Hospital, Makkah, for their assistance with data retrieval and patient management. The authors also acknowledge the Institutional Review Board in Makkah for reviewing and approving the study protocol.