Acta Orthopaedica 2011; 82 (5): 606–609 Type-I fractures were treated with cuff and collar immobi- lization. Type II injuries were treated either nonoperatively or operatively. Type-III and type-IV injuries were treated opera- tively. Exclusion criteria were primarily nonoperatively treated fractures, open fractures, fractures that required open reduc- tion, and patients with neurological abnormalities that were found at the time of presentation. 503 children (55% boys) with an average age of 6.5 (0.5– 16) years sustained a type-II, type-III, or type-IV supracon- dylar fracture. 440 children fulfilled the inclusion criteria and were included in the study. The vast majority of these were extension-type fractures (97%, n = 427). All patients included were treated with closed reduction and the fracture was either stabilized with percutaneous crossed pins or antegrade nailing, depending on the surgeons’ prefer- ence. The method of treatment was not a matter of fracture instability. Fracture reduction was performed in the operating room under general anesthesia and image intensifier control. The maneuver for reduction was initial traction in an extended position of the elbow joint, followed by flexion and dorsal pressure with the thumb onto the distal fragment in extension- type fractures and simultaneously pronating the forearm. Proper fracture reduction with flexed elbow joint was evalu- ated in a position of 90° external rotation, in the anteroposte- rior view, and in 90° internal rotation. Crossed K-wires (1.6–2 mm) were inserted percutaneously and either bent outside the skin or cut below the level of the skin. An above-elbow cast was applied for 5–6 weeks. Explo- ration of the ulnar nerve was not performed. Early implant removal (in cases of irritation of the ulnar nerve) was not performed. Implant removal was performed together with cast removal in cases of K-wires being bent outside the skin. Children with K-wires cut below the level of the skin had the implant removed on a day-surgery basis 3 months after injury. Antegrade nailing was performed with 2 K-wires (1.6–2 mm) inserted from a skin incision located 1 cm distal to the tuberos- ity of the deltoid muscle. The humeral cortex was opened with an awl. The K-wires were bent first and the tip was blunted to ease the insertion. The implants were positioned into the radial and ulnar column of the distal humerus (Figures 1–3). Highly unstable fractures with a high grade of instability were stabilized with a third nail. Immobilization with a cast was not performed. In cases of heavy, painful swelling of the soft tis- sues, a splint was used for 7–10 days. Implants were removed after 2–4 months on a day-surgery basis. A neurological examination was done within 24 h of opera- tive intervention. Iatrogenic injury to the ulnar nerve was treated with physiotherapy and an orthotic device during the night in cases of sensomotoric affection. The functional outcome was graded from excellent to poor according to the Linscheid-Wheeler score (Linscheid and Wheeler 1965). 607 Figure 1. An isolated type-IV supracondylar humeral fracture in a 5-year-old boy. Figure 2. After closed reduction, antegrade nailing was performed using 2 nails. The implants spread correctly from the distal diaphysis into the radial and ulnar column. Immobilization was not required; frac- ture stability was high. Figure 3. Regular follow-up 2 months after the injury, with free range of motion and normal axis of the elbow joint. Statistics For comparison of groups, chi-square test was used and p-val- ues < 0.05 were considered statistically significant.