Gartland type I Undisplaced or minimally displaced fractures can be treated by using an above elbow splint in 90 degrees flexion for 3 weeks. Orthopaedic cast and extreme flexion should be avoided to prevent compartment syndrome and vascular compromise. In case the varus of the fracture site is more than 10 degrees when compared to the normal elbow, closed reduction and percutaneous pinning using X-ray image intensifier inside operating theater is recommended. In one study, for those children who was done percutaneous pinning, immobilisation using a posterior splint and an arm sling has earlier resumption of activity when compared to immobilisation using collar and cuff sling. Both methods gives similar pain scores and activity level at two weeks of treatment. Gartland type II Gartland Type II fractures requires closed reduction and casting at 90 degrees flexion. Percutaneous pinning is required if more than 90 degrees flexion is required to maintain the reduction. Closed reduction with percutaneous pinning has low complication rates. Closed reduction can be done by applying traction along the long axis of the<unk>  with elbow in slight flexion. Full extension of the elbow is not recommended because the neurovascular structures can hook around the proximal fragment of the<unk> . If the proximal<unk>  is suspected to have pierced the brachialis muscle, gradual traction over the proximal<unk>  should be given instead. After that, reduction can be done through hyperflexion of the elbow can be done with the olecranon pushing anteriorly. If the distal fragment is internally rotated, reduction maneuver can be applied with extra stress applied over medial elbow with pronation of the forearm at the same time. Gartland type III and IV Gartland III and IV are unstable and prone to neurovascular injury. Therefore, closed or open reduction together with percutaneous pinning within 24 hours is the preferred method of management with low complication rates. Straight arm lateral traction can be a safe method to deal with Gartland Type III fractures. Although Gartland Type III fractures with posteromedial displacement of distal fragment can be reduced with closed reduction and casting, those with posterolateral displacement should preferably be fixed by percutaneous pinning. Percutaneous pinning Percutaneous pinning are usually inserted over the medial or lateral sides of the elbow under X-ray image intensifier guidance. There is 1.8 times higher risk of getting nerve injury when inserting both medial and lateral pins compared to lateral pin insertion alone. However, medial and lateral pins insertions are able to stabilise the fractures more properly than lateral pins alone. Therefore, medial and lateral pins insertion should be done with care to prevent nerve injuries around elbow region. Percutaneous pinning should be done when close manipulation fails to achieve the reduction, unstable fracture after closed reduction, neurological deficits occurs during or after the manipulation of fracture, and surgical exploration is required to determine the integrity of the blood vessels and nerves. In open fractures, surgical wound debridement should be performed to prevent any infection into the elbow joint. All Type II and III fractures requiring elbow flexion of more than 90° to maintain the reduction needs to be fixed by percutaneous pinning. All Type IV fractures of<unk><unk>  are unstable; therefore, requires percutaneous pinning. Besides, any polytrauma with multiple fractures of the same side requiring surgical intervention is another indication for percutaneous pinning. Follow up For routine displaced<unk>  fractures requiring percutaneous pinning, radiographic evaluation and clinical assessment can be delayed until the pin removal. Pins are only removed when there is no tenderness over the elbow region at 3 to 4 weeks. After pin removal, mobilisation of the elbow can begin. Neurovascular complications Absence of radial pulse is reported in 6 to 20% of the<unk>  fracture cases. This is because brachial artery is frequently injured in Gartland Type II and Type III fractures, especially when the distal fragment is displaced postero-laterally (proximal fragment displaced antero-medially). Open/closed reduction with percutaneous pinning would the first line of management. However, if there is no improvement of pulse after the reduction, surgical exploration of brachial artery and nerves is indicated, especially when there is persistent pain at the fracture site (indicating limb ischaemia), neurological deficits (paresthesia, tingling, numbness), and additional signs of poor perfusion (prolonged capillary refilling time, and bluish discolouration of the fingers). Meanwhile, for pink, pulseless hand (absent radial pulse but with good perfusion at extremities) after successful reduction and percutaneous pinning, the patient could still be observed until additional signs of ischaemia develops which warrants a surgical exploration. Isolated neurological deficits occurred in 10 to 20% of the cases and can reach as high as 49% in Type III Gartland fractures. Neurapraxia (temporary neurological deficits due to blockage of nerve conduction) is the most common cause of the neurological deficits in<unk>  fractures. Such neurological deficits would resolve in two or three months. However, if the neurology is not resolved for this time frame, surgical exploration is indicated.
Supracondylar humerus fracture
Radial head fracture
Proximal humerus fracture
Jefferson fracture
Bosworth fracture
Scapular fracture
Scaphoid fracture
Cuboid fracture