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- Discussion:
    - posterior cortex is disrupted w/ no cortical contact;
    - distal fragment is displaced posteriorly and proximally (by pull of triceps);
    - w/ medial displacement, the medial periosteal hinge is intact;
    - w/ lateral displacement, the lateral periosteal hinge is intact;

- Physical Exam:
    - the proximal fragment tip may penentrate into the brachialis muscle;
          - if the brachialis is buttonholed by the distal humeral spike, then the muscle can be milked off the spike by grasping the proximal arm and squeezing sequentially from proximal to distal;
                 - avoid excessive medial squeezing (to avoid N/V injury);
 
          - references:
                 - Closed Reduction and Percutaneous Pinning of Displaced Supracondylar Humerus Fractures in Children: Description of a New Closed Reduction Technique for Fractures with Brachialis Muscle Entrapment.

- Radiographs:
    - on AP view displacement may be posterolateral or posteromedial which has implications for both the reduction and surgical managment;
    - adequacy of rotational alignment of distal fragment, is difficult to determine;
          - rotation of distal fragment is best determined by CT;
          - rotation of distal frag of > 10 deg results in a unacceptable varus deformity;

- Treatment:
    - reduction;
    - percutaneous pin fixation:
           - displaced supracondylar frxs are reduced by closed methods & stabilized by percutaneous pin;
           - this permits clinical evaluation of carrying angle once frx is stabilized;
    - open reduction is indicated for difficult closed reduction (especially when the brachialis has button-holed through the brachialis)

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Treatment of the displaced supracondylar fracture of the humerus (type III) with closed reduction and percutaneous cross-pin fixation.

Management of displaced extension-type supracondylar fractures of the humerus in children

Displaced fractures of the medial humeral condyle in children.

Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years.

Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning.

Displaced supracondylar fractures of the elbow in children. A report on the fixation of extension and flexion fractures by two lateral percutaneous pins.

Transarticular fixation for severely displaced supracondylar fractures in children.

Year Book: Transarticular Fixation for Severely Displaced Supracondylar Fractures in Children.