Atypical supracondylar fractures are defined as those supracondylar fractures which pose a challenge in either reduction or fixation or both. Hence, a supracondylar fracture which is not amenable for the standard closed reduction and lateral divergent pinning may be classified as atypical. We have included the following fracture patterns as atypical in this article: 1) Reverse oblique fractures, 2) Rotationally unstable fractures, 3) Comminuted supracondylar fractures, 4) Supracondylar fracture with intra-articular extension and 5) Flexion type fractures. We have described ways to recognize these fractures with tips and tricks to reduce and stabilize them with relevant literature and case examples. It is important to be aware of these atypical injuries to identify them and manage them appropriately.

Mismanagement of pediatric elbow injuries is not uncommon because of lack of knowledge of anatomy and development of elbow joint. This article describes postnatal development of elbow joint and radiological landmarks essential to differentiate normal and abnormal radiographs. Elbow joint is formed from six secondary ossification centres the order of appearance of which on radiographs can be remembered by the mnemonic “CRITOE”. The osteology, ligamentous and neurovascular anatomy of elbow have been described. Standard and special radiographic landmarks have been discussed while are invaluable to assess pediatric elbow radiographs especially in the setting of trauma.

Monteggia fracture dislocation in children is not so common, interesting and often missed injury pattern in children. The article reviews the historical aspects, classifications and their importance, clinical and radiological aspects and principles of management of this injury. It also deals with management of late presenting Monteggia lesions and has some case examples to illustrate practical management of fresh injury and delayed cases.

Medial epicondyle fractures are common in adolescent age group and uncommon in younger age. Unossified elbow in a younger child may pose a challenge in diagnosis. Historically fracture displacement has been quoted and used frequently as criteria for management. Plain radiographs which are routinely used for management, may underestimate the displacement. Incarcerated and open medial epicondyle fractures remain absolute indications for open reduction. Elbow dislocation, Instability, Ulnar Nerve injury, Associated fracture or ligamentous injuries and physical demands of the patient must also be considered during decision making. Isolated fractures have yielded excellent results when managed conservatively. Complications of conservatively managed fractures are rarely symptomatic. The decision to operatively manage these injuries must be individualised after considering the above mentioned factors.

Paediatric elbow radiographs pose a particular challenge to orthopaedic surgeons as the non-ossified regions are poorly visualized on plain radiographs of very young children. Therefore, a high index of suspicion must be maintained when a young child presents with a swollen and painful elbow, yet the Xrays do not reveal any obviously displaced fractures. There are eight injuries that have been labelled “TRASH” lesions – “The Radiographic Appearance Seemed Harmless”. Elbow radiographs need to be examined closely for malalignment, displaced flecks of bone which may be attached to larger osteochondral fragments, and asymmetry when compared with the contralateral elbow. MRI provides the best anatomical detail and can help plan appropriate management. If timely diagnosis is not made or the injury is not managed properly, severe complications may arise such as growth disturbance, inadequate reduction of intra-articular fragments, and persistent malalignment of the elbow joint.

A good outcome in Acute Lateral condyle fractures can be achieved by proper assessment and protocol based treatment. Clinical assessment of fracture stability can be indirectly assessed by associated soft tissue swelling, fracture crepitus elbow joint stability. Radiographs will help in determining the displacement and thereby the fracture stability and classify the fracture. It should essentially include all three views, the Anteroposterior, 15 degrees Internal Oblique and Lateral views, during initial as well as during follow-up. If stability and pattern of fracture cannot be determined on radiographs, especially in very young children, MRI and Ultrasonography will aid in determining the stability of undisplaced fractures by looking at intact cartilage hinge. Stable fractures (Song's Grade 1 and 2) can be managed non-operatively. Weekly followup radiographs out of the cast for the first 2 weeks is essential as majority of undisplaced fractures get displaced within first 2 weeks. Displaced fractures are treated by closed or open reduction. Intra operative arthrogram can aid assessment of fracture fragment and its reduction. Two K-wires, one placed transversely and other obliquely at an approximate angle of 45-60 degrees, will be sufficient to provide good stability. A screw can be placed in older children with a large capitellum or a metaphyseal fragment. A low threshold for open reduction should be considered with an aim to achieve good articular reduction. The commonest concern is lateral prominence causing Pseudovarus deformity. It usually resolves over sometime.

Lateral condyle humerus fracture in children is known to have union complications. Delay in diagnosis, pull at the common extensor origin, precarious blood supply and lack of appropriate treatment may result in non-union. Non-union of lateral condyle can lead to progressive cubitus valgus. Progressive cubitus valgus may be associated with pain, instability and stiffness of the elbow and ulnar nerve paresis. Plain radiographs of the elbow are required for the assessment of the joint congruity, size of the lateral condyle fragment, extent of the elbow deformity and physis status. Corrective osteotomy with anterior transposition of the ulnar nerve gives good cosmetic and functional results.

Distal humeral physeal seperations are a rare and clinically important injury. It can be misinterpreted due to the unossified nature of the distal humeral physis. The appropriate management and imaging guidelines have been included for better management of this entity which carries a good prognosis.

Introduction: Supracondylar Fracture of Humerus is one of the most common fractures in children. Good results can be obtained in the majority of typical fracture patterns with proper and prompt care. In India, the delay in presentation is a key factor in treatment decision making. This could be due to poor awareness, prior treatment with native bone setters or other care providers. Materials and Methods: Typical Extension type Supracondylar Fracture of Humerus is reviewed here in this article with appropriate current evidence of care. Literature review of the delayed presenting ones and their results were also listed and discussed. Conclusion: It has been proven that good results can be obtained in cases with delay in presentation. This is especially important in the Indian scenario where some delay in presentation can be expected. Emergency reduction and fixation is not necessary unless there is a neurovascular compromise, Fixation patterns for the Gartland Type I to Type III are discussed. The Type IV pattern of fracture with inherent instability of reduction has to be watched for and appropriately stabilised. Radiological landmarks of Bauman's angle, Anterior Humeral Line, which determine whether reduction is satisfactory are discussed in the article.

Introduction: The management of supracondylar fractures of the humerus in children without a palpable radial pulse is the subject of considerable controversy in the literature. The incidence of pulseless extremity ranges from 2% to 24% in different series. Materials and methods: A detailed physical examination and appropriate use of various imaging modalities will assist in determining the need for vascular exploration. These injuries are surgical emergencies that require immediate operative intervention. Therefore, units that treat supracondylar fractures in children must have protocols in place to avoid unnecessary hesitation or delay. Conclusion: This review article presents the different points of view regarding management of these potentially limb threatening injuries and provides an algorithm for management based on the latest evidence in the literature.