supracondylar humeral fractures are the most common fractures in children under 7  years old . the vast majority are extension type , resulting from a fall onto an outstretched hand , where the elbow is hyperextended , the olecranon is driven into the olecranon fossa and the anterior humeral cortex fails in tension . neurovascular complications are reported in 519  % of displaced fractures [ 2 , 3 ] , due to the close proximity of structures such as the brachial artery and the anterior interosseous nerve . there is anecdotal evidence that there is an increase in the incidence of supracondylar fractures during school holidays , and that falls from play equipment such as monkey bars and trampolines commonly cause these injuries . the aims of this study were : to compare the incidence of supracondylar fractures during term - time and during holidays in children of school age.to determine the population characteristics , mechanisms of injury , grades of fractures according to gartland   and incidence of any neurovascular complications over a 3-year period at a large district general hospital . to compare the incidence of supracondylar fractures during term - time and during holidays in children of school age . to determine the population characteristics , mechanisms of injury , grades of fractures according to gartland   and incidence of any neurovascular complications over a 3-year period at a large district general hospital . the identification of common mechanisms and times of injury may serve to improve safety and contribute to primary prevention in the future . this retrospective study included all patients aged under 16  years old who had upper limb radiographs over the 3-year period from 1 july 2008 to 30 june 2011 and who were diagnosed with a supracondylar fracture . data were collected from the electronic medical records , trauma database and the radiology picture archiving and communication system ( pacs ) regarding age , sex , side , date of injury , gartland type , mechanism , presence of any neurovascular compromise and management . the dates of all school holidays during the study period were obtained from the local education authority website . all school - aged children at the time of injury were identified and the weekly incidence of fractures in this cohort was calculated during the school holidays and during term - time . following application of the exclusion criteria , data were analysed for 159 patients , with a median age of 6  years 1  month ( range 1  year to 14  years 4  months ) ( fig . 1bar chart showing age distribution of all supracondylar humeral fractures during the study period bar chart showing age distribution of all supracondylar humeral fractures during the study period eighty - four patients ( 53  % ) were male and 59  % fractures occurred on the left side . there were four flexion - type injuries ( 3  % ) , two of which were sustained during falls from a horse . the 155 ( 97  % ) extension - type injuries comprised 46 , 28 and 26  % gartland type i , ii and iii fractures , respectively . sixty - five patients ( 41  % ) were treated operatively : all flexion - type and gartland type iii fractures underwent closed / open reduction  +  k wiring . twenty - one ( 48  % ) of the gartland ii fractures required manipulation under a general anaesthetic  + /  k wire ( table  1).table  1the management and sex distribution of each of the gartland typesnumberm : fmanagementi71 ( 46  % ) 33:38all conservative in popii44 ( 28  % ) 25:1923 conservative in pop21 mua  + /  k wireiii40 ( 26  % ) 22:18all mua  + /  k wireflexion42:23 open reduction  +  k wire1 mua the management and sex distribution of each of the gartland types a total of six patients had documented neurovascular compromise , all of which had sustained gartland iii fractures . two patients developed an ulnar nerve palsy post - operatively : one underwent surgical exploration , where the nerve was found to be intact and in the other case , the medial wire was removed at 2  weeks . both patients had full recovery of ulnar nerve function within 2  months of injury . there were two isolated nerve injuries at presentation : a radial nerve neurapraxia which was managed conservatively and fully recovered by 3  months , and a median nerve injury which underwent direct repair at 6  months post - injury and had a good recovery . two children had signs of vascular compromise : one had an intermittent white pulseless hand  on presentation , the hand was pink with a palpable pulse . however , it became white and pulseless when the elbow was flexed and placed into a backslab . , it again became white and pulseless ; this fully resolved following open reduction of the fracture . the other child had a pink pulseless hand together with median and ulnar nerve palsies  the pulse returned when the fracture was reduced . this patient later underwent exploration and neurolysis of the median and ulnar nerves at 4  weeks post - injury , with a full recovery by 3  months . the majority ( 38  % ) of fractures were sustained during falls from play equipment , almost half of which involved a trampoline ( fig . 2a , b ) . sixteen percent of fractures occurred following falls off furniture , such as chairs , sofas or beds ; these tended to be among younger children.fig . 2pie charts showing a mechanism of injury , and b proportions of each type of playground equipment involved pie charts showing a mechanism of injury , and b proportions of each type of playground equipment involved there were 115 patients identified in the school - aged cohort , with a median age of 6  years 10  months . forty - four fractures occurred during school holidays and 71 occurred during term - time ( 49 on school day , and 22 during term - time weekends ) . the weekly incidence of supracondylar fractures during school holidays was significantly higher than that during term - time ( 1.16 vs. 0.60 , p  =  0.0005 ,  test ) . further , taking into account term - time weekends , there remained a significant increase in the daily incidence of fractures during school holidays ( 0.15/day ) compared to school days ( 0.08/day ) and term - time weekends ( 0.10/day ) , p  =  0.0263 . within the holiday periods , the incidence during the spring and summer was significantly higher than during autumn and winter ( fig . 3monthly frequency of supracondylar humeral fractures during term time and holiday time monthly frequency of supracondylar humeral fractures during term time and holiday time as in previous studies , there is a peak incidence of supracondylar fractures at around 6  years of age [ 3 , 5 ] , with a predominance of boys being affected [ 3 , 6 , 7 ] . there was a predominance of type i fractures in this population , which is consistent with some previous reports , but in contrast to some others [ 6 , 9 ] . this variability in the rates of type i fractures may reflect either differences in activity levels between different populations less high - energy activities in the current population  or increased radiological diagnosis of undisplaced fractures . of the 84 displaced extension - type fractures , there was documented neurological deficit in five patients ( 6  % ) , three of which were noted on presentation . this incidence of nerve injuries is slightly lower than other reports in the literature [ 3 , 811 ] ; however , as this is a retrospective notes - based study , the apparent discrepancy may be due to the lack of documentation rather than a true lower incidence . few studies have looked at the mode of injury in supracondylar humeral fractures ; however , there is much anecdotal evidence suggesting a high incidence of fractures following falls off playground equipment such as monkey bars and trampolines . these results confirm such beliefs , with 38  % of fractures associated with playground equipment . a large proportion ( 16  % ) also occurred following falls off furniture , which tended to be among younger pre - school children , as similarly reported by farnsworth et al . . while we can not stop children from playing , the primary prevention of supracondylar fractures may be aided by targeting the playground environment . the introduction of softer landing surfaces beneath play equipment , lower heights , increased adult supervision and an improvement in the overall safety may have significant effects on the incidence of supracondylar fractures , as shown by park et al . . this study further corroborates the anecdotal evidence that there is an increase in the incidence of supracondylar fractures during school holidays . within the cohort of school - aged children , the weekly rate of fractures during school holidays is almost twice that of the term - time rate ( 1.16 vs. 0.60 ) . unfortunately , little can be done to reduce the higher incidence during holiday times , other than preventative measures in the home and in playgrounds , as mentioned above . this study demonstrates the epidemiology of paediatric supracondylar fractures managed at a district general hospital over a 3-year period . the population in this study reflects those in the published literature . the age range , sex distribution , side predominance and rate of neurovascular injury are similar . the results provide evidence that play equipment such as trampolines , monkey bars and climbing frames carry a high risk of injury and suggests that further guidance may be needed with regards to playground safety . as expected , the incidence of supracondylar humeral fractures in children is significantly higher during school holidays , in particular the summer holidays , and supports the long - standing anecdotal evidence .
purposethe purpose of this study was to investigate the epidemiology of paediatric patients sustaining supracondylar humeral fractures , to identify common mechanisms of injury and to corroborate the anecdotal evidence that fractures occur more frequently during school holidays.methodsall paediatric patients who presented to the accident and emergency department with a supracondylar distal humerus fracture over the 3-year period from 1 july 2008 to 30 june 2011 were included in the study . 
 data were collected from the electronic medical records and radiology picture archiving and communication system ( pacs ) regarding age at injury , sex , gartland type , date of injury , mechanism and management . 
 the dates of all school holidays during the study period were obtained from the local education authority website.resultsa total of 159 patients were identified , with a median age of 6  years 1  month ( range 1  year to 14  years 4  months ) ; 53  % of patients were male . 
 the 155 extension - type injuries comprised 46 , 28 and 26  % gartland i , ii and iii fractures , respectively . 
 sixty - five patients ( 41  % ) were treated operatively . 
 six patients had either neurological and/or vascular complications ; however , none had any long - term neurological compromise and none required vascular surgical intervention . 
 the mechanism of injury was recorded in 118 cases , the majority ( 37  % ) of which were sustained during falls from play equipment . among the patients , 
 115 were of school age . 
 the weekly incidence during school holidays was significantly higher than that during term - time ( 1.16 vs. 0.60 , p  =  0.0005).conclusionsthis study demonstrates the epidemiology of paediatric supracondylar fractures managed at a district general hospital over a 3-year - period . 
 this work supports the long - standing anecdotal evidence that play equipment carries a high risk of injury and that the incidence of supracondylar fractures is significantly higher during school holidays .