Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention

Open Exploration and Reduction of Paediatric Supracondylar Humerus Fracture with Pink, Pulseless Hand in Resource-Limited Settings

Background: Supracondylar humerus fractures (SHFs) are common paediatric injuries, with high risk of vascular compromise. Some patients present with a 'pink, pulseless hand', caused by occlusion of brachial artery flow but with collateral circulation preserving distal perfusion. Management of these patients remains controversial, especially when resources may be limited for prolonged hospitalisation and serial monitoring by skilled staff. The aim of this study is to present the intraoperative findings, surgical procedures done and outcomes at 6 weeks for patients with paediatric supracondylar fractures with a pink pulseless hand. Methods: We retrospectively identified 13 patients who presented to a public hospital between January 2019 and May 2023 with a displaced SHF and pink, pulseless hand. All patients underwent an open reduction with an anterior approach allowing for exploration, protection and repair of neurovascular structures. Distal flow was restored in the brachial artery either with topical lidocaine application, thrombectomy or artery reconstruction. Results: Out of 13 patients, all had intact median nerves and 10 had intact arteries (69%), of which seven were interposed at the fracture site and four were in vasospasm. Of the three patients with true arterial injury (23%), two had a crushed artery and one had thrombosis of the artery. Peripheral pulses were restored within an hour of fracture open reduction in all patients. At final follow-up, a mean 6 weeks postoperatively, all patients had recovered without neurovascular deficit, compartment syndrome or Volkmann ischemic contracture. Conclusions: In resource-limited settings, we recommend performing open exploration and reduction for patients with SHFs with pink, pulseless hand. This approach prevents iatrogenic neurovascular injury during closed reduction attempts, allows for immediate repair of a brachial artery injury and avoids unnecessary hospitalisation and serial monitoring. Level of Evidence: Level IV (Therapeutic).

Management of Volkmann's Ischemic Contracture: Case Series of 32 patients

Introduction: Volkmann’s contracture condition is of high prevalence in our population and is linked to therapeutic faults. The treatment and its results are determined according to the severity of the lesions. Methods: This retrospective study was performed in three centers and was conducted over 30 years (1987–2018); it included 32 patients. The disabilities of the arm, shoulder and hand (DASH) score and the Weber test were used to evaluate the functional outcome looking at mid and long-term results. Results: Thirty-two patients were treated for Volkmann’s Ischemic Contracture (VIC). The age ranged from 4 to 58 years, with 19 patients aged under 15. Wrist fracture was the predominant cause in 16 cases. Fourteen patients obtained a completely functional hand, seven good functional results, four fair functional results, and seven poor results. Discussion: In comparison with other studies, we noticed significant differences: apart from the dominant male sex and right side, this is one large case series conducted over 30 years (1987–2018) looking at mid-and long-term results. All the patients presented with severe or moderate lesions on the first visit. In our study, the wrist fracture is predominant compared to elbow fractures and soft trauma. X-rays are especially helpful and are a first-line investigation for identifying displaced fractures and other associated lesions. Our study population is not large, and the treatment methods are varied, so it is impossible to provide statistically relevant correlations between the treatment method and outcome. But this work is based on the experience of more than 30 years, which makes it possible to help adequate decision making according to the state of the lesions. This study is a level IV case series.

Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

Background

The optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial. Some clinicians recommend close observation after closed reduction and percutaneous pinning of the fractures, while some recommend surgical exploration if the radial pulse is unpalpable. The present study aimed to analyze the benefits and outcomes of close observation for treating pediatric supracondylar humeral fractures with a pink pulseless hand.

Methods

Thirteen consecutive children presenting with a pink pulseless hand following supracondylar humeral fracture were enrolled in this study. Preoperative and postoperative color-flow Duplex ultrasound detection was used to assess brachial artery compromise in most cases. Urgent closed reduction and percutaneous pinning of the fractures were attempted first. Close observation was carried out when the hand was pink and pulseless with an absent radial pulse.

Results

Preoperative color-flow Duplex ultrasound showed no disruption of the brachial artery in cases detected. Compression of the artery by the proximal fragment was observed in most cases, with one case of entrapment of the artery between fragments, and thrombus considered in two cases. All cases underwent urgent surgery, after which nine experienced immediate return of the radial pulse. The remaining four without a palpable pulse were managed with close observation and no deterioration of the vascular status was observed; therefore, no surgical exploration was performed. Postoperative color-flow Duplex ultrasound revealed continuity of the artery and rich collateral circulation. Patients completed an average of 4.5 years of follow-up, during which no major complications occurred. All patients achieved excellent limb function.

Conclusions

Our study demonstrates that close observation after urgent closed reduction and percutaneous pinning is a sufficient approach for the treatment of pediatric supracondylar humeral fractures accompanied with a pink pulseless hand. Surgical exploration is not necessary as long as the hand is warm and well perfused. Color-flow Duplex ultrasound is beneficial for assessing vascular compromise and determining treatment strategies.

Vascular examination predicts functional outcomes in supracondylar humerus fractures: a prospective study

PURPOSE

This article prospectively examines the functional outcome measures following management of vascular insult secondary to paediatric supracondylar humerus fractures (SCHFX) using validated outcome measures.

METHODS

The three-year, prospective, IRB-approved study consecutively enrolled operative SCHFX patients. Clinical data included presence and symmetry of the radial pulse in injured and uninjured extremities, Doppler examination of non-palpable (NP) pulses and perfusion status of the hand. Pediatric Outcomes Data Collection Instruments (PODCI) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) Measures were used to assess functional outcome at final follow-up. Multiple regression analysis was used to determine the relationship between the presence of a vascular abnormality and functional outcome while controlling for other injury parameters.

RESULTS

A total of 146/752 enrolled patients (mean age 6.8 years; range 2 years to 13 years) completed functional outcome measures at final follow-up. Of these, 20 (14%) patients had abnormal vascular exams at presentation: nine (6%) with palpable asymmetric pulse and 11 (7.5%) with NP pulse. Of those with NP pulses, nine/11 (6%) were Dopplerable and two (1.5%) lacked identifiable Doppler signal. Patients with a symmetric, palpable pulse demonstrated better PODCI pain and comfort scores (95.2 versus 85.2) (p < 0.0001), and QuickDASH scores (10.9 versus 21.6) (p < 0.007) compared to those with any abnormal vascular examination. Patients with palpable pulses, regardless of symmetry, demonstrated significantly higher PODCI pain and comfort scores (94.6 versus 84.7) (p < 0.003) than NP pulses.

CONCLUSIONS

In children with operative SCHFX, an abnormal vascular examination at presentation is predictive of poorer outcomes in pain and upper extremity function. A palpable pulse, versus NP, is predictive of better pain and comfort at final follow-up.

LEVEL OF EVIDENCE

II.

Management of supracondylar fractures of the humerus in children

Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.

Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.

Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.

Gartland’s classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.

Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.

Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.

About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.

Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically.

Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049

Pulse oximetry for the diagnosis and prediction for surgical exploration in the pulseless perfused hand as a result of supracondylar fractures of the distal humerus

BACKGROUND

The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus.

METHODS

A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair.

RESULTS

In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise.

CONCLUSIONS

The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Arterial damage accompanying supracondylar fractures of the humerus

BACKGROUND

Arterial damage is sometimes associated with supracondylar fractures of the humerus. Diagnosis and careful management of the fracture and arterial repair is crucial.

OBJECTIVES

The aim of this study was to determine the prevalence and outcome of supracondylar fractures of the humerus with signs and symptoms of limb ischemia, before and after arterial decompression or arterial reconstruction.

MATERIALS AND METHODS

From September 2004 to July 2010, 225 consecutive patients with supracondylar fracture of the humerus were prospectively recruited.

RESULTS

From among 75 cases with Gartland type III fractures, 22 were found to have vascular injury.. Of the 22 cases with vascular injury, 7 patients underwent arterial reconstruction. The other 15 received arterial decompression. All patients had a satisfactory outcome.

CONCLUSIONS

A high level of suspicion and careful clinical evaluation leading to an early diagnosis and management of vascular injury accompanying supracondylar fracture is very important to prevent unnecessary sequelae ranging from limb claudication, and compartment syndrome to more severe complications like Volkmann's contracture and even limb loss.

[Supracondylar fractures of the humerus in children]

BACKGROUND

Supracondylar humerus fractures are common in children. Severe complications are rare. We present an overview of treatment options and prognosis.

MATERIAL AND METHODS

The article is based on a non-systematic search in PubMed and experience from our own clinical research.

RESULTS

The injury is usually caused by falling from a height with the arm in extension. The mean age is about 6 years. Undisplaced fractures are treated conservatively with a cast. Displaced fractures should not be treated with a cast alone, as this may cause malunions and permanent neurovascular complications. The rate of complications after traction of displaced fractures is substantially lower than for immobilisation in cast alone. Traction and percutaneous pinning yield similar results, but percutaneous pinning is less expensive--mainly because it shortens the hospital stay. In addition, the risk of cubitus varus deformity seems to be reduced. Today the treatment of choice is closed reduction and percutaneous pinning. Choice of pin configuration is at the surgeon's discretion. Crossed pins are more common than two lateral pins, although medial pins can affect the ulnar nerve. However, the affection is almost always transient. Deep infection after percutaneous pinning is very rare.

INTERPRETATION

Percutaneous pinning of displaced supracondylar humerus fractures in children is cheap and the results are good.

CT angiography in pediatric extremity trauma: preoperative evaluation prior to reconstructive surgery

Computed tomographic angiography (CTA) is a noninvasive modality for evaluating the vascular system and planning treatment strategies. The goal of this study was to validate the clinical utility of CTA in assessment of suspected pediatric extremity traumatic vascular injury, prior to emergent and delayed reconstructive surgery. A retrospective review was performed of all operative patients under 18 years of age who underwent multidetector-row CTA for evaluation of suspected extremity vascular injury. Parameters investigated included age, type of injury, referral source, temporal relationship between the injury and the CTA, CTA findings, operations performed, intraoperative findings, and clinical outcome. Between January 2002 and September 2005, 10 pediatric patients (6 males/4 females; mean age 8 years old, range 3-17) sustained either blunt (N = 8) or penetrating (N = 2) trauma and underwent CTA of the upper (N = 5) or lower extremities (N = 5). A total of 30% (3/10) of patients were referred from the emergency department acutely, 50% (5/10) were referred from the inpatient wards subacutely, and 20% (2/10) were referred from the outpatient clinics electively. Half (N = 5) underwent CTA to evaluate need for vascular repair, whereas half (N = 5) underwent CTA to evaluate local vasculature for flap reconstruction. Overall, 40% (4/10) of CTA findings were normal, whereas 60% (6/10) revealed traumatic vascular injuries. Pertinent nonvascular findings included soft tissue defects (60%, 6/10), fractures (40%, 4/10), and contracture deformities (20%, 2/10). In all cases, procedures were completed without complications, and intraoperative findings confirmed those from CTA. At a mean follow-up of 28 months, all injuries have healed without complications. CTA is a reliable noninvasive modality to evaluate pediatric patients with suspected traumatic extremity vascular injury and to plan treatment strategies for both vascular repair and extremity reconstruction.

Treatment of pink pulseless hand following supracondylar fractures of the humerus in children

Although acute vascular injury is a common complication in children with severely displaced supracondylar humeral fractures, the management of patients with a pink pulseless hand still remains controversial. Between 1994 and 2006, 66 children with displaced supracondylar fractures of the humerus were treated. Five patients had an absence of the radial pulse with an otherwise well perfused hand. In one patient, radial pulse returned after closed reduction of the fracture. In four patients, open reduction and vascular exploration was required. Three patients had brachial artery occlusion because of thrombus formation. Thrombectomy was performed, which led to the restoration of a palpable radial pulse. In one patient with open fracture, brachial artery contusion and spasm were found, and treated by removal of adventitia. Surgical exploration for the restoration of brachial artery patency should be performed, even in the presence of viable pink hand after an attempt at closed reduction.