Supracondylar fractures of the humerus in children remain a challenging problem. The algorithm for neurovascular complications has yet to be resolved. The possibility of Volkmann’s ischemic contracture is rare but devastating. The role of arteriography and indications for operative repair of the brachial artery remain controversial. In addition, the treatment of a pink yet pulseless hand is also unclear. This study assesses a single university approach to with questionable arterial status after supracondylar humerus fracture. The purpose is to assess the various types of vascular injuries and to recommend an appropriate therapeutic approach.
Over a four-year span, 519 children were treated for supracondylar fractures. Twenty-four of these cases had diminished pulse at the time of hospital admission. Only 13 were available for follow-up including x-rays and range of motion. Vascular follow-up included pressure examination and Doppler examinations of the arm. The patients were divided into three groups according to the vascular injury: (a) tear or entrapment of the brachial artery; (b) spasm of the artery and (c) compression of the artery relieved by manipulation of the fracture. As expected, the supracondylar fractures were severe in 22 of the 24 cases. Complete displacement was noted. Interestingly, three fractures had little displacement and were classified as a Gartland type 1 or 2. Three children were noted to have median nerve deficit.
Twenty-three of the 24 fractures were fixed in the operating room under general anesthesia. Exploration of the artery was indicated if either an open fracture was present or failure of the pulse to return after reduction of the fracture. Eleven cases did not have restoration of the pulse after reduction. Exploration was thus performed. Angiography was either performed in a formal angiography suite or in the operating room. Intimal tear was the most common defining. Of the 11 patients who underwent exploration, eight were treated with angioplasty, and one end-to-end anastomosis, and one saphenous vein graft patch. All procedures were performed through a standard open approach. Upon exploration, four of the 11 case were found to have no tear. These patients either had spasm or entrapment of the intact artery.
Follow-up revealed that none of the 24 children had any persistent deficit. Two children developed complication with cubitus varus and osteomyelitis. All 13 patients that were examined had palpable normal pulses. The vascular studies were unremarkable for abnormalities. There were other mild problems noted such as shorten extremity, occasional parenthesis and occasional pain.
This series did not find any association between signs of ischemia and the type of arterial injury. Absent pulse appears to be the most reliable sign of arterial injury. The authors conclude that formal angiography before surgery is only justified in special instances, including cases where there were other fractures and the exact location of arterial injury is unclear or when the return to the operating room is being debated. Furthermore, angiography in the face of arterial spasm could prevent unnecessary surgery. However, if a child has already gone to the operation room for closed reduction and pinning then an intraoperative angiogram or direct exploration can be performed. In most incidences, reduction of the fracture will be followed by return of the pulse and exploration will not be necessary.
In our institution, when there is a question concerning the vascular status of the arm after supracondylar fracture, direct exploration of the supracondylar fracture seems obvious. The authors tried to extend their conclusions to increase the indications for operative exploration. The authors described retarded development of the limb, exercise-induced ischemia and symptoms of claudication and cold intolerance. However, these complications are uncommon in clinical practice and limbs should be treated according to vascular exam following reduction.
Pediatric, Vascular, Supracondylar, Humerus, Fracture