Orthopaedic Jobs

Vascular Injuries in Supracondylar Frx


- Discussion:
    - vascular compromise occurs in about 5-20% of children w/ supracondylar frx;
    - less than 1% will be complicated by compartment syndrome and the resulting sequelae of Volkmann's contracture;
           - note that a median nerve palsy, may mask a pending compartment syndrome (because there will be no pain);
    - references:
           - Clinical Characteristics of Severe Supracondylar Humerus Fractures in Children

    - anatomic considerations:
           - frxs w/ posterolateral displacement of distal fragment are more susceptible to vascular injury, since the medial spike of the proximal
                     humerus can tether the brachial artery
           - also consider tenting of the artery from the biciptal aponeurosis;
           - ref: The bicipital aponeurosis may be involved in the anatomical etiology of arterial compromise after swelling in supracondylar fracture.

- Treatment:
    - while patient is being worked up, consider applying a continuous pulse ox so nurses can follow an objective measurement of perfusion; 
    - closed reduction:
            - if circulation is not restored by closed reduction, immediate open reduction and surgical exploration of the artery is indicated;
            - arteriography is not indicated since it provides little additional information and only delays restoration of circulation to the extremity;
            - arteriography: (should it be done?)
                    - fracture reduction usually restores the pulses, and therefore reduction should not be delayed by waiting for an
                            angiographic study;
                    - arteriography is only indicated if circulation is not restored following reduction 
                    - ref: Management of vascular injuries in displaced supracondylar humerus fractures without arteriography.
     - open reduction and arterial exploration and repair
             - management arterial trauma:  - see intimal injuries and microvascular technique
             - morbidity assoc w/ surgical exposure of the artery is low;
             - procrastination will only increase patient morbidity; 
             - note the need to release the bicipital aponeurosis;
                    - ref: The bicipital aponeurosis may be involved in anatomical etiology of arterial compromise after swelling in supracondylar fracture.
             - w/ possible compartment syndrome will need fasciotomy;  
             - references:
                    - Arterial reconstruction using basilic vein from zone of injury in supracondylar humeral frx: a clinical and radiological series.
                    - Microsurgical reconstruction of brachial artery injuries in displaced supracondylar fracture humerus in children.


Hand ischemia associated with elbow trauma in children

Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in children: Urgent management and therapeutic consensus.

Management of the Pulseless Pediatric Supracondylar Humeral Fracture

Acute neurovascular complications with supracondylar humerus fractures in children.

Pulseless arm in association with totally displaced supracondylar fracture.

The pink pulseless hand

Pink pulseless hand following supra-condylar fractures: an audit of British practice

Management of pulseless pink hand in pediatric supracondylar fractures of humerus.

Perfused, Pulseless, and Puzzling: A Systematic Review of Vascular Injuries in Pediatric Supracondylar Humerus Fractures and Results of a POSNA Questionnaire

Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children.

Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, April 1, 2016 10:38 am