Vascular Injuries in Supracondylar Frx : Wheeless' Textbook of Orthopaedics

- 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.