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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.

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

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Acute neurovascular complications with supracondylar humerus fractures in children.

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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