Vascular injuries associated with supracondylar humerus

fracture in children UNIT OF VASCULAR SURGER

DEPARTMENT OF SURGERY

KING FAHAD HOSPITAL-HOFOUF

DR ALI ALSALMAN

DR M. ALMOMATTEN

PATIENTS & METHODS Retrospective review of pediatric patients

who were diagnosed to have vascular injury associated with supracondyler humerus

fracture and managed at KFHH over 7 years period(Jan2005-dec 2011 )

10 patients presented with pulseless ischemic hand following closed reduction of supracondyler fracture of humerus.

.

Results • 10 PTS were included n the study

• MEAN AGE : 7 (3—11YRS)

• SEX: MAINLY MALE PTS( M:F 6 : 4 )

TIME OF PRESENTATION

MAJORITY OF THE PATIENTS

PRESENTED WITH LESS

THAN 6 HOURS .

DIAGOSTIC MODALITIES

CLINICAL ASSESMENTCLINICAL ASSESMENT

DUPLEX SCAN DUPLEX SCAN

CLINICAL ASSESMENTCLINICAL ASSESMENT

HAND HELD DOPPLER HAND HELD DOPPLER

RESULTS 10 cases presented with ischemic

pulseless hands following supracondylar fracture of humerus .

surgical exploration of cubital fossa done in 8 patients who continued to have pulseless ischemic hand after # reduction.

RESULTS on exploration of the cubital fossa the

brachial artery was found trapped at the fracture site which was released in all

of the 8 cases . 5 patients had theire pulses returned back

shortly after the release . brachial artery was found crushed and

thrombosed in 3 patients which all were repaired by interpositional vein graft using

ipsilateral basilic vein .

RESULTS one patient presented with

pulseless ischemic hand and open fracture distal humerus where immediate exploration and repair of the transected brachial artery using a basilc vein .

RESULTS one patient had close reduction

and fixation however the hand still pulseless but warm and well perfused therefore patient was managed conservatively and the pulse regained after few hours .

RESULTS• -Associated nerve injury• MEDIAN(2pts) & ULNAR(1pt) NERVE

INVOLMENT WERE NEUROPREXIA ONLY WITH COMPLETE RECOVERY WITHIN 3 MONTHS

RESULTS

EPSILATERAL BASILIC VEIN WAS USED IN ALL CASES REQUIED ARTERIAL REPAIR

OUTCOME

-followup 12month(average) LIMB SALVAGE RATE : 100 %

MORTALITY RATE : ZERO

ALL PTS HAD NORMAL,SYMETRICAL CIRCULATORY&NEUROLOGICAL FUNCTIONS OF THE UPPER LIMBS

DISCUSION-Supracondyler # of humerus is a common

trauma in children, associated with 4-12% of brachial artery injury,

-Echemosis in the cubital fossa,botton holdin of brachialis muscle, postero-lateral displacement of the the fracture (x-ray) indicate potential neurovascular injury

-Careful clinical assessment, non-invasive vascular studies:most valuable tools to assess vascular insuffciency in these cases

V ascular involvement

(10-15% with type IIIP resent with absent

)pulse

• Medial displacement of the distal fragment places the radial nerve at risk

• Lateral displacement of the distal fragment places the median nerve and brachial artery at risk.

Operative ManagementSystemic heparinizationDebride injured vessels to macroscopically normal arterial wallRemove any intraluminal thrombus with Fogarty catheters (proximal and distal to the arterial injury)Flush with heparinized saline solution: proximal and distal arterial luminaNo tension arterial repair, interupted sutures using 7.0 prelene

Interposition autogenous vein graft

• Arterial reconstruction using the basilic vein from the zone of injury in pediatric supracondylar humeral fractures: a clinical and radiological series.

• Lewis HG, Morrison CM, Kennedy PT, Herbert KJ • The authors describe the advantages of using the basilic vein as an arterial

conduit in the management of children with supracondylar humeral fractures

requiring vascular repair. This series confirms the safety of using a donor vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. Benefits include a single surgical wound on the less conspicuous medial side of the arm, reduced operating time, and preservation of donor veins that may be subsequently required for the management of atherosclerotic disease.

• PMID:• 12621186• [PubMed - indexed for MEDLINE]

• The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children.

• Griffin KJ, Walsh SR, Markar S, Tang TY, Boyle JR, Hayes PD.• Abstract

• Supracondylar fractures of the humerus are the commonest upper limb fractures in children, accounting for up to 70% of all paediatric elbow fractures.] and are often complicated by neurovascular injury. Much confusion surrounds the management of the child with a "pink pulseless hand" post-fracture reduction and several treatment options have been proposed including observation, immediate exploration and angiography. The literature contains a number of case series with variable follow-up. A

child with a pink pulseless hand post-fracture reduction can be managed expectantly unless additional signs of vascular compromise develop, in which case exploration should be undertaken.

• PMID:• 18851922• [PubMed - indexed for MEDLINE]

CONCLUSION• Carefull clinical assessement with high

idex of suspecion remains the most valuable tool for early detection& intervention of vascular injury associated with these fractures in order to prevent ischemic complications