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Consider Brachial Damage in All Pediatric Supracondylar Humerus Fractures

Posted on: 11/30/1999
Supracondylar humerus fractures, fractures of the elbow, are a common injury in children. Despite their frequency, though, there isn't a lot of agreement on how best to treat this injury, as surgeons use different techniques and have differing opinions as to when surgery is needed. Some of the issues that come up are the different types of significant complications that may occur as a result of the fractures, such as stiffness, nerve injuries (neurologic), and deformities. In particular, doctors are concerned with vascular injuries, injuries to the blood vessels. If blood cannot get down to the tissues in the lower arm and hand, damage begins quickly.

Up to 20 percent of patients with a supracondylar humerus fracture may not have a pulse that can be felt in the lower arm (wrist). If the hand is cool, surgery must be done as soon as possible to prevent permanent damage to the arm and hand. However, there isn't much research that has been done about the role of surgery if the pulse is absent but the hand is warm, receiving blood. The authors of this article conducted a review of data to understand how often arterial (blood vessel that provides the pulse) damage occurs with this type of fracture among children.

Researchers found 19 usable articles with 331 cases of pulseless supracondylar fractures. Using this information, the researchers surveyed members of the Pediatric Orthopaedic Society of North America (POSNA) to see what their opinions would be regarding the percentage of these types of fractures that had brachial artery injuries (cool pulseless hands and warmer pulseless hands). Two hundred fifty four surgeons returned their surveys.

Of the 331 cases, 157 did not regain a pulse after surgery was performed to correct the fracture. Of these 157, 82 percent were found to have damage of the brachial artery, although members of POSNA had estimated that only 28 percent would have this type of damage. Ninety-eight of the pulseless fractures had pink hands, which means there was adequate blood circulation, Seventy percent of this group had brachial artery injury, while the POSNA estimated that there would only be 17 percent affected.

Only one complication occurred after full open surgery, osteomyelitis (inflammation or infection in the bone). Another patient had surgery delayed because of a Volkmann contracture, contracture of the wrist.

Damage to the brachial artery can result in having to amputate the affected arm later on, so detecting and correcting this type of damage is an important issue. Delayed treatment can also result in Volkmann contractures, cold intolerance, embolisms, and retarded growth of the arm. When the researchers looked for treatment recommendations, they found that more than half the papers recommended immediate surgery for warm pulseless fractures, but only 16 percent of the surveyed surgeons felt the same way. As well, as demonstrated, the surgeons vastly underestimated the percentage of injuries that involved the brachial artery. Thus, it is important for surgeons to both expect to find more patients with brachial injuries, even if the hands are warm and pink.

References:
Lydia White, MD, et al. Perfused, Pulseless, and Puzzling: A Systemic Review of Vascular Injuries in Pediatric Supracondylar Humerus Fractures and Results of a POSNA Questionnaire. In Journal of Pediatric Orthopaedics. June 2010. Vol. 30. No. 4. Pp. 328-335.

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