Vascular Injury in Pediatric Elbow Fractures Is Less More? Todd Blumberg, MD PGY-1, Orthopaedics and Sports Medicine 4 August 2011

HPI TA, a 7yo RHD M, fell off trampoline and landed on L hand and sustained a type III supracondylar humerus fracture on 5/7/2011 Presented to Yakima General ED, found to lack dopplerable radial pulse After ortho and vascular consults in Yakima, transferred to SCH for further care

Injury Films – displaced type III SCH fx 5/7/2011

Gartland classification Anterior cortex fails first with resultant posterior displacement of distal fragment Type I – Non-displaced fracture Type II—displaced with intact posterior cortex Type III— displaced with no cortical contact Tachdijan’s Pediatric Orthopaedics

Injury Films – displaced type III SCH fx 5/7/2011

Operative course Taken to OR for open reduction, pin fixation Loss of doppler signal from brachial artery noted at initial exposure No doppler signal to radial and ulnar arteries; but hand noted to still have adequate blood supply with brisk capillary refill …but…after fixation, hand noted to be poorly perfused Intraoperative vascular consultation obtained

Radial artery noted to have area of discoloration On exploration, an intimal flap injury was observed as the cause of obstruction. Radial artery repaired and thrombectomy performed Transient reperfusion No radial or ulnar pulses in ICU post-op

LUE arteriogram performed next day Abrupt termination of the brachial artery flow Reconstitution of the distal brachial artery proximal to bifurcation of radial and ulnar arteries Transferred to HMC after arteriogram; still without dopplerable radial or ulnar pulses Underwent fasciotomy and primary repair of brachial artery with end-to-end anastamosis at HMC

Left upper extremity arteriogram

Left upper extremity arteriogram

Vascular Injury in SCH fx ~15% of all fractures in children and ~60-80% of all fractures about the elbow in children (Noaman, 2006) Brachial artery compromise in ~11% of all SCH fractures (Blakey, 2009) Vessel injury vs. vasospasm vs. tethering at fx site Brachial artery injury in 38% of displaced SCH fx (Campbell et al., 1995) Absent radial pulse in 19% of displaced SCH fractures (Griffin, 2008) Noaman, 2006 Blakey, 2009 Campbell 1995 Griffin 2008

Neurovascular compromise When proximal fragment displaces anteromedially, brachial artery and median nerve are at risk for injury Tachdijan’s Pediatric Orthopaedics

SCH fracture Controversy regarding best treatment when associated with a vascular injury Traditional treatment has been observation, but some studies suggest early exploration may be indicated in a subset of patients 13

The ‘Pink, Pulseless’ Hand Robust collateral circulation allows the distal extremity to remain viable despite brachial artery disruption Green, Skeletal Trauma 14

To revascularize or not to revascularize? White et al. (2009) identified 102 cases of ‘pink, pulseless’ hands 61/102 (60%) remained pulseless after CRPP 47/61 (77%) had a documented injury to the brachial artery and underwent revascularization with good results  “justify intervention”

To revascularize or not to revascularize? By contrast, Sabharwal et. al (1996) noted a high rate of asymptomatic occlusion and residual stenosis after repair of brachial artery In children, brachial artery is small and “revascularization attempts may be futile” Recommend close observation with frequent neurovascular checks before more invasive correction of a ‘pink, pulseless’ hand is performed

Less is More? Ramesh et. al (2011) reviewed 105 type III SCH fx 15/105 (14%) found to have ‘pink, pulseless’ hand All had CRPP without brachial artery exploration Return of radial pulse at 3 weeks in 6/15 (40%) and 15/15 (100%) by 6 weeks post-op Average of 36 months (20-52 months) f/u, no neurological deficit in any patients

Less really is More? Choi et al. (2010) reviewed 1255 SCH fractures; 33/1255 presented without a radial pulse 24/33 were “pink”; 9/33 were “white” No vascular repair for the ‘pink, pulseless’ hands 21/24 had CRPP [3 had ORPP due to open fx] 11/21 had palpable pulse after CRPP 10/21 remained pulseless but well perfused after CRPP Fx fixation was sufficient in 24/24 cases. No compartment syndrome or neuro deficits occurred

Risk Stratification Is there a subset of patients that should have early brachial artery exploration, even with a ‘pink, pulseless’ hand? Mangat et al. (2009) reviewed 19 patients with a perfused but pulseless hand after type III SCH fx 8/19 were explored early (3-15 hours, avg. 8)

Artery tethered to fracture site at early exploration? Yes 6 cases No 2 cases Nerve tethered? Nerve tethered? Yes 4 cases No 2 cases Yes 0 cases No 2 cases All 4 with clinical palsy None with clinical palsy Concomitant AIN or median nerve palsy is strongly predictive of nerve and vessel entrapment Mangat et. al, 2009

Pink, Pulseless hand AIN or median nerve palsy = “red flag” Anatomical proximity  concern for both vessel and nerve entrapment Pink, pulseless hand + AIN or median nerve palsy = open exploration (Mangat et. al, 2009) Tachdijan’s Pediatric Orthopaedics

The Pink, Pulseless Hand Urgent reduction and stabilization with CRPP If AIN or median nerve palsy is present, proceed with early exploration If no return of pulse after CRPP, but hand is still perfused, consider expectant management

References Sabharwal S, Tredwell SJ, Beauchamp RD, Mackenzie WG, Jakubec DM, Cairnes R, LeBlanc JG. Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop. 1997;17:303-10 Copley LA, Dormans JP, Davidson RS. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. J Pediatr Orthop. 1996;16:99-103 Palmer EE, Niemann KM, Vesely D, Armstrong JH. Supracondylar fracture of the humerus in children. J Bone Joint Surg Am. 1978;60:653-6 Battaglia TC, Armstrong DG, Schwend RM. Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus. J Pediatr Orthop. 2002;22:431-9 Campbell CC, Waters PM, Emans JB, Kasser JR, Millis MB. Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop. 1995;15:47-52. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg [Am] 2008;90-A:1121-32. Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B 2006;15:51-7. Luria S, Sucar A, Eylon S, et al. Vascular complications of supracondylar humeral fractures in children. J Pediatr Orthop B 2007;16:133-43. Griffin KJ, Walsh SR, Markar S, et al. The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. Eur J Vasc Endovasc Surg 2008;36:697-702 Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg [Br] 2009;91-B:1487-92.