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 ASSESMENT DUPLEX SCAN DUPLEX SCAN CLINICAL ASSESMENT 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

Vascular involvement (10-15% with type III Present 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 Management  Systemic heparinization  Debride injured vessels to macroscopically normal arterial wall  Remove any intraluminal thrombus with Fogarty catheters (proximal and distal to the arterial injury)  Flush with heparinized saline solution: proximal and distal arterial lumina  No 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 KJLewis HGMorrison CMKennedy PTHerbert 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: [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.Griffin KJWalsh SRMarkar STang TYBoyle JRHayes 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: [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