COMPOUND ELBOW DISLOCATION AND BRACHIAL ARTERY RUPTURE

A case of brachial artery rupture following compound dislocation of the elbow is reported. Arterial injury is a well-known complication of a supracondylar fracture of the humerus, but is very rare in association with elbow dislocation. A reversed saphenous vein graft was used for treatment of the arterial injury and is the recommended method of management.     

The Pulseless Supracondylar Elbow Fracture: A Rational Approach

BackgroundSupracondylar humerus fractures are the most common type of pediatric elbow fracture, accounting for 60–70% of all elbow fractures in children. Initial trauma and subsequent fracture displacement may damage surrounding neurovascular structures, leading to reports of associated neurovascular injury at rates as high as 49%, with vascular compromise reported in 3–19% of cases. This may be attributable to complete transection, kinking of the artery with reduced flow, thrombosis, intimal tear, arterial contusion or spasm, entrapment of the vessel within the fracture site or traumatic aneurysm of the brachial artery with subsequent thrombus formation. PurposeWhile there is general agreement that a child presenting with a pulseless white (dysvascular) hand associated with a displaced supracondylar humerus fracture requires emergent operative management, whether or not surgical exploration of the brachial artery is warranted in a patient with a pulseless pink hand is debatable. Given the lack of consensus, an individualized approach based on clinical findings at initial presentation, including quality of distal perfusion including doppler signal, associated median nerve injury, availability of a surgeon with microvascular skill-set, and access to vigilant post-operative monitoring, combined with an open discussion of the pros and cons of various treatment options with the family is prudent. MethodsHerein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience.ResultsWe recommend emergent management of pulseless supracondylar fractures, especially those that present with a pulseless white hand or with a dense median nerve palsy, with operative fracture reduction and fixation. In all children presenting with a pulseless supracondylar humerus fracture, the vascular status should be reassessed after adequate fracture reduction and fixation, and in patients with continued signs of abnormal distal perfusion, such as weak or absent Doppler signals or sluggish capillary refill, surgical exploration of the brachial artery with reestablishment of adequate distal flow should be conducted immediately.ConclusionMuch of the existing evidence surrounding the supracondylar humerus fracture associated with a pink, pulseless hand is of low quality. This shortcoming should serve as an impetus for establishment of an international registry of all dysvascular pediatric supracondylar fractures, with adequate documentation of the vascular exam before and after reduction, intra-operative and post-operative management and long term follow-up, to provide optimal management guidelines based on robust evidence.     

肱骨髁上骨折并发症98例临床分析

目的：探讨肱骨髁上骨折并发症发生率,发生原因及防治对策。方法：对302例肱骨髁上折伴合并症的98例进行临床分析,结果：血管损伤54例（55．1％）,神经损伤23例（23．4％）,感染4例（4．1％）,肘内翻14例（14．3％）,肘外翻3例（3．1％）,结论：血管损伤多为骨折断刺激和压迫肱动脉,神经损伤由于神经挫伤,牵拉和压迫引起,感染系清创不彻底,肘内翻大部分系尺偏型骨折,肘外翻由于骨折矫正不当所致。合理的复位,良好的固定及正确的X线评价是防治并发症的重要的措施。     

Traumatic laceration of the radial nerve following supracondylar fracture of the elbow. A case report

Traumatic laceration of the median, ulnar, or radial nerve is an extremely rare complication of supracondylar fracture of the humerus in children. A recent review of the literature disclosed only two reported cases of a laceration involving the radial nerve; a third such injury in an 8-year-old boy is reported in the present paper. Traumatic neuropraxia of one or more of the three adjacent peripheral nerves is a more common complication of supracondylar fracture, with the great majority of these lesions responding to conservative treatment. Vascular compromise secondary to traumatic laceration of the brachial artery is a more frequently observed injury, with an incidence in some series as high as 10%. Clinical findings that suggest vascular injury, therefore, warrant a more aggressive approach, either by arteriography or surgical exploration.     

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

Background

The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus.

Methods

A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair.

Results

In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise.

Conclusions

The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.     

环抱式接骨板与骨粘胶治疗四肢长骨干粉碎性骨折疗效评价

目的：评价环抱式接骨板与骨粘胶联合治疗四肢长骨干粉碎性骨折的疗效。方法：骨粘胶粘接骨碎块,环抱式接骨板固定骨折端,切开复位内固定治疗四肢长骨干粉碎生骨折35例,结果;35例38处上下肢骨干粉碎骨折,经1－2年随访,均在术后3个月内愈合,功能恢复良好,无接骨板断裂及再骨折。结论：该接骨板不钻孔,不用螺钉,对髓内血管及骨内膜无损伤,固定可靠,骨粘胶粘接强度大,粘接骨块可行,有止血护创等作用,两者联合应用,缩短了手术时间,但此法不适用于扁平骨及干骺段等不规则部位骨折,且取出此普通接骨板较难。     

A case of supracondylar humerus fracture with vascular impairment. Open it up?

Supracondylar humerus fracture is one of the most frequent fractures in childhood. A serious complication is an injury to the neurovascular structures which could potentially result in severe functional impairment. We are presenting the case of a 3-year-old girl with a supracondylar humerus fracture in our emergency department and highlight the diagnostic and therapeutic steps in managing this situation. Initially, the hand was well perfused but showed to be pulseless in the operating theater after preparation for surgery. After open reduction and internal pin fixation the neurovascular structures were explored and the brachial artery was repaired by means of a cephalic vein graft. On follow up the patient presented with normal hand function and without vascular or neurologic deficits. As concomitant vascular injuries after supracondylar humerus fractures are rare, it can be difficult to discriminate a pink pulseless hand from a patient with essential vascular injury. Our case also demonstrates the need for short-term reevaluation of the clinical status. When in doubt there should be no hesitation to perform open surgery and vascular repair.     

Compression of the ulnar nerve by an aneurysm. A case of late complication after a supracondylar fracture.

A 26-year-old man with a history of a supracondylar fracture of the left humerus 10 years ago had weakness and tingling of the fourth and fifth fingers of the left hand due to ulnar-nerve entrapment confirmed by electromyography. Angiography revealed complete obstruction of the brachial artery at the elbow and an aneurysm in the ulnar collateral artery at the medial epicondyle of the humerus. After reconstruction of the brachial artery and resection of the aneurysm, recovery was uneventful. Electromyography 6 months postoperatively was normal.     

Radial nerve injury during double plating of a displaced intercondylar fracture

Double-plate fixation is a popular treatment method for intercondylar humeral fractures. Ulnar nerve complications are emphasized, but radial nerve complications are rarely mentioned. We present a case of iatrogenic radial nerve palsy following open reduction and double plating of a supracondylar/intercondylar fracture of the humerus. Before surgery, only a sensory deficit in the radial nerve territory was present, but after surgery, there was a complete motor deficit of the wrist and finger extensors. On exploration, a segment of nerve was found crushed within the reduced lateral condyle fracture site, with a screw from the posteroradial plate going through the nerve. Although rare, radial nerve injury can occur with posteriorly displaced supracondylar/intercondylar humerus fractures. When preoperative signs of radial nerve injury are present, we recommend that the radial nerve be identified and protected during double-plate fixation.     

Dislocation of the median nerve and brachial artery in supracondylar fractures of the humerus

Two patients are described in whom the median nerve was dislocated and incarcerated between the fragments of a supracondylar fracture of the humerus. In one, the brachial artery was similarly incarcerated and was in spasm. In the second, the brachial artery had been ruptured by the upper fragment. Circulation was restored by operation in both instances. The mechanism of dislocation is discussed.     

Neurovascular injury complicating displaced proximal fractures of the humerus

Three cases with injury of the axillary artery and brachial plexus complicating a displaced proximal fracture of the humerus are presented. In two patients the arterial injury was not recognized on admission. Vascular repair had to be carried out in all three cases. Two patients showed a persistent neurological deficit. In two of the cases, the arterial injury may have been caused by an attempt at closed reduction of the fracture. The possibility of axillary arterial injury should be considered in proximal fractures of the humerus with severe medial displacement of the shaft of the humerus.     

Entrapment of the median nerve and brachial artery after supracondylar fractures of the humerus in children

Four patients, all children, with dislocation and entrapment of the median nerve and brachial artery following supracondylar fractures of the humerus are described. Circulation and neural function were restored in all cases by operation. Exploration of the neurovascular structures is recommended if dislocation and entrapment of the median nerve and brachial artery are suspected.     

Supracondylar process of the humerus causing brachial artery compression and digital embolization in a fast-pitch softball player. A case report

The supracondylar process of the humerus is a rare abnormality found in 0.4-2.7% of the population. It has been documented to cause neurovascular compression in the upper extremity owing to its local impingement on the median nerve and brachial artery at its medial location on the humerus just proximal to the elbow. The authors report the first known case of digital ischemia from embolization of thrombus caused by local compression of the brachial artery attributed to a supracondylar process.     

The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures

We present a study of the pattern of elbow fractures in children under 15 years of age, during a 5-year period, with special reference to supracondylar humerus fractures. The incidence was 308/100 000 per year; 58% of the children had a fracture in the supracondylar area of the humerus. There were 355 elbow fractures, and there were 164 boys (46%) and 191 girls (54%). The mean age for the entire group was 7.9 years (for boys, 7.2 years; for girls, 8.5 years). Of 209 supracondylar fractures (including 5 combination fractures), 134 were type I, 40 were type II, and 35 were type III (as classified by Gartland). Associated temporary nerve injuries involving the median, radial, and ulnar nerves were seen in 15 patients with type III supracondylar fractures. Associated brachial artery injuries were seen in 6 patients, 5 of whom had type III fractures.     

Repeated floating elbow injury after high-energy trauma

The floating elbow is an uncommon injury occurring both in children and in adults. Two reports of rare variants of floating elbow injury have been published, but to the best of our knowledge, no recurrence of this injury has been described. We present a complex pattern of floating injury, occurring in the same limb 3 years after a floating elbow lesion, which included supracondylar fracture of the humerus and associated ipsilateral midshaft fracture of forearm bones. Satisfactory outcomes were finally obtained. This clinical case illustrates the importance of carefully assessing floating elbow injuries when they occur to optimize the surgical strategies and the adequate timing of the treatment. A comprehensive literature review of the floating elbow injuries is here reported.     

Peripheral nerve injuries following gunshot fracture of the humerus

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.     

肱骨中上段骨折合并肱动脉损伤的手术治疗(附9例)

目的 探讨肱骨中上段骨折合并肱动脉损伤的特点，提出手术治疗的方法。方法 自2000年来，采用单侧外固定架骨折固定、自体大隐静脉桥接修复肱动脉治疗9例。结果 随访1～2年，吻合段血管均无狭窄。除1例骨折术后骨不连，再次手术外，余骨折均达临床愈合，肢体功能恢复满意。结论 术式对肱骨中上段骨折合并肱动脉损伤治疗较为理想，操作简单，具有推广应用价值。     

Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique

OBJECTIVES: Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement. DESIGN: Single cohort retrospective. SETTING: Metropolitan university tertiary care center. PATIENTS AND PARTICIPANTS: Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%). INTERVENTION: Patients were treated with a combination of medial and lateral pins using a mini-incision technique. MAIN OUTCOME MEASUREMENTS: Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing. RESULTS: The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period. CONCLUSIONS: The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.     

Neurological complications in children with supracondylar fractures of the humerus.

OBJECTIVE: To study the incidence of primary and secondary nerve injury in supracondylar fractures of the humerus, and to find out which factors may be responsible for iatrogenic nerve injuries. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 32 children admitted with type II or type III supracondylar fracture of the humerus. MAIN OUTCOME MEASURES: Incidence of primary and secondary nerve injury and their relation to type of fracture and treatment. RESULTS: 3 patients developed primary nerve injuries (9%). 4 further children developed nerve injury during treatment. All these children had several closed reductions attempted before definitive treatment was given (either pinning with a Kirschner wire or overhead traction). CONCLUSION: Several attempts at closed reduction may cause iatrogenic nerve injury in unstable supracondylar fractures of the humerus.     

Axillary artery entrapment following proximal humeral fracture: a case report and review of literature

Injury to the axillary artery following proximal humerus fracture is a very rare occurrence. The most common mechanism of axillary artery injury is fracture dislocation, resulting with intimal tears, arterial lacerations or avulsions. The most common lesion is the subtotal transaction of the vessel. In this report, we aim to define entrapment of axillary artery by tethering of anterior circumflex humeral artery, which is an unreported mechanism of injury that occurred after a proximal humerus fracture. Diminution of pulse with abduction of arm was the only finding at initial examination, and diagnosis was confirmed with angiography. Treatment was accomplished through ligation and release of anterior circumflex artery with reduction and fixation of fracture fragments, resulting with full recovery. We also have reviewed current literature about axillary artery injuries following proximal humeral fracture.