Pediatric Brachial Artery Injury Due to Supracondylar Humerus Fractures: A Case Series
Courtney L. Grant, MD, Dipankar Mukherjee.
Inova Fairfax Medical Campus, Vienna, VA, USA.
Objective: Supracondylar humerus fractures in children present with brachial artery injury in 3 to 14% of cases. Following fracture reduction and stabilization, some cases result in a pink and well perfused hand despite an absent radial pulse, known as the pink pulseless hand. The decision to manage this nonoperatively with observation or with surgical exploration remains debatable. We report the management and outcomes of five cases at our institution.
Methods: A retrospective chart review at a level I trauma center of patients less than age 18 years with supracondylar humerus fractures who underwent brachial artery exploration. Explorations were performed by four different vascular surgeons between 2015-2016. Patient presentation, surgical management, and follow-up were reviewed.
Results: Five patients (four males, mean age 5.4 years) presented with type III supracondylar humerus fracture after falls, four with a pink pulseless hand, one with an avascular hand. Closed reduction and percutaneous pinning resulted in five pink hands, only one with a palpable pulse and one with return of radial Doppler signal. Both of these patients were discharged home. Of the remaining three pink pulseless hands with absent signals, two were admitted for observation and only one underwent immediate brachial artery exploration. The four cases initially managed nonoperatively eventually underwent exploration -- two for persistent lack of signals (postreduction day one), and two presenting with compartment syndrome after discharge (postreduction days one and three). Intraoperative findings included three brachial artery entrapments, one arterial compression due to hematoma, and one complete arterial transection requiring thrombectomy and a venous interposition graft. Immediate restoration of a triphasic signal was observed in all patients and at postoperative follow-up (ranging from 4 months to 2 years), all patients had a palpable radial pulse. Two developed mild contraction at the elbow and two with mild interosseous nerve palsy noted to improve over time.
Conclusion: All patients with a pink pulseless hand that recover a radial pulse or doppler signal after reduction should be admitted and closely monitored with frequent neurovascular checks for at least 24 hours before being discharged as they can develop compartment syndrome. Cases without return of a radial doppler signal after reduction should prompt immediate brachial exploration.
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