ACUTE VASCULAR COMPLICATIONS IN 300 STAGE IV SUPRACONDYLAR FRACTURES IN CHILDREN

Abstract

Purpose of the study: To analyse 300 supracondylar fractures with major displacement presenting with acute vascular comprimise and to propose an effective therapeutic strategy in a tertiary referral centre.

Material and Methods: Three hundred patients aged 18 months to 14 years were treated for Larange stage IV supracondylar fracture of the humerus in the same centre. Acute vascular compromise was noted in 46 cases (15%). The radial pulse was absent in all patients with two different contexts: ‘pink hand’ with good distal perfusion in 41 cases (13.5%) and ‘white hand’ with ischemia in five cases (1.5%). Nerve injury was associated in half of the cases, predominantly involving the medial nerve (87%). Emergency management included repeated assessment of the vascular and nervous status using a departmental protocol and Doppler control together with oxygen saturation. Emergency anatomical reduction and stable percutaneous fixation, with lateral and medial wires via a minimal medial exposure to control the ulnar nerve, was performed in all cases. Post-operative immobilisation with a posterior splint at 90° of elbow flexion. Repeated postoperative clinical surveillance: distal perfusion, O2 saturation and Doppler assessment.

Results: 90% of the cases with vascular compromise had posterolateral displacement. Post reduction, the radial pulse was restored immediately in 28 cases and secondarily in 10. The three remaining cases with an absent radial pulse but with a pink hand developed ischemia necessitating surgical exploration revealing incarceration of the brachial artery and medial nerve within the fracture site. Release of the brachial artery restored the radial pulse.

The five cases of primary ischemia with absent pulse and a white hand were managed by emergency reduction followed by exploratory surgery and vascular repair which restored the radial pulse, excepting one case which required anterior fasciotomy.

Conclusion: Early vascular complications after stage IV supracondylar humerus fractures are common in children. This study identified the following points: priority is required for reduction of these fracture and emergency stabilisation; posterolateral displacement is associated with a higher risk of vascular complications; these injuries should be treated in a specialised centre; the absence of a radial pulse with a pink hand warrants repeated observation during the postoperative period; it is not an absolute indication for invasive investigation and surgical exploration; the absence of a pulse with a white hand requires surgical vascular exploration.