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CASE REPORT

Children's Hospital Los Angeles

Children's Hospital Los Angeles

Great comments so far I have a question for all the pediatric orthopedic surgeons and those surgeons that take pediatric trauma call: If a patient like this presents to the emergency room at your local hospital what is the ideal treatment for the on-call orthopedic surgeon, ER physician, advanced p...ractice providers who do not routinely see emergent Pediatric injuries? Not every ER is fortunate to have experts on staff that can handle this injury. Should an attempt at closed reduction be done and then patient be transferred? What are your tips for outlining facilities when you get this call in the middle of the night regarding a pulseless patient?

Great case and reduction. What was the outcome for the pulse, and what is your treatment plan for a patient who remains pulseless but perfumed after anatomical reduction?

Nice case which highlights some of the variability in management of these problems and the question about where they should be managed. A helpful algorithm is included in the review from Shah et al. The authors note that patients with AIN or medial nerve palsy are at higher risk for late ischemia ...or compartment syndrome, and immediate exploration is recommended if "there is less than perfect vascularity to the hand." The AUC for Pediatric Supracondylar Humerus Fractures with Vascular Injury 2015 states that in the scenario of a pulseless extremity, transfer of the patient to another facility should be considered if no qualified vascular or microvascular surgeon is available at that institution. This could be the case at a free standing children's hospital if the pediatric surgeons don't typically do vascular work or the opposite at an adult hospital with a vascular surgeon but not an orthopaedist who frequently manages pediatric elbow fractures.

J Hand Surg Am. 2013 Jul;38(7):1399-403; quiz 1404.

Treatment of the "pink pulseless hand" in pediatric supracondylar humerus fractures.

J Hand Surg Am. 2013 Jul;38(7):1399-403

Apurva S Shah | Peter M Waters | Donald S Bae

This is a great case with excellent comments from distinguished orthopedic surgeons nationally and internationally below. With that being said, I will not reiterate many of the points of this case have been previously discussed. In response to Jan's earlier question, for the community orthopedis...t or ED physician, it is well accepted that any splint placed, should be placed in relative extension at 30-45 degrees. Splints placed at higher amounts of flexion (90 degrees or more) have been shown to increase compartment pressures, especially in the deep volar compartment of the forearm and potentially lead to compartment syndrome and its potential complications. (see the attached articles) In regard to ED reduction, authors have previously given their opinion that this may be a good idea in cases with extreme displacement. I have seen no scientific evidence for or against this practice. With that being said, I personally do encourage this in my own practice in specific instances. Some of our patients present to outside ED's 3-4 hours from our institution. In these situations, when skin is at risk, the fracture is open with exposed bone, there is a pucker from the fragment piercing the brachial fascia, there is severe displacement, or there is vascular compromise, I will typically have the outside ED perform a reduction with gentle traction and a milking maneuver. I instruct them in how to do this and let them know that the goal is not a perfect reduction, but instead to "make the arm, look like an arm". I then have them place a splint in 30 to 45 degrees of flexion as discussed above. In this case, I would take the patient to the OR that evening and would most likely do a laterally based construct. If I complete an open reduction or there is medial comminution, I will place a medial pin. In addition to Dr. Brock's description of placing the medial pin, I typically place this pin last. The fracture is at least partially stabilized at this point, which allows me to extend the elbow and help the potentially subluxated ulnar nerve to drift posterior to the medial epicondyle for safer pin entry. (see attached article) Finally, a close exam after final pin placement is key. Confirming vascular status by return of pulse, doppler or at least having a pink hand is paramount. The other component to exam is your fluoroscopic imaging. Mubarak showed that posterior and medial gapping in flexion type fractures may indicate the ulnar nerve is entrapped. While gapping at the fracture in flexion types, as Dr. Glotzbecker mentioned, may indicate an entrapped artery. Once this is complete, close post operative examination is also key as a median nerve paresthesia may mask compartment syndrome, for that reason I would consider a splint in severe cases to allow for easy access to the arm until time of discharge when a well molded split cast would be placed. (see attached article)

Ther Clin Risk Manag. 2018;14:1061-1066. Epub 2018 Jun 6.

Medial comminution as a risk factor for the stability after lateral-only pin fixation for pediatric supracondylar humerus fracture: an audit.

Ther Clin Risk Manag. 2018;14:1061-1066. Epub 2018 Jun 6.

Yoon Hae Kwak | Jae-Hyun Kim | Young-Chang Kim | Kun-Bo Park

J Child Orthop. 2007 Sep;1(3):177-80. Epub 2007 Sep 1.

Beware of ulnar nerve entrapment in flexion-type supracondylar humerus fractures.

J Child Orthop. 2007 Sep

Suzanne Steinman | Tracey P Bastrom | Peter O Newton | Scott J Mubarak

J Pediatr Orthop. 2002 Jul-Aug;22(4):431-9.

Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus.

J Pediatr Orthop. 2002 Jul-Aug

Todd C Battaglia | Douglas G Armstrong | Richard M Schwend

J Bone Joint Surg Br. 1979 Aug;61-B(3):285-93.

Volkmann's contracture in children: aetiology and prevention.

J Bone Joint Surg Br. 1979 Aug

S J Mubarak | N C Carroll

Good case that highlights the most important issues to analyze in this type of injury. I agree that this fractures should be treated in the OR as soon as possible, with most of them doing well with CRPP. Point out that pulse is just one indicator of blood flow, more important is forearm and hand pe...rfussion (color, warmth, arterial capillary return and pain). A pulseless, poorly perfussed hand requieres emergency treatment with a notifyed vacular o microvascular surgeon on the potencial need. If the hand is pulseless but well perfused this could be by transient brachial arterial spasm or due to brachial artery injury with distal perfussion mantained by collateral circulation. As described by Badkoobehi H et al, in the emergency room, flexing the elbow to approximately 30 to 45 and applying gentle traction may restore the pulse and improve prefusion as this maneuver relieves tension from the anterior structures, and may separate the sharp edge of the proximal fragment from the brachial artery and median nerve.

J Bone Joint Surg Am. 2015 Jun 3;97(11):937-43.

Management of the pulseless pediatric supracondylar humeral fracture.

J Bone Joint Surg Am. 2015 Jun 3

Haleh Badkoobehi | Paul D Choi | Donald S Bae | David L Skaggs

Internal Tibial Torsion

PMID: 2193037 J Pediatr Orthop. 1990 Jul-Aug;10(4):559-63.

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Lower positional deformity in infants and children: a review.

Lower positional deformity in infants and children: a review.

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Internal Tibial Torsion Differential QID: 425 (OBQ08.39)

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Lower positional deformity in infants and children: a review.

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