Supracondylar fractures: posterolateral type with brachialis muscle penetration and neurovascular injury.

Twenty-seven children with vascular deficit associated with the displaced posterolateral type of supracondylar fracture were explored surgically. Twenty-two children had median nerve signs. Associated clinical findings were bruising, tethering or puckering of the skin in the antecubital region, and a palpable subcutaneous medial spike of the proximal humeral fragment, indicating that the brachialis muscle was penetrated. Manipulation was avoided in such cases. At exploration, the neurovascular bundle was found trapped anterior to the fracture edge in 18 cases, dislocated behind the fracture edge in five cases, and separated by the spike in four cases. Fasciotomy of the antecubital region was performed, and the neurovascular bundle was released from entrapment. The vessel pulsated after release in 21 cases, vascular procedures were done in four, and the vessel ends were ligated in two completely lacerated vessels. Manipulation should be avoided in displaced posterolateral supracondylar fractures with neurovascular deficit when there is clinical evidence that the brachialis muscle belly has been buttonholed.