Sabharwal Samir, Margalit Adam, Swarup Ishaan, Sabharwal Sanjeev
Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD USA.
Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA USA.
Indian J Orthop. 2020 Oct 13;55(1):47-54. doi: 10.1007/s43465-020-00273-6. eCollection 2021 Feb.
Supracondylar 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.
While 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.
Herein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience.
We 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.
Much 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.
肱骨髁上骨折是儿童肘部骨折最常见的类型，占儿童所有肘部骨折的60% - 70%。初始创伤及随后的骨折移位可能损伤周围的神经血管结构，导致相关神经血管损伤的报告发生率高达49%，其中3% - 19%的病例出现血管受损。这可能归因于动脉完全横断、动脉扭结伴血流减少、血栓形成、内膜撕裂、动脉挫伤或痉挛、血管被困于骨折部位或肱动脉创伤性动脉瘤伴随后血栓形成。
虽然普遍认为，对于伴有移位肱骨髁上骨折且手部无脉呈白色（血运障碍）的儿童需要紧急手术治疗，但对于手部无脉呈粉红色的患者是否有必要对肱动脉进行手术探查仍存在争议。鉴于缺乏共识，基于初始表现的临床发现采取个体化方法是审慎的，这些发现包括远端灌注质量（包括多普勒信号）、相关正中神经损伤、具备微血管技能的外科医生可用性以及术后严密监测的条件，同时要与家属就各种治疗选择的利弊进行公开讨论。
在此我们概述我们的治疗原则，这些原则是在仔细考虑现有文献并结合实践经验制定的。
我们建议对无脉的肱骨髁上骨折进行紧急治疗，尤其是那些手部无脉呈白色或伴有严重正中神经麻痹的骨折，进行手术复位和固定。对于所有伴有无脉肱骨髁上骨折的儿童，在充分的骨折复位和固定后应重新评估血管状况，对于持续存在远端灌注异常体征的患者，如多普勒信号微弱或消失或毛细血管再充盈缓慢，应立即对肱动脉进行手术探查并重建足够的远端血流。
许多关于伴有粉红色无脉手部的肱骨髁上骨折的现有证据质量较低。这一缺陷应促使建立一个所有血运障碍性儿童肱骨髁上骨折的国际登记处，充分记录复位前后的血管检查、术中及术后管理以及长期随访情况，以便根据有力证据提供最佳治疗指南。
