Distal Humeral Shaft Fracture with Simultaneous Ipsilateral Supracondylar Humeral Fracture in a Child: A Case Report

@#In children, simultaneous ipsilateral fracture of the distal shaft humerus and supracondylar humerus is rare. To the best of our knowledge, there are no available data on supracondylar humeral fracture (SCHF) combined with ipsilateral distal humeral shaft fracture. This report aimed to discuss a novel case with an appropriate management scheme. We present a case of a 5-year-old boy with ipsilateral distal shaft humerus fracture and SCHF. He underwent closed reduction and antegrade elastic stable intramedullary nail (ESIN) fixation with good clinical outcome. These injuries affect a child’s bony growth, and careful treatment is warranted. Upper extremity fractures could present in different combinations. The ESIN procedure with antegrade technique facilitated reduction and fixation of the fracture by prevention of iatrogenic ulnar nerve injury or pin-tract infection. Moreover, it allowed performance of early range of motion exercises.

Fractura supracondílea de húmero y extremidad sin pulso. Uso de oximetría de pulso como predictor de lesión vascular en un caso pediátrico / Pulseless limb and supracondylar humeral fracture; use of pulse oximetry as a predictor of vascular injury in a pediatric case

Las fracturas supracondíleas del húmero (FSCH) representan la segunda lesión más frecuente en la infancia. La clasificación de Gartland, de acuerdo con la dirección y magnitud del desplazamiento orienta hacia su tratamiento. Las fracturas grado I solo requieren inmovilización y los grados del II al IV necesitan reducción generalmente cerrada, y fijación con agujas de Kirschner percutáneas. En los grados III y IV las lesiones neuro-vasculares se pueden presentar debido a las relaciones anatómicas de la fractura. La lesión vascular se debe sospechar y tener siempre en cuenta, debido a las secuelas que se pueden presentar de no tomar una conducta adecuada a tiempo. Actualmente existe controversia acerca de cuándo realizar la exploración quirúrgica ante una extremidad bien perfundida, sin pulso radial como resultado de una FSCH. Varios autores han reportado la utilidad de la onda de pulso en la oximetría como predictor de lesión vascular. En este artículo se presenta un caso clínico de FSCH con extremidad sin pulso y lesión de la arteria braquial, su manejo y evolución final.

Supracondylar fractures of the humerus are the second most frequent lesion of infancy. Gartland's classification uses the direction and magnitude of the displacement to determine its treatment. Grade I fractures need only immobilization and grades II to IV need reduction, generally closed, and percutaneous fixation with Kirschner needles. Neurovascular lesions may be present in grades III and IV because of the anatomic relations to the fracture. Vascular injury must always be suspected and taken into consideration because of the sequelae that may occur if not given adequate treatment promptly.There is currently controversy over when to do a surgical exploration in a well-perfused limb with absent radial pulse resulting from a supracondylar humeral fracture. Several authors have reported the usefulness of the waveformof the pulse oximeter in predicting vascular injury. In this article we present a clinical case of supracondylar humeral fracturewithpulseless limb and brachial artery injury, its management, and the outcome.

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

BACKGROUND: The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus. METHODS: A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair. RESULTS: In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise. CONCLUSIONS: The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Abordaje miniinvasivo lateral en fracturas supracondileas del humero en los niños / Lateral mini invasive approach in supracondylar humeral fractures in children

Introducción: La fractura supracondílea inestable cerrada del húmero en los niños es una patología que puede requerir la reducción abierta. El objetivo de este trabajo es presentar el abordaje quirúrgico miniinvasivo lateral como una excelente alternativa de tratamiento. Materiales y métodos: Se trataron 46 niños de 2 a 12 años, con mayor incidencia entre los 5 y los 7 años, y una distribución 3:2 entre varones y niñas, que presentaban una fractura cerrada de tipo III de Gartland, sin compromiso neurovascular, que no se pudo reducir mediante la manipulación externa, dada la inestabilidad de la fractura, la interposición de los tejidos blandos o la carencia de radioscopia. El abordaje miniinvasivo lateral fue de 3 a 4 cm en la piel a través de un espacio intermuscular y demandó un tiempo quirúrgico de 14 ± 2 minutos. Resultados: Todas las fracturas consolidaron, la movilidad se recuperó por completo, con buena alineación del ángulo de carga del codo. No se registraron lesiones nerviosas permanentes, miositis osificante ni infecciones profundas. Conclusiones: El abordaje miniinvasivo lateral, utilizado para el tratamiento de estas fracturas, es simple, rápido, reproducible, no requiere instrumental o equipamiento especial, produce mínima pérdida sanguínea, tiene escasa morbilidad, y determina una rápida recuperación y retorno a las actividades escolares.

Background: Closed, unstable supracondylar humeral fractures in children may require an open reduction. We present the lateral mini invasive surgical approach as an excellent treatment alternative. Methods: Forty six children aged 2 to 12, presenting Gartland Type III closed fractures were treated. The incidence was higher in those aged 5 to 7, with a 3:2 male-female distribution, no neurovascular involvement, irreducible with external manipulation because of fracture instability, soft tissue interposition, or no radioscopy available. The lateral mini invasive approach was three to four centimeters long, and proceeded through an inter-muscular plane. The surgery lasted 14+/-2 minutes. Results: All fractures healed, and motion was fully recovered, with good alignment of the elbow load angle, no permanent nerve lesions, ossifying myositis or deep infections.Conclusions: The lateral mini invasive approach used to treat these fractures is simple, fast, reproducible, does not require special instrumentation or equipment, involves minimal blood loss, low morbidity, good recovery and fast return to school.

The cost effectiveness analysis in the treatment of closed totally displaced supracondylar humeral fracture in children comparing closed reduction and pinning with open reduction and pinning: A ramdomized controlled trial.

To analyse the cost and the effects in terms of the difference in Baumann's angle of the fracture side from the normal side and to compare between closed and open reduction group. To compare the satisfaction, the complication rates and the range of motions between two groups of treatment and to consider the treatment of choice for closed totally displaced supracondylar humeral fracture. Material and Methods: A randomized controlled trial was performed on 20 patients, all with closed totally displaced supracondylar humeral fracture less than 13 years old. Ten cases were in group A closed reduction and pinning and 10 cases were in group B open reduction and pinning. Results: The general characteristics in both groups are not differect in age (mean+ S.D.) = 6.9+ 3.1, 6.3+ 2.8. P = 0.66, 95% CI -2.2, 3.4), sex, side, displacement and nerve injury preoperatively. All cases healed with good range of motion and results. The Baumann's angle difference = 2.53+ 1.8 in group A and 2.09+ 1.7 in group B with no statistical significant difference (P = 0.44, 95% CI = -1.2, 2.08) and also no difference in satisfaction and complications. The total cost, however in provider's perspective and parents' perspective were significantly higher in open reduction group than closed reduction group (P = 0.029, <0.001 respectively). Conclusion: Closed reduction should be considered first as the treatment of choice because of lower cost. In case of failure, open reduction can be performed and wil achieve good results by the experienced surgeon.