Hand ischemia associated with elbow trauma in children

Area of Science:

• Pediatric Surgery
• Orthopedic Trauma
• Vascular Surgery

Background:

• Hand ischemia in children following elbow trauma, termed pink pulseless hand (PPH), is often managed nonoperatively based on the assumption of arterial spasm.
• The underlying mechanism of arterial compromise in PPH has not been thoroughly investigated.

Purpose of the Study:

• To investigate the mechanism of brachial artery injury in pediatric patients presenting with hand ischemia after elbow trauma.
• To challenge the assumption that PPH is solely due to arterial spasm and advocate for surgical exploration.

Main Methods:

• Retrospective review of 12 pediatric patients undergoing brachial artery exploration for hand ischemia post-elbow trauma at a level I trauma center.
• Analysis of operative findings, including intimal flaps, thrombosis, and neurovascular entrapment.

Main Results:

• 67% of patients (8/12) had brachial artery thrombosis with intimal flaps; 33% (4/12) had brachial artery and median nerve entrapment.
• All patients achieved palpable radial pulses post-exploration.
• Three patients with entrapment experienced residual median nerve deficits, with partial recovery in two.

Conclusions:

• Brachial artery injury, including thrombosis and entrapment, should be anticipated in pediatric hand ischemia following elbow trauma.
• Absence of palpable wrist pulses post-orthopedic fixation necessitates immediate brachial artery exploration.
• PPH is not solely a consequence of arterial spasm and may indicate a significant brachial artery injury requiring surgical intervention.