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Approach to supracondylar humerus fractures with neurovascular compromise in children
Murat Aksakal1, Cenk Ermutlu, Bartu Sarısözen
1Department of Orthopedics and Traumatology, Yüksek İhtisas Training and Research Hospital, Bursa, Turkey.
Insights
Avoid forcing closed reduction in Gartland Type 3 supracondylar humerus fractures (SHFs) with severe signs like edema or absent pulse. The anterior approach offers better neurovascular visualization and intervention options for these complex pediatric fractures.
Area of Science:
- Pediatric Orthopedics
- Pediatric Trauma Surgery
- Vascular Surgery
Background:
- Gartland Type 3 supracondylar humerus fractures (SHFs) in children can present with significant neurovascular compromise.
- Assessing and managing these injuries requires careful consideration of reduction techniques and potential complications.
Purpose of the Study:
- To evaluate neurovascular compromise in pediatric Gartland Type 3 SHFs.
- To identify factors predicting the need for open reduction.
- To compare clinical outcomes of anterior open reduction versus closed reduction.
Main Methods:
- A retrospective review of 65 pediatric patients surgically treated for SHFs between 2002 and 2008.
- Fractures were managed with closed reduction and percutaneous pinning; open reduction was used when closed methods failed or vascular compromise was present.
- Patient data, physical findings, reduction adequacy, and functional/cosmetic outcomes were assessed.
Main Results:
- Vascular pathology was observed in all patients with pre-operative vascular compromise signs, with half requiring intervention.
- Closed reduction failed in 93% of cases with significant edema, ecchymosis, and dimple sign.
- Median nerve entrapment occurred in 4 patients despite normal neurological exams; functional and cosmetic outcomes were similar between open and closed reduction groups.
Conclusions:
- Forcing closed reduction is contraindicated in SHFs with marked edema, ecchymosis, dimple sign, or absent radial pulse.
- The anterior surgical approach is preferred for its direct visualization of the neurovascular bundle and capacity for intraoperative intervention.
- This approach facilitates timely management of neurovascular issues during pediatric SHF treatment.
Objective:
The aim of this study was to evaluate neurovascular compromise in childhood Gartland Type 3 supracondylar humerus fractures (SHFs), identify the factors correlated with increased need of open reduction and compare the clinical outcome of anterior open reduction with that of closed reduction.
Methods:
The study included 65 patients (46 male, 19 female; mean age: 7.03 years, range: 1 to 14 years) treated surgically for SCH fracture between January 2002 and June 2008. Fractures underwent closed reduction with percutaneous pinning when possible. Open reduction was performed when adequate reduction via the closed technique failed or vascular compromise were indications for open reduction. Patient demographics, physical examination findings, adequacy of reduction, functional and cosmetic outcomes were assessed.
Results:
During the antecubital approach, vascular pathology was noted in all patients with signs of vascular compromise at physical examination. Half of these patients underwent vascular intervention. Closed reduction failed in 93% of patients with concomitant edema, ecchymosis and dimple sign. Of these, the median nerve was trapped between the bone fragments in 4 patients with normal neurological examinations. Functional and cosmetic results of open reduction were similar to closed reduction (p>0.05).
Conclusion:
Closed reduction should not be forced in cases with marked edema, ecchymosis, dimple sign, and absence of radial pulse. The anterior approach is the surgical approach of choice due to direct visualization of neurovascular bundle and availability of neurovascular intervention by extending the same approach.
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