Postoperative brachial artery entrapment associated with pediatric supracondylar fracture of the humerus: a case report
© The Author(s). 2017
Received: 10 October 2016
Accepted: 8 February 2017
Published: 14 March 2017
Severely displaced supracondylar fractures of the humerus in children are frequently associated with complications including neurovascular injuries, non-union, or compartment syndrome. In the current literature, no report exists about postoperative brachial artery entrapment in combination with an inconspicuous preoperative neurovascular examination.
We present a case of a 6-year-old white boy with a pulseless radial and ulnar artery after open reduction and internal fixation of a severely displaced supracondylar fracture of his right humerus (Gartland type III) using four K-wires. Remarkably, the preoperative neurovascular examination was inconspicuous. Doppler ultrasound of his brachial artery revealed no pulse when his elbow was in flexion and a faint pulse when it was in full extension 10 hours postoperatively. Revision surgery was performed immediately. On intraoperative examination, a kinking of his brachial artery caused by an entrapment of the tunica externa in the reduced fracture was seen and the artery was released by microsurgical arteriolysis immediately. At the final follow-up examination, positive palpable pulse with good capillary filling and, according to Flynn’s criteria, an excellent recovery of elbow function was observed 3 months postoperatively.
This case demonstrates a rare complication of postoperative artery entrapment with inconspicuous preoperative neurovascular examination. It strongly emphasizes the need for a standardized postoperative neurovascular assessment with fully flexed as well as fully extended elbow.
KeywordsCase report Pediatric supracondylar fracture of the humerus Gartland type III Neurovascular complications Entrapment of the brachial artery Open K-wire fixation
Supracondylar fractures of the humerus are common elbow fractures in children [1–4]. Gartland’s classification based on the degree of displacement of the distal fragment is used frequently . Fractures with complete displacement of the distal fragment (Gartland type III) are frequently associated with various complications such as neurovascular injuries, non-union, or compartment syndrome that can lead to a Volkmann’s contracture or even amputation of the affected limb [3, 5–8]. Preoperative neurovascular assessment scores (for example, Liverpool Upper-limb Fracture Assessment) have already been proposed to optimize evaluation of children presenting with upper limb injuries in Accident and emergency (A&E) departments . The following case presents a rare vascular complication despite an inconspicuous preoperative neurovascular examination and emphasizes the importance of a thorough postoperative neurovascular assessment.
Gartland type III fractures are highly correlated with primary neurovascular lesions [11–14]. Posteromedial displacement is associated with radial nerve injuries, whereas posterolateral displacement is associated with median nerve injuries. Brachial artery injuries occur in both types of displacement equally [15, 16]. Typical vascular injuries are intimal tear, thrombus formation, and division or spasm of the vessel [17, 18]. The initial therapy of pediatric supracondylar fractures with an absent radial pulse and a cold white hand is closed reduction and fixation with K-wires. If the initial attempt is unsuccessful in restoring the pulse, open reduction and vascular exploration is mandated . Management of children with absence of their radial pulse with a well-perfused hand is still controversial [19–21]. Remarkably, no difference between early surgical treatment (8 hours or less following injury) and delayed surgical treatment (more than 8 hours following injury), with regard to the perioperative complication rates, is reported . Due to serious primary neurovascular lesions and difficult physical examination in young patients, a standardized neurovascular assessment has already been proposed . In the current literature, only a few reports about delayed neurovascular complications exist [23–25]. In fact, an excellent clinical long-term outcome can be expected if postoperative circulatory failure is treated immediately . In general, artery entrapment syndromes, for example caused by a humeral bony spur, are usually clinically unapparent and symptoms only occur with specific movements, such as extension or flexion of the elbow [26, 27]. Arguably, a thorough postoperative neurovascular assessment with fully flexed as well as fully extended elbow can detect a postoperative artery entrapment.
This case demonstrates a rare complication of a postoperative brachial artery entrapment despite inconspicuous preoperative neurovascular examination. This strongly emphasizes the need for a standardized postoperative neurovascular assessment in a full range of elbow motion.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
DL, JG, SG, MD, ES, JW, and particularly PJ were major contributors concerning the management of the patient, review of the articles, and manuscript preparation. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Ethics approval and consent to participate
Not applicable. The patient was examined as part of regular consultation and hospitalization.
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