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Pulseless Supracondylar Humerus Fracture With Anterior Interosseous Nerve or Median Nerve Injury—An Absolute Indication for Open Reduction?

Harris, Liam R., MD*; Arkader, Alexandre, MD; Broom, Alexander, BS*; Flynn, John, MD; Yellin, Joseph, MD; Whitlock, Patrick, MD, PhD; Miller, Ashley, MD; Sawyer, Jeffrey, MD§; Roaten, John, MD§; Skaggs, David L., MD, MMM*; Choi, Paul D., MD*

Journal of Pediatric Orthopaedics: January 2019 - Volume 39 - Issue 1 - p e1–e7
doi: 10.1097/BPO.0000000000001238
Trauma Upper Extremity
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Background: Optimal management for a pulseless supracondylar humerus fracture associated with anterior interosseous nerve (AIN) or median nerve injury is unclear. The purpose of this study was to determine the incidence of pulseless supracondylar humerus fractures associated with AIN or median nerve injury, to assess open versus closed surgical management, to determine factors associated with the need for neurovascular intervention, and to report the outcome.

Methods: A retrospective review was performed at 4 pediatric trauma hospitals on all patients who sustained a Gartland III or IV supracondylar humerus fracture with the combination of absent distal palpable pulses and AIN or median nerve injury between 2000 and 2014. Choice of treatment, details regarding preoperative and postoperative exam findings, follow-up course, and outcome were recorded.

Results: A total of 71 patients met inclusion criteria; 52 patients (73%) underwent closed reduction (CR); 19 patients (27%) underwent open reduction (OR) and early antecubital fossa exploration. The index procedure of CR plus percutaneous pinning was sufficient treatment in 50 (of 52, 96%) patients with only 2 requiring reoperation. One patient developed compartment syndrome approximately 9 hours after CRPP (13.5 h after time of injury) and underwent emergent fasciotomies. Of the 19 patients who underwent OR and early exploration, 6 needed vascular procedures, 5 required detethering of entrapped surrounding fibrous tissues. Forty patients were diagnosed with median nerve palsy versus 31 diagnosed with AIN palsy. There was no significant difference between patients presenting with median nerve versus AIN palsy, with similar rates of need for OR (10/40; 25% vs. 9/31; 29%), rate of compartment syndrome (3/40; 7.5% vs. 3/31; 9.7%), need for reoperation (4/40; 10% vs. 6.5%), and ultimate resolution of nerve palsy (4/36; 20.1% vs. 3/30; 10%). Compartment syndrome developed in 6 (of 71, 8.5%) patients and was associated with poor perfusion status on presentation and delayed time from injury to surgery. In patients with at least 3-month neurological follow-up, 59 (of 61, 97%) patients had complete resolution of nerve palsy.

Conclusions: Although previous authors have suggested a pulseless SCH fx with an associated AIN or median nerve injury should be treated with exploration and OR, 70% (50/71) of the patients in this series were treated with a CR. In this series, both AIN and median nerve palsies among patients presenting with pulseless extremity and Gartland III or IV SCH fracture, offer similar rates of OR, risk of compartment syndrome, and resolution of nerve palsy.

Level of Evidence: Level IV.

*Children’s Hospital Los Angeles, Los Angeles, CA

Children’s Hospital of Philadelphia, Philadelphia, PA

Cincinnati Children’s Hospital, Cincinnati, OH

§Campbell Clinic Orthopaedics, Memphis, TN

Funding source: No external funding was secured for this study.

Approved by the Institutional Review Board at Children’s Hospital Los Angeles.

The authors declare no conflicts of interest.

Reprints: David L. Skaggs, MD, MMM, Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Boulevard Mailstop #69, Los Angeles, CA 90027. E-mail: dskaggs@chla.usc.edu.

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