- Email: [email protected]
Diagnosis of vascular injury in children with supracondylar fractures of the humerus
Injury (1988) 19,11-13
Printedin
11
Great Britain
Diagnosis of vascular injury in children with supracondylar fractures of the humerus Lars R. Vasli Surgical
Department,
Akershus
Central Hospital,
University
Summary Four children with suspected vascular injury after supracondylar fractures of the humerus are presented. A noninvasive technique has been used in the diagnosis of vascular injury. A simple non-invasive method using the Doppler equipment connected to a spectrum analyser may exclude the need for arteriography and surgical exploration.
INTRODUCTION arteries in the arm is potentially dangerous. Supracondylar fracture of the humerus is common in childhood and traumatic wounding of the brachial artery has been reported as high as 10 per cent (Banskota and Volz, 1984). The effect of acute arterial occlusion at the elbow varies from case to case, and may be serious. Therefore an aggressive diagnostic approach is suggested when vascular injury is suspected. Arteriography or surgical exploration has been recommended to confirm vascular injury. In the present report four cases are presented to illustrate the usefulness of a non-invasive technique in the diagnosis of a traumatic vascular lesion. We have used the Doppler waveform on the spectral analyser to recognize vascular injury. The normal waveform has three components to the velocity. The first and most important is INJURY of the main
Fig. 1. Waveform from right radial artery (uninjured side. See text. 0
I9XXButterworth & Co
~n~2~~l~x3/xx/oloo1
l-03
(Publishers) $0340
Ltd
of Oslo, Norway
a high forward flow during systole, and usually there are two diastolic components. Both arms are recorded for comparison. PATIENTS AND METHODS Nineteen children with a supracondylar fracture of the humerus were admitted in 198.5. Four children with suspected vascular injury were examined in the noninvasive vascular laboratory. The Doppler waveform was recorded at the radial artery in both arms. The waveform was obtained by means of an 8MHz bidirectional probe positioned 45-60” to the skin surface and connected to a spectral analyser. Normal waveforms, Case 3, are illustrated in Fig. 1; the waveform from the left injured arm has a high forward flow during systole and two components during diastole. On the right uninjured arm the waveform is slightly higher in the first systolic component probably due to more vasoconstriction on this side, but the difference between the two sides is not significant. An abnormal waveform, Case 2, is illustrated in Fig. 2; there is a marked difference in waveform on the right uninjured side and the left injured side. On the left injured side the arterial velocity signal has lost all its normal components.
side), and left radial artery (injured side). Normal waveform on injured
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 1
Fig. 2. Waveform from right radial artery (uninjured injured left side. See text.
side), and left radial artery (injured side). Pathological waveform on
CASE REPORTS Case 1
A lo-year-old boy fell from a rope and sustained an open displaced supracondylar fracture of the humerus. The radial pulse was not palpable. However, with a portable Doppler ultrasound machine pulse signals were found over the radial artery; temperature and sensibility in the hand were normal. The fracture was reduced and stabilized by percutaneous pinning. The circulation was satisfactory postoperatively though the radial pulse was difficult to palpate. The next day the patient was referred to the non-invasive vascular laboratory. The velocity waveform recorded at the radial artery on the injured arm was pathological (Fig. 2). Emergency arteriography confirmed a blockage of the brachial artery. At operation a ruptured arterial intima and thrombosis was found. The intima was sutured and the artery was closed with a venous patch. At follow-up 8 months after the accident the patient had recovered fully with normal function of the arm. Case 2 A i-/-year-old boy fell from a tree and sustained a displaced supracondylar fracture of the humerus. The radial pulse was present. The fracture was reduced and stabilized with percutaneous pinning. The next day the radial pulse was difficult to palpate and the patient was referred to the non-invasive vascular laboratory. The velocity waveform noted on the spectral analyser connected to the Doppler apparatus was pathological. Emergency arteriography confirmed an injury of the brachial artery. At operation the artery was found to be contused and its lumen occluded. The arterial wall was repaired with a venous patch. The postoperative period was uncomplicated and the patient recovered with normal circulation at follow-up after 7 weeks. Case 3 An ll-year-old boy fell from a swing and sustained a supracondylar fracture of the left humerus. The radial pulse was difficult to palpate. The fracture was treated with overhead skeletal traction via an olecranon screw, because other attempts to reduce it were unsuccessful. At the non-invasive vascular laboratory the velocity waveform of the radial artery was analysed and was found to be normal (Fig. 1). Therefore
arteriography was not performed and recovery was uncomplicated with normal circulation at follow-up after 10 weeks. Case 4 An 8-year-old boy fell from his bicycle and sustained a supracondylar fracture of the right humerus. The radial pulse was difficult to palpate but after the fracture was treated with overhead olecranon traction the radial pulse was satisfactory. The next morning the radial pulse was hardly palpable. The velocity waveform in the radial artery was normal and arteriography was not performed. The patient recovered without complications and at follow-up after 7 weeks the fracture had healed and the circulation in the arm was clinically normal.
DISCUSSION Vascular injury is one of the most serious complications of a supracondylar fracture of the humerus in children.
Acceptable function of the arm is achieved in patients even with severe displacement and poor reduction as long as the nerves and blood vessels are not injured (Walbe et al., 1985). When clinical findings suggest a vascular injury arteriography and/or surgical exploration are recommended (Banskota and Volz, 1984). Evaluation of arterial injury may be difficult from clinical signs only. In three patients reported to have suspected lesions of the brachial artery only one had an arterial injury verified peroperatively (Walloe et al., 1985). Arteriography is an invasive procedure with a complication risk of about 24 percent (Hessel et al., 1981). Furthermore, in children angiography has to be performed under general anaesthesia. With this background a simple non-invasive procedure to evaluate the peripheral pulse in these patients is most welcome. Doppler waveform analysis is a sensitive method for evaluation of patients with peripheral arterial disease (Banskota and Volz, 1984). The Doppler velocity signal by itself is no reliable indicator of normal circulation. Doppler equipment connected to the spectrum analyser produces an objective picture of the velocity waveform which can be compared with the contralateral normal side and easily interpreted as normal or
Vasli: Diagnosis of vascular injury
abnormal. evaluates
in children
This simple non-invasive investigation easily the arterial circulation in a few minutes. This
should eliminate arteriography
or at least normal arterio-
grams or explorations on normal brachial arteries. Non-invasive investigation may exclude candidates for arteriography and unnecessary surgical exploration of the brachial artery in children with a supracondylar fracture of the humerus.
13 Hessel S. J., Adams D. F. and Abrahams H. L. (1981) Complications of angiography. Radiology 138, 273. Walloe A., Egund N. and Eikelund L. (1985) Supracondylar fracture of the humerus in children: review of closed and open reduction to a proposal for treatment. Injury 16, 296. Paper accepted 15 June 1987.
REFERENCES Banskota A. and Volz R. G. (1984) Traumatic laceration of the radial nerve following supracondylar fracture of the elbow. Clin. Orthop. 184, 150.
Reyuesfsfor
reprintsshould
Nordbyhagen, Norway.
be addressed to: Lars R. Vasli MD, Surgical Department,
Akershus Central Hospital, University of Oslo, N-1474
Printedin
11
Great Britain
Diagnosis of vascular injury in children with supracondylar fractures of the humerus Lars R. Vasli Surgical
Department,
Akershus
Central Hospital,
University
Summary Four children with suspected vascular injury after supracondylar fractures of the humerus are presented. A noninvasive technique has been used in the diagnosis of vascular injury. A simple non-invasive method using the Doppler equipment connected to a spectrum analyser may exclude the need for arteriography and surgical exploration.
INTRODUCTION arteries in the arm is potentially dangerous. Supracondylar fracture of the humerus is common in childhood and traumatic wounding of the brachial artery has been reported as high as 10 per cent (Banskota and Volz, 1984). The effect of acute arterial occlusion at the elbow varies from case to case, and may be serious. Therefore an aggressive diagnostic approach is suggested when vascular injury is suspected. Arteriography or surgical exploration has been recommended to confirm vascular injury. In the present report four cases are presented to illustrate the usefulness of a non-invasive technique in the diagnosis of a traumatic vascular lesion. We have used the Doppler waveform on the spectral analyser to recognize vascular injury. The normal waveform has three components to the velocity. The first and most important is INJURY of the main
Fig. 1. Waveform from right radial artery (uninjured side. See text. 0
I9XXButterworth & Co
~n~2~~l~x3/xx/oloo1
l-03
(Publishers) $0340
Ltd
of Oslo, Norway
a high forward flow during systole, and usually there are two diastolic components. Both arms are recorded for comparison. PATIENTS AND METHODS Nineteen children with a supracondylar fracture of the humerus were admitted in 198.5. Four children with suspected vascular injury were examined in the noninvasive vascular laboratory. The Doppler waveform was recorded at the radial artery in both arms. The waveform was obtained by means of an 8MHz bidirectional probe positioned 45-60” to the skin surface and connected to a spectral analyser. Normal waveforms, Case 3, are illustrated in Fig. 1; the waveform from the left injured arm has a high forward flow during systole and two components during diastole. On the right uninjured arm the waveform is slightly higher in the first systolic component probably due to more vasoconstriction on this side, but the difference between the two sides is not significant. An abnormal waveform, Case 2, is illustrated in Fig. 2; there is a marked difference in waveform on the right uninjured side and the left injured side. On the left injured side the arterial velocity signal has lost all its normal components.
side), and left radial artery (injured side). Normal waveform on injured
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 1
Fig. 2. Waveform from right radial artery (uninjured injured left side. See text.
side), and left radial artery (injured side). Pathological waveform on
CASE REPORTS Case 1
A lo-year-old boy fell from a rope and sustained an open displaced supracondylar fracture of the humerus. The radial pulse was not palpable. However, with a portable Doppler ultrasound machine pulse signals were found over the radial artery; temperature and sensibility in the hand were normal. The fracture was reduced and stabilized by percutaneous pinning. The circulation was satisfactory postoperatively though the radial pulse was difficult to palpate. The next day the patient was referred to the non-invasive vascular laboratory. The velocity waveform recorded at the radial artery on the injured arm was pathological (Fig. 2). Emergency arteriography confirmed a blockage of the brachial artery. At operation a ruptured arterial intima and thrombosis was found. The intima was sutured and the artery was closed with a venous patch. At follow-up 8 months after the accident the patient had recovered fully with normal function of the arm. Case 2 A i-/-year-old boy fell from a tree and sustained a displaced supracondylar fracture of the humerus. The radial pulse was present. The fracture was reduced and stabilized with percutaneous pinning. The next day the radial pulse was difficult to palpate and the patient was referred to the non-invasive vascular laboratory. The velocity waveform noted on the spectral analyser connected to the Doppler apparatus was pathological. Emergency arteriography confirmed an injury of the brachial artery. At operation the artery was found to be contused and its lumen occluded. The arterial wall was repaired with a venous patch. The postoperative period was uncomplicated and the patient recovered with normal circulation at follow-up after 7 weeks. Case 3 An ll-year-old boy fell from a swing and sustained a supracondylar fracture of the left humerus. The radial pulse was difficult to palpate. The fracture was treated with overhead skeletal traction via an olecranon screw, because other attempts to reduce it were unsuccessful. At the non-invasive vascular laboratory the velocity waveform of the radial artery was analysed and was found to be normal (Fig. 1). Therefore
arteriography was not performed and recovery was uncomplicated with normal circulation at follow-up after 10 weeks. Case 4 An 8-year-old boy fell from his bicycle and sustained a supracondylar fracture of the right humerus. The radial pulse was difficult to palpate but after the fracture was treated with overhead olecranon traction the radial pulse was satisfactory. The next morning the radial pulse was hardly palpable. The velocity waveform in the radial artery was normal and arteriography was not performed. The patient recovered without complications and at follow-up after 7 weeks the fracture had healed and the circulation in the arm was clinically normal.
DISCUSSION Vascular injury is one of the most serious complications of a supracondylar fracture of the humerus in children.
Acceptable function of the arm is achieved in patients even with severe displacement and poor reduction as long as the nerves and blood vessels are not injured (Walbe et al., 1985). When clinical findings suggest a vascular injury arteriography and/or surgical exploration are recommended (Banskota and Volz, 1984). Evaluation of arterial injury may be difficult from clinical signs only. In three patients reported to have suspected lesions of the brachial artery only one had an arterial injury verified peroperatively (Walloe et al., 1985). Arteriography is an invasive procedure with a complication risk of about 24 percent (Hessel et al., 1981). Furthermore, in children angiography has to be performed under general anaesthesia. With this background a simple non-invasive procedure to evaluate the peripheral pulse in these patients is most welcome. Doppler waveform analysis is a sensitive method for evaluation of patients with peripheral arterial disease (Banskota and Volz, 1984). The Doppler velocity signal by itself is no reliable indicator of normal circulation. Doppler equipment connected to the spectrum analyser produces an objective picture of the velocity waveform which can be compared with the contralateral normal side and easily interpreted as normal or
Vasli: Diagnosis of vascular injury
abnormal. evaluates
in children
This simple non-invasive investigation easily the arterial circulation in a few minutes. This
should eliminate arteriography
or at least normal arterio-
grams or explorations on normal brachial arteries. Non-invasive investigation may exclude candidates for arteriography and unnecessary surgical exploration of the brachial artery in children with a supracondylar fracture of the humerus.
13 Hessel S. J., Adams D. F. and Abrahams H. L. (1981) Complications of angiography. Radiology 138, 273. Walloe A., Egund N. and Eikelund L. (1985) Supracondylar fracture of the humerus in children: review of closed and open reduction to a proposal for treatment. Injury 16, 296. Paper accepted 15 June 1987.
REFERENCES Banskota A. and Volz R. G. (1984) Traumatic laceration of the radial nerve following supracondylar fracture of the elbow. Clin. Orthop. 184, 150.
Reyuesfsfor
reprintsshould
Nordbyhagen, Norway.
be addressed to: Lars R. Vasli MD, Surgical Department,
Akershus Central Hospital, University of Oslo, N-1474