- Email: [email protected]
Long-term Follow-up of Vascular Reconstructions after Supracondylar Humerus Fracture with Vascular Lesion in Childhood
Eur J Vasc Endovasc Surg (2011) 42, 684e688
Long-term Follow-up of Vascular Reconstructions after Supracondylar Humerus Fracture with Vascular Lesion in Childhood* P. Konstantiniuk a,*, G. Fritz b, T. Ott c, U. Weiglhofer d, S. Schweiger a, T. Cohnert a a
University Hospital Graz, Department of Vascular Surgery, Auenbruggerplatz 29, 8010 Graz, Austria University Hospital Graz, Department of Radiology, Graz, Austria c General Hospital Leoben, Department of General Surgery, Leoben, Austria d University Hospital Graz, Department of General Surgery, Graz, Austria b
Submitted 10 January 2011; accepted 15 June 2011 Available online 4 August 2011
KEYWORDS Long term follow-up; Supracondylar humerus fracture; Childhood; Vascular reconstruction
Abstract Introduction: Supracondylar humerus fractures in childhood present with a pulseless but well-perfused hand in 2.6% of cases and with limb-threatening ischaemia in <1%. Conservative treatment is widely used in non-limb-threatening ischaemia, in particular if the child is very young (<2.5 years). It has been sufficiently proven that conservative treatment may retard growth. The aim of our study was to determine long-term patency rates after surgical reconstruction and growth impairment, if any, after surgical vascular reconstruction. Patients and methods: Between June 1990 and June 2004, 12 children (mean age 6.6 years, eight boys and four girls) with supracondylar fracture with vascular lesions underwent surgical reconstruction at the Department of Vascular Surgery at the University Hospital, Graz. Patient files were reviewed retrospectively. All patients were recalled for physical (forearm length and volume) and ultrasonographic examinations (forearm blood flow) in 2005 and for ultrasonographic examinations (reconstructed vascular area) in 2011, with a final mean follow-up time of 14.0 years (range 6.8e20.9 years). Results: Twelve patients, 10 of whom had undergone growth measurements in 2005, were available for the latter examination. All were doing well, with patent vascular reconstructions. Seven reconstructed brachial arteries were enlarged, two of which with intramural calcifications, four did not show abnormalities and one presented with 45% thinning. There were no differences between affected and healthy forearms concerning volume, length and blood flow.
* Previous publication: Some oral presentations in Austria (held in German) for the Austrian Society of Surgery and Austrian Society of Vascular Surgery. * Corresponding author. Peter Konstantiniuk, University Hospital Graz, Department of Vascular Surgery, Auenbruggerplatz 29, 8010 Graz, Austria. Tel.: þ43 316 385 81911; fax: þ43 316 385 14656. E-mail address: [email protected] (P. Konstantiniuk).
1078-5884/$36 ª 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvs.2011.06.028
Long-term Follow-up of Vascular Reconstructions in Childhood
685
Conclusions: Our data emphasise that surgical reconstruction is effective in terms of blood supply and growth. In cases with interposition of greater saphenous vein or venous patch plasty, we found a high risk for development of enlargements. We suggest that these patients be followed periodically, with ultrasound studies, to detect aneurysms and/or thrombotic changes as early as possible. ª 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Introduction About 75% of all paediatric fractures involve the upper extremity.1 Fractures near the elbow represent 8% of upper-extremity injuries (or 6% of all fractures), and supracondylar humerus fractures are the most common in this region. About 2.6% of these children present with a pulseless but well-perfused hand.2 Limb-threatening ischaemia is present in <1% of these traumas. Conservative treatment is widely used in non-limbthreatening ischaemia, particularly if the child is very young (2.5 years).3 It has been sufficiently proven that conservative treatment of a vascular trauma may retard growth, as a result of reduced blood supply to the epiphyseal region and reduced muscular blood flow. This may as well be a sequel of the fracture itself with disturbances of the epiphyseal cartilage, but this is still poorly understood. To lessen this gap, we undertook a long-term follow-up study after surgical arterial intervention. We investigated the patency rate and the morphology of the operated area and e expecting side differences in growth e forearm length and volume as well as blood flow.
The flow values for the radial and ulnar arteries were summarised as forearm blood flow. In 2011, all patients underwent B-mode and duplex ultrasonography of the reconstructed brachial artery with diameter measurements.
Physical examination The length of both forearms was measured from the tip of the olecranon to the tip of the ulnar styloid process. Forearm volumetry was performed by measuring the circumference 5 cm distal to the elbow joint, at midforearm and 5 cm proximal to the wrist and computing the volume of the two frustums (a frustum is the portion of a cone bordered by two parallel planes).
Statistics All calculations were performed with Statistical Package for Social Sciences (SPSS) 15.0. Values of the injured and healthy sides were compared with a paired samples’ t-test. P-values below 0.05 were considered significant, while those between 0.05 and 0.1 indicated a trend.
Patients and Methods Results Patients Between June 1990 and June 2004, 12 children with supracondylar fracture with vascular lesions were treated surgically at the Department of Vascular Surgery at the University Hospital in Graz. Patient files were reviewed retrospectively. In 2005, all patients were recalled for physical and ultrasonographic examinations. Ten children provided informed consent and were examined as planned. There was a second recall in 2011; all the children took part and had ultrasonographic measurements.
Ultrasound In 2005, all patients underwent B-mode and duplex ultrasonography of the bilateral brachial arteries to determine the continuity of blood flow and the diameter of the brachial artery. If the cross-sectional surface of the reconstructed artery was increased by at least 50% compared with the artery proximal to the reconstruction, it was called enlarged. If the enlargement was concentric without definable beginning or end, it was classified as ectasia; sharply defined eccentric dilatation was classified as focal aneurysm. Blood flow in the radial and ulnar arteries at mid-forearm was measured with the Siemens Elegra Sonoline ultrasound device (serial number 7451).
Trauma and primary surgery Twelve children with a mean age of 6.6 (3.1e9.7) years, eight boys and four girls, suffered a supracondylar fracture of the humerus with obvious or suspected vascular lesion (Table 1). In seven cases, the left humerus was affected and, in five cases, the right one. In four cases, the dominant side was injured, in eight cases the non-dominant. There were three open and nine closed fractures. In four cases, there was a functional neural lesion that disappeared after some weeks. Five children had an intimal lesion, three a complete rupture of the brachial artery and two an entrapment; one child showed an entrapment in combination with open injury of the brachial artery (caused by wire or bone fragment) and one child presented with a spastic brachial artery without lesion. Primary preoperative diagnostic consisted of angiography in five cases and computed tomography with vascular reconstruction in one case; in six cases, there was no preoperative vascular diagnostic work-up. Primary orthopaedic treatment consisted of closed reduction in eight cases and open reduction in four cases. The primary vascular surgical technique was interposition of the greater saphenous vein in six children, transverse arteriotomy, exploration and direct closure in three cases and venous patch plasty in three cases. Two children needed re-operation: one child underwent interposition of the greater saphenous vein, while
Clinical data of the injured children. Dominant Injured Follow-up Type of Neural side side time (years) humerus injury fracture
#1
5.16 m
6/7/1990
r
l
20.89
open
e
#2
8.22 m
5/1/1991
r
r
19.93
closed
#3
9.68 f
8/19/1995 r
l
15.69
closed
#4
3.09 f
10/26/1995 r
l
15.47
closed
#5
5.64 m
4/14/1996 r
l
14.99
closed
#6
8.98 m
7/5/1996
r
r
14.85
closed
#7
5.77 m
10/8/1997 r
l
13.50
closed
#8
8.53 f
3/18/1998 l
r
13.11
closed
#9
3.27 f
10/26/1999 r
r
11.44
open
5/16/2000 r
r
10.92
open
ulnar nerve (functional & reversible) e intimal lesion 1) angiography closed reposition 1) transverse arteriotomy, 2) sonography and wire fixation exploration and direct closure 2) interposition of GSV (thigh)a e entrapment angiography closed reposition mobilisation, and wire fixation transverse arteriotomy, exploration and direct closure ulnar nerve entrapment angiography closed reposition mobilisation, (functional & and wire fixation venous patch reversible) plasty of two strictures with GSV patches (lower leg) e spasm e open reposition transverse arteriotomy, and wire fixation exploration and direct closure e entrapment, e closed reposition Interposition of open and wire fixation GSV (thigh)b injury - removal - closed reposition and wire fixation e complete e open reposition Interposition of rupture and wire fixation GSV (thigh) e intimal lesion e closed reposition Interposition of and wire fixation GSV (lower leg) ulnar and complete 1) e open reposition 1) interposition median nerve rupture 2) sonography and wire fixation of GSV (lower leg) (functional & 3) angiography 2) removal of interposition reversible) 3) interposition of GSV (thigh)c
#10 7.04 m
Vascular trauma
Vascular diagnostics
complete e rupture intimal lesion angiography
Type of osteosynthesis
Vascular technique
Follow-up status
open reposition and wire fixation closed reposition and wire fixation
interposition of GSV (thigh) interposition of GSV (lower leg)
ectatic ectatic with intramural calcifications ectatic with intramural calcifications
NAD
aneurysmatic
45% thinning
ectatic
NAD ectatic ectatic
P. Konstantiniuk et al.
Case Age Sex Date of surgery
686
Table 1
7/22/2000 r
l
10.73
closed
e
#12 5.83 m
6/4/2004
l
6.84
closed
ulnar nerve intimal (functional & lesion reversible)
r
intimal lesion
angiography
computed tomography with vascular reconstruction
closed reposition resection of 8 mm, and wire fixation end to end anastomosis & venous patch plasty (GSV lower leg) closed reposition patch plasty with and wire fixation accompanying vein
NAD
NAD
GSV: Greater saphenous vein; NAD: no abnormality detected. a On the day of the trauma angiography was unremarkable, but the next day, an intimal lesion was found. The artery was exposed, cross-opened, examined with a Fogarty catheter and closed directly. Two days later, there was no radial pulse and sonography revealed thrombosis of the brachial artery. Ultimately, a GSV interposition was performed. b Primarily the fracture was repositioned and wire fixed. Then the artery was exposed. It was entraped in the fracture gap so the wires had to be removed. The artery showed a small injury (wire? bone fragment?). An interposition with GSV was performed. c Primarily the heavily contaminated bone fragments were cleaned. The artery was completely ruptured so an interposition with GSV from lower leg was performed. On day 15 the boy presented with bleeding out of the cast. Sonography showed a false aneurysm of the proximal anastomosis. The interposition was removed and the brachial artery ligated, leaving the forearm with sufficient blood supply. The infected tissue was treated locally by antiseptics and systemically with antibiotics. On day 28 a new interposition was performed with GSV from the thigh. The operation and postoperative course were uneventful.
Long-term Follow-up of Vascular Reconstructions in Childhood
#11 8.28 m
687
Figure 1 Ectatic venous interposition at follow-up (ultrasonographic finding with intramural calcifications).
Figure 2 Aneurysmatic venous patch plasty at follow-up (ultrasonographic finding).
p
the other one suffered an infection of the anastomosis of the venous graft. The graft was removed and a second interposition of greater saphenous vein was performed 13 days later.
Opposite side
0.95 0.59 0.343
Follow-up results
Affected side
865.7 25.50 0.0695
After a mean follow-up time of 14.0 years (range 6.8e20.9 years), all patients were doing well and their reconstructions were patent. Six reconstructed brachial arteries were ectatic : the largest two presented with intramural calcifications (Fig. 1), one presented with a focal aneurysm (Fig. 2), four did not show abnormalities and one displayed 45% thinning. There were no differences between affected and healthy forearms concerning volume, length and blood flow (Table 2).
Mean values
866.5 25.55 0.0627
Table 2 Comparison of follow-up measurements between healthy and injured side.
Volume (ml) Length (cm) Blood flow (l/min)
688
P. Konstantiniuk et al.
Discussion and Conclusions
Conflict of Interest/Funding
Our data emphasise that surgical reconstruction is effective in terms of blood supply and growth and provides excellent longterm patency rates. Delay in vascular exploration might cause a compartment syndrome. If not treated in time, muscular necrosis will then require debridements and partial-thickness skin grafting of the forearm, possibly accompanied by nerve palsies.4 With further delay or if the compartment syndrome is left untreated, there will be fibrosis of the forearm musculature, called Volkmann’s ischaemic contracture,5 or the worstcase scenario of amputation due to gangrene.6, 7 It is well known that conservative treatment may be preferable, particularly if the child is very young.2 There were some conservatively treated children within the observation period, but we are not able to provide data on them. Omitting vascular reconstruction might lead to limb shortening and, in rare cases, claudication upon effort. Although most reports concern vascular injury after arterial catheterisation of the leg in the first year of life,8e13 there seems to be no doubt that there can be late sequelae in cases of supracondylar fracture with arterial injury. White and colleagues14 reviewed 331 cases of pulseless supracondylar fractures. Of the fractures that stayed pulseless in spite of adequate reduction, 82% were found to have a brachial artery injury. Facing excellent surgical long-term results, we are in line with the authors suggesting a more aggressive vascular evaluation and vascular exploration. There is one case (compare #6 in Table 1) with a very small artery in the cubital region (45% cross-sectional surface compared with the brachial artery at mid-upper arm). We assume this to be a result of overexpansion at the point of the primary trauma. The artery was crossopened, explored and directly sutured. Further follow-up will show if a more aggressive surgical treatment (e.g., patch plasty) would have been the better approach. In cases of greater saphenous vein interposition or venous patch plasty, we found a high risk for the development of ectatic lesions (7/10). Over time, these ectatic lesions, like other aneurysms, may cause problems, such as partial thrombosis, and a tendency to embolise. The appearance of intramural calcifications in two cases is a strong indication of an overstrained wall. There is one case report of a 3-year-old boy with transient ischaemic symptoms secondary to thrombo-embolism from a brachial artery aneurysm (but not associated with trauma).15 We suggest periodic follow-up including ultrasonography for timely detection of aneurysms and/or thrombotic changes.
None.
References 1 Klimkiewicz JJ, Bradley JP, Sawyer JR. Pediatric elbow fractures and dislocations. In: DeLee D, editor. Orthopaedic sports medicine. Principles and practice. 2nd ed., Vol. 1. Philadelphia: Saunders; 2003. 2 Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010;30(1):50e6. 3 Lazarides MK, Georgiadis GS, Papas TT, Gardikis S, Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J Vasc Surg 2006;43:72e6. 4 Ramachandran M, Skaggs DL, Crawford HA, Eastwood DM, Lalonde FD, Vitale MG, et al. Delaying treatment of supracondylar fractures in children. J Bone Joint Surg 2008;90-B(9): 1228e33. 5 Mubarak SJ, Carroll NC. Volkmann’s contracture in children, aetiology and prevention. J Bone Joint Surg 1979;61B:285e93. 6 Shaker IJ, White JJ, Signer RD, Golladay ES, Haller JA. Special problems of vascular injuries in children. J Trauma 1976;16: 863e7. 7 Ottolenghi CE. Acute ischemic syndrome: it’s treatment; prophylaxis of Volkmann’s syndrome. Am J Orth 1960;2:312e6. 8 Guy RL, Holland JP, Shaw DG, Fixsen JA. Limb shortening secondary to complications of vascular cannulae in the neonatal period. Skeletal Radiol 1990;19:423e5. 9 Currarion G, Engle MA. The effects of ligation of the subclavian artery on the bones and soft tissues of the arms. J Pediatr 1975; 67:808. 10 Smith C, Green RM. Pediatric vascular injuries. Surgery 1981; 90(1):20e31. 11 Mortensson W. Angiography of the femoral artery following percutaneous catheterization in infants and children. Acta Radiol Diagn 1976;17:581e93. 12 Bassett III FH, Lincoln CR, King TD, Canent RV. Inequality in the size of the lower extremity following cardiac catheterization. South Med J 1968;61:1013e7. 13 Jacobsson B, Carlgren LE, Hedvall G, Sivertsson R. A review of children after arterial catheterisation of the leg. Pediatr Radiol 1973;1:96e9. 14 White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop 2010;30(4):328e35. 15 Fann JI, Wyatt J, Frazier RL, Cahill JL. Symptomatic brachial artery aneurysm in a child. J Pediatr Surg 1994;29(12):1521e3.
Long-term Follow-up of Vascular Reconstructions after Supracondylar Humerus Fracture with Vascular Lesion in Childhood* P. Konstantiniuk a,*, G. Fritz b, T. Ott c, U. Weiglhofer d, S. Schweiger a, T. Cohnert a a
University Hospital Graz, Department of Vascular Surgery, Auenbruggerplatz 29, 8010 Graz, Austria University Hospital Graz, Department of Radiology, Graz, Austria c General Hospital Leoben, Department of General Surgery, Leoben, Austria d University Hospital Graz, Department of General Surgery, Graz, Austria b
Submitted 10 January 2011; accepted 15 June 2011 Available online 4 August 2011
KEYWORDS Long term follow-up; Supracondylar humerus fracture; Childhood; Vascular reconstruction
Abstract Introduction: Supracondylar humerus fractures in childhood present with a pulseless but well-perfused hand in 2.6% of cases and with limb-threatening ischaemia in <1%. Conservative treatment is widely used in non-limb-threatening ischaemia, in particular if the child is very young (<2.5 years). It has been sufficiently proven that conservative treatment may retard growth. The aim of our study was to determine long-term patency rates after surgical reconstruction and growth impairment, if any, after surgical vascular reconstruction. Patients and methods: Between June 1990 and June 2004, 12 children (mean age 6.6 years, eight boys and four girls) with supracondylar fracture with vascular lesions underwent surgical reconstruction at the Department of Vascular Surgery at the University Hospital, Graz. Patient files were reviewed retrospectively. All patients were recalled for physical (forearm length and volume) and ultrasonographic examinations (forearm blood flow) in 2005 and for ultrasonographic examinations (reconstructed vascular area) in 2011, with a final mean follow-up time of 14.0 years (range 6.8e20.9 years). Results: Twelve patients, 10 of whom had undergone growth measurements in 2005, were available for the latter examination. All were doing well, with patent vascular reconstructions. Seven reconstructed brachial arteries were enlarged, two of which with intramural calcifications, four did not show abnormalities and one presented with 45% thinning. There were no differences between affected and healthy forearms concerning volume, length and blood flow.
* Previous publication: Some oral presentations in Austria (held in German) for the Austrian Society of Surgery and Austrian Society of Vascular Surgery. * Corresponding author. Peter Konstantiniuk, University Hospital Graz, Department of Vascular Surgery, Auenbruggerplatz 29, 8010 Graz, Austria. Tel.: þ43 316 385 81911; fax: þ43 316 385 14656. E-mail address: [email protected] (P. Konstantiniuk).
1078-5884/$36 ª 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvs.2011.06.028
Long-term Follow-up of Vascular Reconstructions in Childhood
685
Conclusions: Our data emphasise that surgical reconstruction is effective in terms of blood supply and growth. In cases with interposition of greater saphenous vein or venous patch plasty, we found a high risk for development of enlargements. We suggest that these patients be followed periodically, with ultrasound studies, to detect aneurysms and/or thrombotic changes as early as possible. ª 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Introduction About 75% of all paediatric fractures involve the upper extremity.1 Fractures near the elbow represent 8% of upper-extremity injuries (or 6% of all fractures), and supracondylar humerus fractures are the most common in this region. About 2.6% of these children present with a pulseless but well-perfused hand.2 Limb-threatening ischaemia is present in <1% of these traumas. Conservative treatment is widely used in non-limbthreatening ischaemia, particularly if the child is very young (2.5 years).3 It has been sufficiently proven that conservative treatment of a vascular trauma may retard growth, as a result of reduced blood supply to the epiphyseal region and reduced muscular blood flow. This may as well be a sequel of the fracture itself with disturbances of the epiphyseal cartilage, but this is still poorly understood. To lessen this gap, we undertook a long-term follow-up study after surgical arterial intervention. We investigated the patency rate and the morphology of the operated area and e expecting side differences in growth e forearm length and volume as well as blood flow.
The flow values for the radial and ulnar arteries were summarised as forearm blood flow. In 2011, all patients underwent B-mode and duplex ultrasonography of the reconstructed brachial artery with diameter measurements.
Physical examination The length of both forearms was measured from the tip of the olecranon to the tip of the ulnar styloid process. Forearm volumetry was performed by measuring the circumference 5 cm distal to the elbow joint, at midforearm and 5 cm proximal to the wrist and computing the volume of the two frustums (a frustum is the portion of a cone bordered by two parallel planes).
Statistics All calculations were performed with Statistical Package for Social Sciences (SPSS) 15.0. Values of the injured and healthy sides were compared with a paired samples’ t-test. P-values below 0.05 were considered significant, while those between 0.05 and 0.1 indicated a trend.
Patients and Methods Results Patients Between June 1990 and June 2004, 12 children with supracondylar fracture with vascular lesions were treated surgically at the Department of Vascular Surgery at the University Hospital in Graz. Patient files were reviewed retrospectively. In 2005, all patients were recalled for physical and ultrasonographic examinations. Ten children provided informed consent and were examined as planned. There was a second recall in 2011; all the children took part and had ultrasonographic measurements.
Ultrasound In 2005, all patients underwent B-mode and duplex ultrasonography of the bilateral brachial arteries to determine the continuity of blood flow and the diameter of the brachial artery. If the cross-sectional surface of the reconstructed artery was increased by at least 50% compared with the artery proximal to the reconstruction, it was called enlarged. If the enlargement was concentric without definable beginning or end, it was classified as ectasia; sharply defined eccentric dilatation was classified as focal aneurysm. Blood flow in the radial and ulnar arteries at mid-forearm was measured with the Siemens Elegra Sonoline ultrasound device (serial number 7451).
Trauma and primary surgery Twelve children with a mean age of 6.6 (3.1e9.7) years, eight boys and four girls, suffered a supracondylar fracture of the humerus with obvious or suspected vascular lesion (Table 1). In seven cases, the left humerus was affected and, in five cases, the right one. In four cases, the dominant side was injured, in eight cases the non-dominant. There were three open and nine closed fractures. In four cases, there was a functional neural lesion that disappeared after some weeks. Five children had an intimal lesion, three a complete rupture of the brachial artery and two an entrapment; one child showed an entrapment in combination with open injury of the brachial artery (caused by wire or bone fragment) and one child presented with a spastic brachial artery without lesion. Primary preoperative diagnostic consisted of angiography in five cases and computed tomography with vascular reconstruction in one case; in six cases, there was no preoperative vascular diagnostic work-up. Primary orthopaedic treatment consisted of closed reduction in eight cases and open reduction in four cases. The primary vascular surgical technique was interposition of the greater saphenous vein in six children, transverse arteriotomy, exploration and direct closure in three cases and venous patch plasty in three cases. Two children needed re-operation: one child underwent interposition of the greater saphenous vein, while
Clinical data of the injured children. Dominant Injured Follow-up Type of Neural side side time (years) humerus injury fracture
#1
5.16 m
6/7/1990
r
l
20.89
open
e
#2
8.22 m
5/1/1991
r
r
19.93
closed
#3
9.68 f
8/19/1995 r
l
15.69
closed
#4
3.09 f
10/26/1995 r
l
15.47
closed
#5
5.64 m
4/14/1996 r
l
14.99
closed
#6
8.98 m
7/5/1996
r
r
14.85
closed
#7
5.77 m
10/8/1997 r
l
13.50
closed
#8
8.53 f
3/18/1998 l
r
13.11
closed
#9
3.27 f
10/26/1999 r
r
11.44
open
5/16/2000 r
r
10.92
open
ulnar nerve (functional & reversible) e intimal lesion 1) angiography closed reposition 1) transverse arteriotomy, 2) sonography and wire fixation exploration and direct closure 2) interposition of GSV (thigh)a e entrapment angiography closed reposition mobilisation, and wire fixation transverse arteriotomy, exploration and direct closure ulnar nerve entrapment angiography closed reposition mobilisation, (functional & and wire fixation venous patch reversible) plasty of two strictures with GSV patches (lower leg) e spasm e open reposition transverse arteriotomy, and wire fixation exploration and direct closure e entrapment, e closed reposition Interposition of open and wire fixation GSV (thigh)b injury - removal - closed reposition and wire fixation e complete e open reposition Interposition of rupture and wire fixation GSV (thigh) e intimal lesion e closed reposition Interposition of and wire fixation GSV (lower leg) ulnar and complete 1) e open reposition 1) interposition median nerve rupture 2) sonography and wire fixation of GSV (lower leg) (functional & 3) angiography 2) removal of interposition reversible) 3) interposition of GSV (thigh)c
#10 7.04 m
Vascular trauma
Vascular diagnostics
complete e rupture intimal lesion angiography
Type of osteosynthesis
Vascular technique
Follow-up status
open reposition and wire fixation closed reposition and wire fixation
interposition of GSV (thigh) interposition of GSV (lower leg)
ectatic ectatic with intramural calcifications ectatic with intramural calcifications
NAD
aneurysmatic
45% thinning
ectatic
NAD ectatic ectatic
P. Konstantiniuk et al.
Case Age Sex Date of surgery
686
Table 1
7/22/2000 r
l
10.73
closed
e
#12 5.83 m
6/4/2004
l
6.84
closed
ulnar nerve intimal (functional & lesion reversible)
r
intimal lesion
angiography
computed tomography with vascular reconstruction
closed reposition resection of 8 mm, and wire fixation end to end anastomosis & venous patch plasty (GSV lower leg) closed reposition patch plasty with and wire fixation accompanying vein
NAD
NAD
GSV: Greater saphenous vein; NAD: no abnormality detected. a On the day of the trauma angiography was unremarkable, but the next day, an intimal lesion was found. The artery was exposed, cross-opened, examined with a Fogarty catheter and closed directly. Two days later, there was no radial pulse and sonography revealed thrombosis of the brachial artery. Ultimately, a GSV interposition was performed. b Primarily the fracture was repositioned and wire fixed. Then the artery was exposed. It was entraped in the fracture gap so the wires had to be removed. The artery showed a small injury (wire? bone fragment?). An interposition with GSV was performed. c Primarily the heavily contaminated bone fragments were cleaned. The artery was completely ruptured so an interposition with GSV from lower leg was performed. On day 15 the boy presented with bleeding out of the cast. Sonography showed a false aneurysm of the proximal anastomosis. The interposition was removed and the brachial artery ligated, leaving the forearm with sufficient blood supply. The infected tissue was treated locally by antiseptics and systemically with antibiotics. On day 28 a new interposition was performed with GSV from the thigh. The operation and postoperative course were uneventful.
Long-term Follow-up of Vascular Reconstructions in Childhood
#11 8.28 m
687
Figure 1 Ectatic venous interposition at follow-up (ultrasonographic finding with intramural calcifications).
Figure 2 Aneurysmatic venous patch plasty at follow-up (ultrasonographic finding).
p
the other one suffered an infection of the anastomosis of the venous graft. The graft was removed and a second interposition of greater saphenous vein was performed 13 days later.
Opposite side
0.95 0.59 0.343
Follow-up results
Affected side
865.7 25.50 0.0695
After a mean follow-up time of 14.0 years (range 6.8e20.9 years), all patients were doing well and their reconstructions were patent. Six reconstructed brachial arteries were ectatic : the largest two presented with intramural calcifications (Fig. 1), one presented with a focal aneurysm (Fig. 2), four did not show abnormalities and one displayed 45% thinning. There were no differences between affected and healthy forearms concerning volume, length and blood flow (Table 2).
Mean values
866.5 25.55 0.0627
Table 2 Comparison of follow-up measurements between healthy and injured side.
Volume (ml) Length (cm) Blood flow (l/min)
688
P. Konstantiniuk et al.
Discussion and Conclusions
Conflict of Interest/Funding
Our data emphasise that surgical reconstruction is effective in terms of blood supply and growth and provides excellent longterm patency rates. Delay in vascular exploration might cause a compartment syndrome. If not treated in time, muscular necrosis will then require debridements and partial-thickness skin grafting of the forearm, possibly accompanied by nerve palsies.4 With further delay or if the compartment syndrome is left untreated, there will be fibrosis of the forearm musculature, called Volkmann’s ischaemic contracture,5 or the worstcase scenario of amputation due to gangrene.6, 7 It is well known that conservative treatment may be preferable, particularly if the child is very young.2 There were some conservatively treated children within the observation period, but we are not able to provide data on them. Omitting vascular reconstruction might lead to limb shortening and, in rare cases, claudication upon effort. Although most reports concern vascular injury after arterial catheterisation of the leg in the first year of life,8e13 there seems to be no doubt that there can be late sequelae in cases of supracondylar fracture with arterial injury. White and colleagues14 reviewed 331 cases of pulseless supracondylar fractures. Of the fractures that stayed pulseless in spite of adequate reduction, 82% were found to have a brachial artery injury. Facing excellent surgical long-term results, we are in line with the authors suggesting a more aggressive vascular evaluation and vascular exploration. There is one case (compare #6 in Table 1) with a very small artery in the cubital region (45% cross-sectional surface compared with the brachial artery at mid-upper arm). We assume this to be a result of overexpansion at the point of the primary trauma. The artery was crossopened, explored and directly sutured. Further follow-up will show if a more aggressive surgical treatment (e.g., patch plasty) would have been the better approach. In cases of greater saphenous vein interposition or venous patch plasty, we found a high risk for the development of ectatic lesions (7/10). Over time, these ectatic lesions, like other aneurysms, may cause problems, such as partial thrombosis, and a tendency to embolise. The appearance of intramural calcifications in two cases is a strong indication of an overstrained wall. There is one case report of a 3-year-old boy with transient ischaemic symptoms secondary to thrombo-embolism from a brachial artery aneurysm (but not associated with trauma).15 We suggest periodic follow-up including ultrasonography for timely detection of aneurysms and/or thrombotic changes.
None.
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