Bruise Location in Supracondylar Humerus Fractures Predicts Specific Neurovascular Injuries

Abstract

Purpose: The presence of soft tissue injury in pediatric supracondylar humerus fractures (SCHFs) has been shown to be an independent predictor of any neurovascular injury. Potentially expanding this concept, the specific neurovascular structure injured around the elbow is thought to be dependent upon the direction and magnitude of fracture displacement and subsequent soft tissue injury. Therefore, it was hypothesized that the bruise location following SCHF is indicative of the anatomic location of maximal soft tissue injury and therefore is a specific prognosticator of which neurovascular structure may be injured. Methods: Retrospective chart review of all SCHFs treated at a tertiary pediatric hospital from 2007 to 2017 collected information on bruise location, neurovascular injury patterns, and outcomes. Bruise location was classified as anterior, anterolateral, anteromedial, or posterior. Injury radiographs were reviewed by a blinded pediatric orthopaedic surgeon to neurovascular structure injured. Results: Of 2845 SCHFs identified, 267 (9.4%) had concomitant neurovascular injury—of which 128 (47.9%) met inclusion criteria. Among the vascular injuries, all bruising was anteromedial (28/45, 62.2%, P <0.05) or anterior (17/45, 37.8%, P >0.05). Fractures with anteromedial bruising correlated with median nerve injury (24/27, 88.9%, P <0.05), whereas fractures with anterolateral bruising correlated with radial nerve injuries (24/25, 96.0%, P <0.05). Bruising or radiographic evaluation correctly identified 60.2% and 64.1% of neurovascular injuries, respectively, whereas the combination identified 82.0% of neurovascular injuries correctly. Bruise location identified 23 neurovascular injuries not predicted by radiographic evaluation alone. Conclusion: Bruise location is an important physical examination finding that can be used as an adjunct to improve the diagnostic accuracy of neurovascular injury in SCHFs in conjunction with neurovascular physical examination and radiographic evaluation. SCHFs with anterior or anteromedial bruising should raise concern for vascular injury. In addition, anteromedial bruising is predictive of a median nerve injury and anterolateral bruising is predictive of radial nerve injury. This adjunct diagnostic is particularly helpful in a noncooperative child or if performed by a clinician with limited experience in diagnosing neurovascular injuries or interpreting pediatric elbow radiographs. Level of Evidence: Level IV, case series.

Predictive factors for open reduction of flexion-type supracondylar fracture of humerus in children

“…The rotated medial spike may injure the ulnar nerve, puncture the nerve sheath, or increase the risk of ulnar nerve entrapment during closed reduction. In addition, the spread of the periosteum and the penetration of the triceps muscle of the medial spike increases the difficulty of CRIF [ 20 , 21 ]. Furthermore, the medial periosteum disruption aggravates instability and the medial column rotational displacement always occurs during closed reduction.…”

Research: Construction and validation of elbow function prediction model after supracondylar humerus fracture in children

“…The following complications may occur: secondary displacement, premature epiphyseal closure, nonunion of the fracture, nerve damage, valgus deformity of the elbow, and infection of the K-wire tract. [7] At present, relevant studies have been carried out at home and abroad on the risk factors of SHF in children, such as obesity as a risk factor for aggravating supracondylar humerus fracture; [9][10][11][12] soft tissue injury location as an independent predictor of vascular nerve injury in supracondylar fractures; [13] the incidence of supracondylar humerus fractures is higher in summer than in other seasons. [14] Although relevant research has suggested pertinent indicators as risk factors for fractures, their clinical usability and effectiveness are far from optimal.…”

“…At present, relevant studies have been carried out at home and abroad on the risk factors of SHF in children, such as obesity as a risk factor for aggravating supracondylar humerus fracture; [9–12] soft tissue injury location as an independent predictor of vascular nerve injury in supracondylar fractures; [13] the incidence of supracondylar humerus fractures is higher in summer than in other seasons. [14]…”