Supracondylar Fractures of the Humerus: Association of Neurovascular Lesions with Degree of Fracture Displacement in Children—A Retrospective Study

Abstract

Supracondylar humerus fractures (ScHF) account for 60% of fractures of the elbow region in children. We assessed the relationship between neurovascular complications and the degree of fracture displacement as rated on the basis of modified Gartland classification. Moreover, we aimed to evaluate predisposing factors, e.g., age and gender, and outcomes of neurovascular complications in ScHF. Between 2004 and 2019, we treated 329 patients with ScHF at the Department of Traumatology and Orthopedics of the Upper Silesian Child Centre, Katowice, Poland. Mean age of patients (189 boys and 140 girls) was 7.2 years (Confidence interval: 6.89, 7.45). Undisplaced fractures were treated conservatively with a cast. Displaced fractures were managed by closed reduction and percutaneous Kirschner wire fixation using two pins inserted laterally. We retrospectively assessed the number of neurovascular lesions at baseline and recorded any iatrogenic injury resulting from the surgical intervention. Acute neurovascular lesions occurred in 44 of 329 ScHF patients (13.4%). The incidence of accompanying neurovascular injuries was positively associated with the severity of fracture displacement characterized by Gartland score. Vascular injuries occurred mainly in Gartland type IV ScHF, while nerve lesions occurred in both Gartland type III and IV ScHF. We noted a significantly higher mean Gartland score and mean age at injury in the group of children suffering from neurovascular injuries when compared to those in the group without such injuries (p = 0.045 and p = 0.04, respectively). We observed no secondary nerve lesions after surgical treatment. For the treatment of ScHF in children, we recommend closed reduction and stabilization of displaced fractures with K-wires inserted percutaneously from the lateral aspect of the upper arm. We advocate vessel exploration in case of absent distal pulses after closed reduction but do not consider primary nerve exploration necessary, unless a complete primary sensomotoric nerve lesion is present.

Retrospective Mid-Term Follow-Up of Posttraumatic and Iatrogenic Neurovascular Complications in Surgically Treated Paediatric Patients with Distal Humerus Fracture

“…However, the indication for CT angiography is still debated and should not delay fracture reduction [ 27 ]. Tomaszewski et al reported good clinical results for children with SCHF and vascular injury at the one-year follow-up [ 12 ], which is in line with our study data. Our study demonstrates mostly excellent clinical outcomes at mid-term follow-up.…”

“…Differences between these numbers and those reported in the current study may be attributable to selection bias—the interest in the current studs was the operatively managed fracture population. The indication to operative management is directly related to fracture displacement, which has an inherently higher risk of neurovascular injury [ 12 , 13 ]. Interestingly no correlation was identified between neurological injury and the number or location of K-wires.…”

“…Rigorous examination of clinical status in compliant patients by a specialised paediatric orthopaedic surgeon demonstrated the rate of iatrogenic nerve injury to be 3% [ 13 ]. The majority of neurovascular injuries were due to initial trauma and associated with the degree of displacement [ 12 , 13 ]. In the current study, the distal humerus fracture subtype showed no significant effect.…”

“…However, this should not be taken for granted. Tomaszewski et al demonstrated that after an initial nerve injury associated with supracondylar humerus fracture, complete nerve recovery occurred on average 122 days after surgery [ 12 ].…”

Median Nerve Palsy in Pediatric Supracondylar Humerus Fractures Recovers Faster With Open Than Closed Reduction

“…The management of SCHF with vascular or nerve injury remains debated, perhaps due to their relative infrequency and concerns about the long-term sequelae in this subset of patients. Median nerve injuries complicate ~5% to 10% of SCHF, occurring most commonly in extension-type fractures 1–4 . Several studies have evaluated the management of SCHF with vascular compromise, with or without nerve involvement, but few have focused specifically on SCHF-induced median nerve injury.…”