AAOS AUC can take treatment to the next level
Supracondylar humerus fractures (SHFs) are the most common fractures in children, and the annual rate of SHF presentation is estimated to be 177 per 100,000 children. More than 90 percent exhibit extension or posterior displacement of the distal fracture fragment. This fracture is associated with a high incidence of complications, including neurologic and vascular injury, as well as compartment syndrome.
In children, SHF is associated with vascular complications in about 20 percent of cases. When reduction of the fracture fails to reduce the pulse and perfusion of the hand, the rate of concomitant brachial artery injury may be as high as 82 percent. The severity of such associated injuries has precipitated ongoing investigation and debate over optimal management of the “perfused but pulseless limb” in pediatric SHF. The “perfused but pulseless limb” after pediatric SHF refers to the common scenario when the radial pulse is absent to palpation (pulseless); however, the hand is warm to the touch with equal capillary refill compared to the contralateral hand (perfused).
Treatment of pediatric SHF with associated vascular injury can be complex. In most cases, limb perfusion improves after closed reduction and percutaneous pinning (CRPP). Rather than relying on previous experience and training, practitioners need an evidence-based algorithm. In addition, high-quality evidence to support a treatment pathway remains limited, as demonstrated in the 2011 AAOS Appropriate Use Criteria (AUC), The Treatment of Pediatric Supracondylar Humerus Fractures: Evidence-based Guideline and Evidence Report.
Researchers recently conducted a survey of the CORTICES (Children’s Orthopedic Trauma and Infection Consortium for Evidence-based Studies) group (www.cortices.org). CORTICES represents 20 pediatric Level I trauma centers across North America whose mission is to improve the quality, safety, and value of care for trauma and infection in pediatric patients. Only 50 percent (n = 10/20) of pediatric hospitals have a protocol in place for the management of a threatened limb and for the management of type III pediatric SHF.
When asked who is responsible for vascular coverage, respondents said adult vascular surgery (30 percent), plastic surgery (30 percent), and hand/orthopaedic surgery (40 percent). Finally, 80 percent of respondents believed there is a need for further clarification and creation of guidelines on the treatment of arterial injury associated with pediatric SHF.
The responses further illustrate room for improvement in this area of treatment. Boston Children’s Hospital developed a threatened-limb protocol, stipulating that any child with vascular concern will trigger an assessment by the pediatric general surgeon on call, who will then determine the need for interventional radiology, orthopaedic surgery, or plastic surgery, depending on the nature of the injury and vascular coverage roster. This team-based approach has decreased variation and improved action time for such clinical scenarios (see case study, page 33).
To streamline decision making for clinicians who care for children with SHF, AAOS developed AUC on the management of pediatric supracondylar humerus fractures with vascular injury. The purpose of the AUC was to evaluate the treatment options in a heterogeneous patient population and improve patient care while acknowledging the subtleties in clinical decision making. As substantial evidence to guide the management of dysvascular pediatric SHF is not available, the AUC pediatric SHF work group synthesized the best available evidence using the clinical expertise of physicians from multiple specialties.
The study group found six treatment scenarios that demonstrated variable degrees of vascular embarrassment after CRPP of SHF. A further series of five assumptions regarding the clinical situation were established prior to application of the AUC recommendations. Eighteen treatment options were reviewed and deemed “appropriate,” “may be appropriate,” and “rarely appropriate.” In five of six clinical scenarios, the AUC designated that best treatment for SHF with vascular injury included a vascular consultation when possible (performed by a vascular surgeon, pediatric general surgeon, or qualified surgeon with specialized microvascular or vascular training). When there is a concern for vascular perfusion following CRPP of pediatric SHF, the consensus was that a careful vascular assessment by a physician skilled in vascular repair is necessary. In patients with a persistent lack of perfusion and pulselessness despite anatomic fracture reduction, immediate open vascular exploration is indicated. Moreover, if an appropriate expert is not available, transferring the patient to an institution with an available vascular surgeon is considered an important treatment option. At the same time, in some remote communities, it is possible that no expert is available within a reasonable travel distance. In many cases, a local surgeon has to measure the risk of time delay in treatment for the poorly vascularized limb when making such decisions.
The AUC on pediatric SHF with vascular injuries is a meaningful guideline that provides additional resources for surgeons caring for children who have sustained trauma. Vascular complications most frequently occur with extension Gartland type III SHF. The risk of brachial artery injury and nerve deficit is higher in posterolateral displacement of a fracture. Given the prominence of the medial metaphysis of the proximal fracture fragment, the brachial artery may be either directly injured, stretched over the displaced fracture, or entrapped during fracture reduction.
Depending on the degree of vascular injury, a series of treatment options exist, including removal of the offending adventitia/fascia/periosteum, evacuation of arterial thrombus with a Fogarty catheter or arteriotomy, application of nitroglycerin or papaverine, repair of partial arterial rupture, and/or vein grafting across the injured arterial segment.
Data concerning the outcomes of arterial repair and reconstruction after pediatric SHFs are limited to small case series. A study by Sabharwal et al., reported on 13 extension-type SHF with vascular injuries. A series of treatments for the vascular injuries were performed, including mobilization of neurovascular structures and release of soft-tissue leash (n = 4), vascular reconstruction with interposition vein-patch angioplasty (n = 4), end-to-end anastomosis (n = 1), thrombectomy (n = 1), and intra-arterial thrombolysis with urokinase (n = 3). The authors found that although early revascularization is technically feasible, there was a high rate of asymptomatic reocclusion and residual stenosis.
Badkoobedhi et al., reviewed the treatment options associated with pulseless SHF. The authors outlined two different treatment options: (a) immediate vascular exploration or (b) 24 to 48 hours of close inpatient observation, during which if perfusion does not return, prompt return to the operating room for vascular exploration is indicated.
Alves et al., published early outcomes of interpositional vein grafting for reconstruction of brachial artery injury in 20 children with SHF. They concluded that the technique is safe and effective, with most children experiencing patent arteries at follow-up. Prior to that manuscript, only a handful of other case series reported on a variety of treatment methods associated with the dysvascular arm in the setting of pediatric SHF.
Finally, a study by Louahem and Cottalorda reported on 68 type III Gartland SHFs with acute ischemia; three patients required release and decompression to brachial artery to restore flow, one had an end-to-end anastomosis, and four had a saphenous vein graft.
Treatment variation remains a challenge
Vascular coverage at pediatric hospitals exists in many different shapes and forms. In many cases, practitioners who provide adult vascular coverage with variable pediatric experience are responsible for the management of dysvascular limb after pediatric SHF. Other common scenarios include two or three different subspecialty services sharing the vascular call. For example, vascular call may be split weekly by an orthopaedic microvascular hand team, plastic surgery microvascular team, and general surgery/transplant team, each with different treatment philosophies based on specialty training and experience. The reality is that tremendous practice and treatment variation exists at the top of the pulseless supracondylar humerus pyramid of care.
Although AAOS has worked to define guidelines and treatment algorithms for the many clinical scenarios associated with pediatric SHF, treatment variation remains a challenge. The current variation that tops the pediatric SHF vascular injury pyramid is primarily related to the different philosophies and subspecialty training of the services that make up “vascular call” in pediatric hospitals. Fortunately, literature provides well-described algorithms for managing dysvascular limbs. The current AUC for the management of pediatric SHF with vascular injury help guide clinicians toward safe and effective care. In the future, guidelines for treatment at the top of the pulseless supracondylar pyramid may decrease existing practice variation.
SHF case study: Pulseless supracondylar humerus fracture
Three-year-old female presents to your hospital after transfer from an outside institution. She has an isolated injury after a fall from a play structure. The injury occurred at 2 p.m., and the patient is being assessed in your institution at 6 p.m. Examination (Fig. 1) demonstrates a grossly extended limb in a posterior slab with no evidence of injury but significant ecchymosis anteriorly with puckering of the skin. No radial pulse is present, and the hand is slightly cooler than the contralateral limb. The patient demonstrates anterior interosseous nerve (AIN) palsy with intact radial and ulnar motor and sensory examination.
She is taken urgently to the operating room. Fig. 2 illustrates her immediate post-fixation radiographs at approximately 8 p.m. The alignment is felt to be anatomic, but there is no restoration of radial pulse. After 30 minutes, the hand remains cooler compared to the contralateral hand, with sluggish capillary refill. The decision is made to open the elbow to explore the fracture. There is a band of periosteum entrapped in the fracture site, which is compressing the brachial artery. The pins are removed, and the brachial artery is explored with aid of a plastic surgeon. There is a large thrombus within the artery, and the decision is made to perform a saphenous vein bypass graft of the injured area of the antecubital fossa. Subsequent to revascularization, a decompressive fasciotomy of the anterior forearm is performed. A well-padded posterior splint is applied. She is admitted for neurovascular monitoring for the next 48 hours, which is uneventful, and the patient is discharged 72 hours after surgery.
Postoperative course is uneventful, and her three-month post-injury radiographs (Fig. 3) demonstrate adequate healing of the fracture and essentially normal range of motion with 5 degrees lacking of terminal elbow extension and flexion to 120 degrees. Her AIN palsy has completely resolved.
AAOS. Appropriate use criteria for the management of pediatric supracondylar humerus fractures with vascular injury. Adopted June 12, 2015.
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Benjamin Shore, MD, MPH, FRCSC, is assistant professor of orthopaedic surgery in the Department of Orthopaedic Surgery at Boston Children’s Hospital and Harvard Medical School. He can be reached at email@example.com.