Approach to the pediatric supracondylar humeral fracture with neurovascular compromise.

Abstract

Supracondylar fractures of the humerus are exceedingly common in pediatric patients but may present treatment challenges when complicated by neurovascular compromise. Patients presenting with poor perfusion should be treated with urgent reduction because this is a limb-threatening emergency. If perfusion does not improve, or if a previously perfused extremity loses perfusion after reduction, arterial exploration is warranted. Controversy exists over whether to observe or explore a reduced, perfused, but pulseless extremity with a supracondylar fracture. Minimal management requires that these injuries be carefully monitored for 48 hours for loss of perfusion or the development of compartment syndrome. In general, nerve injuries accompanying supracondylar fractures of the humerus are neurapraxias and may be treated conservatively; however, nerve palsy with accompanying pulselessness warrants immediate exploration. Patients should be treated more urgently if excessive swelling, antecubital ecchymosis, skin puckering, an absent pulse, or fractures in the same limb are present. If a hand is not perfused or compartments are firm, emergent treatment should be considered.