Çocuklarda nörovasküler yaralanmalı suprakondiler humerus kırıklarına yaklaşım

Year 2013, Volume: 47 Issue: 4, 244 - 249, 18.09.2013

Murat Aksakal Cenk Ermutlu Bartu Sarisozen Burak Akesen

Abstract

Amaç: Bu çalışmanın amacı Gartland Tip 3 suprakondiler humerus kırıklarında (SHK) nörovasküler yaralanmaları incelemek, artmış açık redüksiyon gereksinimi ile ilişkili faktörleri ortaya koymak ve anterior açık redüksiyonun klinik sonuçlarını kapalı redüksiyonla kıyaslamaktı.
Çalışma planı: Ocak 2002 – Haziran 2008 tarihleri arasında SHK nedeniyle cerrahi uygulanan 65 hasta (46 erkek, 19 kız; ortalama yaş: 7.03, dağılım: 1-14) çalışmaya dahil edildi. Kapalı redüksiyon ve perkütan pinleme öncelikli tedavi yöntemi olarak düşünüldü. Kapalı teknikle yeterli redüksiyon sağlanamaması veya dolaşım sorunu bulgularının olması açık redüksiyon endikasyonu olarak kabul edildi. Hasta demografikleri, fizik muayene bulguları, redüksiyon kalitesi, fonksiyonel ve kozmetik sonuçlar incelendi.
Bulgular: Fizik muayenede dolaşım sorunu olan hastaların hepsinde antekubital yaklaşım esnasında damar patolojisine rastlandı. Bu hastaların yarısına vasküler girişim uygulandı. Ödem, ekimoz ve gamze bulgusu birlikteliği olan hastaların %93’ünde kapalı redüksiyon girişimi yeterli olmadı. Bu hastalardan nörolojik muayenesi normal olan dördünde median sinirin kırık fragmanları arasında sıkışmış olduğu görüldü. Açık redüksiyonun fonksiyonel, ve kozmetik sonuçları kapalı redüksiyon uygulananlar ile benzerdi (p>0.05).
Çıkarımlar: Belirgin ödem, ekimoz ve gamze bulgusu olan ve radial nabzın alınamadığı olgularda kapalı redüksiyonda ısrar edilmemelidir. Anterior yaklaşım damar, sinir yapılarının doğrudan gözlenebilmesi ve aynı kesinin uzatılması ile gerekli ek girişimlerin yapılabilmesine olanak tanıması nedenleriyle tercih edilecek cerrahi yaklaşım olmalıdır.

Keywords

Antekubital; anterior yaklaşım; kapalı redüksiyon; nörovasküler yaralanma; suprakondiler humerus kırığı.

Approach to supracondylar humerus fractures with neurovascular compromise in children

Abstract

Objective: The aim of this study was to evaluate neurovascular compromise in childhood Gartland Type 3 supracondylar humerus fractures (SHFs), identify the factors correlated with increased need of open reduction and compare the clinical outcome of anterior open reduction with that of closed reduction.
Methods: The study included 65 patients (46 male, 19 female; mean age: 7.03 years, range: 1 to 14 years) treated surgically for SCH fracture between January 2002 and June 2008. Fractures underwent closed reduction with percutaneous pinning when possible. Open reduction was performed when adequate reduction via the closed technique failed or vascular compromise were indications for open reduction. Patient demographics, physical examination findings, adequacy of reduction, functional and cosmetic outcomes were assessed.
Results: During the antecubital approach, vascular pathology was noted in all patients with signs of vascular compromise at physical examination. Half of these patients underwent vascular intervention. Closed reduction failed in 93% of patients with concomitant edema, ecchymosis and dimple sign. Of these, the median nerve was trapped between the bone fragments in 4 patients with normal neurological examinations. Functional and cosmetic results of open reduction were similar to closed reduction (p>0.05).
Conclusion: Closed reduction should not be forced in cases with marked edema, ecchymosis, dimple sign, and absence of radial pulse. The anterior approach is the surgical approach of choice due to direct visualization of neurovascular bundle and availability of neurovascular intervention by extending the same approach.

Keywords

Antecubital, anterior approach, closed reduction, neurovascular compromise, supracondylar humerus fracture

References

• Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959;109:145-54.
• 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; 30:50Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008;90:1121-32.
• White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systemic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop 2010;30:328-35.
• Pretell-Mazzini J, Rodriguez-Martin J, Auñon-Martin I, Zafra-Jimenez ZA. Controversial topics in the management of displaced supracondylar humerus fractures in children. Strategies Trauma Limb Reconstr 2011;6:43-50.
• Danielsson L, Pettersson H. Open reduction and pin fixation of severely displaced supracondylar fractures of the humerus in children. Acta Orthop Scand 1980;51:249-55.
• Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM. Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996;10:410-5.
• Ramachandran M, Skaggs DL, Crawford HA, Eastwood DM, Lalonde FD, Vitale MG, et al. Delaying treatment of supracondylar fractures in children: has the pendulum swung too far? J Bone Joint Surg Br 2008;90:1228-33.
• Gosens T, Bongers KJ. Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury 2003;34:267-73.
• Mazda K, Boggione C, Fitoussi F, Penneçot GF. Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children. A prospective study of 116 consecutive patients. J Bone Joint Surg Br 2001;83:888-93.
• Wilkins KE. Residuals of elbow trauma in children. Orthop Clin North Am 1990;21:291-314.
• Garbuz DS, Leitch K, Wright JG. The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop 1996;16:594-6.
• Copley LA, Dormans JP, Davidson RS. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. J Pediatr Orthop 1996;16:99
• Elstrom JA, Pankovich AM, Kassab MT. Irreducible supracondylar fracture of the humerus in children. A report of two cases. J Bone Joint Surg Am 1975;57:680-1.
• Fleuriau-Chateau P, McIntyre W, Letts M. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Can J Surg 1998;41:112-8
• Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B 2006;15:51-7.
• Luria S, Sucar A, Eylon S, Pinchas-Mizrachi R, Berlatzky Y, Anner H. Vascular complications of supracondylar humeral fractures in children. J Pediatr Orthop B 2007;16:133-43.
• Ay S, Akinci M, Kamiloglu S, Ercetin O. Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005;25:149-53.
• Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008;17:171-8.