THE OUTCOME OF PULSELESS PINK HAND FOLLOWING CLOSED SUPRACONDYLAR FRACTURE HUMERUS IN PEDIATRICS.

Management of children with supracondylar humeral fractures with pulseless pink hands is still controversial, whether to choose operative or conservative treatment. Proponents of conventional treatment mentioned that most patients can restore the motor and sensory function of the hand shortly after the injury without the need to restore distal pulse by surgery. Opponents of this treatment strategy claim that many patients will develop limb shortening a few years after the injury leading to functional and psychological problems. In this study, we made a comparison of the outcomes of each treatment to help in making policy for the treatment of such types of injuries in our center. This study answers the question "Which method is preferred for treating supracondylar humeral fracture with suspected vascular injury represented by pulseless pink hand, and what are the short and long-term outcomes of each treatment method. The main objective of the study is to settle a policy for the treatment of such types of injuries in our center. This study is a retrospective for the 10-year period from 2010 to 2020, it included 74 patients with blunt trauma to one upper extremity. All patients were children aged one year to fourteen years. Patients with penetrating trauma, combined penetrating and blunt trauma, victims of burns and explosions, and patients with other co-morbidities were excluded. We have two treatment strategies: Conservative (watchful waiting) and Operative exploration. We compared the outcomes of these two strategies regarding the short-term outcome (6 months follow-up) and the long-term outcome (5 years follow-up). We looked for acute and chronic limb ischemia and chronic pain syndrome as the short-term follow-up, while we took limb shortening and chronic limb ischemia and limb function as variables of the long-term follow-up. We don't have the ability to control patients for the psychological examination by a psychiatrist, therefore; we excluded this variable from our study.

Pseudoaneurysm of the brachial artery in an infant due to vaccination: a case report.

BACKGROUND: Pseudoaneurysm is a known complication of penetrating arterial injuries such as catheterization, gunshot wounds, and open fractures. Vaccination is an effective method for preventing multiple, serious, infectious diseases in children. Common adverse reactions related to vaccination include fever, swelling, redness, and pain. Brachial pseudoaneurysm after vaccination has not been previously reported. CASE PRESENTATION: Herein we describe a novel case of brachial pseudoaneurysm after vaccination in a child aged 1 year and 3 months. A pulsatile mass was formed in the medial left arm of the infant 10 days after vaccination at a community hospital and gradually grew larger. Preoperative images depicted an eccentric aneurysm in the brachial artery and a swirling flow pattern in the mass. The pseudoaneurysm was excised, and vein graft interpositioning was successfully performed. There were no short-term or long-term complications during the follow-up period. CONCLUSIONS: Brachial pseudoaneurysm is a rare complication of vaccination via intramuscular injection. Medical staff should avoid puncture wounds to the brachial artery during vaccination, especially in infants.

Brachial artery injuries - the impact of the anatomical site of injury on postoperative outcomes.

BACKGROUND: The start of the armed conflicts in Libyan society in 2011 led to a dramatic increase in the incidences of unusual types of brachial artery injuries, which were previously uncommon. In this study, the postoperative outcomes have been compared prospectively between patients who have had injuries at the proximal anatomical half of the brachial artery with those who suffered injuries at the distal anatomical half. METHODS: A cohort study was undertaken to compare patients who had an injury at the proximal anatomical half of the brachial artery (considered as the first group) and patients who had an injury at the distal anatomical half of the brachial artery (considered as the second group). This was undertaken to analyse the influence of the anatomical site of injury on the postoperative outcomes in patients who underwent urgent surgical repair procedures at the hospital from February 2011 to December 2016. RESULTS: Out of fifty-one patients, 31 (60.8%) patients had gunshot injuries, 12 (23.5%) had explosive injuries, four (7.8%) had stab wounds and four (7.8%) were victims of road traffic accidents. There were 13 (25.5%) patients in the first group and 38 (74.5%) patients in the second group. Three patients (5.9%) had postoperative arterial occlusion due to thrombosis, while two (3.9%) had postoperative graft occlusion due to thrombosis; the other two (3.9%) had compartment syndrome. CONCLUSION: Based on the anatomical background, critical limb ischaemia and postoperative ischaemic complications, as well as delayed limb amputation, are more associated with the injuries to the proximal anatomical half of the brachial artery due to poor collateral circulation at this level.

Strategy of pulseless pink supracondylar humerus fracture treatment in children: a comparison of two approaches.

PURPOSE: The appropriate treatment of pulseless pink supracondylar humerus fractures (SCHF) remains controversial. In this study, the outcomes of two treatment approaches (with and without vascular surgery) were compared. MATERIAL AND METHODS: This was a retrospective multicenter study of patients with pulseless pink SCHFs treated in ten pediatric surgery, trauma, or orthopedics departments in the Czech and Slovak Republic between 2014 and 2018. RESULTS: Of the total 3608 cases of displaced SCHF, 125 had the pulseless pink SCHF. Of those, 91% (114/125) did not undergo vascular surgery and 9% (11/125) underwent vascular surgery. The patients who did undergo vascular surgery had radial artery pulsation restored more frequently in the operating room (73% vs. 36%; p = 0.02), within 6 h (91% vs. 45%; p = 0.004), and within 24 h of surgery (91% vs. 57%; p = 0.05). However, 72 h after surgery, there was no significant difference in palpable radial artery pulsation between the vascular surgery and the non-vascular surgery groups (91% vs. 74%; p = 0.24). Additionally, no significant differences in long-term neurological (9% vs. 22%; p = 0.46) or circulatory (9% vs. 7%; p = 0.57) deficits were found between the two groups. CONCLUSION: While vascular surgery in patients with pulseless pink SCHFs is associated with a more prompt restoration of radial artery pulsation, no statistical significant differences in terms of the restoration of neurological deficits or the risks of long-term neurological or circulatory deficits were found between patients with and without vascular surgery.

Traumatic brachial artery injury successfully treated with a stent-graft: A case report.

There are few reports on brachial artery injury treated with stent-grafts. A 69-year-old man presented with a crush injury to the left upper arm. Enhanced computed tomography revealed left humerus fracture and disruption of the blood flow of the brachial artery along with paresis of the forearm. Following external fixation of the fracture, we performed endovascular therapy for brachial artery injury. Using real-time ultrasound imaging guidance, the injured lesion was crossed by the wire, and Viabahn endoprosthesis was placed in the left brachial artery. Hemostasis was achieved, and blood flow to the forearm was restored. Subsequently, the paresis improved.

Reparo de lesão vascular não letal causada por tamanduá-bandeira (Myrmecophaga tridactyla) no Brasil / Repair of non-lethal vascular injury caused by giant anteater (Myrmecophaga tridactyla) in Brazil

Resumo O tamanduá-bandeira é um mamífero encontrado na América Central e na América do Sul. Esse animal possui garras que podem chegar a 6,5 cm de comprimento, utilizadas para escavar formigueiros e obter alimento, além de servir para sua defesa. Relatamos o caso de paciente masculino de 52 anos, com histórico de epilepsia, que foi levado desacordado ao pronto-socorro, devido a lesões no seu braço direito causadas por um tamanduá. Frente à suspeita de trauma vascular, o paciente foi submetido a exploração cirúrgica, que evidenciou uma lesão combinada de vasos braquiais, submetida a reparo. Apresentou boa evolução do quadro, recebendo alta hospitalar no segundo dia de pós-operatório e, no seguimento ambulatorial, evoluiu sem sequelas neurológicas ou vasculares.

Abstract The giant anteater is a mammal found in Central and South America. These animals have claws that can reach 6.5 centimeters in length, which they use to dig anthills to obtain food and for defense. We report the case of a 52-year-old male patient with a history of epilepsy who was taken unconscious to the emergency room due to injuries to his right arm caused by an anteater. He underwent surgical exploration to investigate suspected vascular trauma, revealing a combined (arterial and venous) injury of the brachial vessels, which were repaired. He recovered well and was discharged on the second postoperative day. During outpatient follow-up he continued to improve, with no neurological or vascular sequelae.

The risk of iatrogenic radial nerve and/or profunda brachii artery injury in anterolateral humeral plating using a 4.5 mm narrow DCP: A cadaveric study.

INTRODUCTION: Fixation of humeral shaft fractures with a plate and screws can endanger the neurovascular structure if proper care is not taken. No studies to our knowledge have studied the risk of iatrogenic radial nerve and/or profunda brachii artery (RNPBA) injury from each screw hole of a 4.5 mm narrow dynamic compression plate (narrow DCP). The purpose of this study is to evaluate the risk of RNPBA injury in anterolateral humeral plating with a 4.5 mm narrow DCP. MATERIAL AND METHODS: 18 humeri of 9 fresh-frozen cadavers in the supine position were exposed via the anterolateral approach with 45 degrees of arm abduction. A hypothetical fracture line was marked at the midpoint of each humerus. A precontoured ten-hole 4.5mm narrow DCP was applied to the anterolateral surface of the humerus using the fracture line to position the center of the plate. All screw holes were drilled and screws inserted. The cadaver was then turned over to the prone position with 45 degrees of arm abduction, and the RNPBA exposed. The holes through in which 100% of the screw had contact with or penetrated the RNPBA were identified as dangerous screw holes, while lesser percentages of contact were defined as risky. RESULTS: The relative distance ratios of the entire humeral length from the lateral epicondyle of the humerus to the 4th, 3rd, 2nd and 1st proximal holes were 0.64, 0.60, 0.56 and 0.52, respectively. The most dangerous screw hole was the 2nd proximal, in which all 18 screws had contacted or penetrated the nerve, followed by the risky 1st (12/18), 3rd (8/18) and 4th (2/18) holes. CONCLUSION: In humeral shaft plating with the 4.5mm narrow DCP using the anterolateral approach, the 2nd proximal screw hole carries the highest risk of iatrogenic radial nerve and/or profunda brachii artery injury.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses.

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

Severe injury to the brachial neurovascular bundle and muscles due to a horse bite: a case report.

INTRODUCTION: Only a small portion of horse injuries are related to horse bites. In the majority of these occurrences, injuries are minor and self-treated. However, in some cases, the injury may be destructive and limb- and life-threatening. In these instances, the patient requires complex surgery and compound perioperative care. CASE REPORT: We present the case of a 35-year-old Albanian male farm-worker in whom a horse bite caused an extensive lacero-contusive and avulsive wound to the arm. The wound resulted in injury to the brachial artery, brachial and basilic vein, and biceps and brachialis muscles. Nerve structures and underlying humerus remained intact. The initial management of the severe hemorrhagic shock caused by the bleeding at the site of injury included reconstruction of the brachial artery by interposing saphenous graft and that of the brachial vein by termino-terminal anastomosis. Basilic vein was ligated. The wound was extensively debrided, and after a drain was placed in the wound, biceps and brachialis muscles were reconstructed. The patient received several units of red blood cells and fresh frozen plasma before and after surgery, as well as antibiotic, antitetanic, and antirabies prophylaxes. He had several consecutive necrectomies in the following days. However, due to postoperative sepsis and hemorrhagic shock at time of admission, the patient developed acute renal failure, therefore requiring several hemodialysis sessions. After his general and local condition was stabilized, the patient also underwent several reconstructive surgeries. CONCLUSION: Horse bites of large extent require a multidisciplinary approach. The composition of the team of physicians needed for treatment varies depending on the degree of the injury and eventual complications. In the case of our patient, emergency department physicians, vascular and plastic surgeons, intensive care specialists, nephrologists, and infective care specialists were involved. In different instances, the inclusion of other specialists may be necessary to save and functionalize the limbs of the patient, or save his/her life.

[Arterial trauma of the upper limbs: Particularities of the population in Tunisia and risk factors for amputation]. / Traumatismes artériels des membres supérieurs : particularités de la population en Tunisie et facteurs de risque d'amputation.

AIM OF THE STUDY: The purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss. METHODS: This was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate. RESULTS: The average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma. CONCLUSION: Prompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

Brachial Artery Injuries Operative Management and Predictors of Outcome.

BACKGROUND: Brachial artery injuries are rare. The objectives of the study are to report our experience and identify predictors of outcome. The hypothesis of the study is that maintaining ischemic times less than six hours results in improved outcomes. METHODS: This is a retrospective 118-month study. The outcome measure is total operative time from admission to restoration of blood flow, and outcomes are survival and limb salvage. Statistical analyses used in the study are univariate and multivariate stepwise logistic regression. RESULTS: There were 124 patients with 131 brachial artery injuries. Mechanism of injury (MOI) included the following: penetrating: 108 (87%) and blunt: 16 (13%). Operative management included the following: 77 (62%) reverse saphenous vein interposition grafts, 37 (29.8%) end-to-end anastomosis, and 4 (3.2%) ligation. Fasciotomies were performed in 23 (19.2%) patients. Outcomes of the study were as follows: 120 patients survived and the overall survival rate was 96.8%, adjusted survival rate excluding intraoperative deaths was 100%, overall limb salvage/amputation rate was 95.1%/4.9%, and adjusted limb salvage/amputation rates excluding intraoperative deaths were 98.3%/1.67%. Univariate analysis showed the mean ischemic times for survivors as 5 ± 3.1 hrs (300 ± 186 min) versus ischemic times for non survivors as 3 ± 2.2 hrs (180 ± 132 min) (P = 0.017); Injury Severity Score (ISS) (P = 0.002); and estimated blood loss (EBL) (P = 0.024). Logistic regression identified independent predictors of outcome for survival: MOI: penetrating [P = 0.015, RR - 4.29, 95% CI: 1.49-12.36]; Glasgow Coma Score < 7 [P < 0.001, RR - 21.71, 95% CI: 9.37-50.32]; ISS > 15 [P < 0.005, RR - 4.98, 95% CI: 1.68-14.73]; and patients not requiring ED thoracotomy [P = 0.009, RR - 7.48, 95% CI: 2.58-21.69]. CONCLUSIONS: Brachial artery injuries are rare. For patients not requiring ED thoracotomy, Glasgow Coma Score, ISS, and EBL predicted survival. The adjusted limb salvage rate was 98.3%. Patients with brachial artery injuries die from associated injuries, experiencing less ischemic times than survivors who are able to undergo repairs.

Brachial Artery Pseudoaneurysm After Supracondylar Humerus Fracture: A Case Report.

CASE: A 9-year-old boy with a widely displaced Type-III supracondylar humerus fracture presented with a painful mass at the antecubital fossa after pin fixation. Exploration of the mass caused bleeding from a brachial artery pseudoaneurysm that necessitated repair with a saphenous vein graft. Six weeks later, the fracture had healed without complications. CONCLUSION: We describe an unusual presentation of a pediatric supracondylar humerus fracture that highlights the importance of including vascular injury in the differential diagnosis for similar presentations.

Acute Upper Limb Ischemia Due to Delayed Presentation of a Brachial Artery Pseudoaneurysm Post-Venipuncture.

Brachial artery pseudoaneurysms (BAPs) are rare but could lead to complications of high morbidity. We report a case of a BAP presenting with hand ischemia and median nerve neuropathy nearly a decade after the inciting iatrogenic trauma, successfully treated with excision and direct repair. This report highlights that untreated pseudoaneurysms can be indolent and present late with both symptoms of embolization and local compression.

Through Thick or Thin: Disparities in Perioperative Anticoagulant Use in Trauma Patients.

Although vascular surgery guidelines recommend immediate anticoagulation for acute occlusion of a peripheral artery, it is unclear whether trauma surgeons follow this practice. A survey regarding the use of perioperative anticoagulation was sent to surgeons who perform their own peripheral arterial repairs after traumatic injury to define contemporary practice patterns. This survey demonstrated minimal consensus opinion regarding the management of extremity vascular injuries, strongly suggesting the need for a consensus conference, meta-analysis, and prospective studies to guide further care.

Critical errors in infrequently performed trauma procedures after training.

BACKGROUND: Critical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors. METHODS: In a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts. RESULTS: Resident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error. CONCLUSION: Low trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.

Management of the Pediatric Pulseless Supracondylar Humeral Fracture: A Systematic Review and Comparison Study of "Watchful Expectancy Strategy" Versus Surgical Exploration of the Brachial Artery.

BACKGROUND: Pulseless hand after a supracondylar humeral fracture (SHF) in children is well known in the bibliography. Although things are clearer in the management of a "pale pulseless hand," controversy still exists about the "pink pulseless hand" (PPH). METHODS: We reviewed the literature from the electronic database PubMed for studies with main object the vascular injuries after SHF in children and especially the pulseless hand. The primary search terms were "supracondylar humeral fracture" and "vascular injuries". In our final study, 16 articles were gathered and analyzed. RESULTS: We collected 608 pulseless SHFs, regardless of the vascular status, 203 PPHs, and 109 pale pulseless hands. We compared two different strategy methods when the hand remained pulseless after the reduction and fixation of the fracture: (1) the close observation strategy and (2) the surgical exploration of the artery. The close observation strategy was the treatment of choice in PPH, whereas the surgical exploration of the brachial artery was mostly performed in pale pulseless hands. CONCLUSIONS: Closed reduction and fixation of the fracture should be the priority in all pulseless SHFs, both pink and pale. In poorly perfused pale hands, after the reduction and fixation of the fracture, there is a chance that radial pulse may return (we found that this chance is approximately 30%). If not, immediate surgical exploration of the artery is strongly indicated. In well-perfused pink hands, the traditional dogma of "watchful waiting" should not be revisited as long as no signs of deterioration of the vascular status appear. LEVEL OF EVIDENCE: Level I-Systematic review of level I studies.