Arterial Reconstruction Using the Basilic Vein from the Zone of Injury in Pediatric Supracondylar Humeral Fractures: A Clinical and Radiological Series

Abstract

The authors describe the advantages of using the basilic vein as an arterial conduit in the management of children with supracondylar humeral fractures requiring vascular repair. Eight children, aged 3 to 10 years, presented with supracondylar humeral fractures and vascular injury. In all eight children, the arteries were successfully reconstructed with a reversed, interposition basilic vein graft harvested from the ipsilateral arm. The basilic vein was anatomically consistent with few side branches and was an excellent size match for the brachial artery. There were no postoperative thromboses. At a minimum follow-up of 1 year, all children had palpable radial pulses and the vein grafts were patent with no anastomotic or other focal stenoses. This series confirms the safety of using a donor vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. Benefits include a single surgical wound on the less conspicuous medial side of the arm, reduced operating time, and preservation of donor veins that may be subsequently required for the management of atherosclerotic disease.

Microsurgical reconstruction of brachial artery injuries in displaced supracondylar fracture humerus in children

“…4,9 More than 95% of these fractures are displaced in extension, which may lead to a variety of neurological and vascular complications. 1 In this series all the supracondylar fractures were extension type and the mechanism of injury was falling on the outstretched arm. Louahem et al 15 reported that 29 patients (14%) out of 210 children suffering from severely displaced supracondylar fracture humerus had vascular complications.…”

“…Louahem et al 15 reported that 29 patients (14%) out of 210 children suffering from severely displaced supracondylar fracture humerus had vascular complications. Skaggs and Pershad 1,16 reported that the incidence of vascular injury of displaced supracondylar fractures has ranged from 3 to 12% of patients. Campbell et al 6 reported that 38% of their cases had evidence of injury to the brachial artery.…”

“…It has big value in doubtful cases, specially cases with absent radial pulse and pink hand. Many authors 1,[25][26][27] recommend surgical exploration of a suspected brachial artery injury in contrast to conservative approach recommended by others. 6,[17][18][19] A further advantage of surgical exploration is that the fracture can be reduced under direct vision, thereby avoiding further damage to the neurovascular bundle.…”

“…The management of a child with an absent radial pulse following closed reduction remains controversial. 1,18 Many surgeons are reluctant to explore a supracondylar fracture with neurovascular deficit because the limb is usually not threatened, 6,17,19 while others recommend brachial artery exploration in cases of white pale hand, 20 but it is clear that a significant arterial injury may exist without a detectable change in distal pulse or evidence of ischemia. 21 In this series the main indication for exploration of the brachial artery was absent radial pulse either after closed reduction and percutaneous pinning or in cases with high risk of brachial artery injury as in open fractures, brachialis muscle tethering, and sever elbow swelling.…”

“…More than 95% of all supracondylar fractures are displaced in extension either in a posteromedial or posterolateral direction. 1,2 Rarely anterior displacement of the distal humeral fragment results from flexion forces created by a fall directly on the olecranon. 3,4 Clinical evaluation of a child with a potential supracondylar fracture includes a comprehensive history and physical examination of both the entire upper extremity and the rest of the child to rule out a concomitant injury.…”