The neurovascular status must be examined in patients with
supracondylar fractures. Avoid treating the patient with a cast that may cause
hyperflexion of the elbow. Bending the elbow too much may affect the brachial
artery. It may not be acceptable to reduce the fracture at 90° of elbow flexion. In
these cases, choose a different alternative to casting, such as pinning (closed
or open technique).
It is important to remember that Volkmann’s ischemic
contracture may occur due to injury to the brachial artery. You have to make
sure that you restore the circulation.
A few scenarios to go over
1.
The Patient has good circulation with no radial
pulse (hand perfused)
a.
In this case, you would do a closed reduction
and pinning as well as in-patient monitoring for 24-48 hours in order to assess
the circulation of the extremity
2.
Cold Cyanotic Hand (no perfusion or you may have
underperfusion)
a.
This
may occur before or after attempting reduction
b.
The
patient must immediately go to the operating room for closed or open reduction
and pinning (No matter if the hand is underperfused or perfused at all)
c.
Monitor
the circulation for anticipation of improvement
d.
If
there is no immediate improvement, explore the antecubital fossa in order to
explore the brachial artery
e.
Have
the help of a vascular surgeon
f.
Assess
the circulation
You want to think of this scenario like a knee dislocation. If you have
pulses or no pulses with a knee dislocation, then you reduce the knee
dislocation. It is the same with supracondylar fractures: pulses or no pulses,
pink or not pink hand, cold cyanotic hand—do closed reduction and pinning. It
is a more urgent condition if there are perfusion problems.
3.
Perfusion
Disappears During Reduction or Monitoring
a.
If the
perfusion gets worse after reduction of the fracture, then you need to find out
what has happened.
b.
You
will need to perform an open exploration and without an arteriogram
4.
Circulation
Disappears After Closed Reduction and Pinning
a.
Reduction
caused harm to the patient
b.
The
pins need to be removed, the fracture needs to be unreduced and check the
circulation.
c.
Check
to make sure that the neurovascular bundle does not become trapped in the
fracture gap after closed reduction and pinning.
