2 Pediatrics CASES
CASE 2
A 6-year-old boy fell from the monkey bars a few hours ago and had immediate pain and deformity of his elbow. He was seen at his local ER which transferred him to your Level 1 pediatric trauma center for further evaluation and treatment. On arrival at midnight, he complains of pain at the elbow but not anywhere else. He reports normal sensation in the hand. His hand is warm and well-perfused, but you cannot feel a radial pulse. His motor examination is
intact. X-rays reveal a type III supracondylar humerus fracture. Your next step in management is:
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Apply a splint and discharge to home, have patient return in the morning for surgery.
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Apply a splint and admit to the floor for surgery as an add-on to the end of the OR day tomorrow, ask nurses to do neurovascular checks every shift.
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Apply a splint and admit to the floor for serial neurovascular checks every couple of hours with an early first case start in the morning.
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Call the OR and demand to bump the urgent appendectomy that is going into the OR in a few minutes.
Discussion
The correct answer is (C). The child has a pulseless, but perfused supracondylar humerus fracture. Given the potential vascular status change that could occur, close monitoring is imperative. Since the hand is perfused, it is not an emergency (thus choice D is incorrect). The child does need to be monitored closely with vascular status checks every few hours, so sending the child home or having a nurse do checks only once every shift is not sufficient monitoring, since you then may have a delay in recognizing decreasing perfusion to the hand. Thus, answer C is correct— the patient should be splinted, admitted, and closely monitored. Should there be a decline in vascular status, the patient should be taken emergently to the OR. Some surgeons would prefer to take the child to the OR as soon as possible rather than waiting until the morning, but that is surgeon preference.
You get an early start time, and the child is in the OR by 7 AM. The child was monitored by nursing and the on-call resident every 1 to 2 hours overnight, and the hand remained warm and well-perfused. There is still no pulse preoperatively. In the OR, the child is placed under general anesthesia. After positioning, prep/drape, and time-out, you proceed with fracture reduction. You perform the milking maneuver and then traction to bring the fracture out to length. You then perform the reduction maneuver to reduce the distal fragment to the shaft. You obtain AP, lateral, and column views with the fluoroscan, and the fracture is anatomically reduced. You stabilize the fracture with three lateral k-wires with at least 2 mm of pin spread at the fracture site and bicortical purchase. You then obtain additional images to ensure the fracture fixation is stable, and you note that there is not a gap anteriorly at the fracture site. The hand remains warm and well-perfused with brisk cap refill once you extend the arm out of the flexed position that it was in for pinning. You still do
not feel a radial pulse.
Your next step in management is:
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Explore the brachial artery.
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Perform an angiogram.
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Monitor the patient in the OR for an hour, and if the pulse does not return, explore the artery.
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Splint the arm and monitor the child in the PACU for an hour—if the examination is stable postoperatively, compared to preoperatively, child can be discharged to home.
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Splint the arm and monitor the child in the hospital for at least 24 hours with frequent, regular vascular checks to ensure no decline in perfusion.
Discussion
The correct answer is (E). Immediate exploration of the brachial artery is not indicated if the child’s hand has remained warm and well-perfused. An angiogram also is not indicated. Studies have shown that a perfused hand immediately post-op can change, and the limb can become dysvascular postoperatively. Children with a pulseless, but perfused supracondylar fracture are therefore monitored for 24 to 72 hours postoperatively in the hospital before discharge to ensure that if there is vascular change or issues with swelling, this is caught and acted upon as soon as possible.
About 12 hours after the patient was taken to the recovery room, you are paged by the floor nurse. He report that the child has been requiring increasing frequency of pain medication since the postoperative check and has maxed out on what you ordered. On examination, the child appears anxious. You find that the splint is not too tight. Hand is warm and well-perfused with brisk cap refill; there is still no radial pulse. Sensory examination is stable compared to preoperative examination. There is increased pain when the fingers are passively extended. You look back over the medication record and see that initially no pain medication was required, but since about 3 hours post-op, the patient has been requesting it with increasing frequency.
What do you do next for management?
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Apply ice to the forearm and elbow regions.
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Elevate the arm so hand is as high above the heart as possible.
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Obtain an MRI to assess the soft tissues and the fracture reduction.
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Return to OR to measure compartments and fasciotomy.
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Increase pain medication dose and check on patient every 2 hours to ensure that sensory and motor examination remain stable.
Discussion
The correct answer is (D). The clinical scenario presented is consistent with compartment syndrome. Bae showed that in children, pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome. An increasing analgesia requirement was a more sensitive indicator of compartment syndrome—particularly when combined with clinical findings such as pain with passive range of motion, anxiety and agitation, as seen in this patient. Compartment syndrome is an emergency and therefore ice, elevation, and more pain medication will only serve to mask/worsen the problem. An MRI is not indicated nor helpful in this scenario. For this child, you would return to the OR for compartment pressure checks and releases to prevent further damage from compartment syndrome.
Objectives: Did you learn...?
Evaluation and initial treatment of a pulseless supracondylar humerus fracture?
Differences in management between pulseless and perfused versus pulseless and nonperfused scenarios?
Management of the persistent pulseless, but perfused limb after fracture reduction?
Signs of compartment syndrome in children?