title: Hand ischemia associated with elbow trauma in children.
abstract: OBJECTIVE
  Previous observational studies suggest that children with hand ischemia following elbow trauma can be safely observed if Doppler signals are present in the wrist arteries (pink pulseless hand, PPH). Nonoperative management of PPH is predicated on the assumption that PPH results from local arterial spasm, but the mechanism of arterial compromise has not been investigated. We hypothesized that PPH signifies a brachial artery injury that requires surgical repair.
  
  
  METHODS
  Retrospective review of operations performed on children with hand ischemia following elbow trauma at a level I trauma center pediatric hospital.
  
  
  RESULTS
  Between 2003 and 2010, 12 children (seven males, mean age 7.4 years) underwent brachial artery exploration for hand ischemia following elbow trauma (11 supracondylar fractures, one elbow dislocation) due to falls (n = 10) or motor vehicle crashes (n = 2). At presentation, three subjects had normal radial pulses, eight subjects had Doppler signals but no palpable pulses, and one had weak Doppler flow with advanced hand ischemia. Six of the nine subjects without palpable pulses also had neurosensory changes. All 12 subjects underwent brachial artery exploration either initially (n = 2) or following orthopedic fixation (n = 10) due to persistent pulselessness. At operation, eight of 12 patients (67%) had focal brachial artery thrombosis due to intimal flaps, and four had brachial artery and median nerve entrapment within the pinned fracture site. At discharge, all 12 subjects had palpable radial pulses, but three with entrapment had dense median nerve deficits. One of the three subjects with dense neurologic deficit had complete recovery of neurologic function at ten months. The other two subjects had residual median nerve deficits with partial recovery at 5 and 6 months follow-up, respectively. No patient developed Volkman's contracture.
  
  
  CONCLUSIONS
  Brachial artery injuries should be anticipated in children with hand ischemia associated with elbow trauma. Neurovascular entrapment at the fracture site is a possible complication of orthopedic fixation. Absence of palpable wrist pulses after orthopedic fixation should prompt immediate brachial artery exploration. PPH should not be considered a consequence of arterial spasm in these patients.
authors.affiliation: Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390-9157, USA.
authors.forename: Pavan
authors.initials: P
authors.lastname: Brahmamdam
authors.forename: Mitchell
authors.initials: M
authors.lastname: Plummer
authors.forename: J Gregory
authors.initials: JG
authors.lastname: Modrall
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Megison
authors.forename: G Patrick
authors.initials: GP
authors.lastname: Clagett
authors.forename: R James
authors.initials: RJ
authors.lastname: Valentine
mesh_terms: D000368:Aged; D001916:Brachial Artery / Q000293:injuries* / Q000503:physiopathology / Q000601:surgery; D004551:Elbow Joint / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D005592:Fracture Fixation / Q000009:adverse effects; D050723:Fractures, Bone / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D006225:Hand / Q000098:blood supply*; D006776:Hospitals, Pediatric; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D008297:Male; D009408:Nerve Compression Syndromes / Q000209:etiology; D017534:Radial Artery / Q000503:physiopathology; D011859:Radiography; D012042:Registries; D012189:Retrospective Studies; D013781:Texas; D014193:Trauma Centers; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014656:Vascular Surgical Procedures; D057772:Vascular System Injuries / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D000092464:Elbow Injuries