Keywords
deep vein thrombosis - humeral fractures - thrombosis - venous thromboembolism - child
Introduction
Humeral supracondylar fractures represent one third of all pediatric limb fractures
in children under 7 years old, and are a cause of significant morbidity in the pediatric
population.[1]
[2]
The complications most frequently encountered in this setting include neurovascular
injuries, compartment syndrome, malunion, and functional impairment.[1]
[2]
Nerve and vascular injuries can be iatrogenic, or they may occur after a traumatic
event. Vascular compromise can be caused by vessel rupture, kinking, compression,
spasm, or intimal lesion, and the incidence increases according to the degree of fracture
dislocation.[3]
The overall incidence of vascular complications associated with supracondylar fractures
ranges from 3,2 to 14,3%, but may be as high as 20% in Gartland type III fractures.[3]
[4] Upon inspection, ecchymosis in the antecubital fossa with skin and brachialis tethering
are warning signs of neurovascular damage.[4] Although the incidence and management of arterial injuries in supracondylar fractures
is well established in the literature, little has been said about vein compromise.
Venous thromboembolism (VTE) in children is rare, ranging from 0.01% to 0.2% of pediatric
hospitalizations; higher rates are observed in specific groups, including those with
central venous catheters (CVC), malignancies, obesity and those submitted to major
surgeries.[5]
[6]
In pediatric trauma patients, the risk of developing VTE is uncertain. The severity
of the injury, increasing age, anemia, external fixation, obesity, length of hospital
stay, postoperative complications, spinal cord injury and the presence of a CVC are
well known risk factors in this population.[6]
[7]
[8] Some anatomical locations are also more prone to thrombotic events, that is, trauma
to the head, the spine or major vessels, as well as pelvic and lower limb fractures.[8]
We report a case of humeral vein thrombosis after a supracondylar fracture in a child,
given its rarity and difficult diagnosis, considering its potential complications.
Case Report
A 7-year-old girl was transferred to our emergency department after a fall with an
outstretched arm which resulted in a supracondylar fracture of the left humerus, Gartland
type III ([Fig. 1]). She had been previously immobilized with a posterior splint at an outside hospital.
Fig. 1 Radiograph of the supracondylar humerus fracture (Gartland type III).
Upon presentation, she complained of pain and had a cold and reddish forearm, with
a peripheral oxygen saturation of 89% to 90% and weak palpable radial and ulnar pulses
([Fig. 2]).
Fig. 2 Ecchymosis in the antecubital fossa.
After splint removal, the pain subsided, she had a weak radial pulse, normal capillary
refill, and the hand oximetry reached 98%. On an emergency basis, the patient underwent
a smooth manipulation with closed reduction and pinning with 2 divergent lateral Kirschner
wires and immobilization in a posterior splint at 120° of flexion ([Fig. 3]). Six hours postoperatively, the child had a pain-free and warm upper extremity,
a peripheral oxygen saturation of 100%, and palpable distal pulses.
Fig. 3 Closed reduction and fixation with two percutaneous Kirschner wires.
At 48 hours following surgery, there was persistent pain and progressive tender edema
with skin blistering ([Fig. 4]). The peripheral pulses were normal, and there was no pain exacerbation, with passive
mobilization of the fingers. After excluding compartment syndrome, a venous duplex
ultrasonography was performed, which revealed deep venous thrombosis (DVT) of the
humeral vein.
Fig. 4 Edema and blistering of the skin 48 hours postoperatively.
Treatment with 20 mg of subcutaneous low-molecular-weight heparin was initiated and
maintained for 3 months. One week after surgery, the child was pain-free, with edema
improvement, and was discharged from the hospital. At 3 months of follow-up, the fracture
had healed healed, and the elbow had full range of motion (0° to 120°), without additional
skin or vascular complications ([Figs. 5] and [6]). There were no embolic events. The studies conducted were negative for thrombophilia.
Fig. 5 Range of motion at three months of follow-up.
Fig. 6 Intact skin and full extension at three months of follow-up.
Discussion
The management of supracondylar fractures of the humerus can be demanding. Early complications
include damage to neurovascular or muscular structures and compartment syndrome.[9] Neurological injuries, most frequently in the form of neuropraxia, are common (~
20%), affecting mostly the median nerve and its anterior interosseous branch.[3]
[9] The most disastrous injuries are vascular, for, when left untreated, they can lead
to neurologic deficits, muscle stiffness or Volkmann ischemic contractures.[9] Hardware-related complications and malunion sequelae are usually later events.[9]
According to the literature, pediatric trauma patients have a prevalence of VTE of
0.3 to 0.8 for every 1,000 trauma discharges.[7] In addition, emergent or urgent surgeries are more likely to result in VTE than
elective procedures.[6]
For the diagnosis, clinical suspicion is needed and a detailed vascular examination
is crucial, with assessment of pulses, temperature of the limb, capillary return and
pulse oximetry.[3] The use of intraoperative or postoperative ultrasound is also helpful to assess
the patency of the vessels.[4] In some cases, pulse oximetry waveform can be used to determine the need for vascular
exploration.[10]
The sequelae of VTE, namely postthrombotic syndrome, death, and the risk of recurrence
have not been fully investigated in children.[5] The morbidity of DVT depends on the location and and severity of the injury, inducing
mainly pain and swelling when in the extremities.[5]
In children, VTE is associated with increased mortality, particularly among the younger
patients, and it varies from 1% to 8%.[5]
[6] Guzman et al.[7] searched for an association between VTE and mortality in children, and they concluded
that patients with upper-limb fractures and VTE had the highest overall mortality
rate (6.4%). This increased mortality is thought to be due to a delay in diagnosis
and treatment (owing to a lower index of suspicion) and/or because of the anatomical
proximity of the upper-extremity veins to the right-sided chambers of the heart.[7]
The rationale to identify the groups at risk of developing VTE among children is to
prevent death secondary to pulmonary embolism.[7] Currently, there is no consensus for thromboprophylaxis in the pediatric field,
nor risk-stratification for VTE.[5]
[6]
Given the rare incidence of VTE in this age group, delays in diagnosis are frequent.
In the case herein reported, the edema, skin coloration and blistering were crucial
to raise suspicion. So far, there are many studies focusing on arterial and nervous
complications, but none about venous thromboembolism in this setting.
The aim of the present case report is to raise attention to a rare vascular complication
of a humeral supracondylar fracture. To our knowledge, the present is the first report
of this complication.
All orthopedic surgeons must be aware of the existence of upper-extremity DVT to make
an early diagnosis.
We, therefore, recommend a detailed neurovascular examination before and after surgery,
and, if the clinical suspicion is high, an evaluation with Doppler sonography.
