无脉性粉色手综合症:电动机的方法和流程图,感觉和血管检查

文摘

髁上的肱骨骨折是最常见的儿童肘部损伤,包括60%的儿童肘部损伤。肘部和前臂骨折应怀疑孩子使用上肢肘关节疼痛或失败后下降。骨折通常发生在弱metaphyseal骨近端窝。仔细检查整个手臂应该执行,用温柔和任何区域或肿胀应该x光照片作为多个断裂(如髁上的裂缝和半径/尺骨骨折)并不少见。彻底电机、感觉和血管考试应该执行,困难在儿科组但是应该尝试并记录准确。评估血管状态在肱骨髁上的骨折是重要的多达20%的流离失所的骨折伴有血管妥协。在这里,我们提出一个病例报告的7岁女孩持续扩展类型髁上的肱骨骨折与无脉动的粉红色的手。紧急操作进行,但不成功,后刺切口被使用骨峰值减少骨折碎片。据我们所知,有各种各样的治疗方法和流程图的血管妥协伴随各种相关的风险和并发症没有特定的协议。

介绍

儿童肱骨髁上的骨折的发病率由于畸形愈合,神经与血管的并发症和筋膜室综合征。这些骨折是最常见的在不到10岁的儿童,5岁之间发病高峰,8年,这些骨折通常需要手术1]。扩展断裂占大约98%的伤害,他们通常发生的结果落在伸出的手和腕背屈和肘部在过伸或轻微弯曲。在过伸,线性力作用在扩展肘部由联锁转化成弯曲力的鹰嘴窝。的metaphyseal骨小梁在这个领域是薄因此可以产生裂缝的一支重要力量。肘部与髁上的肱骨骨折的特点是肿胀和畸形。移位性骨折,肘部的S形畸形发展由于测角和翻译的骨折碎片前骨膜眼泪。射线照片,鲍曼的角度将改变与正常10 - 20度,和脂肪垫(前部和后部)将看到迹象。注意运动和感觉考试应该被记录下来。血管检查应该包括脉冲,温暖、毛细血管再充盈和手的颜色以及床头多普勒和脉搏血氧计监测。

分类

髁上的肱骨骨折

1。扩展名类型

2。弯曲型

修改Gartland的分类

类型1:< 2毫米的位移

类型2:铰链后方

类型3:流离失所

类型4:替换为扩展和弯曲

病例报告

7岁的女孩来到伤亡约2点与髁上的扩展类型肱骨骨折后肢体降至大约2.5英尺的高度在她居住在下午6点左右。她立即被送往当地的医生做了初步评估和x射线CT血管造影术。桡动脉并不觉得周边的感觉也都完好无损。肘板上方的应用,被称为KLE医院血管损害的进一步管理视图(2]。病人是有意识的和面向时间地点和人,血液流动稳定。她提出了一个封闭的扩展类型的骨折。没有皱纹。小心电机、感官和血管评估做了牺牲品。所有的径向运动和感觉功能,中位数和尺骨神经完好无损。灌注血管检查得出结论,手很好(温暖、红色)与桡动脉脉搏缺席。外面CT血管造影报告non-visualization 61毫米肱动脉段上方的分歧表明横断面肱动脉(3]。紧急情况无法进行整形,整形手术团队。操纵闭合复位是尝试,但没有成功。后刺切口被飙升的帮助下,骨折碎片试图减少但骨折碎片是下滑。前切口是在整形手术团队肘的窝的筋膜切开术(4]。的解剖是发现骨折碎片之间的肱动脉被侵犯以及肱二头肌肌肉,没有横断肱动脉。肱动脉被释放后的撞击释放桡动脉脉搏感到骨折碎片与k-wires减少交叉的,分别从外侧和内侧(5]。高于肘板应用和她进行了过程。病人在观察24小时;她的汽车和感官评估再次评估和建议后随访6周(数字1 - 5)。

结果

桡动脉是立即就感到释放冲击和断裂是减少。固定左上肢的建议。病人随访6周后,重复x光拍摄令人满意和K-wires被移除。物理治疗和患者开始恢复了全方位的运动在左肘关节与所有神经与血管的状态完好无损,没有畸形(图6和7)。

讨论和结论

肱动脉损伤是高度在髁上的肱骨骨折、移位的风险,因为它经常被拉伸/弯折/切断的移位性骨折碎片之间的二头肌brachii或骨折碎片。由于尺骨端拘束supratrochlear动脉肱动脉是在更高的风险。肘关节周围的侧枝循环有助于保持四肢的血管分布,因此患者往往没有任何血管勘探管理。径向复发性动脉远侧地出现肘与径向股深brachii的抵押品分支吻合。优越的尺骨抵押品动脉,下行抵押品,源自于肱动脉吻合后尺骨复发和劣质尺动脉抵押品。血液供应受损或被忽视的血管妥协可能土地到麻烦像福尔缺血并发症。神经与血管的妥协可能复杂化流离失所髁上的骨折在10%到20%的情况下。Gartland类型III受伤需要关注关于血管损伤值和前骨间的神经是最常受伤的扩展类型。大多数外科医生管理通过闭合骨折复位,其次是稳定往往交叉柯式(K)电线和桡动脉脉搏立即返回。在病人,近端骨折碎片的边缘和二头肌brachii造成肱动脉的弯折,导致无脉性肢体。 There was formation of multiple collateral blood vessels, bypassing the major artery to supply the distal hand, and thus preventing ischemic gangrene of the upper limb. Apart from the clinical assessment, various tools and imaging methods such as Doppler ultrasound and angiography could aid in a detailed vascular assessment. Doppler ultrasound could be performed rapidly at the bedside for vascular assessment and estimation of the severity of the vascular injury. Hence, we believe that before proceeding further for any modality these three points should be noticed likewise, presence of radial artery Doppler signals, presence of good pulse oximeter waveforms and oxygen saturation >95% and intact Median Nerve function. Computed tomography (CT) angiography done showed a report about transection with turned out to be an impingement which was later identified and located at the fracture site intraoperatively. CT angiography still played a role in cases where pre-operative planning was needed, such as in complicated injuries with comminuted fractures or suspected segmental artery injuries. In patient with vascular compromise due to a displaced supracondylar humeral fracture, the consensus was to track and reduce the fracture gently. The maneuver of flexing the elbow up to 45 degree and gentle traction could relieve the pressure from the anterior structures, potentially separating the sharp edges of the proximal fracture fragment from the neurovascular structures, hence improving the perfusion. If the fracture was not reduced, and there was a vascular compromise, an open reduction and exploration of the brachial artery would be indicated. Similarly, if the vascular assessment showed a pale and pulseless upper limb, an open reduction and exploration of the artery would also be indicated. In the patient, a trial of manipulation was done but the fracture fragments were slipping and not reducing which later on turned out that a good stretch of brachial artery was struck at the fracture site and bicep brachii. Hence, we believe that a trial of manipulation should be given along with a posterior stab incision could be useful in cases where the reduction is not sustained as it’ll be helping even if the upper limb is going further in compartment syndrome and vascular compromise depending upon the time of patient’s presentation to ER.

引用

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