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June 24, 2015

New AAOS guidelines, mobile app outline steps for treating rare, yet potentially devastating, child elbow fractures with vascular injury

ROSEMONT, Ill.- New guidelines from the American Academy of Orthopaedic Surgeons (AAOS) outline steps for assessing and treating child elbow fractures with vascular injury, a rare yet potentially devastating condition that if not treated quickly and appropriately, can result in permanent damage and loss of function in the arm and hand. The Appropriate Use Criteria (AUC) for Supracondylar Humerus Fractures with Vascular Injury is available on the Academy’s website, and through the OrthoGuidelines mobile app .

Child supracondylar humerus fractures (fractures above the elbow joint) are among the most common elbow injuries, typically requiring reduction (realignment) and pinning to stabilize and return the arm and elbow to full function. In some instances, the injury also damages the arm’s vascular system, diminishing blood flow (perfusion) resulting in a hand that either is warm and red, or white and cold, without a pulse.

“When physicians face one of these cases, which may be once in a blue moon, it can be uncomfortable deciding what the next steps should be,” said James O. Sanders, MD, former chair of AAOS AUC within the Committee on Evidence-Based Quality and Value. “These criteria are really meant to help doctors in the heat of the moment. No one sees enough of these to become a true expert in how to deal with them.”

Depending on the patient’s vascular status and perfusion, the orthopaedist is directed to next steps and possible interventions. For example, if the child has a suspected vascular injury after the fracture has been pinned and set, but the hand is warm and red with a pulse, in-hospital observation is recommended without intervention. In all situations where the hand is without a pulse, the criteria recommend that the child be assessed by a vascular surgeon, or immediately transferred to a facility with such expertise.  If the hand is white without a pulse, the AUC recommends consideration of removing the fixation and possibly obtaining an angiogram.
“As the surgeon goes through the AUC steps, their decisions are assisted to treat the patient appropriately in the heat of the moment,” said Dr. Sanders. “If something doesn’t work, the criteria identify another process.
“The American Academy of Orthopaedic Surgeons takes patient safety very seriously,” said Dr. Sanders
This is one of the more important AUCs, meant to really help in an acute situation, and to ensure that the child who has this is going to be OK.”
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