72.8 Forearm traction fails to restore the pulse of a child with a supracondylar fracture

This is the child whose supracondylar fracture is complicated by ischaemia of his forearm. He is unlucky in that signs of ischaemia persist, even with his arm extended in forearm traction and any tight cast or bandage removed. Take him to the theatre. There are two things you can do: (1) You can release the tension in his antecubital fossa and relieve the pressure on his vessels. (2) You can decompress his forearm muscles to relieve the compartment syndrome (73.7)., Opinions vary as to which of these is the most important. Releasing the tension in his antecubital fossa is easier and may be all that is necessary. Don’t delay; a wait of 3 or 4 hours may make all the difference between a normal and a totally useless arm. If you act promptly his prognosis is likely to be good. Don’t try to inspect or repair his brachial artery—this is a highly skilled task, it is rarely necessary, and, because the collateral circulation round the elbow is so good, a blocked brachial artery does not necessarily cause Volkmann’s ischaemic contracture.

OPERATING FOR ISCHAEMIA

Don’t explore the child’s antecubital fossa until you have tried to reduce the fracture, because this may itself be enough to improve the circulation his arm.

Make the lazy ’S’ incision as in A, Fig. 72-12, beginning above the flexor crease on the inner border of his biceps tendon.

Figure 72.12: EXPLORING THE ANTECUBITAL FOSSA. Don’t explore the child’s antecubital fossa until you have tried to reduce the fracture, because this may itself be enough to improve the circulation his arm. After Campbell permission requested.

Pull back the flaps, incise his tight deep fascia and his bicipital aponeurosis (B). Pale or blue–black muscle will bulge from the wound. There may be a tight haematoma. Remove it. This may be enough to relieve the obstruction and restore his circulation.

CAUTION! Don’t meddle with his brachial artery, or try to resect the spastic section.

DECOMPRESSING A CHILD’S FOREARM MUSCLES if the above methods fail, and his forearm is swollen, carry the Incision down through it, as in Fig. 73-11. Slit his deep fascia in the length of the incision. Pale oedematous muscles will burst through the slit fascia. Decompress the superficial and deep volar compartments of his arm, as in Section 73.7.

POSTOPERATIVE CARE Leave the flaps open, and dress the child’s wound. Don’t sew it up. If the fracture is not reasonably reduced, apply forearm traction. If it is reduced, apply a collar and cuff.

Skin graft the wound after 4 days. If a contracture develops, see Section 72.10.