Pseudo-aneurysm of the brachial artery after reduction and fixation of a displaced supracondylar elbow fracture in a child

INTRODUCTION: About 10% of supracondylar humerus fractures in children are associated with distal ischemia. In case of acute limb ischemia after reduction and fixation, it is recommended to explore the brachial artery surgically without delay. However, there is no consensus on the management of intermediate situations, like a perfused hand with a weak pulse after fracture fixation.CASE REPORT: A 6 years old boy presented a displaced Gartland type III supracondylar humerus fracture with no radial or ulnar pulse and hand ischemia. Immediately after closed reduction and internal fixation, the pulses were still missing. A Duplex ultrasound of the radial artery showed an arterial flow, although diminished compared to the contralateral limb. Ten minutes later, a weak radial pulse was noticed and the hand perfusion was progressively increasing. Therefore, we suspected an arterial spasm. At 48 hours, distal pulse was present and the saturometer showed 98% of O2. The patient was discharged. At day 11, the patient complained about a painful tumefaction above the elbow. An injected CT-scan showed a pseudo-aneurysm of the brachial artery surrounded by an hematoma. Forearm arteries were patent. The injured segment of the brachial artery was resected and replaced by a venous graft. At 2-month follow up, there were no vascular or cutaneous complications, Duplex ultrasound examination was normal and the fracture was healed.DISCUSSION: This case highlights a "grey zone" between complete ischemia and complete recovery after supracondylar fracture fixation with initial ischemia. In such situations, a full duplex ultrasound examination, or a contrast CT-Scan of the upper limb arteries seem appropriate.