Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children

Editor's Choice - International Perspective on Extremity Vascular Trauma in Children: A Scoping Review

OBJECTIVE

Extremity vascular trauma in children can result in significant morbidity and mortality. Most published studies have focused on supracondylar humeral fracture related injuries, with little focus on other injuries. This scoping review describes the current state of knowledge on paediatric vascular injuries in the upper and lower limbs, excluding injuries related to supracondylar humeral fractures.

METHODS

MEDLINE, PubMed, Web of Science, and Cochrane databases were searched for relevant studies evaluating the epidemiology, diagnosis, management, and outcomes of upper and lower limb vascular trauma in those aged under 18 years. Studies related to supracondylar humeral fractures were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews was used.

RESULTS

A total of 39 studies was included, all of which were retrospective, and 74% of which were based in North America or Europe. Extremity vascular trauma was reported to cause 0.6 - 4.4% of all paediatric trauma admissions, with penetrating mechanisms and upper limb injuries being the most common. Operative intervention was reported in 80 - 100% of children in the included studies. Primary repair was the most commonly reported operative intervention, followed by interposition graft and bypass graft. Synthetic graft use was less commonly reported (incidence range 0.5 - 33%). Lower limb fasciotomies and amputations were not commonly reported (incidence range 0 - 23% and 0 - 13%, respectively). The mortality rate appeared low, with 23 studies reporting no deaths (incidence range 0 - 4%). Complications were reported inconsistently, with no uniform outcome or follow up measures used.

CONCLUSION

The incidence of extremity vascular trauma appears low in children, with penetrating mechanisms and upper extremity injuries appearing to dominate. Most studies are from high income countries, with probable selection bias towards those treated by operative intervention. Prospective studies are required focusing on patterns of injury, rates of operative and endovascular intervention, and long term outcomes.

Management of upper extremity arterial penetrating vascular trauma

Penetrating vascular injuries in the upper extremity are relatively uncommon; suboptimal treatment may result in significant morbidity including amputation. Arterial trauma accounted for 68% of amputations (24% in the upper extremity) during World War II. Although surgical techniques including microsurgical principles have matured, results vary secondary to the mechanism of injury, systemic factors, anatomic considerations and physiologic events. This annotated review article is based upon the literature and the author's 42 years of vascular trauma experience including over 1500 revascularizations and replantations. It discusses the complex interplay of associated injuries; the mechanism of injury, the location of the injury; the collateral circulation; the extent of soft tissue damage; the adequacy of debridement; the significance of pre-existing conditions; and magnitude of wound contamination. Based upon this evaluation, a guide to indications for arterial reconstruction is provided and a comprehensive management plan for vascular trauma may be derived.

A psychometric comparison of patient-reported outcome measures used in pediatric hand therapy

STUDY DESIGN

Retrospective case series.

INTRODUCTION

Patient-reported outcome measures are important for research and also for informing clinical practice. The Pediatric Outcomes Data Collection Instrument (PODCI) and the Canadian Occupational Performance Measure (COPM) are commonly used in pediatric hand therapy. Both are validated in research, but no data exist regarding their relative merits for clinical practice.

PURPOSE OF THE STUDY

This study compares the psychometric properties of the PODCI and COPM in children receiving hand therapy to examine their relative utility in clinical practice.

METHODS

We assessed the psychometric properties of the PODCI and COPM in 75 children receiving hand therapy. Treatment outcomes were assessed simultaneously with the PODCI (Upper Extremity Function and Pain and Comfort scales), COPM (Performance and Satisfaction scales) at baseline and posttreatment time points. Interim scores were included for a subset of patients. Each scale was assessed for responsiveness, ceiling effect, and concurrent and discriminate validity.

RESULTS

All scales, except PODCI/Pain from interim to completion, were able to detect changes over the course of therapy. However, both COPM scales demonstrated greater responsiveness and less severe ceiling effects than both PODCI scales at all time points. All scales had weak concurrent validity and limited discriminate validity.

CONCLUSIONS

The COPM is more responsive to changes during treatment and less hindered by a ceiling effect than the PODCI. Weak concurrent validity between the PODCI and COPM suggests that they measure different things in this population.

Evaluating surgical outcomes in pediatric extremity vascular trauma

BACKGROUND

The purpose of this study was to evaluate the epidemiology and management of pediatric vascular extremity trauma to assess injury patterns and other factors that may contribute to poor outcomes.

METHODS

Using the California Office of Statewide Health Planning and Development discharge database, we identified pediatric patients with extremity arterial trauma admitted to acute-care hospitals from 2007 to 2014. Demographics, management patterns, and outcomes were collected and analyzed.

RESULTS

A total of 775 patients were treated for an extremity arterial injury. Overall, 40% were admitted to pediatric trauma centers and 39% to adult trauma centers. Management was predominantly by open surgical repair. Injury to the common femoral artery was associated with mortality (Hazard Ratio 3.9; 95% CI 1.1-14.5; p < 0.05). Popliteal artery injuries (Odds Ratio [OR] 4.8; 95% CI 1.2-19.9; p < 0.05) and anterior tibial artery injuries (OR 7.1; 95% CI 1.4-37.3; p < 0.05) had an increased risk of amputation. There was no difference in amputation or mortality rates by hospital category.

CONCLUSIONS

Pediatric extremity arterial injuries are rare. In California, outcomes are similar by hospital type. Common femoral artery injuries are associated with an increased risk of mortality, while popliteal and anterior tibial artery injuries are associated with an increased risk of amputation.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

Level III.

Pediatric Replantation and Revascularization

Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications.