Case Report
European Journal of Trauma and Emergency Surgery
Volkmann Ischemic Contracture Due to Traditional Practice Hind Mahmood1, Abdulzahra Hussain1,2
Abstract An 11-year-old boy presented with three days’ history of blunt trauma to the left shoulder due to a fall to the ground. The boy was taken to the traditional practitioner, who applied a very tight bandage over a piece of cartoon on the upper left humerus, which resulted in progressive pain and swelling of the whole left upper limb and impairment of movement and sensation. The tight bandage was removed after 48 h and fasciotomy was performed at Aljamhuri Hospital in Taiz, Yemen. The child was brought to our hospital after the family was informed about the need for left forearm amputation. We performed four sessions of debridement of the dead muscles and soft tissues of the flexor and extensor compartments of the left upper limb. After three months, the left upper limb healed with fixed flexor contracture of the elbow and wrist joint. Manipulation and release of adhesions and subsequent skin grafting was performed and the elbow joint was kept in extension, the wrist in the neutral position, and the interphalangeal joints in flexion. Although the limb was saved, its aesthetic appearance was retained, and some sensation was achieved, the lost motor function of the forearm (including the hand) was irreversible. Key Words Compartment syndrome Æ Volkmann ischemic contracture Æ Fasciotomy Æ Debridement Æ C-reacting protein Eur J Trauma Emerg Surg 2008
affect any part of the body, including the abdomen and extremities, and may lead to organ failure [1]. Different causes of it and methods of diagnosis have been identified, and the great advantage of prevention is well documented and highlighted in the literature. Currently, the most effective treatment for established compartment syndrome is surgical decompression [2]. One serious consequence of CS affecting extremities is Volkmann ischemic contracture (VIC). This may be congenital or acquired due to trauma or the application of a tight tourniquet, splint or cast around the affected limb [3]. Supracondylar humerus fracture is associated with CS; about 8% of these severely displaced fractures are characterized by vascular complications, and urgent anatomical reduction is needed to avoid CS [4]. VIC is a rare problem in developed countries due to the presence of an advanced health infrastructure and prevention facilities based on early detection and treatment of the underlying cause. However, the picture is different in developing nations, where VIC can still result in loss of limb function due to completely avoidable pathology. The strategy for managing CS and its consequences (VIC) has seen significant progression in recent years. Different approaches have been shown to be effective and approved for CS treatment. In this work, we report a case in which we were involved in part of the management. The aim is to show the impact of the poor knowledge of traditional practitioners, especially in rural areas of Yemen. We also discuss what can be done to treat an established Volkmann ischemic contracture.
DOI 10.1007/s00068-008-8086-9
Introduction Compartment syndrome (CS) results from increased pressure within a specific anatomical region. It can
1 2
General Surgery Department, Alburaihy Hospital, Taiz, Yemen, General Surgery Department, Princess Royal University Hospital, Farnborough Common, Kent, UK.
Received: June 1, 2008; revision accepted: September 23, 2008; Published Online: November 3, 2008
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
Case Report An 11-year-old boy sustained a blunt trauma to the left shoulder by falling to the ground in a village near Taiz, Yemen. Because of traditional beliefs, the family
Mahmood H, Hussain A. Volkmann Ischemic Contracture due to Traditional Practice
took the boy to the traditional practitioner, who manipulated the left shoulder, which was suspected of being dislocated, and applied a very tight bandage over pieces of wood and cartoon. This was kept on for two days before the child developed severe pain and swelling of the affected limb, but this was explained by the traditional practitioner as being expected after such trauma. The child was then taken to a government hospital, where the bandage was removed and fasciotomy was performed, and the family was told about the need for left forearm amputation. The parents refused the proposed amputation, and the child was brought to our hospital on the third day following the trauma. On examination, his temperature was 37.9 °C, his pulse rate was 105 min–1, and his blood pressure was 100/55 mmHg. Local examination revealed ecchymosis at the site of the bandage, swollen whole left upper limb, loss of sensation and paralysis. Radial pulsation was present but weak. Investigations showed: hemoglobin: 9.0 g/dl, white cell count (WCC): 13,000 mm–3, C-reactive protein (CRP): 57 iu/l, blood urea: 32 mg/100 ml, creatinine: 1.5 mg/100 ml. X-ray of the left upper limb revealed no fracture or dislocation. Four sessions of wound debridement including excision of dead muscles were performed. In the first session, the wound was bandaged lightly (not circumferentially) and nursed in a raised position. The patient received a broad-spectrum antibiotic and two units of blood transfusion. The second session of wound excision was performed one week later. The patient was discharged from hospital after ten days, and the third and the fourth sessions were performed as day cases two and four weeks later, respectively. Three months later, the patient developed flexor contracture of the left elbow and wrist joint. Manipulation under anesthesia was performed for both joints with release of dense fibrosis and subsequent skin grafting to cover the cubital fossa. Unfortunately, in spite of improvement in the sensation of the left upper limb, there was no obvious motor function after six months. One year later, there was no movement but the sensation was progressively improving, and by that time the boy had almost complete sensation of radial distribution, although median and ulnar nerve sensation had only recovered partially.
Discussion Increased pressure within potential spaces or compartments of the body, such as the abdomen, chest, brain, orbit, and the extremities may result in CS. The main pathophysiological change is interference with the blood supply by whatever causes it. Different
etiologies have been defined, including trauma, infection, inflammation, prolonged surgeries in certain fixed positions, and other less frequent causes. Because the arterial supply of the arm is unique, as the collateral circulation is particularly good [5], gangrene or critical ischemia is rare in the upper limb. However, it is crucial to diagnose CS at an early stage and to eliminate its preventable complications. Compartment syndrome of the upper limb can result in different degrees of tissue damage, ranging from temporary impairment to total loss of function of bones, muscles, nerves, skin and soft tissues. The muscle undergoes infarction with the formation of muscle sequestrum; this is followed by a central area of necrosis with subsequent fibrosis, which leads to shortening of the muscle and deformity. Nerves in the area of the vascular ischemia also undergo ischemic paralysis, which becomes irreversible if the occlusion is prolonged. If the occlusion is not relieved for more than 12 h, the skin and other soft tissues also undergo necrosis, resulting in sloughing or gangrene [6], as in our case (Figures 1 to 4). In the congenital type, the baby usually has bluish discoloration of the affected limb or unilateral welldemarcated necrotic plaque, wrist edema, bullae over fingers, and flaccid paralysis at wrist [7]. A relatively small number of such cases have been published. The commonest type of upper limb CS to be acquired usually results from trauma, such as supracondylar fracture of humerus or iatrogenic injuries such as from an overdone tourniquet, a tight cast or traditional bandage, or even careless modern surgical practice. Both sexes and all age groups can be affected. The comatose multiply injured patient, the patient under anesthesia, the very young patient, delayed presentation, and the patient with spasticity are all at high risk of developing CS and subsequent VIC [8]. The clinical findings of pain, swelling, paresthesia, paralysis, pallor and pulselessness are consistent with poor blood supply. Blood examination will reveal evidence of acute inflammatory responses (WCC and CRP), anemia in the majority of cases, and sometimes impairment of renal function due to myoglobin deposition in the renal tubules. In our patient, the renal function was not affected, while all inflammatory indicators were raised. The most important factor influencing the outcome of compartment syndrome is the presentation time; therefore, a low threshold for surgical exploration and fasciotomy is advocated when acute compartment syndrome is suspected on clinical grounds [9]. However, there was no correlation between the time from diagnosis to fasciotomy and residual deficits. A time as
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
Mahmood H, Hussain A. Volkmann Ischemic Contracture due to Traditional Practice
short as 70 min was associated with residual deficit, but a time as long as 315 minutes (patient with deficits) was associated with no functional deficits [10]. Emergency relief of compartment pressure in the form of the immediate removal of external pressure of whatever cause, fasciotomy, fixation of fractures, and debridement of dead tissues is crucial. Multiple operations may be needed subsequently to manage the established complications of CS. Tendon lengthening gave unsatisfactory results because of recurrence of the contracture. Excision of fibrotic muscle tissue, neurolysis and tenolysis, sometimes combined with a tendon transfer, gave good hand function results in patients with sufficient remaining muscle tissue [11]. In our case, in spite of initial treatment and the four sessions of debridement over a three-month period, the result was fixed flexion contractures of left elbow, wrist and digits with total loss of motor function and impairment of sensation over the affected limb. Subsequent division of fibrosis and skin grafting was performed. The elbow was kept in extension, the wrist in the neutral position, and the interphalangeal joints in flexion. Because of the extensive damage to the muscular components of the upper limb, operations such as tenolysis, muscle slide or transfer are expected to be of very limited benefit in this case. Other forms of operation have been suggested that aim to improve nerve function and restore limb shape and action. Early nerve neurolysis was reported to be useful if there are symptoms of nerve entrapment [12]. Flexor muscle slide and wide excision with functional free-muscle transfer has been described as an effective surgical option for the management of established
Figure 2. Lateral view.
Figure 3. Anteromedial view.
Figure 4. Lateroposterior view, infarction of the deltoid muscle.
deformity and poor hand motor function [13]. Reduction of the contracture using two-level shortening osteotomy in the proximal and distal thirds of the forearm bones as a modified Colzi procedure can be a good option for ischemic contracture in certain cases [14]. Postoperative physiotherapy is important to improve residual limb function [15].
Figure 1. Flexor compartment, extensive infarction of major muscles.
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
Conclusion Bad primary management of the trauma patient could result in irreversible complications of an entirely preventable pathology. Early diagnosis and appropriate intervention is mandatory to prevent compartment syndrome and its associated loss of limb function. Some new surgical approaches can improve function of the mild–severe form of established ischemic contracture.
Mahmood H, Hussain A. Volkmann Ischemic Contracture due to Traditional Practice
References 1.
2.
3. 4.
5.
6.
7.
8.
9.
Urban J. Median nerve decompression in ischemic contracture of the forearm. Chir Narzadow Ruchu Ortop Pol 1999;64:609–13. Stevanovic M, Sharpe F. Management of established Volkmann’s contracture of the forearm in children. Hand Clin 2006;22:99–111. Tsoneva D, Hinev S, Dafinova K, Yaramov N. Abdominal compartment syndrome. Khirurgiia (Sofiia) 2007;63:33–7. Chen H, Li F, Sun JB, Jia JG. Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage. World J Gastroenterol 2008;14:3541–8. Silfen R, Amir A, Sirota L, Hauben DJ. Congenital Volkmann – Lesser ischemic contracture of the upper limb. Ann Plast Surg 2000;45:313–7. Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B 2006;15:51–7. Krezien J, Richter H, Gussmann A, Schildknecht A. Compartment syndrome and Volkmann contracture – can they be prevented in supracondylar humerus fracture? Chirurg 1998;69:1252–6. Natarajan M, Mayilvahanan N. Vascular Injuries. In: Book of Orthopedics and Traumatology. 2005 (6th ed.). Chennai: MN Orthopaedic Hospital. http://www.bonetumour.in/ INDEX2.HTM Cham PM, Drolet BA, Segura AD, Esterly NB. Congenital Volkmann ischemic contracture: a case report and review. Br J Dermatol 2004;150:357–63.
10. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg 2008;16:30–40. 11. Homemaker VH, Hulsewe KW, Stroeken HJ, Hoofwijk AG. The acute compartment syndrome of the arm. Ned Tijdschr Geneeskd 2004;148:2235–40. 12. Ultee J, Hovius SE. Functional results after treatment of Volkmann’s ischemic contracture: a long-term followup study. Clin Orthop Relat Res 2005;431:42–9. 13. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008;90:1121–32. 14. Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE. Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop 2008 [Epub ahead of Print]. 15. Skaggs DL, Sankar WN, Albrektson J, Vaishnav S, Choi PD, Kay RM. How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children? J Pediatr Orthop 2008;28:139–41.
Address for Correspondence Abdulzahra Hussain, FRCS General Surgery Department Princess Royal University Hospital Farnborough Common Orpington BR6 8ND Kent, UK Phone (+44) -7949 393 892, Fax -1689 864 488 e-mail: [email protected]
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
European Journal of Trauma and Emergency Surgery
Volkmann Ischemic Contracture Due to Traditional Practice Hind Mahmood1, Abdulzahra Hussain1,2
Abstract An 11-year-old boy presented with three days’ history of blunt trauma to the left shoulder due to a fall to the ground. The boy was taken to the traditional practitioner, who applied a very tight bandage over a piece of cartoon on the upper left humerus, which resulted in progressive pain and swelling of the whole left upper limb and impairment of movement and sensation. The tight bandage was removed after 48 h and fasciotomy was performed at Aljamhuri Hospital in Taiz, Yemen. The child was brought to our hospital after the family was informed about the need for left forearm amputation. We performed four sessions of debridement of the dead muscles and soft tissues of the flexor and extensor compartments of the left upper limb. After three months, the left upper limb healed with fixed flexor contracture of the elbow and wrist joint. Manipulation and release of adhesions and subsequent skin grafting was performed and the elbow joint was kept in extension, the wrist in the neutral position, and the interphalangeal joints in flexion. Although the limb was saved, its aesthetic appearance was retained, and some sensation was achieved, the lost motor function of the forearm (including the hand) was irreversible. Key Words Compartment syndrome Æ Volkmann ischemic contracture Æ Fasciotomy Æ Debridement Æ C-reacting protein Eur J Trauma Emerg Surg 2008
affect any part of the body, including the abdomen and extremities, and may lead to organ failure [1]. Different causes of it and methods of diagnosis have been identified, and the great advantage of prevention is well documented and highlighted in the literature. Currently, the most effective treatment for established compartment syndrome is surgical decompression [2]. One serious consequence of CS affecting extremities is Volkmann ischemic contracture (VIC). This may be congenital or acquired due to trauma or the application of a tight tourniquet, splint or cast around the affected limb [3]. Supracondylar humerus fracture is associated with CS; about 8% of these severely displaced fractures are characterized by vascular complications, and urgent anatomical reduction is needed to avoid CS [4]. VIC is a rare problem in developed countries due to the presence of an advanced health infrastructure and prevention facilities based on early detection and treatment of the underlying cause. However, the picture is different in developing nations, where VIC can still result in loss of limb function due to completely avoidable pathology. The strategy for managing CS and its consequences (VIC) has seen significant progression in recent years. Different approaches have been shown to be effective and approved for CS treatment. In this work, we report a case in which we were involved in part of the management. The aim is to show the impact of the poor knowledge of traditional practitioners, especially in rural areas of Yemen. We also discuss what can be done to treat an established Volkmann ischemic contracture.
DOI 10.1007/s00068-008-8086-9
Introduction Compartment syndrome (CS) results from increased pressure within a specific anatomical region. It can
1 2
General Surgery Department, Alburaihy Hospital, Taiz, Yemen, General Surgery Department, Princess Royal University Hospital, Farnborough Common, Kent, UK.
Received: June 1, 2008; revision accepted: September 23, 2008; Published Online: November 3, 2008
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
Case Report An 11-year-old boy sustained a blunt trauma to the left shoulder by falling to the ground in a village near Taiz, Yemen. Because of traditional beliefs, the family
Mahmood H, Hussain A. Volkmann Ischemic Contracture due to Traditional Practice
took the boy to the traditional practitioner, who manipulated the left shoulder, which was suspected of being dislocated, and applied a very tight bandage over pieces of wood and cartoon. This was kept on for two days before the child developed severe pain and swelling of the affected limb, but this was explained by the traditional practitioner as being expected after such trauma. The child was then taken to a government hospital, where the bandage was removed and fasciotomy was performed, and the family was told about the need for left forearm amputation. The parents refused the proposed amputation, and the child was brought to our hospital on the third day following the trauma. On examination, his temperature was 37.9 °C, his pulse rate was 105 min–1, and his blood pressure was 100/55 mmHg. Local examination revealed ecchymosis at the site of the bandage, swollen whole left upper limb, loss of sensation and paralysis. Radial pulsation was present but weak. Investigations showed: hemoglobin: 9.0 g/dl, white cell count (WCC): 13,000 mm–3, C-reactive protein (CRP): 57 iu/l, blood urea: 32 mg/100 ml, creatinine: 1.5 mg/100 ml. X-ray of the left upper limb revealed no fracture or dislocation. Four sessions of wound debridement including excision of dead muscles were performed. In the first session, the wound was bandaged lightly (not circumferentially) and nursed in a raised position. The patient received a broad-spectrum antibiotic and two units of blood transfusion. The second session of wound excision was performed one week later. The patient was discharged from hospital after ten days, and the third and the fourth sessions were performed as day cases two and four weeks later, respectively. Three months later, the patient developed flexor contracture of the left elbow and wrist joint. Manipulation under anesthesia was performed for both joints with release of dense fibrosis and subsequent skin grafting to cover the cubital fossa. Unfortunately, in spite of improvement in the sensation of the left upper limb, there was no obvious motor function after six months. One year later, there was no movement but the sensation was progressively improving, and by that time the boy had almost complete sensation of radial distribution, although median and ulnar nerve sensation had only recovered partially.
Discussion Increased pressure within potential spaces or compartments of the body, such as the abdomen, chest, brain, orbit, and the extremities may result in CS. The main pathophysiological change is interference with the blood supply by whatever causes it. Different
etiologies have been defined, including trauma, infection, inflammation, prolonged surgeries in certain fixed positions, and other less frequent causes. Because the arterial supply of the arm is unique, as the collateral circulation is particularly good [5], gangrene or critical ischemia is rare in the upper limb. However, it is crucial to diagnose CS at an early stage and to eliminate its preventable complications. Compartment syndrome of the upper limb can result in different degrees of tissue damage, ranging from temporary impairment to total loss of function of bones, muscles, nerves, skin and soft tissues. The muscle undergoes infarction with the formation of muscle sequestrum; this is followed by a central area of necrosis with subsequent fibrosis, which leads to shortening of the muscle and deformity. Nerves in the area of the vascular ischemia also undergo ischemic paralysis, which becomes irreversible if the occlusion is prolonged. If the occlusion is not relieved for more than 12 h, the skin and other soft tissues also undergo necrosis, resulting in sloughing or gangrene [6], as in our case (Figures 1 to 4). In the congenital type, the baby usually has bluish discoloration of the affected limb or unilateral welldemarcated necrotic plaque, wrist edema, bullae over fingers, and flaccid paralysis at wrist [7]. A relatively small number of such cases have been published. The commonest type of upper limb CS to be acquired usually results from trauma, such as supracondylar fracture of humerus or iatrogenic injuries such as from an overdone tourniquet, a tight cast or traditional bandage, or even careless modern surgical practice. Both sexes and all age groups can be affected. The comatose multiply injured patient, the patient under anesthesia, the very young patient, delayed presentation, and the patient with spasticity are all at high risk of developing CS and subsequent VIC [8]. The clinical findings of pain, swelling, paresthesia, paralysis, pallor and pulselessness are consistent with poor blood supply. Blood examination will reveal evidence of acute inflammatory responses (WCC and CRP), anemia in the majority of cases, and sometimes impairment of renal function due to myoglobin deposition in the renal tubules. In our patient, the renal function was not affected, while all inflammatory indicators were raised. The most important factor influencing the outcome of compartment syndrome is the presentation time; therefore, a low threshold for surgical exploration and fasciotomy is advocated when acute compartment syndrome is suspected on clinical grounds [9]. However, there was no correlation between the time from diagnosis to fasciotomy and residual deficits. A time as
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
Mahmood H, Hussain A. Volkmann Ischemic Contracture due to Traditional Practice
short as 70 min was associated with residual deficit, but a time as long as 315 minutes (patient with deficits) was associated with no functional deficits [10]. Emergency relief of compartment pressure in the form of the immediate removal of external pressure of whatever cause, fasciotomy, fixation of fractures, and debridement of dead tissues is crucial. Multiple operations may be needed subsequently to manage the established complications of CS. Tendon lengthening gave unsatisfactory results because of recurrence of the contracture. Excision of fibrotic muscle tissue, neurolysis and tenolysis, sometimes combined with a tendon transfer, gave good hand function results in patients with sufficient remaining muscle tissue [11]. In our case, in spite of initial treatment and the four sessions of debridement over a three-month period, the result was fixed flexion contractures of left elbow, wrist and digits with total loss of motor function and impairment of sensation over the affected limb. Subsequent division of fibrosis and skin grafting was performed. The elbow was kept in extension, the wrist in the neutral position, and the interphalangeal joints in flexion. Because of the extensive damage to the muscular components of the upper limb, operations such as tenolysis, muscle slide or transfer are expected to be of very limited benefit in this case. Other forms of operation have been suggested that aim to improve nerve function and restore limb shape and action. Early nerve neurolysis was reported to be useful if there are symptoms of nerve entrapment [12]. Flexor muscle slide and wide excision with functional free-muscle transfer has been described as an effective surgical option for the management of established
Figure 2. Lateral view.
Figure 3. Anteromedial view.
Figure 4. Lateroposterior view, infarction of the deltoid muscle.
deformity and poor hand motor function [13]. Reduction of the contracture using two-level shortening osteotomy in the proximal and distal thirds of the forearm bones as a modified Colzi procedure can be a good option for ischemic contracture in certain cases [14]. Postoperative physiotherapy is important to improve residual limb function [15].
Figure 1. Flexor compartment, extensive infarction of major muscles.
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
Conclusion Bad primary management of the trauma patient could result in irreversible complications of an entirely preventable pathology. Early diagnosis and appropriate intervention is mandatory to prevent compartment syndrome and its associated loss of limb function. Some new surgical approaches can improve function of the mild–severe form of established ischemic contracture.
Mahmood H, Hussain A. Volkmann Ischemic Contracture due to Traditional Practice
References 1.
2.
3. 4.
5.
6.
7.
8.
9.
Urban J. Median nerve decompression in ischemic contracture of the forearm. Chir Narzadow Ruchu Ortop Pol 1999;64:609–13. Stevanovic M, Sharpe F. Management of established Volkmann’s contracture of the forearm in children. Hand Clin 2006;22:99–111. Tsoneva D, Hinev S, Dafinova K, Yaramov N. Abdominal compartment syndrome. Khirurgiia (Sofiia) 2007;63:33–7. Chen H, Li F, Sun JB, Jia JG. Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage. World J Gastroenterol 2008;14:3541–8. Silfen R, Amir A, Sirota L, Hauben DJ. Congenital Volkmann – Lesser ischemic contracture of the upper limb. Ann Plast Surg 2000;45:313–7. Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B 2006;15:51–7. Krezien J, Richter H, Gussmann A, Schildknecht A. Compartment syndrome and Volkmann contracture – can they be prevented in supracondylar humerus fracture? Chirurg 1998;69:1252–6. Natarajan M, Mayilvahanan N. Vascular Injuries. In: Book of Orthopedics and Traumatology. 2005 (6th ed.). Chennai: MN Orthopaedic Hospital. http://www.bonetumour.in/ INDEX2.HTM Cham PM, Drolet BA, Segura AD, Esterly NB. Congenital Volkmann ischemic contracture: a case report and review. Br J Dermatol 2004;150:357–63.
10. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg 2008;16:30–40. 11. Homemaker VH, Hulsewe KW, Stroeken HJ, Hoofwijk AG. The acute compartment syndrome of the arm. Ned Tijdschr Geneeskd 2004;148:2235–40. 12. Ultee J, Hovius SE. Functional results after treatment of Volkmann’s ischemic contracture: a long-term followup study. Clin Orthop Relat Res 2005;431:42–9. 13. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008;90:1121–32. 14. Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE. Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop 2008 [Epub ahead of Print]. 15. Skaggs DL, Sankar WN, Albrektson J, Vaishnav S, Choi PD, Kay RM. How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children? J Pediatr Orthop 2008;28:139–41.
Address for Correspondence Abdulzahra Hussain, FRCS General Surgery Department Princess Royal University Hospital Farnborough Common Orpington BR6 8ND Kent, UK Phone (+44) -7949 393 892, Fax -1689 864 488 e-mail: [email protected]
Eur J Trauma Emerg Surg 2008 Ó URBAN & VOGEL
