Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children

Abstract

Elbow region fractures are the most common injuries in children. Among them, supracondylar fractures of the humerus are the most frequent. Massive displacement of the fractured bone causes severe injury to the soft tissue of that particular region. As a result, various types of injuries to the brachial artery such as entrapment, laceration, spasm of the vessel, and the presence of an intimal tear or thrombus formation are usually observed. The main goal of this study was to present our approach to children with supracondylar humerus fractures associated with brachial artery injuries. We would especially like to emphasize the necessity for other conservative or operative treatment concerning pulseless hand symptoms coexisting with supracondylar fractures of the humeral bone in children population. Data from 67 children were evaluated in our study. Supracondylar fractures were classified according to the Gartland’s scale. All patients had displaced extension type III injuries. During our follow-up study, we used Flynn’s grading system to evaluate functions of the elbow joint, forearm and wrist. Mean follow-up was 18 months; range, 13 months to 4 years. In the follow-up study, very good or good results were achieved in all 32 patients treated conservatively together with 6 patients with pulseless pink hand symptom. Very good or good results were achieved in 88 % of 35 patients operated on. Children who, after satisfactory closed reduction, have a well-perfused hand but absent radial pulse do not necessarily require routine exploration of the brachial artery. Conservative treatment should be applied unless additional signs of vascular compromise appear. Thus, exploration of the cubital fossa should be performed only if circulation is not restored by closed reduction.

Oxygen saturation measurement in dislocated supracondylar fractures in children

“…Throughout years 1984-2002 in our Deparment only 3,6 % out of 786 fractures were operated with exploration of cubital fossa. Although hemodynamic and neurological complications are not so common, patients may present both or even brachial artery injury with multi upper limb nerve insufficiency [6,12].…”

“…Those said complications include signs of vascular compromise and poor blood perfusion: pain on a passive stretch of the wrist, failure to record oxygen saturation, absence of capillary refill, low hand's temperature [11]. Necessary steps in treatment of pulseless cold hand are straightforward [6] but the management of the pulseless perfused hand in association with a supracondylar humerus fracture remains controversial. Some authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation.…”

“…Because supracondylar fractures of the humerus in pediatric population is a surgical emergency, admission to a clinic is of prime importance and ought to be immediate. This is a crucial step, especially with any ischemic disturbances of the distal part of the upper limb [6]. Diagnostic and treatment for this injury is well established but any errors or neglects are irreversible.…”

“…In case of perfusion disturbances manifesting by "pulseless pale hand" surgical exploration is needed for restoration of brachial artery. The disturbance may be due to different mechanism, such as laceration, entrapment, spasm of the vessel, thrombus formation or intimal tear within artery [6,9]. When it comes to nerve damage the most common manifestation is neuropraxia that resolves spontaneously [10] (Fig.…”

Classifications In Brief: The Gartland Classification of Supracondylar Humerus Fractures

“…While the Gartland classification does not specifically incorporate neurovascular compromise, vascular injury has been found to occur almost exclusively in extension type III or higher supracondylar humerus fractures [17], and these injuries were not considered in Gartland's classification. The brachial artery can be occluded, in spasm, entrapped, severed, or tethered by the proximal fragment of the supracondylar fracture before or after reduction.…”