Perfused, Pulseless, and Puzzling: A Systematic Review of Vascular Injuries in Pediatric Supracondylar Humerus Fractures and Results of a POSNA Questionnaire

Abstract

Our study revealed that common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evalvation and vascular exploration and repair in selected cases. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile.

The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children

“…4 However, opinions differ about the management of those who do not recover a radial pulse but have good peripheral perfusion as judged by a pink and warm hand. 1,3,12,19,20 Whereas Choi et al 18 considered that reduction of the fracture alone is usually sufficient, White et al 12 considered that absence of the pulse indicates arterial injury even if the hand appears pink and warm, and recommended further vascular investigations in such cases.…”

“…CCDS correctly identified arterial lesions and normal patency of the brachial artery was restored. Along with others, 4,12,14,17,26 we emphasise that in those cases, a satisfactory temporary collateral circulation could not have guaranteed a good long-term outcome. Cold intolerance, sometimes with Raynaud's phenomenon, dysaesthesia, claudication of the forearm, delayed development and growth arrest of the involved limb and complete loss of function have been reported following arterial damage associated with a supracondylar fracture.…”

“…Cold intolerance, sometimes with Raynaud's phenomenon, dysaesthesia, claudication of the forearm, delayed development and growth arrest of the involved limb and complete loss of function have been reported following arterial damage associated with a supracondylar fracture. 4,7,9,12,17 In Blakey et al's 4 series of 26 patients with a pink pulseless hand after reduction of the fracture with a mean follow-up of 15.5 years, only four had undergone an exploration, three immediately, when an arterial repair was possible and one 48 hours after the injury, which was unsuccessful. Thus, 23 patients developed an ischaemic contracture of the forearm and hand and they concluded that a pink pulseless limb is ischaemic and recommended urgent exploration under these circumstances.…”

“…From the current literature, it is apparent that the diagnosis of arterial injury has been mainly based on physical examination and, with some exceptions, 12,21 little importance has been attached to supplementary vascular diagnostic techniques that during the last few years have become noninvasive and allow a precise diagnosis of the type of arterial injury. [22][23][24][25] In four of the eight pink pulseless hands in our study, CCDS and UV on admission showed compression and displacement of the brachial artery with mild spasm and decreased blood flow.…”

“…[1][2][3][4] In those with an arterial injury the fracture is usually a posterolaterally displaced Gartland 5 type III injury, [6][7][8] with additional involvement of the median nerve or its anterior interosseous branch in 12% to 20% of cases. 4,[9][10][11][12] In some children with mild symptoms, the level of suspicion for arterial injury is low and many authors suggest that a patient with a pulseless but pink and warm hand should be managed expectantly after reduction of the fracture, assuming that the arterial spasm would resolve and collateral circulation would compensate for the temporary circulatory impairment. 1,[12][13][14] However, others have questioned this approach 2,12,14,15 and Blakey et al 4 reported that 23 of 26 children with a pink, pulseless hand faced ischaemic complications in the long-term.…”