Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

Abstract

Background The optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial. Some clinicians recommend close observation after closed reduction and percutaneous pinning of the fractures, while some recommend surgical exploration if the radial pulse is unpalpable. The present study aimed to analyze the benefits and outcomes of close observation for treating pediatric supracondylar humeral fractures with a pink pulseless hand. Methods Thirteen consecutive children presenting with a pink pulseless hand following supracondylar humeral fracture were enrolled in this study. Preoperative and postoperative color-flow Duplex ultrasound detection was used to assess brachial artery compromise in most cases. Urgent closed reduction and percutaneous pinning of the fractures were attempted first. Close observation was carried out when the hand was pink and pulseless with an absent radial pulse. Results Preoperative color-flow Duplex ultrasound showed no disruption of the brachial artery in cases detected. Compression of the artery by the proximal fragment was observed in most cases, with one case of entrapment of the artery between fragments, and thrombus considered in two cases. All cases underwent urgent surgery, after which nine experienced immediate return of the radial pulse. The remaining four without a palpable pulse were managed with close observation and no deterioration of the vascular status was observed; therefore, no surgical exploration was performed. Postoperative color-flow Duplex ultrasound revealed continuity of the artery and rich collateral circulation. Patients completed an average of 4.5 years of follow-up, during which no major complications occurred. All patients achieved excellent limb function. Conclusions Our study demonstrates that close observation after urgent closed reduction and percutaneous pinning is a sufficient approach for the treatment of pediatric supracondylar humeral fractures accompanied with a pink pulseless hand. Surgical exploration is not necessary as long as the hand is warm and well perfused. Color-flow Duplex ultrasound is beneficial for assessing vascular compromise and determining treatment strategies.

A Modern Day Timeline for In-Hospital Monitoring in Perfused, Pulseless Pediatric Supracondylar Humerus Fractures

“…In the larger cohort studies of Choi et al 1 and Weller et al, 11 both of which observe for 24 to 48 hours postoperatively, only 1 patient in the Weller's study required return to the OR for a cool hand that developed at 9 hours postoperatively. Contrary to that, Ramesh et al 2 recommended observation for 3-7 days postoperatively, with their cohort averaging 4.3 days stay, and Xie et al 23 report an average length of stay of 5.4 days. Neither of these studies report an unexpected postoperative event or the need to return to the OR during the period of prolonged observation.…”

Systematic review of paediatric pulseless pink humerus supracondylar fractures

“…However, the decision to surgically explore the BA in a well-perfused, pulseless hand remains a controversial one among vascular and orthopedic surgeons. While there have been other systematic reviews performed on this topic [4,5], since then, new primary research has emerged to shed more light on this age-old conundrum [6][7][8][9]. As such, we think it is appropriate to revisit this topic to provide an update on the management of pink pulseless SCHFs.…”

Duplex ultrasound for assessing vascular impairment after supracondylar humerus fractures

“…Thus it remains uncertain what "watchful waiting" can mean to both clinician and patient, and color-coded duplex ultrasound could be beneficial to assess the nature of vascular compromise and inform treatment decisions. [8] The diagnosis of vascular impairment in SHF can be challenging. Young age, stress, different developmental levels, high body mass index, casts or dressings, sedation, or anesthesia with concomitant low systemic blood pressure can hamper the neurovascular examination.…”

“…Furthermore, the “pink pulseless hand” is not always consistently and unequivocally defined. Thus it remains uncertain what “watchful waiting” can mean to both clinician and patient, and color-coded duplex ultrasound could be beneficial to assess the nature of vascular compromise and inform treatment decisions [8] …”