Treatment of pink pulseless hand following supracondylar fractures of the humerus in children

Abstract

Although acute vascular injury is a common complication in children with severely displaced supracondylar humeral fractures, the management of patients with a pink pulseless hand still remains controversial. Between 1994 and 2006, 66 children with displaced supracondylar fractures of the humerus were treated. Five patients had an absence of the radial pulse with an otherwise well perfused hand. In one patient, radial pulse returned after closed reduction of the fracture. In four patients, open reduction and vascular exploration was required. Three patients had brachial artery occlusion because of thrombus formation. Thrombectomy was performed, which led to the restoration of a palpable radial pulse. In one patient with open fracture, brachial artery contusion and spasm were found, and treated by removal of adventitia. Surgical exploration for the restoration of brachial artery patency should be performed, even in the presence of viable pink hand after an attempt at closed reduction.Résumé Au cours d'une fracture supra condylienne du coude déplacée, les complications vasculaires sont relativement fréquentes. Le traitement, lui aussi, est largement controversé, notamment lorsqu'il existe une absence de pouls radial après la fracture. Entre 1994 et 2006, 66 enfants présentant une fracture supra condylienne du coude ont été traités. 5 présentaient une complication vasculaire avec absence de pouls radial. Chez un des patients, le pouls radial est réapparu après réduction à foyer fermé. Chez les 4 autres patients, il a été nécessaire de faire une réduction sanglante avec exploration vasculaire. 3 des patients avaient une occlusion de l'artère humérale. La thrombectomie a été réalisée avec restauration du pouls radial. Sur un patient, il s'agissait d'une contusion de l'artère brachiale avec spasme et une réapparition du pouls après endar térectomie. L'exploration vasculaire chirurgicale doit être réalisée même si la main se recolore après une réduction à foyer fermé.

Management of acute ‘pink pulseless’ hand in pediatric supracondylar fractures of the humerus

“…As these patients had a good capillary refill and no evidence of compartment syndrome or worsening neurology, they were managed without surgical exploration, contrary to what has been suggested in recent literature [2,3,7]. The authors however, caution that the patients in this series did not have excruciating pain distal to the elbow that persisted beyond 12 h after the injury unlike that reported by Blakey et al [2].…”

“…This has implications on the normal radial pulse of patients treated by vascular reconstruction. It can be attributed to the lush collateral circulation, as evidence of a patent brachial artery using vascular studies has not been confirmed in these reports [2,3,7].…”

“…More recently, several authors have discouraged this method of treatment and have suggested that all patients with a persistent pulseless well-perfused hand to undergo surgical exploration of the vascular injury [2,3,7]. Korompilias et al [7] reported on five patients with a pink pulseless hand and recommended vascular exploration for the restoration of brachial artery patency, even in the presence of a viable well-perfused hand after an attempt at closed reduction. Mangat et al [3] reviewed 19 patients over a 14-year period and found a coexisting anterior interosseous or median nerve palsy to be a predictive indicator of nerve and vessel entrapment.…”

“…There is no dispute regarding the need for surgical exploration in the patient with a supracondylar fracture and a cool white hand. However, management strategies have differed in patients with an absent radial pulse and a well-perfused pink hand despite achieving a successful reduction [2][3][4][5][6][7]. Recommended treatment options include observation [8], immediate exploration of the artery [9,10], exploration if the pulse has not recovered by 24 h [11], immediate angiography [12] and transfemoral brachial artery urokinase thrombolysis [13].…”

Volkmann Ischemic Contracture Due to Traditional Practice

“…Flexor muscle slide and wide excision with functional free-muscle transfer has been described as an effective surgical option for the management of established 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].…”