Should You Explore the Brachial Artery in Children Who Have a Perfused Hand but No Palpable Radial Pulse After Sustaining a Supracondylar Humeral Fracture?

Abstract

The articles by Weller et al. and Scannell et al. add another seventy patients to the literature describing good outcomes for closely observed patients who have a perfused hand but no palpable radial pulse after undergoing closed reduction and percutaneous pinning of a supracondylar humeral fracture. Weller et al. described a high-volume experience at their institution, where the approach is to observe most patients who have a perfused hand but no palpable pulse in association with a supracondylar humeral fracture (this approach varies according to the preference of the attending surgeon, however, so some of these fractures were explored during the time course of the study). If a palpable radial pulse does not return following closed reduction and percutaneous pinning, the rationale for exploration of the brachial artery in their center hinges on the outcome of Doppler assessment of the radial artery; that is, vascular consultation and exploration for those without a Doppler signal, and observation for those who have a Doppler signal. Their paper has the limitations of a retrospective study, and they do not have very long follow-up on the patients. They do report on the cases of two patients that provide valuable teaching points. One patient, who had improved vascular status after undergoing closed reduction and percutaneous pinning, had subsequent deterioration during observation and was returned to the operating room for exploration after developing a cool, poorly perfused hand. Another patient with a perfused hand but no palpable radial pulse developed an ischemic contracture of the forearm despite having a benign and routine postoperative hospital course. This patient had no palpable pulse before or after closed reduction and percutaneous pinning but had a Doppler signal at the radial artery before and after and had a palpable pulse prior to discharge from the hospital. After discharge, the patient …