Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

Li-Wei Xie,Juan Wang,Zhi-Qiang Deng

doi:10.1186/s12891-020-03877-z

Abstract

BackgroundThe 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.MethodsThirteen 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.ResultsPreoperative 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.ConclusionsOur 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.

Highlights

The optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial
Compromised vasculature occurs in 2.6–20% of cases of displaced Supracondylar humerus fractures (SHFs) in children [3,4,5,6], with two kinds of brachial artery injuries reported to be associated with SHFs: those presenting with a pale pulseless hand and those with a pink pulseless hand (PPH) which is well perfused without a palpable radial pulse [6,7,8]
The present study aimed to address this gap in the knowledge by analyzing the outcomes of conservative management for pediatric SHFs with a PPH, and to evaluate the utility of color-flow Duplex ultrasound (CFDU) for assessing lesions of the brachial artery

Summary

Introduction

The optimal treatment for pediatric supracondylar humeral fractures accompanied with a pink pulseless hand is controversial. Compromised vasculature occurs in 2.6–20% of cases of displaced SHFs in children [3,4,5,6], with two kinds of brachial artery injuries reported to be associated with SHFs: those presenting with a pale pulseless hand and those with a pink pulseless hand (PPH) which is well perfused without a palpable radial pulse [6,7,8]. Urgent closed reduction and percutaneous pinning (CRPP) is the primary treatment in both situation, and vascular exploration is often required in the case of a pale pulseless hand [6,7,8, 10, 11]. The optimal treatment for a PPH in terms of whether to perform immediate vascular exploration or manage with close observation is controversial in cases where the radial pulse is still not palpable after CRPP [10, 11]. Blakey et al reported a high incidence of compartment syndrome associated with a PPH following SHFs [16], and the incidence has been reported to increase from 0.2–4.5% in cases with co-existing neurovascular compromise [17]

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Results

Discussion

Conclusion