Pulseless Limb Research Articles

Preoperative vascular assessment of patients with a supracondylar humeral fracture and a perfused, pulseless limb

The 'pink, pulseless hand' is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of 'normal perfusion' were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion.

Pediatric Floating Elbow Injuries Are Not as Problematic as They Were Once Thought to Be: A Systematic Review

Pediatric ipsilateral supracondylar humerus and forearm fractures (floating elbow), are historically reported to have a high rate of complications, including pediatric acute compartment syndrome (PACS). As a result, treatment paradigms for these types of injuries differ in the urgency, extent of fixation, and type of immobilization than if each fracture were treated in isolation. We aimed to systematically review the literature on pediatric floating elbow injuries and assess the reported risk of PACS along with risk factors for poor outcomes. A systematic review was performed in November 2019 in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search of the PubMed and Embase databases was conducted for peer-reviewed literature between 1999 and 2019. Two reviewers filtered the results, looking for articles in English that reported >10 pediatric floating elbow cases. Primary outcomes were the rate and risk factors for developing PACS. Secondary outcomes included patient and injury characteristics, treatment strategies, other complications (eg, neurovascular injuries), and final outcomes. The initial search yielded a total of 150 studies. Following review, 11 studies were included, with 433 patients available for review. The mechanism of injury was a fall in 96% of cases. Closed reduction and percutaneous pinning was the most common treatment performed for both fractures. Only 8/433 patients (2%) developed PACS. The incidence of a pulseless limb at presentation was 4%, and all patients regained a pulse following reduction. Three cases of iatrogenic ulnar nerve injury were reported in the setting of medial pin placement. Good to excellent results were reported in 83% to 100% of patients, based on the modified Flynn criteria. Despite being limited to heterogenous and retrospective case series, the evidence reviewed in this study contradicts the current belief of a high risk of PACS or other complications in pediatric floating elbows. PACS is much more common with displaced fractures in the setting of delayed treatment. The rate of other complications is comparable to isolated supracondylar humerus fractures. Evidence supports treating these injuries in an urgent fashion in the setting of a displaced fracture, although fixation of both distal and proximal fractures is not supported by evidence. The outcomes of pediatric floating elbows are generally good and do not reflect the poor prognosis that adult floating elbows represent. Level IV-systematic review of level IV studies.

A Cervical Rib, One Clupea Rufus and a Case of (Pseudo) Thoracic Outlet Syndrome?

Introduction: We discuss the case of a female patient presenting with acute right subclavian artery occlusion with an incidental cervical rib. Methods: A 67-year-old female (non-smoker, non-diabetic) presented with acute right upper limb ischemia manifesting as a pale, pulseless limb, paraesthetic limb without paralysis; three years prior to presentation, she had suffered a road traffic accident causing right-sided rib fractures and a malunited medial clavicular fracture. She was treated with anticoagulation with acceptable provisional functional recovery, allowing her to go on a ‘cruise of a lifetime’ that she had saved for. Computed tomography angiography (CTA) showed the presence of arterial occlusion extending from the proximal right subclavian artery (RSA) to the 2nd part of the axillary artery [AxA, *= malunited right clavicular fracture; Figure 1]. Note was made of a right cervical rib from the CTA which could also be retrospectively correlated on clinical examination. As this was felt to be a manifestation of arterial thoracic outlet syndrome (A-TOS) due to the presence of a cervical rib, an endovascular approach was dispensed with given considerations of a higher incidence of stent occlusion/fractures in this scenario. Results: The patient underwent exploration of the right thoracic inlet via combined supra-and infra-clavicular incisions. The cervical rib was noted to be oriented so posteriorly as to not really impinge on the neurovascular bundles, and thus resection was deemed unnecessary in order to avoid any potential related morbidity. Following division of the scalenus anterior as standard to expose the proximal RSA, a subclavian-axillary bypass was undertaken via a retroclavicular tunnel using a 6mm heparin-bonded PTFE graft (Propaten, Gore Medical, Flagstaff, USA) with full functional restoration and perfusion evidenced by palpable brachial and ulnar pulses [Figure 2]. The radial artery remains occluded, likely due to chronic thromboembolic occlusion. Complications such as phrenic nerve palsy and pneumothorax did not occur. The patient is maintained on aspirin and apixaban. Conclusion: The vast majority of cervical ribs are asymptomatic (1); the presence of a cervical rib in association with a subclavian arterial occlusion can be a red herring leading to the diagnosis of A-TOS and loss of an endovascular option. The malunited clavicular fracture was the likely ætiopathogenetic factor and should be considered besides the more typical pathologies that focus on the costoclavicular space (2) particularly in the context of late presentation and a prior history of trauma (3). Nevertheless, whilst operations such as subclavian-axillary bypass are becoming increasing rare in the endovascular era, they can be undertaken safely and with good result, and the modern endovascular surgeon needs to be prepared to do so. Though long-term results for such operations are not available in large numbers, surrogate results from axillo-axillary bypass (>85% 10-year primary patency) could be possibly noted as encouraging in this high flow area (4).

Late Presentation of Paediatric Pink Pulseless Supracondylar Fracture of Humerus: A Case Report

Supracondylar humeral fracture is the most common elbow injury in children. It may be associated with a vascular injury in nearly 20% of the cases with a pink pulseless limb. We present a unique case of a paediatric pink pulseless supracondylar humeral fracture, seen late, on the 16th-day post-trauma. Open reduction, cross Kirschner wiring, and brachial artery exploration and repair were performed, and the patient recovered well. Early open reduction and exploration of the brachial artery with or without prior CT angiography was a safe approach in treating patients who presented at 16 days.

Predictive factors determining outcomes in pulseless limb in paediatric supracondylar fractures of humerus

IntroductionAmongst all the complications associated with paediatric supracondylar humerus fractures, significant vascular injury is reported in only 1% cases, of which, less than 1% develop Volkmann's ischemic contracture. This study evaluates factors, like delay in presentation of the injury, limb perfusion and pulse, in determining functional outcome in a supracondylar humerus fractures with pulseless limb. Materials & methodsTwenty-one paediatric patients with a pulseless supracondylar humerus fracture presenting from 2012 to 2014 were included. The patients were divided into 3 groups with Group A (pulse returned post-reduction, n=13), Group B (pink pulseless hand, n=7) and Group C (white pulseless hand, n=1). 11 patients in group A and 4 patients in Group B presented within 6h. of injury while the remaining patients presented after 6h. The primary outcome was vascular status as indicated by radial pulse and perfusion, and secondary outcomes included functional parameters assessed with Mayo Elbow Performance Score and Flynn criteria. ResultsMean peripheral SpO2 in Group A patients was higher than Group B and Group C had a non-recordable oxygen saturation. Mean capillary refill time was more in Group A than Group B whereas in Group C patient had blanching and no capillary refill was seen. Mean Mayo Elbow Performance Score of Group A patients was highest as compared to Group B and Group C. Patients presenting within 6h. of injury had a higher mean Mayo Elbow Performance score as compared to the patients presenting after 6h of injury. Functional outcome as measured by Flynn Criteria was excellent in 13 patients. 6 patients had a good, 2 had fair outcome. A moderate negative corrélation (R=−0.5798) was seen between the time elapsed from the injury and the Mayo Elbow Performance score. ConclusionDuration to presentation since injury, limb perfusion and presence of peripheral pulses seem to be important predictive factors determining the outcomes in pulseless supracondylar fracture humerus.

A Pulseless Limb Poorly Predicts an Arterial Injury in Combat Trauma

A pulseless limb is considered a hard sign of an arterial injury after penetrating trauma in the civilian population. However, the reliability of this finding has never been examined in combat trauma. The purpose of this study was to examine the reliability of the pulseless limb in the combat trauma population. Reasons for false positive physical examination findings were also identified. The Joint Theater Trauma Registry identified all patients who presented to a military treatment facility (MTF) in Kandahar, Afghanistan, with a penetrating extremity injury over a 2-year period. Patients found to have a pulse deficit on initial physical examination were followed, and the results of the subsequent computed tomographic angiogram or arteriogram recorded. Patient demographics, injury patterns, and physiological data were examined. Standard statistical analysis was performed. From 2011 to 2012, 644 patients were treated at a single MTF for lower extremity penetrating injuries. The most common mechanisms of injury were explosions (62%) and gunshot wounds (20%). Of the 577 patients with complete medical records, 448 patients (78%) presented with palpable pulses, 115 patients (20%) presented with a pulseless limb, and 14 (2%) presented with hard signs of vascular injury. Of those with a pulseless limb and abnormal ankle-brachial index (ABI) or no ABI obtained who underwent further radiologic imaging, 38 patients (77%) had no arterial injury identified. Compared with those with a palpable pulse, patients with a pulseless limb without an arterial injury were more likely to have a higher Injury Severity Score (ISS), lower hematocrit, lower pH, greater base deficit, higher heart rate, more frequent use of tranexamic acid, and received greater volumes of packed red blood cells, plasma, and crystalloids. Our results demonstrate that a pulseless limb is a poor predictor of arterial injury and should not be considered a hard sign of vascular injury in the combat population. Variables including a high ISS, anemia, acidosis, and need for resuscitation products, each a surrogate for injury severity, may contribute to the decreased accuracy of the physical examination in our troops. This may translate into unnecessary immediate exploration or other interventions in patients who present with more significant injuries from the battlefield. Future studies must continue to focus on improved algorithms for diagnostic accuracy of extremity vascular injuries in this population.

The Pulseless Limb in War Trauma: Does It Predict an Arterial Injury?

The Pulseless Limb in War Trauma: Does It Predict an Arterial Injury?

Supracondylar Humeral Fractures in Children

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Neonatal Thrombotic Disorders

After completing this article, readers should be able to: 1. List the treatment options for neonatal thrombosis. 2. Describe common sites of thrombosis in the neonate. 3. Delineate the study that should be employed to monitor low-molecular weight heparin. 4. Describe the methods of administering recombinant tissue plasminogen activator. Thrombosis is a special problem of the neonatal period where it occurs with greater frequency than at other times of childhood, affects arteries as well as veins, and has a predilection for major vessels. Factors contributing to arterial thromboses overlap, but differ somewhat from those underlying venous disease. Aortic thromboses in the neonate usually are related to endothelial cell trauma caused by the use of indwelling umbilical artery catheters. Stroke often occurs in the watershed region of the middle cerebral artery, which is particularly vulnerable to low blood flow and ischemia. Prenatal vascular occlusions are rarely proven but often suspected in term infants who have congenital occlusions of large peripheral arteries. A white, pulseless limb suggests a recent arterial occlusion; a black, necrotic extremity reflects long-standing arterial occlusion. Term infants are particularly prone to venous thromboses of the vena cava, renal veins, and cerebral sinuses following episodes of hypotension. Several factors contribute to the higher rate of thrombosis during this life transition: increased red blood cell mass and viscosity, small vascular caliber (especially in relation to catheter diameter), low levels of proteins that are important in coagulation regulation and fibrinolysis, and severity of vascular challenge during the process of labor and delivery. Maternal diabetes, hypoxia, polycythemia, infection, and other causes of disseminated intravascular coagulation are risk factors for neonatal thrombosis. ### RENAL VEIN THROMBOSIS Several syndromes …

Coronary angiography in the presence of peripheral vascular disease: femoral or brachial/radial approach?

Peripheral vascular disease is considered a relative contraindication to the femoral approach for coronary angiography, but no data exist comparing the femoral and brachial/radial routes under these circumstances. We examined the influence of vascular approach on outcome. Two hundred and ninety-seven patients, mean age 67.1 +/- 8.4 years, with clinical or radiographic evidence of aortofemoral peripheral arterial disease underwent diagnostic coronary angiography during a 3-year period at this cardiothoracic center. The approach was successful in 121 of 154 femoral cases (79%) compared with 130 of 143 brachial/radial cases (91%; P < 0.01). Of the 33 failed femoral cases, 15 were then approached from the other femoral artery, with success in 6 (40%), while 18 were approached from the arm, with success in all (100%; P < 0.01). Brachial/radial cases took significantly longer than femoral cases (51 +/- 19 vs. 42 +/- 22 mins; P < 0.01). In cases where the femoral pulse was considered normal, the femoral approach nonetheless failed in 19 of 95 (20%). Major vascular complications (e.g., pulseless limb, arterial dissection, hemorrhage, or false aneurysm) occurred in nine femoral cases vs. zero brachial/radial cases (P < 0.01). Patients with peripheral vascular disease who undergo coronary angiography from the femoral artery have a 1-in-5 risk of procedural failure, necessitating use of an alternative vascular approach, and a 1-in-20 risk of a major vascular complication. Normality of femoral arterial pulsation is not a good predictor of femoral success. Brachial/radial approaches take longer, but succeed more frequently and have a negligible major vascular complication rate. We believe that patients with peripheral vascular disease should undergo coronary angiography via brachial or radial approach. Cathet. Cardiovasc. Intervent. 49:32-37, 2000.

Coronary angiography in the presence of peripheral vascular disease: Femoral or brachial/radial approach?

Peripheral vascular disease is considered a relative contraindication to the femoral approach for coronary angiography, but no data exist comparing the femoral and brachial/radial routes under these circumstances. We examined the influence of vascular approach on outcome. Two hundred and ninety-seven patients, mean age 67.1 +/- 8.4 years, with clinical or radiographic evidence of aortofemoral peripheral arterial disease underwent diagnostic coronary angiography during a 3-year period at this cardiothoracic center. The approach was successful in 121 of 154 femoral cases (79%) compared with 130 of 143 brachial/radial cases (91%; P < 0.01). Of the 33 failed femoral cases, 15 were then approached from the other femoral artery, with success in 6 (40%), while 18 were approached from the arm, with success in all (100%; P < 0.01). Brachial/radial cases took significantly longer than femoral cases (51 +/- 19 vs. 42 +/- 22 mins; P < 0.01). In cases where the femoral pulse was considered normal, the femoral approach nonetheless failed in 19 of 95 (20%). Major vascular complications (e.g., pulseless limb, arterial dissection, hemorrhage, or false aneurysm) occurred in nine femoral cases vs. zero brachial/radial cases (P < 0.01). Patients with peripheral vascular disease who undergo coronary angiography from the femoral artery have a 1-in-5 risk of procedural failure, necessitating use of an alternative vascular approach, and a 1-in-20 risk of a major vascular complication. Normality of femoral arterial pulsation is not a good predictor of femoral success. Brachial/radial approaches take longer, but succeed more frequently and have a negligible major vascular complication rate. We believe that patients with peripheral vascular disease should undergo coronary angiography via brachial or radial approach. Cathet. Cardiovasc. Intervent. 49:32-37, 2000.

Arthritis as a presenting manifestation of malignancy in children

Arterial thrombosis occurred with about the same frequency in arteries treated with papaverine and placebo. Age (below 1 year or over), sex, race, weight of the child, severity of cardiac status, type of cardiac lesion, site of arteriotomy, or duration of catheterization did not influence the outcome. Seven children had severe arterial spasm as manifested by a cool, pulseless limb and weak oscillations recorded by the oscillometer at the end of the catheterization but with return of the pulse within 4 to 8 hours. In these seven patients, papaverine had been used in three and placebo in four, again demonstrating no particular advantage to the use of topical papaverine.