Treatment of pediatric supracondylar humerus fractures accompanied with pink pulseless hands

Supracondylar humerus fractures (SHFs) are the most common fractures in children and account for approximately 50–70% of pediatric elbow fractures [1, 2]. Compromised vasculature occurs in 2.6–20% of cases of displaced SHFs in children [3‐6], 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 [6‐8]. While vascular compromise in elderly patients with SHFs is rare due to osteoporosis and low-energy trauma compared with pediatric patients, open reduction and plate fixation was recommended for satisfactory outcomes [9]. In pediatric patients, 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 [6‐8, 10, 11]. However, 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].

Some clinicians recommend aggressive surgical exploration and vascular reconstruction due to the concern that delaying reconstruction of the artery will lead to compartment syndrome, ischemic contracture, retarded development of the limb, cold intolerance, and so on [3, 8, 11‐15]. 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].

However, conservative management (close observation) is recommended as long as the hand is warm and well-perfused, with the reasoning that collateral circulation of the elbow joint will provide sufficient blood supply for the limb, and vascular exploration such only be carried out when deterioration of the circular status of the limb occurs [4‐7, 12, 18‐23]. Choi et al. reported that, among patients treatment for absent distal pulse following displaced SHFs, CRPP resulted in a good rate of return of palpable pulse after surgery or achievement of a pulseless but well-perfused status [5]. Good outcomes were achieved without surgical exploration and no patients developed compartment syndrome. Scannell et al. described that CRPP for the treatment of perfused pulseless hand following displaced SHFs resulted in an immediate return of palpable pulse in 20% of patients, with normal radial pulse returning in all patients eventually [18]. However, patent brachial arteries occurred in almost 75% of patients and brachial artery occlusion in 20%; collateral vessels were also found, severe arterial stenosis occurred in one patient, and cold intolerance during participation in ice hockey was reported in one patient. At an average of 20 months follow-up, there were no differences in arm circumference or length, elbow motion, muscle endurance, or grip strength between the injured and uninjured sides. The traditional conservative strategy of close observation has been used for SHFs since 1950s and relies on collateral circulation of the elbow joint [11, 20, 24‐26]. Studies have demonstrated that the limb can kept alive with ligation of the injured brachial artery [27‐29]. Strong collateral circulation has been identified using arteriography or ultrasound around the elbow after SHFs [20].

However, there have been few reports of the use color-flow Duplex ultrasound (CFDU) for the assessment of brachial artery compromise and the status of collateral circulation before and after surgical treatment of SHFs [11, 18, 30, 31]. The present study aimed to address this gap in the knowledge by analyzing the outcomes of conservative management (close observation) for pediatric SHFs with a PPH, and to evaluate the utility of CFDU for assessing lesions of the brachial artery.