Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary?

BACKGROUND: Radically different conclusions exist in the pediatric orthopaedic and vascular literature regarding the management of patients with a pink hand but no palpable radial pulse in association with a supracondylar humeral fracture.
METHODS: One thousand two hundred and ninety-seven consecutive, operatively treated supracondylar humeral fractures in patients presenting to a level-I pediatric trauma center from January 2003 through December 2007 were studied retrospectively. Clinical records were reviewed to determine vascular and neurological examination findings, Gartland classification, timing of surgery, and postoperative complications.
RESULTS: One thousand two hundred and sixty-six patients had a documented radial pulse examination at the time of arrival in the emergency room; fifty-four (4%) of those patients lacked a palpable radial pulse. All fifty-four patients had type-3 fractures. Five (9%) of the fifty-four patients underwent open exploration of vascular structures on the basis of clinical findings of a pale hand, sluggish capillary refill, and/or weak or no pulse detected with use of Doppler ultrasound after closed reduction and percutaneous pinning. All five underwent vascular surgery to restore blood flow (two primary repairs, three saphenous vein grafts). Twenty (37%) of the fifty-four patients had a pulse documented with use of Doppler ultrasound and a pink hand after closed reduction and percutaneous pinning, but the radial pulse remained nonpalpable. These patients were observed in the hospital for signs of ischemia; one of the twenty patients required vascular repair after developing a pale hand nine hours after closed reduction and percutaneous pinning, and the other nineteen patients were also observed while they were in the hospital, and they all regained a palpable pulse either prior to discharge or by the time of the first postoperative visit. When compared with the group of patients with type-3 fractures for whom data regarding nerve examination were available, patients with type-3 fractures who lacked a palpable radial pulse had a higher rate of nerve palsy postoperatively (31% versus 9%, p < 0.0001).
CONCLUSIONS: In this cohort, nearly 10% of patients who presented with a type-3 supracondylar humeral fracture and no palpable radial pulse underwent immediate vascular repair to restore blood flow following closed reduction and percutaneous pinning. However, in our series, the lack of a palpable radial pulse after closed reduction and percutaneous pinning was not an absolute indication to proceed with vascular exploration if clinical findings (i.e., Doppler signal and capillary refill) suggested that the limb was perfused. Careful inpatient monitoring of these patients postoperatively is mandatory to identify late-developing vascular compromise. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.