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The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function
Brian P Scannell1, J Benjamin Jackson, Christopher Bray
1Department of Orthopaedic Surgery, Carolinas Medical Center, 1320 Scott Avenue, Charlotte, NC 28204. E-mail address for B.P. Scannell: bpscannell@gmail.com.
Insights
Children with pulseless supracondylar humeral fractures treated with closed reduction and pinning regained palpable pulses and showed good functional outcomes. However, some experienced brachial artery occlusion despite normal distal pulses and limb growth.
Area of Science:
- Pediatric Orthopedics
- Vascular Surgery
- Trauma Surgery
Background:
- Supracondylar humeral fractures are common in children.
- A perfused, pulseless presentation requires careful management to preserve vascular integrity.
- Intermediate-term outcomes of this specific injury pattern are not well-documented.
Purpose of the Study:
- To evaluate the intermediate-term vascular status and functional outcomes in children with perfused, pulseless supracondylar humeral fractures.
- To assess the effectiveness of closed reduction, percutaneous pinning, and observation in managing this condition.
- To identify potential long-term complications related to brachial artery compromise.
Main Methods:
- Retrospective review of pediatric patients (2007-2011) with Gartland type-III supracondylar humeral fractures and initial pulselessness.
- Vascular assessment included radial pulse palpation, wrist brachial index, and duplex ultrasound.
- Functional outcomes were evaluated using the Pediatric Outcomes Data Collection Instrument (PODCI), grip strength, and range of motion.
Main Results:
- Twenty patients with a mean follow-up of 20 months showed a palpable radial pulse.
- Duplex ultrasound revealed 14 patent brachial arteries, 5 occluded arteries with collaterals, and 1 stenotic artery.
- Despite vascular findings, all patients had normal limb growth, and 13/20 reported better-than-general population function on PODCI.
Conclusions:
- Closed reduction and percutaneous pinning provide good functional outcomes and return of pulse in children with pulseless supracondylar humeral fractures.
- Brachial artery occlusion can occur despite initial perfusion and may be asymptomatic in the intermediate term due to collaterals.
- Long-term monitoring for vascular complications is warranted.
Background:
This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation.
Methods:
Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold.
Results:
Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score.
Conclusions:
After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery.
Level Of Evidence:
Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.
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