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Open Exploration and Reduction of Paediatric Supracondylar Humerus Fracture with Pink, Pulseless Hand in
Sanjana Kanumuri1,2, Sameer Kolimi Subhansab3, Kiran J Agarwal-Harding4,2
1University of Washington School of Medicine, Seattle, WA, USA.
Insights
Pediatric supracondylar humerus fractures with a pink, pulseless hand require open reduction. This surgical approach ensures prompt brachial artery repair and prevents complications, even in resource-limited settings.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Pediatric Trauma
Background:
- Supracondylar humerus fractures (SHFs) are common in children and carry a risk of vascular compromise.
- A 'pink, pulseless hand' indicates brachial artery occlusion but preserved collateral circulation.
- Management is debated, particularly in resource-limited settings.
Purpose of the Study:
- To report intraoperative findings, surgical procedures, and 6-week outcomes for pediatric SHFs with a pink, pulseless hand.
- To evaluate the efficacy of open reduction in these specific cases.
Main Methods:
- Retrospective review of 13 pediatric patients with displaced SHFs and a pink, pulseless hand.
- All patients underwent open reduction via an anterior approach with neurovascular exploration and repair.
- Brachial artery flow was restored using lidocaine, thrombectomy, or reconstruction.
Main Results:
- 10 of 13 patients (77%) had intact arteries; 3 (23%) had arterial injuries (crushed or thrombosed).
- Median nerves were intact in all patients.
- Peripheral pulses were restored within 1 hour of open reduction; all patients recovered without neurovascular deficits at 6 weeks.
Conclusions:
- Open exploration and reduction is recommended for pediatric SHFs with a pink, pulseless hand in resource-limited settings.
- This approach mitigates iatrogenic injury, allows immediate arterial repair, and avoids prolonged hospitalization.
- Outcomes are favorable, preventing long-term complications like compartment syndrome or Volkmann contracture.
Abstract:
Background: Supracondylar humerus fractures (SHFs) are common paediatric injuries, with high risk of vascular compromise. Some patients present with a 'pink, pulseless hand', caused by occlusion of brachial artery flow but with collateral circulation preserving distal perfusion. Management of these patients remains controversial, especially when resources may be limited for prolonged hospitalisation and serial monitoring by skilled staff. The aim of this study is to present the intraoperative findings, surgical procedures done and outcomes at 6 weeks for patients with paediatric supracondylar fractures with a pink pulseless hand. Methods: We retrospectively identified 13 patients who presented to a public hospital between January 2019 and May 2023 with a displaced SHF and pink, pulseless hand. All patients underwent an open reduction with an anterior approach allowing for exploration, protection and repair of neurovascular structures. Distal flow was restored in the brachial artery either with topical lidocaine application, thrombectomy or artery reconstruction. Results: Out of 13 patients, all had intact median nerves and 10 had intact arteries (69%), of which seven were interposed at the fracture site and four were in vasospasm. Of the three patients with true arterial injury (23%), two had a crushed artery and one had thrombosis of the artery. Peripheral pulses were restored within an hour of fracture open reduction in all patients. At final follow-up, a mean 6 weeks postoperatively, all patients had recovered without neurovascular deficit, compartment syndrome or Volkmann ischemic contracture. Conclusions: In resource-limited settings, we recommend performing open exploration and reduction for patients with SHFs with pink, pulseless hand. This approach prevents iatrogenic neurovascular injury during closed reduction attempts, allows for immediate repair of a brachial artery injury and avoids unnecessary hospitalisation and serial monitoring. Level of Evidence: Level IV (Therapeutic).
