Pulseless arm in association with totally displaced supracondylar fracture

Seven children (3-10 years of age) were treated for a type III supracondylar fracture of the humerus. All fractures were reduced and pinned. Closed reduction was performed in four patients; three required open reduction. Before reduction six of the seven patients did not have a distal palpable pulse in the involved forearm. After reduction of the fractures all patients had a pulseless arm and a seemingly viable hand. Doppler pulses were absent or greatly diminished compared with the normal side in all involved extremities. Six patients underwent immediate antecubital fossa exploration of the brachial artery without arteriogram; one patient, referred to us from another facility, underwent angiography followed by immediate exploration. In three patients the brachial artery was directly damaged or transected and was repaired via saphenous vein graft, with reestablishment of distal pulses in each case. In the other four patients the brachial artery was kinked or entrapped at the fracture site, necessitating microdissection to mobilize the vessel and reestablish pulses in each case. At an average follow-up of 30 months, all seven patients had normal circulatory status, including a radial pulse. All fractures had healed, and all extremities had a normal carrying angle and normal elbow motion. Immediate exploration of the antecubital fossa should be considered if an extremity remains pulseless (to palpation and Doppler) after reduction and stabilization of significantly displaced supracondylar fractures of the humerus.