Reaching a crossroads in the management of pink pulseless hand in pediatric supracondylar humerus fracture: exploration Versus conservation

Abstract

Introduction Supracondylar fracture of the humerus (SFH) is the most common fracture of the elbow in the pediatric population (60%) (1, 2). Displaced SFH in children is commonly associated with vascular insult in the form of absent distal pulses. In such cases, the limb can be cold and cyanotic or warm and pink despite the loss of pulse. Immediate exploration of the cold cyanotic limb is the current recommendation (3). The treatment of pink, warm pulseless limbs is still under debate (4). Aim The aim of this study is to evaluate the role of intraoperative in situ conventional angiography in the same setting of fracture fixation in cases of SFH with pink pulseless hands. Patients and methods This is a comparative study between two groups of pediatric patients admitted to Tanta University Hospitals, who suffered from SFH associated with a pink pulseless hand, and who underwent reduction and closed fixation of the fracture. Group (A) includes prospective data from 30 pediatric patients recruited from January 2021 to January 2023, who were managed by same-session conventional in situ brachial artery angiography. Group (B) includes retrospective data records from December 2016 to December 2019, composed of 50 similar age-group patients who were managed conservatively for 6–12 h after fracture fixation. Then after failure to regain distal pulse, CTA was performed to disclose the underlying arterial condition. Results The mean age of patients was 6.4 years ±2.73. The main mode of trauma was falling to the ground on outstretched hand (47% in group A, and 54% in group B). The types of arterial injury were as follows: brachial artery entrapment (27% in group A, 18% in group B), complete transection (7% in group A, 6% in group B), intimal contusion and thrombosis (43% in group A, 56% in group B), arterial spasm (23% in group A, 20% in group B). The mortality rate was 0% and the limb salvage rate was 100% in both groups, however, the number of anesthesia sessions, the mean total operative time, and the duration of hospital stay were significantly lower and in favor of group (A). Conclusion We believe that in situ conventional angiography is the most appropriate, accurate, and rapid diagnostic tool to define the lesion and plan the procedure in pediatrics with a pink, warm, well-perfused pulseless hand associated with SFH.