Two studies examine pulseless fractures and risk for brachial artery injury

The management of supracondylar humerus fracture—the most common fracture around the elbow in children—has long been a controversial topic. Debate has focused on the prevention and treatment of brachial artery injury, in particular on how to proceed when the radial pulse is absent but the hand is pink and warm.

At the 2010 Annual Meeting of the Pediatric Orthopaedic Society of North America (POSNA), one study suggested pursuing further diagnostic measures in any pulseless situation, while another reported that in children, poor perfusion is a more useful indicator for further intervention than the lack of a radial pulse.

Lydia White, MD, and her co-authors—Charles T. Mehlman, DO, MPH, and Alvin H. Crawford, MD, all of Cincinnati Children’s Hospital Medical Center—favored a more aggressive approach. Their study compared documented outcomes with predictions from a POSNA-approved survey on management of these fractures. The survey, distributed to all POSNA members, had a 40 percent response rate (254 responses).

The systematic review of the literature found 331 cases of pulseless supracondylar fractures (regardless of perfusion status). After closed reduction and stabilization, 157 fractures remained pulseless. Of these, 82 percent had a documented brachial artery injury. The POSNA estimate of how frequently this injury would occur was substantially lower (Table 1).

The authors found that 70 percent of the pulseless fractures that had good perfusion also had a documented brachial artery injury. Again, the incidence estimate by POSNA members was much lower—at just 17 percent

Finally, while the research found that 91 percent of patients who underwent revascularization had a patent artery at 1-year follow-up, POSNA members predicted that only 55 percent would show patency.

Watch and wait, or act?
Based on these findings, the authors wrote that “common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evaluation and exploration and repair in selected cases.”

“For years, we’ve just watched patients with fractures who are pulseless but still have a good pink color in the hand,” said Dr. White. “We assumed that the artery was in spasm and the pulse would return. But the meta-analysis showed that the brachial artery was injured in a majority of patients with an absent pulse.”

These findings suggest that physicians should not treat these injuries “cavalierly” and should “be more cautious and concerned about these injuries,” she said.

The consequences of failing to detect a brachial artery injury can be serious, Dr. White said. Among the complications are Volkmann ischemia, forearm claudication, cold intolerance, embolization, sensory-motor problems, and retarded development of the limb. Even when collateral circulation is good, patients have reported long-term dysesthesia or loss of function.

“The biggest problem is that we can’t tell who these kids at risk are,” said Dr. White. “We also don’t know what the long-term risks are of not having a functioning brachial artery, even with good collateral circulation.”

She recommended monitoring all pulseless fractures with Doppler color-flow ultrasound because approximately 20 percent of people have an anatomic abnormality of the local vascularity. In constrast to angiogram, ultrasound is a noninvasive measure. In addition, Doppler ultrasound used in the operating room is helpful in identifying these injuries. She advocated its use in any pulseless fracture.

“Today we have very good repair techniques, and repair can be very successful,” she concluded (Fig. 1).

Another perspective
Paul D. Choi, MD; Rojeh Melikian, MD; and David L. Skaggs, MD, approached the subject from a different angle and came to a somewhat differing, although not necessarily contradictory, conclusion on the management of a child with a pulseless supracondylar humerus fracture.

Their study sought to determine the incidence and outcome of vascular injuries associated with displaced supracondylar humerus fractures in children and identify preoperative factors that would predict the need for vascular repair and complications. A review of 1,255 displaced supracondylar humerus fractures in children treated surgically during a 12-year period at one institution found 33 patients who were pulseless—9 with poor perfusion and 24 with good perfusion.

In the group with poor perfusion, 4 patients had vascular repair, with 2 cases of postoperative compartment syndrome. None of the 24 well-perfused patients underwent vascular repair or later had compartment syndrome. Of the 21 well-perfused patients who underwent closed reduction and pinning, 11 had a palpable pulse following surgery and 10 remained pulseless; all did well clinically.

The authors concluded that the perfusion status of the hand does indeed appear to be a risk factor for the need for vascular repair and vascular complications. Children who had a pulseless and well-perfused hand did uniformly well with fracture reduction alone. Even patients who remained pulseless but had good perfusion after fracture reduction did well clinically. In contrast, children who had a poorly perfused hand had a nearly 50 percent chance of needing an arterial repair and a 22 percent chance of compartment syndrome development.

Later, Dr. Choi discussed the differences as well as overlap of the two studies. “We may be looking at this from different viewpoints,” he said. “Our study suggests that the initial perfusion status of the hand can guide treatment decisions. With a pink, well-perfused hand, fracture reduction should be sufficient. In patients with poor perfusion, the surgeon should be ready to proceed to open reduction and brachial artery exploration, perhaps even having a vascular surgeon on standby.”

While Dr. Choi agreed that an injury to the brachial artery can have potentially serious consequences, the pertinent point, he said, “may not be whether an injury to the brachial artery is present, but what the impact on perfusion is. If the brachial artery is injured and the distal perfusion poor—likely because the collateral circulation is poor—the surgeon should suspect vascular complications and be ready. In a pink, pulseless hand (likely because the collateral circulation is intact), we continue to recommend close observation.”

The two studies also have differing perspectives on the value of and need for intraoperative use of Doppler ultrasound for fractures that remain pulseless. Although Dr. White’s group explicitly recommends the imaging procedure, Dr. Choi notes that patients who were pulseless but had good perfusion demonstrated favorable outcomes, even without additional imaging or other further interventions. He agreed, however, that ultrasound may be useful in differentiating patients at risk and can be part of an effective vascular evaluation.

“Obviously, this is a controversial topic,” he said. “Most recommendations, however, are based on retrospective studies, which have inherent flaws. This points to the overwhelming need for a prospective study.”

Disclosure information: Dr. Crawford—Abbott Spine, DePuy, Harms Study Group, Medtronic, Synthes; Dr. Mehlman: Abbott Spine, DePuy, Harms Study Group, Stryker, Synthes; Dr. Skaggs: Medtronic. Drs. Choi, Melikian, and White—no conflicts.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom line

• Injury to the brachial artery can have potentially serious consequences, such as Volkmann ischemia, loss of limb, and retarded development of the limb.
• The common practice of watchful waiting for pulseless and perfused supracondylar fractures may be open to question in favor of a more aggressive approach.
• Doppler ultrasound may be useful in differentiating patients at risk and can be part of an effective vascular evaluation.
• Prospective studies are needed to provide more definitive information on management of supracondylar humerus fractures.

Managing supracondylar humerus fractures: The puzzle of pulse and perfusion (video)