➤ The prevalence of neurological injuries in patients with displaced supracondylar humeral fractures is 10% to 20%.
➤ The prevalence of vascular injury in patients with displaced supracondylar humeral fractures is ∼15%.
➤ Isolated nerve injuries can commonly be observed without surgical exploration, resulting in nerve recovery over time.
➤ In the ischemic extremity, emergent reduction and pinning is necessary, with reassessment of the vascular status after reduction.
➤ In patients with a perfused, pulseless extremity following a supracondylar humeral fracture, prompt reduction and pinning is recommended. If the extremity remains well perfused but the pulse does not return, continued observation is recommended.
➤ For cases in which a palpable pulse does not return after reduction in a patient with a perfused, pulseless extremity following a supracondylar humeral fracture, many authors have recommended surgical exploration if there is a lack of a normal Doppler signal, if there is an associated median nerve palsy, or if perfusion is inadequate based on clinical observation of capillary refill, color, and warmth.
Supracondylar humeral fractures are one of the most common pediatric elbow fractures, accounting for 55% to 80% of such fractures1. The majority of these fractures occur as the result of a fall onto an outstretched upper extremity2,3. Extension-type fractures account for 98% of supracondylar fractures after a fall onto an outstretched hand with the elbow hyperextended, resulting in posterior displacement of the fracture4. Flexion-type injuries occur approximately 2% of the time after a fall onto a flexed elbow, resulting in anterolateral displacement of the fracture4.
The intimacy of the neurological and vascular structures to the distal aspect of the humerus put them at substantial risk in the setting of a supracondylar humeral fracture. The frequency of neurological deficit after supracondylar humeral fractures is 10% to 20%5,6. The prevalence of vascular compromise in patients with pediatric supracondylar humeral fractures has been reported to range from 2.6% to 4% in large series of all operatively treated fractures and from 14% to 18.6% in series of patients with Gartland type-III3 fractures1,5,7,8.
A number of controversies are associated with the treatment of supracondylar humeral fractures. The majority of these controversies pertain to fractures with associated neurological or vascular injuries. This review will focus on the clinical evaluation, timing of surgery, management, and outcomes for patients with neurological and vascular injuries in the setting of a supracondylar humeral fracture.
Clinical evaluation of a patient who has a suspected supracondylar humeral fracture requires careful attention. Patients commonly present with pain, swelling, and gross deformity at the elbow. When a child with elbow trauma is evaluated, the entire extremity must be examined. Skin should be assessed for any compromise or suggestion of an open fracture. The antecubital region should be examined for ecchymosis and the so-called brachialis sign or pucker sign9,10. This sign is observed in the antecubital region when the proximal fracture fragment has pierced through the brachialis muscle into the deep dermis and results in puckering of the skin (Fig. 1).
Assessment of the vascular status of an injured extremity is essential in cases of displaced fractures as one-sixth of patients can present with vascular compromise distal to the fracture1,5,7,8,11. The clinical question is whether the hand is adequately perfused. The vascular status typically can be classified into one of three common categories: (1) normal perfusion (indicating that the hand is well perfused [warm and pink] and a palpable pulse is demonstrable with Doppler ultrasound); (2) perfused, pulseless (indicating that the radial pulse is not palpable but the hand is perfused, with a capillary refill time of less than two seconds); or (3) ischemic (indicating that the hand is poorly perfused [white] and the radial pulse is neither palpable nor audible with Doppler ultrasound).
Vascular compromise can occur in a number of scenarios. A large antecubital hematoma can cause external compression on the brachial artery, impeding normal flow. The brachial artery can be stretched over the displaced fracture, resulting in vasospasm of the vessel. Entrapment of the artery can occur when the fracture is reduced12. Last, intimal brachial arterial injury as well as complete transection also have been described13. A pulseless extremity with an associated median or anterior interosseous nerve palsy should alert the physician to the possibility of nerve and vessel entrapment or tethering at the fracture site14.
There are a number of ways to assess the vascular status. Visual inspection is important. A large antecubital hematoma or pucker sign can be an indication of an associated vascular injury at the level of the fracture. The radial artery pulse can be palpated at the wrist. If no pulse is palpated, a Doppler examination can be used to assess arterial flow at the wrist. Perfusion of the hand is an important indicator of the vascular status of the limb. Clinical indicators of sufficient distal perfusion include normal capillary refill, skin temperature, and color (typically described as pink). Pulse oximetry has been described as an indirect measure of extremity perfusion15,16. Last, near-infrared spectroscopy (NIRS) has been used to assess tissue and muscle perfusion distal to the injury17. NIRS is a noninvasive method that uses infrared technology to measure tissue perfusion at a depth of ∼1.5 to 2 cm.
A careful neurological examination of the extremity should be performed for patients with supracondylar humeral fractures because of the high prevalence of neurological injury5,6,18,19. In a meta-analysis of 5148 patients, Babal et al. examined the risk of traumatic neurapraxia in patients with extension-type supracondylar fractures as compared with that in patients with flexion-type fractures6. The overall rate of traumatic neurapraxia was 11.3% for all displaced supracondylar humeral fractures. The rate was slightly higher in patients with flexion-type fractures than in those with extension-type fractures. Several other reports have demonstrated rates of neurological injury ranging from 9% to 30% in patients with displaced supracondylar humeral fractures5,20-22.
Fracture type and the direction of fracture displacement may influence the type of nerve injury. Babal et al. found that the anterior interosseous nerve was the most frequently injured nerve in extension-type injures (accounting for 34.1% of associated nerve injuries), whereas the ulnar nerve was the most commonly injured nerve in flexion-type injuries (accounting for 91.3% of associated nerve injuries)6. Louahem et al. found that posteromedial displacement was responsible for injuries to the radial nerve; however, injuries to the median and anterior interosseous nerves were observed in association with posteromedial and posterolateral displacement20. Often, the direction of fracture displacement will stretch the nerves on the concavity of the deformity. Thus, posterior displacement of the fracture appears to stretch or injure nerves anteriorly (the median and anterior interosseous nerves) and anterior displacement of the fracture appears to stretch or injure nerves posteriorly (the ulnar nerve).
It is critical that the surgeon make every effort to detect nerve deficits in these patients through observation of activities and serial examinations when necessary. A documented preoperative examination is important so that any new postoperative neurological deficits can be detected. Thorough neurological assessment may be challenging and unattainable in some children because of pain, anxiety, or poor cooperation with the examination. Median, radial, and ulnar nerve motor function can be assessed by means of grip/grasp, digital extension, and cross-finger testing, respectively. The anterior and posterior interosseous nerves should also be measured with use of the OK sign23 and extension of the thumb. Sensation can be assessed with use of light touch or pin prick to the first dorsal web (radial nerve), second volar fingertip (median nerve), and fifth volar fingertip (ulnar nerve). If intact sensation remains in question, the hand can be wrapped in a wet cloth for several minutes and any area of skin that does not exhibit the normal wrinkling response can be presumed to have an injury to the nerve innervating that area5. Again, it is important to perform all parts of the examination described above, but there may be limitations based on the age and temperament of the child.
Because of the high risk of injury, preoperative assessment of the ulnar nerve is particularly important with flexion-type supracondylar fractures24. If the child is not able to cross the fingers, the examiner can ask the child to pinch the examiner’s finger so that the examiner can palpate contraction of the first dorsal interosseous muscle in order to confirm ulnar motor function.
Patients with displaced supracondylar humeral fractures are at risk for compartment syndrome. Traditional signs and symptoms used to detect compartment syndrome in adults are unreliable indicators of this condition in children but should still be evaluated25. Suspicion should be high for compartment syndrome in pediatric patients with increasing agitation, anxiety, or analgesia requirements. If there is clinical concern about compartment syndrome, objective measurement of compartment pressures, similar to the measurements in adult patients, can be performed. If clinical suspicion is high, then there should be a low threshold for prompt reduction of the fracture in the operating room, with intraoperative assessment of forearm compartment pressures26,27.
In the setting of a vascular injury, compartment syndrome can occur acutely in relation to the injury or after vascular repair and subsequent reperfusion. The risk of compartment syndrome is higher in the pulseless extremity and can occur as much as forty-eight hours after an injury, despite return of the pulse following reduction, as a result of reperfusion26. A recent study indicated that children who undergo vascular repair after supracondylar fractures are also at increased risk for the development of compartment syndrome, even after successful vascular repair27.
The examiner also should have a heightened clinical suspicion for compartment syndrome in the setting of an ipsilateral wrist or forearm fracture and a displaced supracondylar humeral fracture. In the study by Blakemore et al., the risk of compartment syndrome was higher in patients who had more than one fracture in the same extremity28. Conversely, a more recent study by Muchow et al. did not show the risk of compartment syndrome to be higher in patients with ipsilateral supracondylar and forearm fractures29. Regardless, increased vigilance and more urgent treatment are indicated for patients with severe swelling, skin puckering, an absent pulse, or additional fractures in the same limb.
Timing of Operative Intervention
The timing of operative intervention in children with displaced supracondylar humeral fractures remains an area of ongoing debate; however, there is a growing body of literature to support treatment in a delayed fashion in select clinical settings. Traditionally, all patients with Gartland type-III supracondylar humeral fractures underwent emergent surgery. Mehlman et al. challenged this doctrine in a study involving 198 patients in which the perioperative complication rates associated with fractures that were treated eight hours or less after the injury were compared with those associated with fractures that were treated more than eight hours after the injury30. The authors found no differences between the groups in terms of the rates of conversion to open reduction, pin-track infection, or iatrogenic nerve injury, and no patient in either group developed compartment syndrome. Gupta et al. found no significant difference in the rate of perioperative complications or the rate of open reduction between children who underwent early surgical treatment of supracondylar humeral fractures (less than twelve hours after the injury) and those who underwent delayed treatment (more than twelve hours after the injury)31. Other authors have found similar results with regard to the timing of surgery with respect to the rate of complications and the need for open reduction32,33.
Although we are not aware of any studies that have evaluated complications related to the timing of operative intervention in the setting of nerve palsy or a perfused, pulseless extremity in patients with a supracondylar humeral fracture, most authors have strongly encouraged more timely treatment of these injuries26,34. Controversy exists over the urgency of reduction and fixation in the setting of a perfused, pulseless extremity in a patient with a supracondylar humeral fracture. Several studies have suggested that undue delay can increase the risk of complications35-37. Other indications for emergent management include open fractures, dysvascular limbs, skin puckering, ipsilateral limb fractures, and signs or symptoms of evolving forearm or hand ischemia34.
Operative Treatment of Neurovascular Injuries
Traumatic nerve injury is the most frequent complication associated with supracondylar humeral fractures, with a variable prevalence of specific nerve injuries among published series5,6. There is some controversy about exploring nerve injuries in the setting of a supracondylar humeral fracture. Most authors have agreed that, in the setting of an isolated nerve injury and no vascular injury, the nerve palsy can be treated with observation26. However, there is controversy about whether open exploration is necessary for patients with nerve palsy and vascular injury. Some authors have recommended early open exploration when there is coexisting nerve injury with any vascular compromise38. One concern is tethering or entrapment of the nerve and vessel at the fracture site (Fig. 2). Mangat et al. reported on a series of patients with nerve injury who underwent exploration38. A relationship was found between preoperative median and anterior interosseous nerve deficits and vascular entrapment and tethering. The authors recommended early arterial exploration for patients with a Gartland type-III supracondylar fracture who have coexisting anterior interosseous or median nerve palsy. Thus, it is important to recognize that anterior interosseous or median nerve injuries can be associated with vessel entrapment in some instances. However, with collateral blood flow, it is unknown in this setting if the arterial exploration and possible repair recommended by Mangat et al.38 are necessary to achieve improved outcomes and to prevent complications.
Iatrogenic Nerve Injuries
Iatrogenic nerve injures do occur during closed and open treatment of supracondylar humeral fractures. Babal et al., in a subgroup analysis of their data on 1303 patients, reported that the prevalence of iatrogenic neurapraxia was 3.9%, with rates of 3.4% for lateral-only pinning and 4.1% for medial and lateral pinning6. Lateral pinning was associated with an increased risk of median neuropathy, and medial pinning was associated with a risk of injury to the ulnar nerve. In a recent prospective study of patients who were able to comply with a preoperative neurological examination performed by an attending pediatric orthopaedic surgeon, Joiner et al. found that the rate of iatrogenic nerve injury after operative treatment of supracondylar humeral fractures was 3%39.
Fixation of supracondylar humeral fractures with crossed pinning is recommended to improve rotational stability22, but the ulnar nerve is at risk with medial pin placement. In a systematic review, Slobogean et al. studied the association between crossed pinning and the risk of iatrogenic nerve injury40. The results suggested that there is an iatrogenic ulnar nerve injury for every twenty-eight patients managed with crossed pinning as compared with lateral pinning. Rasool, in an early report on six cases of ulnar nerve injury after medial pin placement, found that the pin had been placed in the cubital tunnel in five patients and had either directly penetrated the nerve (two) or constricted the nerve within the cubital tunnel (three)41. In the sixth patient, the nerve was mobile and was fixed anterior to its groove, with the pin causing restricted motion. Ulnar nerve instability has been demonstrated in children and potentially poses another risk for medial pin placement42,43. Wind et al. concluded that one could not accurately predict the location of the ulnar nerve with use of anatomic landmarks alone prior to blind percutaneous medial pin placement44. Operative techniques for medial pin placement, including the use of a small medial incision and pinning the elbow in slight extension after the placement of one or two lateral pins, may decrease the possibility of iatrogenic ulnar nerve injury45.
Treatment of the iatrogenic nerve injury is not thoroughly discussed in the literature, but the question arises as to whether iatrogenic nerve injuries should undergo exploration or pin removal. Khademolhosseini et al. recently reported that the prevalence of iatrogenic nerve injury was 14% (thirty-nine of 272)46. In nearly all thirty-nine patients, Kirschner wires were not removed and nerves were not explored. The authors found that all nerve injuries resolved at a mean of 3.5 months with observation alone. Therefore, they did not advocate for exploration of iatrogenic nerve injuries or removal of Kirschner wires.
The prevalence of arterial compromise in patients with pediatric supracondylar humeral fractures can be high, especially in those with displaced Gartland type-III fractures1,5,7,8. There is little debate regarding the treatment of a cool, pale, white, and pulseless hand in a patient with a supracondylar humeral fracture. In this clinical setting, it is recommended that fracture reduction and percutaneous pin stabilization be performed emergently, with subsequent reassessment of the perfusion to the hand as perfusion commonly improves with reduction of the fracture. Choi et al. found that fracture reduction without exploration was sufficient treatment in five of nine patients with a pulseless, poorly perfused hand1. In the unusual case that perfusion does not improve after fracture reduction, open exploration and possible arterial repair is indicated8,12. In addition, open exploration of the artery is indicated if there is loss of a previously palpable pulse after fracture reduction. The use of preoperative angiography of the injured extremity is not indicated as it only leads to a delay in treatment and does not provide any additional information with regard to the location of the injury as the vascular injury is located at or near the fracture site47,48.
There still is no clear consensus regarding the optimum treatment when a patient has an absent palpable pulse and a perfused hand. Most authors have recommended prompt reduction and pinning26,27,30. White et al., in a systematic review, found that 53% (174) of 331 patients who had a pulseless extremity following a supracondylar humeral fracture had return of a palpable radial pulse after fracture reduction and stabilization37.
The question remains: In the setting of a perfused, pulseless extremity following a supracondylar humeral fracture, is open exploration and vascular repair necessary to prevent ischemia and future complications, or is collateral circulation sufficient? There are two opinions regarding the management of the patient who has a perfused, pulseless extremity following a supracondylar humeral fracture. Some authors have supported close inpatient monitoring of the perfused, pulseless supracondylar humeral fracture after closed reduction and pinning49-53. Other authors have advocated open exploration with or without brachial artery repair in situations in which there is no return of a palpable pulse after fracture reduction and stabilization35,37.
Historically, the authors of several studies have suggested so-called “watchful waiting,” or observation, for the management of patients who have a perfused, pulseless extremity following a supracondylar humeral fracture49-51. This approach has been recommended for patients with a perfused, pulseless hand after closed reduction and pinning, regardless of whether or not the pulse returned. Garbuz et al. studied twenty-two patients, with both good and poor perfusion, who had initially presented with an absent radial pulse at the time of admission49. After initial operative management consisting of open or closed reduction, five patients lacked a palpable pulse but had good perfusion. This cohort of five patients was monitored for forty-eight hours postoperatively, with no additional intervention. No patient developed any neurovascular complications, and all five had normal range of motion and normal functional status after an average duration of follow-up of 4.5 years.
The authors of several recent publications have followed these recommendations and have not demonstrated any major complications of ischemia or any major functional complications in the perfused, pulseless hand1,7,20,52,53. Weller et al. and Choi et al. both recommended that patients who have a perfused limb but no palpable radial pulse after closed reduction and percutaneous pinning of a supracondylar humeral fracture should be observed for twenty-four to forty-eight hours to allow for the identification of patients who are potentially at risk for ischemia or compartment syndrome1,7. Choi et al. stated that collateral circulation is often adequate to maintain perfusion1.
Some authors have recommended immediate exploration because delayed treatment of ischemia can be devastating, resulting in compartment syndrome and late ischemia35,37. Blakey et al. found that twenty-three of twenty-six patients with a pink, pulseless hand following initial management had some evidence of ischemic contracture, and the authors advocated urgent exploration when the pulse does not immediately return after closed reduction35. White et al. advocated more aggressive vascular evaluation and vascular exploration and repair in selected cases37. The authors concluded, on the basis of their meta-analysis, that the absence of a pulse in a patient with a perfused hand is an indicator of arterial injury; of the ninety-eight such patients in their analysis, 70% had a documented arterial injury. The use of Doppler ultrasound after reduction also can change the management of a patient who has a perfused, pulseless extremity following a supracondylar humeral fracture. Rabee et al. reported on a series of six patients, five of whom had pink and well-perfused extremities, who had a persistently absent radial pulse with monophasic Doppler flow signals after closed reduction and percutaneous pinning54. All six patients underwent surgical exploration of the brachial artery and were found to have entrapment of the artery at the fracture site, with immediate return of radial pulse with triphasic Doppler flow on release of the artery. The investigators concluded that a persistently absent radial pulse on Doppler ultrasound in the form of absent or monophasic flow in the radial artery is a reliable indicator of vascular compromise and that surgical exploration should be performed. Schoenecker et al. reported on seven patients who initially underwent closed reduction and pinning of a displaced supracondylar humeral fracture who had a seemingly viable hand but with diminished or absent Doppler pulses55. All patients were then managed with open exploration: three of the patients underwent repair of a brachial artery injury with use of a saphenous vein graft, and the other four required removal and mobilization of the brachial artery, which had become kinked or entrapped at the fracture site. In all cases, the pulse was reestablished and maintained.
On the basis of the available literature, the indications for open exploration of the perfused, pulseless extremity in a patient with a supracondylar humeral fracture include any evidence of ischemia or inadequate perfusion as indicated by clinical observation of capillary refill, color, and warmth of the hand. Additionally, some algorithms27 and other studies54 have recommended surgical exploration of the perfused, pulseless hand after reduction if there is a lack of a normal Doppler signal. Some authors have recommended open exploration for median nerve palsy and vascular injury14,29,38. Although a number of algorithms have been developed27,34,56, no algorithm is universally accepted.
The surgical technique for open exploration is commonly a transverse incision through the antecubital flexion crease (Fig. 3). This incision avoids scar contracture. It can also be easily extended proximally on the medial side and distally on the lateral side to gain better exposure. Through this incision, it is possible to gain access to and visualization of the median nerve, the brachial artery, and the fracture. It is also possible to identify periosteum, brachialis muscle, and nerves or vessels entrapped in the fracture site.
The majority of preoperative neurological injuries are neurapraxias, and recovery is typically seen within six to sixteen weeks after the injury57. Other studies have supported noninterventional waiting in cases of isolated neurological injury. Gosens and Bongers found that all isolated nerve palsies resolved fully within six months58. Scannell et al. evaluated nerve recovery after the observation of perfused, pulseless extremities in patients with supracondylar humeral fractures and reported resolution of nerve palsy in approximately ten weeks52. It is uncommon for nerve deficits not to resolve, and thus nerve exploration at the time of the injury is not recommended when the nerve injury is isolated. The literature is not clear with regard to the percentage of nerve deficits that do not resolve spontaneously. Ramachandran et al. presented a case series of nerve injuries in patients with supracondylar humeral fractures57. Thirteen patients presented with persistent nerve palsies three months after the initial injury. Only two of these thirteen patients required surgery for the treatment of persistent nerve palsies; in the remaining eleven patients, the nerve palsies resolved with time. Both of the patients who underwent surgery had gapping at the fracture site at the time of initial fixation and were found to have nerves entrapped in bone at the time of surgery. On the basis of that series, nerve exploration and neurolysis may be necessary in patients with persistent nerve palsies and gapping at the fracture site.
As discussed previously, iatrogenic injury to the ulnar nerve has been reported following the placement of a medial pin for fracture stabilization18.While the majority of postoperative ulnar nerve deficits will resolve without intervention, neurolysis may be required if deficits persists beyond three months59,60. Lyons et al., in a report on seventeen patients with iatrogenic ulnar nerve palsy, noted that all patients did well, regardless of whether the wire was removed, the nerve was explored, or the patient was managed nonoperatively60. Thus, we commonly recommend observation for these injuries.
Clinical and functional outcomes have been evaluated after careful observation of the perfused, pulseless extremity in patients with a supracondylar humeral fracture. Scannell et al.52 evaluated twenty patients with a perfused, pulseless extremity following a supracondylar humeral fracture who were managed with careful observation after reduction and percutaneous pinning. Immediately following closed reduction and pinning, only five patients (25%) had a return of a palpable pulse. However, all patients had a return of a palpable pulse at the time of the latest follow-up. Similar return of a palpable pulse has been seen in other studies as well. Ramesh et al., in a report on seven patients with perfused, pulseless extremities in whom a supracondylar humeral fracture was treated with observation, noted that all patients had a return of a pulse within six weeks after the injury53. Few studies have evaluated functional outcome. Scannell et al. found that nearly all patients had a functional range of motion at the elbow and functional scores similar to the general population when evaluated with the Pediatric Outcomes Data Collection Instrument (PODCI)52. There were no cases of compartment syndrome or Volkmann ischemic contracture, but one patient had cold intolerance.
Vascular outcomes in patients undergoing exploration and reconstruction also have been evaluated in the literature. Several recent studies have suggested that prompt reduction and assessment of the vascular status is necessary and that failure to do so can result in ischemia and thus a poor functional outcome35,61.
Mixed results have been reported with respect to vessel patency after reconstruction. In the study by Sabharwal et al., thirteen patients with pulseless extremities and supracondylar humeral fractures underwent vascular repair51. The patients underwent a color flow Duplex ultrasound examination and magnetic resonance angiography at a mean of thirty-one months after the injury. The rate of stenosis and re-occlusion was high, leading the authors to support observation rather than surgical intervention. Mangat et al. evaluated vascular status following vessel repair and noted that the limb remained well-perfused and functioned normally even if the radial pulse did not return or the vessel repair was not patent38. Conversely, in a series of twelve patients who underwent vascular reconstruction, Konstantiniuk et al. reported that all patients had vessel patency after an average duration of follow-up of fourteen years62. In an analysis of nineteen published articles, White et al. identified ninety-eight patients with pink, pulseless hands after supracondylar fractures37. Forty-five patients underwent vessel exploration. Five patients were found to have vessels in spasm, and forty had vessel injury requiring repair. At the time of follow-up, the patency rate was 90%. Reigstad et al. reported on five patients who underwent closed reduction and pinning and were subsequently transferred because of absent or slow capillary refill63. At one year after open exploration and vascular reconstruction, all patients exhibited normal and symmetric function in the upper extremities. It is unclear whether return to near-normal function was related to brachial artery patency and return of palpable distal pulses in those patients.
The goal of closed reduction, surgical exploration and/or decompression, and revascularization is to prevent ischemia and poor clinical outcomes35. Any fracture in the elbow region or the upper arm may lead to Volkmann ischemic contracture, but the most commonly reported cause is a supracondylar humeral fracture64. When there is excessive forearm pressure as a result of swelling, or when perfusion to the muscle is insufficient, muscle ischemia ensues. Volkmann contracture occurs when there is a lack of blood flow (ischemia) to the forearm and primarily involves the flexor muscles of the forearm, especially the flexor digitorum profundus and flexor pollicis longus65. The main symptom in a child may be worsening pain or evidence of progressive nerve palsy35. Following a period of ischemia, the muscles become fibrotic and shorten, leading to permanent contractures involving the forearm, hand, and wrist. The treatment options for Volkmann contracture are limited, emphasizing the importance of prevention with vigilance around the time of injury. The goal of treatment is ultimately to prevent ischemia and permanent disability. However, we do not have any current way to assess whether the extremity is being adequately perfused.
Neurological and vascular injuries occur in ∼10% to 20% of patients with displaced supracondylar humeral fractures. Although examination can be challenging in the pediatric population, a careful preoperative, intraoperative, and postoperative neurological and vascular examination should be attempted and documented. There are many aspects of arterial assessment, but the most important is determination of the presence or absence of adequate perfusion distal to the fracture. If the distal aspect of the extremity is ischemic, prompt fracture reduction should be performed. In the unusual case in which adequate perfusion does not return after fracture reduction, immediate surgical exploration and treatment of the brachial artery is indicated. However, there remains substantial controversy regarding the management of patients who have a perfused, pulseless extremity following a supracondylar humeral fracture. In these patients, prompt fracture reduction should be performed and observation is indicated if the pulse returns. If the pulse does not return, a large portion of the current literature supports continued observation. Some authors still recommend arterial exploration if the pulse does not return but the extremity is well perfused. A number of published treatment algorithms have been described27,34,56, but none is universally accepted. Future studies are necessary to determine if there is a subset of patients with a perfused, pulseless extremity following a supracondylar fracture who clinically benefit from arterial exploration.
Source of Funding: No external funds were received in support of this study.
Investigation performed at the Department of Orthopedic Surgery, Levine Children’s Hospital/Carolinas HealthCare System, Charlotte, North Carolina
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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