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CroniconO P E N A C C E S S EC ORTHOPAEDICS

Case Series

Pulseless Pink Hand in Pediatric Humerus Supracondylar Fractures, Early Results of an Ongoing Study

Wael Alsammak1* and Sara Alremeithi2

1Consultant Orthopedic Surgeon, Zulekha Hospital, Residency Program Faculty Member, Rashid Hospital, Dubai, UAE 2Resident Orthopedic and Trauma, Rashid Hospital, Dubai, UAE

Citation: Wael Alsammak and Sara Alremeithi. “Pulseless Pink Hand in Pediatric Humerus Supracondylar Fractures, Early Results of an Ongoing Study”. EC Orthopaedics 10.11 (2019): 11-17.

*Corresponding Author: Wael Alsammak, Consultant Orthopedic Surgeon, Zulekha Hospital, Residency Program Faculty Member, Rashid Hospital, Dubai, UAE.

Received: September 26, 2019; Published: October 15, 2019

AbstractSupracondylar fractures are common in children and most common between 5 - 7 years of age. The indications for emergent ORIF

(Open Reduction Internal Fixation- a type of surgery used to fix broken bones) with vascular explorations are pulseless hand with no perfusion or loss of pulse after close reduction. But the pulseless yet perfused hand the surgeon can wait and observe. Our study aims to question this, as we need to find indications for exploration even if the hand is perfused, yet pulseless. In practice in our region it carries medicolegal consequences if we discharge patient without clearly feeling the radial pulse. Plus if patient arrived at night then kept for observation for the morning the soft tissue swelling will make the procedure carries more morbidity.

Keywords: Pulseless Pink Hand; Humerus; Fractures

Introduction

Supracondylar humerus fractures of Gartland type III with pulseless pink hand comprise a significant dilemma for orthopedic surgeons in regards to whether and when to surgically intervene.

In our study we tried to assort and simplified criteria that would help orthopedic surgeons in reaching that critical decision correctl.

Our study started and spanned over the course of 2 years, 2015 and 2016. We reviewed cases of supracondylar humerus fractures of Gartland type III. And we studied the cases with suspected vascular injury amongst them.

Up till now, we have collected 12 cases out of a total of 168 cases of supracondylar humerus fractures treated in Rashid Hospital, Dubai, over the course of 2 years, 2015 and 2016, that matched our inclusion criteria of:

1. Child (< 13 years old).

2. History of trauma.

3. Supracondylar fracture of Gartland class III.

4. Pulse not palpable at presentation.

5. But hand was well perfused.

Absent radial pulse after Gartland type III supracondylar humerus fractures is mainly caused by one of these types of vascular injuries: Complete vascular injury, thrombosis, partial tears, entrapments, spasm or kinking [1,2].

Complete vascular injury, thrombosis, partial tears and entrapments, would likely result in developing pulseless white hand. On the other spasm or kinking would more likely result in developing a less severe form of vascular compromise, hence the pulseless pink hand [1,2].


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However, the crucial question is, how to distinguish that the patient had developed the latter two, spasm or kinking, as opposed to the more severe former four vascular injuries without resorting to the more aggressive method of direct surgical vascular exploration.

But what does the literature say about supracondylar humerus fractures with vascular injuries?

• Brachial artery compromise was found to be preset in approximately 11% of all supracondylar humerus fractures, vessel injury vs. vasospasm vs. tethering at the fracture site [3].

• Brachial artery injury was found to be preset in 38% of displaced supracondylar humerus fractures [4].

• Radial pulse was absent in 19% of displaced supracondylar humerus fractures [5].

• There was 10% to 20% incidence of an absent radial pulse in children presenting with a Gartland type III supracondylar humerus fracture [6].

Aim of the Study

Our aim was to question whether we can create a protocol or an algorithm for pulseless pink hand.

Our main indicator is to evaluate the accuracy of using intra-operative colored ultrasonography. And our secondary indicator is to add to our results the literature review.

Patients and Methods

Number of patients: Our aim is to recruit a total of 50 cases, however up till now we were able to collect a total of 12 cases.

Gender: Up till now we have 3 girls and 9 boys enrolled in our study.

Age: The subjects’ ages were between 3 - 7 years old, with a mean of 5 years old.

Neurological deficit: Out of our 12 patients, two had median nerve injury which improved after 6 weeks.

Intra-operative colored ultrasonography: Was utilized in all of our 12 patients and was verified by the presence of a radial palpable pulse on follow up (Figure 1).

Vascular observation: Divided into four phases:

1. Immediately after reduction (phase - 1).

2. After 6 hours from surgery (phase - 2).

Figure 1: Intra-operative colored ultrasonography signal showing the presence of a radial pulse on follow up after reduction (a), which can be seen on video, scan the barcode to view the video (b). Brachial artery pulse above the fracture site (c), and

after bifurcation of the artery below the fracture site (d).

(a) (b)

(c) (d)


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3. Before discharge (24 - 48 hrs) (phase - 3).

4. Four weeks at the office visit (> 48 hours) (phase - 4)

Cases

Case 1: A 5 years old boy who presented with a history of fall, sustained left supracondylar humerus fracture, Gartland type III. He had no neurological deficit. The radial pulse was not palpable at presentation. He was taken for emergent closed reduction and K-wires fixation was performed. The pulse returned after 48 hours and the total follow up duration was 12 weeks.

Case 3: A 6 years old girl who presented with a history of fall, sustaining right supracondylar humerus fracture, Gartland type III. She had associated median nerve injury. The hand was pink but there were no palpable pulses pre-operatively. Emergent open reduction and K-wires fixation was performed. The pulse was palpable immediately after reduction. Her total follow up duration was up until 4 weeks.

Figure 2: Radiographs of left supracondylar humerus fracture of case 1, at the initial presentation (left), post-operative (middle), on follow up at 12 weeks (right).

Case 2: A 5 years old boy who presented with a history of fall, sustained left supracondylar humerus fracture, Gartland type III. He had no neurological deficit. He was taken for emergent surgery where open reduction(close reduction attempt failed) and K-wires fixation was performed. The pulse was palpable after reduction. His total follow up duration was 12 weeks.

Figure 3: Radiographs of left supracondylar humerus fracture of case 2, at the initial presentation (a), post-operative (b), on follow up at 12 weeks (right).


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Figure 4: Radiographs of right supracondylar humerus fracture of case 3, at the initial presentation (a), post-operative (b).

Figure 5: The importance of adequate proper reduction, (a) a lateral radiograph after closed reduction showing a small fracture gap. Both the median nerve and the brachial artery were running through the fracture, image (b) shows a lateral radiograph after a proper reduction. Images courtesy of K. S. Mangat, A. G. Martin, C. E. Bache. “The ‘pulseless pink hand

after supracondylar fracture of the humerus in children”. VOL. 9 1- B, No. 11, NOVEMBER 2009 1521.

(a) (b)


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Figure 6: A graph demonstrating the phases at which a palpable radial pulse returned in each case, 58% returned at phase 1, 33% returned at phase 2, 8%

returned at phase 3, and none at phase 4.

Table 1: Summary of the 12 cases enrolled in the study including timing of return of pulse post operatively, their associated injuries, reduction method, and time and duration of follow up.

Results

Discussion

Gartland classification of supracondylar humerus fractures are divided into three types:

• Type I-Non-displaced fracture.

• Type II-displaced with intact posterior cortex

• Type III-displaced with no cortical contact.

The management of pulseless perfused hand post surgical stabilization is controversial in the literature. The management of a child whose hand remains pulseless yet perfused after closed reduction and K-wire fixation continues to divide opinion among orthopedic Associate nerve injury: As per Ramachandran M [8], Nerve injury with coexisting ischemia is indication for exploration [8].

Statistically significant correlation exists between the presence of median nerve injury and the having an associated brachial artery So does the return of the pulse in phase 3 or 4 indicate that brachial artery it patent? No. as demonstrated by Lipscomb and Burleson [10].


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Figure 8: A plain arteriogram demonstrating a good collateral circulation despite an occluded brachial artery (arrow). Image courtaesy of Lipscomb PR, Burleson RJ. Vascular and neural complications in supracondylar fractures of the

humerus in children. J Bone Joint Surg Am 1955; 37: 487e92.

The appropriate ways that demonstrated to support observation of the hand that remains pulseless but pink intra-operatively after accurate reduction include: Doppler ultrasound, pulse oximetry and intra-operative colored ultrasonography. Angiography was not one of them and it demonstrated to be excessive and unnecessary.

Figure 9: In a patient with an open fracture and pulseless pink hand, brachial artery spasm was found. Inaddition, contusion of the brachial artery with haematoma formation on the vascular wall in a small segment of the artery was

revealed (white arrow). After vascular dissection, removal of the haematoma and adventitia in a long segment of the artery, the spasm was released and the radial pulse was restored. Image courtesy of Korompilias AV., et al. “Treatment of pink pulseless hand following

supracondylar fractures of the humerus in children”. International Orthopaedics 33.1 (2009): 237-241.

Chee Cheong Soh [11] demonstrated in series of pulseless perfused hands following operative fixation of supracondylar humerus fractures, Gartland grade III extension type. fractures. That the absence of favorable postoperative pulse oximeter waveforms were predictive of significant brachial artery that mandated surgical exploration and demonstrated significant findings indeed. As opposed to the other group that has a normal waveform post operatively and soon return of the radial pulse without any further need for surgical exploration.


Figure 7: Good waveform on pulse oximeter (upper), Poor waveform on pulse oximeter (lower), as demonstrated by Reuben Chee Cheong Soh., et al., the presence of a poor waveform on pulse oximeter was a good predictor for the need of surgical exploration in

pulseless pink hand [11].

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Volume 10 Issue 11 November 2019©All rights reserved by Wael Alsammak and Sara Alremeithi.

Bibliography1. Shaw BA. “Management of vascular injuries in displaced supracondylar humerus fractures without arteriography”. Journal of

Orthopaedic Trauma 4.1 (1990): 25-29.

2. Noaman HH. “Microsurgical reconstruction of brachial artery injuries in displaced supracondylar fracture humerus in children”. Microsurgery 26.7 (2006): 489-505.

3. Blakey CM., et al. “Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up”. The Journal of Bone and Joint Surgery 91.11 (2009): 1487-1492.

4. Campbell CC., et al. “Neurovascular injury and displacement in type III supracondylar humerus fractures”. Journal of Pediatric Orthopaedics 15.1 (1995): 47-52.

5. Griffin KJ., et al. “The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children”. European Journal of Vascular and Endovascular Surgery 36.6 (2008): 697-702.

6. J E Robb. “The pink, pulseless hand after supracondylar fracture of the humerus in children”. Annotation. Journal of Bone and Joint Surgery 91.11 (2009): 1410-1412.

7. Korompilias AV., et al. “Treatment of pink pulseless hand following supracondylar fractures of the humerus in children”. International Orthopaedics 33.1 (2009): 237-241.

8. Ramachandran M., et al. “Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre”. The Journal of Bone and Joint Surgery 88.1 (2006): 90-94.

9. Luria S., et al. “Vascular complications of supracondylar humeral fractures in children”. Journal of Pediatric 16.2 (2007): 133-143.

10. Lipscomb Paul R., et al. “Vascular and Neural Complications in Supracondylar Fractures of the Humerus in Children”. Journal of Bone and Joint Surgery 37.3 (1955): 487-492.

11. Reuben Chee Cheong Soh., et al. “Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus”. Clinics in Orthopedic Surgery 5.1 (2013): 74-81.

Conclusion

Indications for exploration in pink but pulseless hand include:

1. None accurate reduction

2. Associated nerve injury

3. Negative at least 2 out of 3

• Doppler

• Intra-operative colored ultrasonography

• Good waveform on pulse oximeter.

Limitations of the Study • Still small sample

• Medico-legal aspects

• Difficulty of randomization.

https://www.ncbi.nlm.nih.gov/pubmed/2313426












https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899233/









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