Thurs., 10/8/09 Pediatrics & Injury Prevention, Paper #25, 2:35 pm OTA-2009
Pulseless and Puzzling, Vascular Injuries in Supracondylar Humeral Fractures in Children: A Meta-Analysis of Observational Studies and Results of a POSNA Membership Survey
(FDA = Non-U.S. research conducted within guidelines of my country)
Lydia A. White, MD1 (n); Charles T. Mehlman, DO, MPH2 (n);
Alvin H. Crawford, MD2 (3, 5A, 7-DePuy, A Johnson &Johnson Company);
1University of Cincinnati, Cincinnati, Ohio, USA;
2Cincinnati Children’s Hospital, Cincinnati, Ohio, USA
Purpose: Supracondylar humerus fractures that present with a pink, viable hand yet no pulse continue to be a source of controversy. The purpose of this study was to conduct a meta-analysis of the literature and Pediatric Society of North America (POSNA) poll regarding diagnostic issues related to pulseless supracondylar humeral fractures in children.
Methods: A systemic review of the literature was conducted for relevant observational studies concerning vascular injuries in supracondylar humerus fractures. Single case reports and non-English–language studies were excluded. Pooled meta-analysis was performed for defined subgroups and 95% confidence intervals (CIs) are reported where appropriate. An approved 5-question pulseless supracondylar survey was also sent to the POSNA membership.
Results: The POSNA membership questionnaire achieved an approximate 40% response rate. A total of 313 cases of pulseless supracondylar fractures were reviewed (irrespective of perfusion status). 138 fractures remained pulseless after closed reduction and stabilization. Of the fractures that continued to be pulseless despite adequate reduction, 82% (95% CI = 0.76, 0.88) had a documented brachial artery injury. POSNA members thought this number should be 28% (95% CI = 0.22, 0.34). A total of 102 perfused (also known as pink) supracondylar fractures were identified; 61 of these remained pulseless after closed reduction and stabilization. Of the fractures that remained pulseless, 77% (95% CI = 0.67, 0.87) had a documented brachial artery injury. POSNA members thought this number should be 17% (95% CI = 0.12, 0.22). A total of 54 patients who underwent vascular repair had minimum 2-year follow-up data on their vascular examination, and 91% (95% CI = 0.83, 0.99) of these patients had normal artery flow based on vascular studies. POSNA members thought this number should be 55% (95% CI = 0.48, 0.62).
Conclusion and Significance: Our meta-analysis reveals that common pediatric orthopaedic dogma regarding watchful waiting of pulseless and pink supracondylar fractures needs to be questioned. In the vast majority of cases, an absence of pulse is an indicator of arterial damage, even if the hand appears perfused. This finding supports the practice of aggressive vascular evaluation and possible exploration in an effort to minimize the chance of vascular complications. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile. A survey of POSNA members revealed that there are significant discrepancies between current opinion and literature derived rates.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant