Sat., 10/15/11 Peds, Ger, Hip, Femur & IP, Paper #70, 10:23 am OTA-2011
Management of the Pediatric Pulseless Supracondylar Humerus Fracture: Is Vascular Exploration Necessary?
Amanda L. Weller, MD1; Sumeet Garg, MD2; A. Noelle Larson, MD3;
Nicholas D. Fletcher, MD4; Jonathan R. Schiller, MD5; Michael Kwon, MD6;
Lawson A.B. Copley, MD7; Christine A. Ho, MD7;
1University of Texas Southwestern Medical School, Dallas, Texas, USA;
2Denver Children’s Hospital, Denver, Colorado, USA;
3University of Minnesota, Minneapolis, Minnesota, USA;
4Emory University, Atlanta, Georgia, USA;
5Brown University, Providence, Rhode Island, USA;
6Texas Scottish Rite Hospital for Children
7Children’s Medical Center, Dallas, Texas, USA
Purpose: The purpose of this study is to examine the management of vascular injury in a large case series of pediatric patients with supracondylar humerus fractures who initially presented with a nonpalpable pulse.
Methods: 1297 consecutive operatively treated supracondylar humerus fractures that presented to a Level 1 pediatric trauma center from 2003 to 2007 were reviewed retrospectively. Clinical records were reviewed to determine vascular examination, Gartland classification, neurologic examination, associated injuries, timing of surgery, and postoperative complications.
Results: 1266 patients had documented radial pulse examinations, of which 54 (4%) had absent pulses. All 54 patients had type 3 fractures. Five patients (9%) underwent open exploration of vascular structures based on clinical findings of cool, pale hand, sluggish capillary refill; and/or weak or no dopplerable pulse after closed reduction; 1 of these 5 presented with an open fracture. All 5 were found to have a vascular injury needing repair to restore blood flow. The 4 patients who underwent immediate vascular exploration and repair were all noted to have nondopplerable pulses following reduction and pinning. Twenty patients (37%) had a documented dopplerable pulse and pink hand after closed reduction but the radial pulse remained nonpalpable. These patients were observed in the hospital for signs of ischemia, and one of these did require delayed vascular repair after developing a cool, pale hand; the remaining 19 regained a palpable pulse prior to discharge or by the first postoperative visit. Compared to all type 3 fractures included in the study, those patients with pulseless presentation had a higher rate of nerve palsy documented postoperatively (32% vs 9%; P <0.0001). Time from injury to surgery was also significantly less than other type 3 fractures (8.4 hours vs 16.8 hours; P <0.0001.)
Conclusions: This study demonstrates that almost 10% of patients who presented with a type 3 supracondylar humerus fracture and nonpalpable pulse underwent vascular repair to restore blood flow. However, in our series, a nonpalpable pulse after closed reduction was not an absolute indication to proceed with vascular exploration if clinical findings suggest that the limb is perfused (Doppler signal, capillary refill). Further prospective study is needed to define the role of the Doppler study in the pink, pulseless hand. In addition, pulseless patients also have a significantly higher rate of nerve palsy than patients with palpable radial pulses.
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• 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.