Risk Factors for Vascular Repair and Compartment Syndrome in the Pulseless Supracondylar Humerus Fracture in Children

Author(s): Choi PD, Melikian R, Skaggs DL

Source: J Pediatr Orthop 30(1):50-56, 2010.

Summary:

Supracondylar humerus fractures are common in children.  The indications for vascular repair remain controversial.  The goal of this study was to determine how often fracture reduction alone restores pulses and vascular profusion in children that present with absent distal pulses.  The authors also searched for preoperative factors that were associated with the need for vascular repair and vascular complications.  The methods consisted of 1255 fractures over an 11 year period.  There were 33 patients that presented with a displaced supracondylar fracture and a pulseless extremity.  This subgroup was used for further assessment. 

The children were divided into 2 different groups.  One group had no pulses but well perfused extremities.  The second group consisted of extremities without pulses that were poorly perfused.  The pulseless and well perfused group made up 24 of the 33 patients.  Of these 24 patients, 2 underwent immediate open reduction and percutaneous fixation in addition to irrigation and debridement because the injuries were open.  Twenty-two of the patients underwent close reduction in the operating room.  Twelve patients regained distal pulses and nine had no palpable pulse but maintained signs of perfusion.  One patient did require open reduction because of failure to obtain adequate reduction.  The brachial artery was found to be stretched over the proximal fragment. 

The second cohort of pulseless and poorly perfused extremities consisted of 9 patients.  Interestingly, only 1 patient had anterior interrosseous nerve palsy compared to 8 in the pulseless and well perfused cohort.  Of these 9 patients, 2 patients were transferred from an outside institution and underwent immediate open reduction and cubital fossa exploration.  The other 7 patients underwent an attempt at closed reduction.  Two of the seven patients regained palpable distal pulses and underwent percutaneous pinning for definitive treatment. Five patients did not regain palpable pulses but substantial improvements in perfusion were noted.  These were stabilized with percutaneous pinning and observed.  Two of these patients developed delayed compartment syndrome requiring emergent fasciotomy and brachial artery exploration.  Four children in this cohort required vascular repair after an unsuccessful attempted fracture reduction.  All four were pulseless and poorly perfused.  None of the children with a pulseless and well perfused extremity required vascular repair. 

This study highlights that fact that there are differences in children that present with pulseless extremities.  The well perfused extremities are unlikely to require vascular exploration.  In contrast, nearly half of the patients with poorly perfused extremities required a vascular exploration.  The neurologic status appears to be unrelated as anterior interrosseous nerve palsy was more common in those with well perfused limbs.  This highlights the suspicion for vascular injury requiring treatment in those children with pulseless limbs that are poorly perfused.