Cutting edge Orthopedics

Supracondylar Humerus Fractures • 23  Management of the Pink Pulseless Limb There is no consensus on the optimal treatment algorithm for supracondylar humerus fractures with vascular compromise in the form of a pink pulseless, i.e., adequately perfused, extremity [25, 49, 96]. Previous authors have recommended that the pink pulseless supracondylar fracture should be initially managed with CRPP in an urgent [5, 8, 19, 25, 97, 98] or emergent [9, 14, 99] manner. Following CRPP, it is critical to reevaluate the vascular status of the limb. In a cohort assessed by Choi and colleagues (2010), 52.3% of patients (11 of 21) had return of their radial pulses immediately following CRPP, and none required further intervention [40]. If the pulse does not immediately return, the limb should be observed for 15–20 min in the operating room. Arterial spasm may resolve following reduction, warming, or application of lidocaine [5, 19]. If the pulse returns, the elbow should be splinted in 40–60° of flexion, and the patient observed as an inpatient with frequent neurovascular checks. If the pulse does not return, but the limb is per- fused and an anatomic reduction was obtained without difficulty, the best management strategy is unclear [5, 19, 25, 96]. Some authors advocate for immediate exploration of a limb that remains pulseless after reduction [28, 100, 101]. A systematic review performed by White and colleagues (2010) con- cluded that lack of a pulse indicated an arterial injury rather than arterial spasm 70% of the time [100]. Schoenecker and colleagues (1996) reported on seven patients with pink, pulseless limbs following CRPP who all underwent subsequent exploration. Three of them had transection of the brachial artery, which were reconstructed with vein grafts, and four had kinked or tethered brachial arteries that required release [102]. It is unknown whether the vein graft reconstruction remains patent long term [98, 103]. Without exploration, the radial pulse may return within hours to months after the procedure [30, 99]; however, if the pulse returns several days after the injury, it may be due to collateral dilation rather than brachial artery patency [104]. A pulseless limb has been associated with claudication, cold intolerance, brachial artery thrombus, late compartment syndrome, limb length discrepancy, and limb contracture [19, 25, 30, 40, 96]. However, many authors advocate for conservative management of the pink, pulseless limb with close observation for 48 h [8, 9, 14, 19, 40, 99]. Open Reduction and Pinning Indications Open reduction is indicated for fractures that are open, irreducible, both neurologically compro- mised (median nerve) and vascularly compromised, dysvascular limbs following closed reduction, and pulseless limbs following reduction when a pulse was present preoperatively. Additionally, some authors have recommended open reduction for all limbs that remain pink and pulseless fol- lowing CRPP [28, 100, 101]; however, this is not unanimously agreed upon [25, 49, 96]. Injury to both the brachial artery and median or anterior interosseous nerves is concerning for entrapment in the fracture site and warrants exploration [30, 36].