Courtesy: Prof Nabil Ebraheim,University of Toledo, Ohio, USA

Supracondylar Fracture of the Humerus: Circulatory Assessment and Management

Initial Principles

• Perform a thorough neurovascular examination before and after reduction.
• Avoid elbow hyperflexion beyond 90 degrees during casting because it may compress the brachial artery.
• Closed reduction and percutaneous pinning (CRPP) is the preferred treatment.
• The most feared vascular complication is Volkmann ischemic contracture secondary to brachial artery injury.

Vascular Assessment

Pulseless but Well Perfused (Pink) Hand

Clinical features

• Absent radial pulse.
• Warm, pink hand.
• Normal capillary refill.

Management

• Perform urgent closed reduction and percutaneous pinning.
• Observe for 24 to 48 hours.
• Repeat serial neurovascular examinations.

Rationale

• Adequate collateral circulation maintains hand perfusion despite absence of the radial pulse.

Pulseless and Poorly Perfused (Cold) Hand

Clinical features

• Absent radial pulse.
• Cold hand.
• Pale or cyanotic appearance.
• Delayed capillary refill.

Management

• Proceed immediately to the operating room.
• Perform closed reduction and percutaneous pinning.
• Reassess circulation after reduction.
• If perfusion does not improve, perform immediate brachial artery exploration.

Key point

• Fracture reduction should always be performed before vascular exploration.
• Management principles are similar to vascular injuries associated with knee dislocation.

Loss of Perfusion During Reduction or Observation

Clinical features

• Initially well perfused hand becomes ischemic.

Management

• Perform immediate open exploration of the brachial artery.
• Do not delay treatment with arteriography.

Loss of Circulation After Pinning

Possible causes

• Vascular compromise caused by fracture reduction.
• Entrapment of the neurovascular bundle by fracture fragments or pins.

Management

• Remove the pins.
• Reverse the reduction.
• Reassess circulation.
• If perfusion remains compromised, perform brachial artery exploration.

Intraoperative Surgical Pearls

• Inspect the fracture site for a persistent fracture gap during reduction.
• A persistent gap may indicate interposition or entrapment of the neurovascular bundle.

Management Algorithm

Pulseless but well perfused hand

• Closed reduction and percutaneous pinning.
• Observe with serial neurovascular assessment.

Pulseless and poorly perfused hand

• Closed reduction and percutaneous pinning.
• Reassess perfusion.
• If circulation does not improve, proceed to immediate brachial artery exploration.

Perfusion lost during reduction or observation

• Immediate vascular exploration.

Perfusion lost after pinning

• Remove pins.
• Reverse the reduction.
• Reassess circulation.
• Explore the brachial artery if vascular compromise persists.

Viva Pearls

• A pulseless pink hand should be treated with fracture fixation followed by close observation.
• A cold pulseless hand is a surgical emergency.
• Fracture reduction is the first step in the management of vascular compromise.
• Avoid hyperflexion casting because it can compress the brachial artery.
• The brachial artery is the vessel most commonly injured in supracondylar fractures of the humerus.