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

 

Supracondylar Humerus Fracture with Pulseless Hand

Incidence and Cause

• Occurs in approximately 10–20% of displaced supracondylar fractures.
• Usually results from brachial artery injury.
• The brachial artery may be kinked, stretched, or entrapped by the fracture.
• Median nerve or anterior interosseous nerve injury may be associated.

Important Associations

Median nerve / anterior interosseous nerve

• Loss of the “OK sign”.
• Median or AIN palsy with a pulseless hand is an important warning sign for vascular injury.

Ulnar nerve

• More commonly associated with flexion-type fractures.

Nerve injuries

• Most are neuropraxias and recover spontaneously with time.

Clinical Assessment

Pulse

• Assess the radial pulse.
• Compare the injured limb with the opposite limb.

Perfusion

• Assess pain.
• Assess pallor.
• Assess pulselessness.
• Assess paresthesia.
• Assess paralysis.
• Check capillary refill.
• Capillary refill greater than 2 seconds is abnormal.
• Assess skin temperature.
• A cold limb suggests poor perfusion.
• Assess swelling and edema.
• Increasing analgesic requirement may indicate compartment syndrome.

Types of Pulseless Hand

Pulseless and poorly perfused hand

• Pale and cold hand.
• This is an emergency.

Pulseless but well-perfused hand

• Warm and pink hand.
• Management remains controversial.

Initial Management

• Apply gentle traction.
• Flex the elbow approximately 30–45 degrees.
• Apply a posterior splint.
• This may restore the pulse by relieving arterial kinking or compression.

Pulseless and Poorly Perfused Hand

• Proceed to immediate emergency surgery.
• Perform urgent fracture reduction and pin fixation.
• Reassess the circulation after reduction.
• If the hand remains pulseless and poorly perfused, perform open vascular exploration.
• Brachial artery repair may be required.
• Vein grafting may be necessary depending on the vascular injury.

Pulseless but Pink Hand

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

Monitor for

• Loss of perfusion.
• Increasing pain.
• Anxiety.
• Agitation.
• Increasing analgesic requirement.
• Compartment syndrome.
• If perfusion deteriorates, proceed to immediate exploration.

Important Points

• Approximately 50–70% of patients may regain the pulse after fracture reduction.
• Avoid angiography before reduction because it can delay definitive treatment.
• Median nerve or AIN injury associated with a pulseless hand should raise suspicion of vascular injury.

Compartment Syndrome

• More common with Type III supracondylar fractures.
• Prolonged ischemia is a major concern.
• If ischemia persists for more than 6 hours, fasciotomy may be required.

Exam Summary

Pulseless + pink hand

• Reduce and pin.
• Observe closely.

Pulseless + pale hand

• Reduce and pin urgently.
• If perfusion does not return, explore the brachial artery.

Pulse returns after reduction

• Continue close observation.

No pulse after reduction

• If the hand remains poorly perfused, explore the artery.

High-Yield Pearls

• Pink pulseless hand = reduce, pin and watch closely.
• Pale pulseless hand = emergency reduction and vascular assessment/exploration.
• Always compare vascular status with the contralateral limb.
• AIN palsy presents with inability to make the “OK” sign.