Outcomes of Perfused but Pulseless Versus Well-Perfused Pediatric Supracondylar Humerus Fractures Treated With Closed Reduction and Percutaneous Pinning.

backgroundThe management of pediatric supracondylar humerus fractures (SHF) with a pink pulseless hand (PPH) remains controversial. Traditional teaching advocated urgent vascular exploration, but many centres now favour closed reduction and percutaneous pinning (CRPP), followed by observation if the hand stays warm and well-perfused.

objectiveThis study aimed to compare clinical and radiological outcomes of displaced pediatric SHF in two groups: those presenting with a PPH versus those with a well-perfused hand and palpable pulse. All patients were managed with CRPP.

methodsWe retrospectively reviewed cases at King George's Medical University, a tertiary pediatric orthopaedic centre in India, from January 2018 to December 2023. Children ≤12 years old with closed or Gustilo-Anderson type I open displaced SHF (Gartland type III or IV) treated by CRPP were included. Patients with neurologic deficits, those requiring open reduction, or those undergoing vascular exploration were excluded from the study. Group I (n = 18) presented with a PPH (absent radial pulse, but a pink, warm hand with brisk capillary refill and normal oxygen saturation); brachial artery continuity was confirmed by duplex ultrasound. Group II (n = 24) presented with a well-perfused hand with a palpable radial pulse. All patients underwent CRPP under fluoroscopic guidance. Two lateral K-wires (with an additional wire if needed for stability) were used, and an above-elbow cast was applied in 50-60° flexion. Vascular status was reassessed intra- and postoperatively. Follow-up visits at three, six, and 12 weeks included clinical exams and radiographs. Outcomes evaluated were Flynn's criteria, Baumann's angle, maintenance of reduction, elbow range of motion (ROM), carrying angle, time to union, and final vascular status.

resultsA total of 42 children (mean age 7.5 years, 62% boys) were analysed. The two groups were similar in age, sex, affected side (60% left), and fracture patterns (mostly extension-type with posterolateral displacement). The mechanism of injury differed: Group I experienced more falls during play, whereas Group II experienced more falls from heights (p = 0.05). According to Flynn's criteria, excellent or good functional outcomes were achieved in 94-96% of cases in both groups (77.8% excellent in Group I vs. 79.2% in Group II, plus 16.7% good in each; p = 0.97). Postoperative Baumann's angles were comparable; the mean change in angle from immediately post-op to final follow-up was 1.89° in Group I and 2.25° in Group II (p = 0.72). The final carrying angle was slightly smaller in Group I on the right side (10.3° vs. 11.79° in Group II, p = 0.03), but this ~1.5° difference was not clinically significant. Elbow ROM recovered similarly in both groups: by 12 weeks, all patients attained ≥120° of flexion (p = 0.96). By the final follow-up (nine months), every child had a palpable radial pulse and normal perfusion; none reported cold intolerance.

conclusionsCRPP yields excellent and comparable functional outcomes in pediatric SHF, regardless of whether the radial pulse is initially present, as long as the hand is well perfused. Routine emergent brachial artery exploration is not indicated for most PPHs after fracture reduction, provided that perfusion remains intact and vigilant monitoring is in place. These findings support a conservative observational approach to the PPH in SHF, reserving open vascular surgery for cases that develop signs of ischemia.