Perfused, Pulseless, and Puzzling: A Systematic Review of Vascular Injuries in Pediatric Supracondylar Humerus Fractures and Results of a POSNA Questionnaire

Background: Supracondylar humerus fractures that present with a perfused, viable hand yet no pulse continue to be a source of controversy. The purpose of this study was to conduct a systematic review of the literature and perform a Pediatric Orthopaedic Society of North America (POSNA) opinion poll regarding management of pulseless supracondylar humeral fractures in children. Methods: A systematic review of the literature was conducted for relevant observational studies concerning neurovascular injuries in supracondylar humerus fractures. Single case reports and non-English language studies were excluded. Data were pooled for defined subgroups and 95% confidence intervals were reported. The results from the literature were then compared to popular opinion via a POSNA-approved survey concerning management of pulseless supracondylar humerus fractures. Results: A total of 331 cases of pulseless supracondylar fractures were identified from the literature, irrespective of perfusion status. In all, 157 fractures remained pulseless after closed reduction and stabilization. Of the fractures that continued to be pulseless despite adequate reduction, 82% [95% confidence interval (CI) = 0.82 (0.76-0.88)] were found to have a documented brachial artery injury. POSNA members presumed this number would be 28% [95% CI = 0.28 (0.22-0.34)]. A total of 98 perfused (aka pink) supracondylar fractures were identified. Of these pulseless, perfused fractures, 70% [95% CI = 0.70 (0.58-0.82)] had a documented brachial artery injury. POSNA members speculated that this number would be 17% [95% CI = 0.17 (0.12-0.22). A total of 54 patients had minimum 1 year follow-up data after vascular revascularization, and 91% [95% CI = 0.91 (0.83-0.99)] of these patients had a patent artery based on vascular studies. POSNA members believed this number would be 55% [95% CI = 0.55 (0.48-0.62)]. Conclusions: Our study revealed that common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evalvation and vascular exploration and repair in selected cases. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile.