Purpose: To investigate the mode of presentation, management and outcome of ischaemic contracture following a supracondylar fracture with a pink, pulseless hand. Methods: We reviewed the database at our tertiary referral unit to identify cases over a 20 year period who had been referred for complications of a supracondylar fracture and/or a Volkmann’s ischaemic contracture. Results: We identified 20 children with Volkmann’s ischaemic contracture following a supracondylar fracture. Of these, 4 patients (mean age 5, range 2–11) were referred to us with evidence of an ischaemic contracture but they had always had a pink albeit pulseless hand. Two of these 4 had undergone vascular exploration at 48 hours and at 72 hours but despite this developed an ischaemic contracture. The 2 patients with the most severe contractures have undergone surgical intervention for their contracture, and 2 were managed conservatively with splinting. All 4 cases have residual problems with hand function (mean follow-up 5.5 years, range 2–11). Conclusions: Volkmann’s ischaemic contracture should be a preventable condition. The pink albeit pulseless hand is at increased risk of ischaemic muscle and nerve damage and should not be ignored as the consequences are potentially devastating. Significance: Clinicians must consider whether they feel that their management protocols for the pink, pulseless hand are robust and defensible

Introduction: Approximately 5% of grade III supracon-dylar fractures are associated with vascular compromise. Following closed reduction and K wire stabilisation 60% of childrens surgeons in UK would adopt a policy of observation providing the hand is well perfused. We have retrospectively compared 2 groups of patients to determine whether observation or exploration leads to the best outcome. Materials and Methods: Over a 7 year period 18 patients were identified with pulseless pink hands. Management following reduction and K wire fixation was at the discretion of the admitting consultant. 10 Patients were managed expectantly and 8 patients had immediate exploration of the vessel. Results: Of 10 patients managed by observation, 3 had secondary exploration of the vessel and one patient has developed forearm claudication. Although a palpable radial pulse was present in all cases by 3 months it had returned within 24hrs (suggesting spasm of the artery) in only 3 patients. In 6 of 8 primarily explored brachial arteries the vessel was observed to be tethered to the fracture site. Following release, in 6 of 8 cases the radial pulse had returned within 24hrs. Satisfactory radiological reduction of the fracture does not preclude vessel entrapment. In 8 cases there was an associated median nerve palsy. All of these cases were found to have an anatomical obstruction to the brachial artery. Conclusions: In the majority of cases absent pulse is due to vessel entrapment. Long term perfusion of the forearm is due to collateral circulation. Providing a near anatomical reduction is achieved observation for 24 hours would seem reasonable course of action. If the pulse has not then returned further imaging (arte-riograme/MRA) may be advisable. If there is associated nerve palsy immediate exploration is warranted

The aim of this study was to establish the consensus of opinion amongst trauma surgeons for the management of displaced supracondylar fractures of the humerus in children.

We carried out a postal questionnaire involving 130 orthopaedic surgeons with an interest in paediatric trauma. They were identified as being members of the British Society for Children’s Orthopaedic Surgery.

We received a response rate of 65%. One third of respondents believe that in uncomplicated fractures, reduction should occur within 6 hours of injury and one half felt that ‘pulseless’ fractures should be treated in the same time frame. 60% said they would explore a pulseless arm after midnight, but only 20% would reduce and stabilise uncomplicated fractures. 82% of surgeons stabilise displaced grade III fractures with K wires, of these, the majority would use a‘crossed’ configuration. If after stabilisation the arm remained pulseless, only 16% said they would explore the brachial artery immediately, 23.5% would seek a vascular opinion and 60.5% of surgeons would observe for 24 hours. If the arm remained pulseless but pink after 24 hours, the majority of surgeons would continue to observe and rely on collateral circulation for distal perfusion.

The majority of surgeons would stabilise displaced supracondylar fractures as soon as possible but not after midnight unless the arm was pulseless. If the hand remained pink but pulseless, most felt that continued observation beyond 24 hours was acceptable.

The August 2013 Children’s orthopaedics Roundup. 360 . looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures