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

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients. Cite this article: Bone Joint J 2013;95-B:694–98

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

This annotation discusses the findings of two papers in the current issue describing the management of the neurovascular complications of supracondylar fractures of the humerus in childhood, with particular reference to the indications for and the timing of exploration of the brachial artery and the affected nerves.

We compared two management strategies for the perfused but pulseless hand after stabilisation of a Gartland type III supracondylar fracture. We identified 19 patients, of whom 11 were treated conservatively after closed reduction (group 1). Four required secondary exploration, of whom three had median and/or anterior interosseus nerve palsy at presentation. All four were found to have tethering or entrapment of both nerve and vessel at the fracture site. Only two regained patency of the brachial artery, and one patient has a persistent neurological deficit.

In six of the eight patients who were explored early (group 2) the vessel was tethered at the fracture site. In group 2 four patients also had a nerve palsy at presentation and were similarly found to have tethering or entrapment of both the nerve and the vessel. The patency of the brachial artery was restored in all six cases and their neurological deficits recovered completely.

We would recommend early exploration of a Gartland type III supracondylar fracture in patients who present with a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment.

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys.

Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth.

Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia.

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.