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Management of cold and pulseless hand after closed reduction and percutaneous pinning of pediatric humerus supracondylar fracture: Is it really necessary to explore brachial artery?

Tolga Ege, Mustafa Kurklu, Erkan Kaya, Yalcin Kulahci, Cemil Yildiz, Harun Yasin Tuzun, Selim Turkkan.

Abstract
Introduction: Vascular and neurologic complications are common following pediatric humerus supracondylar fractures. Vascular injuries always require urgent surgical intervention and are responsible for major complications, such as Volkmannís ischemic contracture and amputation. When a patient suffers from a cold and pulseless extremity following a fracture, brachial arterial exploration is generally needed. The aim of the current study is to report our experience in six patients having cold and pulseless hands after closed reduction who were managed by conservative methods.
Patients and Methods: Six patients were included in the study. The mean patient age was 3.2 years (range of 1-6 years). Before the operation, all patients underwent a doppler examination, as all of them had non-palpable radial arteries. Doppler examinations revealed monophasic flow in the brachial and radial arteries. Therefore, patients were immediately operated upon and closed reductions with percutaneous pinning were performed.
Results: We verified anatomical reduction using plain radiographs. However, all patients had cold and pulseless hands. Therefore, papaverine was injected subcutaneously and the operated extremities were warmed and elevated for at least 1 hour. During this period, serial doppler examinations were performed. After a mean period of 30 minutes (range of 15 to 90 minutes), we detected brachial and radial arterial flow upon doppler examination, along with warm hands. Patients were followed for at least two days in the clinic and all of the patients healed without any complications.
Conclusions: We advise initial conservative management of cold and pale hands after reduction of a supracondylar fracture, including warming, elevation and papaverine-HCL injection within at least 30 minutes following surgery. If this treatment fails, emergency arterial exploration is needed. Additionally, if the patient has a cold and pale hand before the operation, arterial exploration is needed along with reduction.

Key words: Humerus supracondylar fracture, arterial lesion, conservative management


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