August 16, 2017
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Strict supervision may help manage pink, pulseless supracondylar fractures in children

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With strict supervision, perfused, pulseless supracondylar fractures can be successfully managed without surgical revascularization and result in long-term positive outcomes when patients reach adulthood, according to a study presented as part of the Free Papers Award Session for Trauma at the 18th EFORT Annual Congress in Vienna.

“This was a retrospective study in which 14 children with a perfused, pulseless supracondylar humeral fracture were evaluated in adulthood,” Rafael Carbonell Escobar, MD, told Orthopaedics Today Europe. “The aim of the study was to investigate the long-term functional results of a pink pulseless supracondylar fracture managed conservatively in childhood.”

Patients were assessed at an average follow-up of 13.5 years. The average patient age at the time of the fracture was 7 years, and the mean age at the most recent follow-up was 20 years. Closed reduction of the fracture, percutaneous pinning and strict supervision of vascular status were used to manage these fractures, without surgical revascularization. The following assessments were performed on all patients: range of motion, carrying angle, elbow stability, grip strength, pinch strength, endurance, discriminatory sensation, length/circumference of the arm and forearm, wrist brachial index, radial pulse, capillary refill time and oxygen saturation in both upper limbs. The Mayo elbow performance score (MEPS) and the short version of the DASH (QuickDASH) and the QuickDASH sports questionnaires were used to evaluate clinical outcomes. Cold intolerance and exercise-induced ischemic symptoms were determined through patient self-reporting.

No elbow instability

“All patients were satisfied with their results,” Carbonell said. “MEPS, QuickDASH and QuickDASH sports showed excellent results in all cases, no patient-referred pain. Nine patients perform sports, five at a competitive level. There was no elbow instability in any case. Thirteen patients showed a normal endurance test — being able to squeeze a ball for 1 minute — with both hands.”

There were significant differences between the injured and uninjured upper limb for flexion (134° vs. 140°), carrying angle (8° vs. 6°) and pinch strength (13 kg vs. 15.5 kg).

Conversely, no significant differences were observed between injured and uninjured upper limbs for extension, pronation, supination, grip strength, capillary refill, wrist brachial index, length of the arm, length of the forearm, circumference of the arm and forearm, or oxygen saturation. All patients demonstrated radial pulse and all patients showed normal discriminatory sensation. A Raynaud’s phenomenon, induced by cold or exercise, was referred by one patient in his fourth and fifth fingers. However, this was not painful and did not limit the patient’s activity.

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Results aid decision-making

According to Carbonell, these findings may help guide clinician decision-making in treating perfused, pulseless supracondylar fractures in children.

“There is controversy regarding a conservative approach based on strict supervision vs. a surgical early revascularization,” Carbonell told Orthopaedics Today Europe. “Through this study, we have verified that strict supervision of a pink pulseless supracondylar fracture without surgical revascularization obtains a good result in the long term when patients reach adulthood.” – by Jennifer Byrne

Disclosure: Carbonell reports no relevant financial disclosures.