Orthopedics

Case Report 

Occlusion Outside the Norm: A Unique Case of the Pulseless, Well-Perfused Hand Following Closed Humeral Shaft Fracture

Hunter L. Bohlen, BA; Dominic J. Gargiulo, DO; Steven G. Thon, MD

Abstract

Transient arterial injury is a common complication encountered in the management of pediatric supracondylar humerus fractures, often presenting as a pulseless hand that appears well perfused, also known as the “pink, pulseless hand.” Arterial injuries in pediatric humeral shaft fractures, on the other hand, are exceedingly rare, especially in closed fractures. The authors report a rare case of a humeral shaft fracture presenting as a pink, pulseless hand. Although this complication was initially managed according to supracondylar protocol, the patient's neurologic status deteriorated. This prompted vascular assessment with computed tomography angiography, revealing a complete occlusion of the brachial artery. At this more proximal level, there is significant risk for compromise of the collateral circulation. The patient was eventually treated successfully with open reduction of the fracture followed by brachial artery repair. Although watchful waiting may be appropriate in the management of this entity for supracondylar fractures, more aggressive management was indicated for this patient because of the occlusion occurring prior to the bifurcation of the brachial artery. The lack of collateral circulation makes improvement in this injury pattern unlikely. This report emphasizes that suspected vascular injury following humeral shaft fractures should be evaluated with computed tomography angiography. If an occlusion is identified, it should be treated aggressively with immediate open fracture reduction and evaluation by a vascular team for possible repair vs grafting. [Orthopedics. 2019; 42(2):e279–e281.]

Abstract

Transient arterial injury is a common complication encountered in the management of pediatric supracondylar humerus fractures, often presenting as a pulseless hand that appears well perfused, also known as the “pink, pulseless hand.” Arterial injuries in pediatric humeral shaft fractures, on the other hand, are exceedingly rare, especially in closed fractures. The authors report a rare case of a humeral shaft fracture presenting as a pink, pulseless hand. Although this complication was initially managed according to supracondylar protocol, the patient's neurologic status deteriorated. This prompted vascular assessment with computed tomography angiography, revealing a complete occlusion of the brachial artery. At this more proximal level, there is significant risk for compromise of the collateral circulation. The patient was eventually treated successfully with open reduction of the fracture followed by brachial artery repair. Although watchful waiting may be appropriate in the management of this entity for supracondylar fractures, more aggressive management was indicated for this patient because of the occlusion occurring prior to the bifurcation of the brachial artery. The lack of collateral circulation makes improvement in this injury pattern unlikely. This report emphasizes that suspected vascular injury following humeral shaft fractures should be evaluated with computed tomography angiography. If an occlusion is identified, it should be treated aggressively with immediate open fracture reduction and evaluation by a vascular team for possible repair vs grafting. [Orthopedics. 2019; 42(2):e279–e281.]

Fractures involving the shaft of the humerus make up only 10% of pediatric humerus fractures. Although vascular injury is a well-known complication of pediatric supracondylar humerus fractures, often manifesting as a pulseless hand that appears well perfused, or the “pink, pulseless hand” (PPH), arterial injury is rarely observed in shaft fractures.1–3 Management of the PPH in supracondylar fractures has been a topic of controversy throughout the literature.4–7

The authors present a case of a PPH in the setting of a humeral shaft fracture. Although this complication is well documented in the setting of supracondylar humerus fractures, to the authors' knowledge, it has not been reported following a closed humeral shaft fracture.2,3 This report suggests that a PPH in the setting of a pediatric humeral shaft fracture should be managed differently from and more aggressively than its supracondylar counterpart because of the level of vascular occlusion.

Case Report

A previously healthy 8-year-old boy arrived as a transfer for an obvious closed deformity to the right upper extremity after a go-kart injury. Initial examination identified swelling to the right upper extremity, with soft and compressible compartments. Sensation was intact to light touch in the radial nerve distribution but subjectively diminished in the median and ulnar nerve distributions. Motor function was intact. The hand was warm and well perfused but notably lacked palpable radial and ulnar pulses. Pulses were observed intermittently on Doppler examination.

Radiographs of the right elbow and humerus showed a distal one-third junction fracture of the humeral shaft (Figure 1). Closed reduction was performed under conscious sedation, and the patient was placed in a long arm coaptation splint. The patient was admitted to the intensive care unit overnight for neurovascular checks every 2 hours.

Preoperative anteroposterior (A) and lateral (B) radiographs of the arm showing a distal one-third humeral shaft fracture.

Figure 1:

Preoperative anteroposterior (A) and lateral (B) radiographs of the arm showing a distal one-third humeral shaft fracture.

Pulses remained impalpable and intermittent on Doppler examination through the following morning. Additionally, the patient reported subjectively worsening paresthesia in the median nerve distribution. A computed tomography angiogram was performed, revealing complete occlusion of the brachial artery at the level of the fracture with reconstitution 3.5 cm distally (Figure 2). The decision was made to urgently proceed to the operating room with both the orthopedic and the vascular teams.

Computed tomography angiogram 3-dimensional reconstruction of the right upper extremity showing loss of brachial artery flow at the fracture site, with distal reconstitution.

Figure 2:

Computed tomography angiogram 3-dimensional reconstruction of the right upper extremity showing loss of brachial artery flow at the fracture site, with distal reconstitution.

The orthopedic surgery team stabilized the fracture with a flexible intramedullary nail. A single flexible nail was advanced in a retrograde fashion from the lateral elbow, achieving a satisfactory reduction and stable fixation of the fracture and allowing the vascular team to begin their repair. The brachial artery was exposed using a direct medial approach. The site of injury was noted to be gray and mottled relative to the remainder of the artery (Figure 3A). Exploration revealed a large thrombus at the site of injury along with a focal transverse circumferential injury to the intima (Figure 3B). This was repaired with a running 7-0 Prolene (Ethicon Inc, Somerville, New Jersey) suture (Figure 3C). A segment of the basilic vein was then harvested and used as a patch for the repair (Figure 3D).

Intraoperative images of the brachial artery repair. Exposure of the brachial artery (arrows) (A). The brachial artery clamped and incised (B). Repair of the intima (C). Basilic vein patch used to repair the brachial artery (D).

Figure 3:

Intraoperative images of the brachial artery repair. Exposure of the brachial artery (arrows) (A). The brachial artery clamped and incised (B). Repair of the intima (C). Basilic vein patch used to repair the brachial artery (D).

Following complete repair and patch application, both the radial and ulnar pulses were strong and palpable. Wounds were then closed, and a posterior slab splint was subsequently applied to the upper extremity. The patient recovered from anesthesia and returned to the intensive care unit for monitoring. Postoperatively, pulses remained palpable.

On postoperative day 1, the patient had palpable pulses and resolution of previous paresthesias. He was discharged in stable condition on postoperative day 2 with close follow-up. The patient went on to recover uneventfully. He was seen in clinic regularly until his fracture healed. The flexible nail was removed 5 months following his initial surgery.

Discussion

The PPH is a well-described phenomenon of pediatric supracondylar humerus fractures; however, to the authors' knowledge, it has not been described as a complication in a pediatric humeral shaft fracture.2–7 The proper approach to the PPH remains a topic of ongoing debate in the treatment of supracondylar humerus fractures. Diminished pulses are reported in up to 20% of cases.5 The first step in management of a pulseless hand is closed reduction of the supracondylar fracture, as pulses are noted to return after reduction in 53% of cases.5 If the hand appears poorly perfused despite adequate reduction, emergent open reduction and arterial repair are clearly indicated.4–6 If pulses remain absent following reduction, but the hand appears well perfused, controversy exists regarding active arterial exploration vs watchful waiting for signs of ischemia as the proper protocol.5 However, recent trends in the literature favor watchful waiting for signs of ischemia before surgical intervention.6

To the authors' knowledge, this is the first case of brachial artery injury with a well-perfused pulseless hand in the setting of a pediatric humeral shaft fracture. The main difference in this case is that the arterial lesion occurred more proximally than it would secondary to supracondylar humerus fracture. The proximal fracture resulted in direct injury to the brachial artery before it branched at the level of the elbow, limiting the ability of the collateral circulation to perfuse the remainder of the extremity. This presentation is different from that of supracondylar fractures, in which the arterial lesion occurs predictably at the supratrochlear branch, as noted by Shaw et al.1 The collateral circulation can usually provide adequate perfusion distally following supracondylar fractures; however, this is unlikely in more proximal lesions, as seen in this case.8 Thus, any patient with a displaced humeral shaft fracture concerning for vascular injury who has not improved after splinting should have a computed tomography angiogram to assess for occlusion of the brachial artery at the site of injury. Any occlusion of the brachial artery proximal to its branches at the level of the elbow should undergo prompt reduction and vascular exploration.

Conclusion

Owing to the progressive deterioration of neurovascular status in the current patient, the authors advocate that future cases of a PPH in a humeral shaft fracture be managed more aggressively than this same issue would in a patient with a supracondylar humerus fracture. As discussed, vascular injury in a humeral shaft fracture is likely to occur proximal to the branching of the brachial artery, thus increasing the risk for collateral compromise and limb ischemia. This case was managed successfully with prompt fracture stabilization and vascular exploration. As opposed to watchful waiting following arterial injury in supracondylar humerus fractures, a more aggressive approach should be taken in the management of brachial artery injury in humeral shaft fractures, as the injury profile is different in the 2 complications.

References

  1. Shaw BA, Kasser JR, Emans JB, Rand FF. Management of vascular injuries in displaced supracondylar humerus fractures without arteriography. J Orthop Trauma. 1990;4(1):25–29. doi:10.1097/00005131-199003000-00004 [CrossRef]
  2. Shrader MW. Proximal humerus and humeral shaft fractures in children. Hand Clin. 2007;23(4):431–435. doi:10.1016/j.hcl.2007.09.002 [CrossRef]
  3. Caviglia H, Garrido CP, Palazzi FF, Meana NV. Pediatric fractures of the humerus. Clin Orthop Relat Res. 2005;432:49–56. doi:10.1097/01.blo.0000156452.91271.fb [CrossRef]
  4. Griffin KJ, Walsh SR, Markar S, Tang TY, Boyle JR, Hayes PD. The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. Eur J Vasc Endovasc Surg. 2008;36(6):697–702. doi:10.1016/j.ejvs.2008.08.013 [CrossRef]
  5. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30(4):328–335. doi:10.1097/BPO.0b013e3181da0452 [CrossRef]
  6. Badkoobehi H, Choi PD, Bae DS, Skaggs DL. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Joint Surg Am. 2015;97(11):937–943. doi:10.2106/JBJS.N.00983 [CrossRef]
  7. Ramesh P, Avadhani A, Shetty AP, Dheenadhayalan J, Rajasekaran S. Management of the acute ‘pink pulseless’ hand in pediatric supracondylar fractures of the humerus. J Pediatric Orthop B. 2011;20(3):124–128. doi:10.1097/BPB.0b013e328342733e [CrossRef]
  8. Debnath UK, Naidu Maripuri S, Hariharan K, Shandall A. Transected brachial artery with pink pulseless perfused limb in an open grade III supracondylar fracture of humerus: a case report and review of literature. Injury Extra. 2007;38(10):360–364. doi:10.1016/j.injury.2007.01.029 [CrossRef]
Authors

The authors are from the Department of Orthopedic Surgery (SGT), Tulane University School of Medicine (HLB), and the Department of Orthopedic Surgery (DJG), Louisiana State University School of Medicine, New Orleans, Louisiana.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Hunter L. Bohlen, BA, Tulane University School of Medicine, 3316 Robert St, New Orleans, LA 70125 ( hbohlen@tulane.edu).

Received: March 28, 2018
Accepted: June 29, 2018
Posted Online: December 13, 2018

10.3928/01477447-20181206-09

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