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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 68-76

Pulseless supracondylar fracture of the humerus: Guidelines for management


Department of Paediatric Orthopaedic Surgery, Rainbow Children's Hospital, Bengaluru, Karnataka, India

Date of Submission29-Mar-2022
Date of Acceptance04-Apr-2022
Date of Web Publication25-May-2022

Correspondence Address:
Jayanth Sundar Sampath
Rainbow Children's Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-3665.346024

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  Abstract 


Introduction: The management of supracondylar fractures of the humerus in children without a palpable radial pulse is the subject of considerable controversy in the literature. The incidence of pulseless extremity ranges from 2% to 24% in different series. Materials and methods: A detailed physical examination and appropriate use of various imaging modalities will assist in determining the need for vascular exploration. These injuries are surgical emergencies that require immediate operative intervention. Therefore, units that treat supracondylar fractures in children must have protocols in place to avoid unnecessary hesitation or delay. Conclusion: This review article presents the different points of view regarding management of these potentially limb threatening injuries and provides an algorithm for management based on the latest evidence in the literature.

Keywords: Fracture, supracondylar humerus, children, pulseless


How to cite this article:
Sampath JS, Kumar G. Pulseless supracondylar fracture of the humerus: Guidelines for management. J Orthop Assoc South Indian States 2022;19, Suppl S1:68-76

How to cite this URL:
Sampath JS, Kumar G. Pulseless supracondylar fracture of the humerus: Guidelines for management. J Orthop Assoc South Indian States [serial online] 2022 [cited 2022 Jul 6];19, Suppl S1:68-76. Available from: https://www.joasis.org/text.asp?2022/19/3/68/346024




  Introduction Top


Supracondylar fracture of the humerus is the most frequent of the serious elbow injuries in a child; reported in about 55%–75% of children with elbow injuries and representing 3%–18% of all pediatric fractures. It is the most common reason for hospitalization following trauma.[1],[2] Injuries around the elbow account for only 10%–12% of all pediatric fractures but result in the highest complication rate of upper limb injuries. Supracondylar fractures commonly occur in children between 5 and 7 years of age, on the nondominant hand (typically left), and have an equal gender distribution. Extension-type supracondylar fractures account for the vast majority (97%–99%), and about 10%–20% of extension-type fractures are associated with a vascular injury.[3]

Mechanism of injury

Supracondylar fractures are typically caused by a fall on the outstretched hand with the elbow in full extension. The olecranon acts as a fulcrum to fracture the thinnest part of the distal humerus; the anterior capsule of the elbow provides the necessary tensile force to cause an extension-type fracture. The proximal fragment forces its way through the brachialis muscle, eventually buttonholing through it and injuring the brachial artery and median nerve, especially when the displacement is posterolateral.[4] When the displacement is posteromedial, the proximal metaphyseal spike can injure the radial nerve [Figure 1]. High-energy injuries can result in the proximal fragment piercing out of the antecubital fossa.[1] The vascular insult can result in arterial compression from the proximal fragment or hematoma, spasm, intimal injury, thrombosis, or transection.[5]
Figure 1: Posterolateral displacement predisposes the median nerve and brachial artery to injury from the sharp edge of the proximal fragment

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  Vascular Anatomy around the Elbow Top


At the elbow, the brachial artery lies anteriorly and bifurcates distally into the radial and ulnar arteries. The arterial anastomoses around the elbow link the brachial artery with the upper ends of radial and ulnar arteries [Figure 2].
Figure 2: Arterial anastomosis around the elbow

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In front of the lateral epicondyle, the profunda brachii artery anastomoses with the radial recurrent artery. Behind the lateral epicondyle, the posterior descending branch of profunda brachii artery anastomoses with the interosseous recurrent branch of the posterior interosseous artery. In front of the medial epicondyle, the inferior ulnar collateral (supratrochlear branch) anastomoses with the anterior ulnar recurrent branch.

In supracondylar fractures with posterolateral displacement, the brachial artery may be stretched or kinked because it is tethered on the ulnar side by the supratrochlear branch [Figure 3]. This branch can be ligated to release the artery if necessary. Excessive manipulation can damage the supratrochlear branch. The brachial artery has no laterally directed branches in the supracondylar region. Interposition of the brachial artery into the fracture site can occur when the proximal fragment penetrates the brachialis muscle lateral to the artery.
Figure 3: Importance of the supratrochlear branch in tethering the brachial artery by the proximal fragment

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  Associated Neurological Deficit Top


Nerve injuries are present in 10%–20% of supracondylar fractures.[6] The nerve injury is a neuropraxia that resolves over time in the vast majority of cases.[7] Co-existing injury to the median or anterior interosseous nerve in a pulseless supracondylar fracture increases the likelihood of an arterial injury.[8],[9] In a series of 71 children, Harris et al. found that the rate of open reduction/vascular exploration was only 30% when there was an injury to both structures.[10]


  Clinical Examination Top


When the child is seen in the emergency department, the entire upper limb must be exposed and examined for co-existing fractures from the shoulder to the wrist. A thorough neurovascular examination must be performed and documented.

The limb will be swollen at the elbow and proximal forearm. Possible firmness of the volar compartment, excessive swelling, and pain on passive finger extension should be noted.

In the antecubital fossa, the skin could be puckered (“Brachialis sign” indicating that the proximal has penetrated the brachialis into the deep dermis)[6] or ecchymotic [Figure 4]. Ho et al. showed that children with severe elbow swelling, ecchymosis, tenting, puckering, and open injury have a significantly higher risk of neurovascular compromise.[11] In an open fracture, the proximal fragment can be seen piercing out through the cubital fossa. In a delayed presentation, the entire limb could be swollen distally even involving the fingers.
Figure 4: “Brachialis sign” with puckering and ecchymosis of the skin over the antecubital area

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An initial examination should establish whether the radial pulse is palpable and if the hand is pink. Hand color, temperature, edema, pulp turgor, and capillary filling time (>3 s) should be noted.[12]

A poorly perfused limb appears pale and feels cold, with delayed capillary filling time and diminished pulp turgor compared to the contralateral limb.

Neurological examination of the upper limb is better tolerated in an anxious child after the limb has been splinted. A quick test to check if the child can perform an “OK sign” can be used as an initial step. Motor-sensory examination for the ulnar, radial, anterior interosseous, and median nerves must be performed in an orderly manner.


  Diagnosis Top


A number of diagnostic and imaging modalities are available to determine the perfusion status of the limb in the acute setting. Given the need for emergent management, the diagnostic tool should be readily available and provide definitive results that can be readily interpreted.

Ultrasound

The Doppler principle can be applied in several ways:

  1. A continuous-wave vascular Doppler probe is a handheld, inexpensive device that is available in most emergency rooms. There is controversy whether a Doppler signal reliably identifies an adequately perfused limb in the absence of a palpable radial pulse.[13],[14]

    The preoperative vascular status of the limb can be classified based on the type of radial pulse into three categories: palpable, diminished (detected by Doppler only), or absent (not detectable by palpation or Doppler). Children in the latter two categories had a similar postoperative course and outcome.[13] The authors concluded that an absent or diminished pulse in the pre- or immediate postoperative period was an early warning sign of limb ischemia that was present in every child who had a vascular injury.

    These findings were confirmed by Weller et al. who used a Doppler probe to detect the radial pulse after fracture reduction in the operating theater.[14] Of 54 children with pulseless but pink hand, four children underwent vascular exploration based on an absent radial pulse, by palpation, and on Doppler. All of the explored cases showed vascular abnormalities necessitating repair. Twenty children with a nonpalpable radial pulse but present on Doppler were treated with observation, only one having delayed vascular compromise requiring exploration. Other authors have reported the occasional need for vascular exploration even after the pulse was detected by Doppler.[15]
  2. Duplex ultrasound provides a 2D image of the blood vessel and the pattern of flow is depicted as a waveform. The radial artery in children normally displays a “triphasic” waveform [Figure 5].[16] Any change in the flow characteristics indicates potential vascular compromise and the need for close monitoring. Rabee et al. utilized the Doppler waveform to decide on the need for vascular exploration in a series of 86 Gartland Type III fractures with six children showing a persistently absent radial pulse post-closed reduction and monophasic flow on Doppler studies (five pink, pulseless and one cold, ischemic limb). The brachial artery was found to be entrapped in the fracture site in all cases without any arterial damage. Careful release of the entrapment resulted in the restoration of blood flow and return of a triphasic flow pattern in every case.[17]
  3. Color-coded duplex scanning (CCDS) of the main arteries of the limb and digital artery ultrasound velocimetry (UV) was recommended by Benedetti et al. for the evaluation of ischemic limbs following supracondylar fractures.[18] CCDS provides additional information about flow direction and amplitude but requires specialized training. The diagnostic assessment took approximately 20 min to perform. In their series of 48 children with Gartland Type III fractures, 11 children had an absent radial pulse. Eight children had a pulseless but perfused hand. CCDS and UV showed a range of abnormalities including severe spasm and displacement of the brachial artery, intimal–media disruption, thrombosis, and reduced flow velocity distally in three children with a pulseless, pink hand after reduction and pinning. Brachial artery exploration and release or repair was required in seven children. The authors recommend routine duplex ultrasound imaging of the brachial artery in all children with an absent radial pulse after fracture stabilization.
Figure 5: A color Doppler image of the brachial artery with waveforms and velocity. The first four waves are “triphasic” and the remaining are “biphasic”

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Disadvantages include mistaking an enlarged collateral vessel as the brachial artery[19] or incorrect diagnosis of an arterial injury resulting in unnecessary exploration of an intact artery.[20]

Angiography

Direct visualization of flow in the brachial artery and the presence of collaterals are possible through the injection of a contrast agent into the vessel. Angiography was the standard of care for ischemic limbs in the past, but its role has, more recently, been questioned.[3] It may be performed preoperatively in the radiology department, immediately after fracture fixation in the operating theater or postoperatively in cases of delayed ischemia.

The location of the arterial injury is likely to be at the fracture site and not a subject of diagnostic doubt. Therefore, routine preoperative arteriography in suspected vascular injury is not currently recommended as it delays definitive treatment and increases the ischemic time.[3],[19],[20],[21] Shaw et al. reviewed a series of 17 children with vascular compromise of 143 Gartland Type III fractures. Reduction and pinning restored the pulse in 14 cases and the remaining three underwent vascular exploration (two intimal tears and one case of arterial entrapment). The authors felt that prereduction arteriography did not contribute to better management.[20]

In contrast, Luria et al. reviewed a series of 23 children with displaced supracondylar fractures and vascular compromise. Eleven children underwent arterial exploration when the radial pulse failed to return after reduction or for an open fracture. Angiography was performed in 6 of the 11 cases (two preoperative and four intraoperative). There was one case of unnecessary arterial exploration due to a false-positive Doppler result. The authors recommend the use of angiography to improve appropriate management of arterial injury associated with pediatric supracondylar fractures. This report from a tertiary vascular surgery center describes a subset with more complex vessel problems that may not be encountered in routine practice.[8]

In conclusion, the decision to perform angiography is best left to the treating vascular surgeon in case of diagnostic doubt or in problematic situations.

Pulse oximetry

The use of oxygen saturation measurement by means of a finger probe for the measurement of limb perfusion is well described in the literature. Being retrospective in nature, most studies have failed to consistently document the relationship between oxygen saturation (SpO2 expressed as %) and vascular insufficiency following supracondylar fractures.

In a study of 781 displaced supracondylar fractures (Gartland Types IIB and III), 37 patients (4.7%) had no palpable radial pulse at presentation.[22] All patients were treated by closed reduction and pinning. The pulse returned in 11 patients after fracture fixation. The remaining 26 patients had an absent radial pulse but perfused hand with a good capillary refill. A pulse oximeter was applied to the affected limb and two distinct groups emerged based on the pulse oximeter waveform. Group 1 comprising 22 children had a good waveform and the radial pulse returned within an hour postoperatively. Group 2 consisted of four cases with poor waveform and all underwent immediate brachial artery exploration. Of the explored cases, the brachial artery was entrapped in the fracture site in one case, the supratrochlear branch of the brachial artery was tented by the fracture edges in two cases, and fracture hematoma was compressing the artery in the remaining case requiring evacuation. All patients recovered well with no evidence of contracture or claudication during follow-up. The authors recommend the use of pulse oximetry to assess perfusion in displaced supracondylar fractures postreduction and decide the need to explore the brachial artery based on the waveform.

This approach has been criticized by others on the basis that the four patients who underwent brachial artery exploration may have done well due to collateral circulation.[3] Nevertheless, pulse oximetry can be a useful tool that can provide additional information to surgeons along with CCDS regarding postreduction limb perfusion.

Less widely used methods include magnetic resonance angiography[19] and near-infrared spectroscopy.[23] At present, these can be considered investigational with no established clinical utility.

The wide range (2.4% to 24%) in the incidence of pulseless hands in different series of displaced supracondylar fractures suggests that there are disparities in the severity of fractures presenting to these institutions. Tertiary trauma centers likely encounter higher energy injuries leading to greater number of abnormal test results and higher rates of exploration.

No single investigation will provide a clear-cut answer to the need for vascular exploration. The strengths and limitations of each must be understood. The surgeon should apply careful discretion in understanding the results and formulating an appropriate treatment plan. An on-call radiologist can help to improve the accuracy and interpretation of imaging studies.


  Management Top


Initial management in the emergency room

The management of a child with a potentially ischemic limb is a surgical emergency. The senior operating surgeon should examine the child and counsel the family, taking informed consent for the entire range of possibilities including intraoperative diagnostic studies, necessity for vascular intervention (saphenous vein graft, etc.), and prolonged hospital stay for monitoring. The higher rate of complications as a consequence of a vascular injury should be explained. While the need for timely intervention cannot be overemphasized, a few minutes taken in examining the child in detail, clearly documenting the findings, and having an honest discussion with the family will go a long way in establishing valuable trust and confidence.

The child must be adequately resuscitated with secure intravenous access and kept fasting for immediate transfer to the operating theater. With appropriate analgesia, partial reduction of a supracondylar fracture in a pulseless limb can be tried in the casualty.[3] The elbow is flexed to 30°–45° and gentle traction is applied until perfusion improves and the pulse is restored. This maneuver can free the neurovascular bundle from the sharp edge of the proximal fragment. The arm is then loosely bandaged in slight flexion and elevated until surgery. Immobilization in >90° flexion should not be attempted due to the risk of worsening compression of vital structures and increasing forearm compartment pressures.[24],[25] [Figure 6] provides a suggested algorithm for the management of pulseless supracondylar fractures.
Figure 6: Management algorithm for the pulseless supracondylar fracture

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Poorly perfused, pulseless limb

The uniform consensus in the literature regarding the management of a pulseless, ischemic limb with cold and pale fingers is for immediate operative fracture reduction and stabilization with percutaneous pins.

Most authors confirm that standard closed reduction of the fracture leads to restoration of radial pulse and circulation in more than 50% of cases.[8],[14],[20],[26] In case the pulse returns and the limb is well perfused, the child is kept under observation as an inpatient for 24–48 h to monitor the circulation and look for signs of compartment syndrome.

In one series of 68 pulseless supracondylar fractures,[27] the authors treated five children presenting with cold, ischemic hands (Group 1) by primary open reduction and exploration of the brachial artery. All patients were found to have severe arterial injuries including transection, intimal tears, and severe laceration. These children had ecchymosis of the antecubital fossa and tethering of the brachialis muscle indicating a more violent injury to the elbow. Three children of 63 in the pulseless, perfused group (Group 2) had an unsuccessful closed reduction. The brachial artery and/or median nerve were found to be incarcerated in the fracture preventing anatomical reduction. Open release of the artery and nerve permitted fracture reduction and restored the pulse in all cases.

If the pulse fails to return with poor perfusion after closed reduction, immediate open vascular exploration is recommended. The risk of vascular injury in this scenario is high and has been estimated at 82%.[28]

Arterial exploration should be performed by a surgeon skilled in vascular techniques including microvascular reconstruction. Noaman[29] reported a series of 31 children who underwent open exploration for a pulseless forearm with a pink or cold hand, absent radial pulse 1 h after closed reduction, open supracondylar fracture with an absent pulse, or fractures with brachialis muscle tethering. The operative findings included traumatic aneurysm, thrombosis, partial tear, and brachial artery entrapment. Circulation was restored by the following methods: end-to-end anastomosis, vein grafting, thrombectomy, release, or direct repair. All children demonstrated good distal perfusion on follow-up with one case of Volkmann's ischemic contracture (VIC). Where indicated, arterial repair through microsurgery appears to yield better long-term patency rates compared to conventional methods.

Open supracondylar fractures are a special consideration. Debridement of the fracture site affords the opportunity to visualize the artery directly. Any injury to the vessel and nerve can be dealt with at the same time as the fracture reduction and fixation.

Well perfused, pulseless limb

There is no consensus in the literature on the management of pulseless but well-perfused limbs.[30] The American Academy of Orthopaedic Surgeons in its guidelines for the management of supracondylar fractures in children was unable to provide any definitive guidance regarding the need for open exploration in the pink, pulseless hand.[12]

Two divergent schools of thought have emerged with regard to the timing of vascular exploration of the pink but pulseless hand.

Immediate exploration (“The Pulse School”)

There is a substantial body of evidence to support the view that an absent or diminished radial pulse is indicative of a significant arterial injury irrespective of perfusion status.[8],[13],[28],[29] Blakey et al. reported on the calamitous effects of delay in timely revascularization of the “pink pulseless hand” with 23 of 26 limbs presenting with ischemic contracture of the forearm and hand.[31] The children were referred to a specialist unit after a mean period of 3 months following the injury. The authors highlighted the importance of increasing pain and a deepening nerve lesion in the postoperative period as indicators of “critical ischaemia” needing urgent vascular exploration. [Figure 7] illustrates a case of neurovascular incarceration at the fracture site requiring exploration in the postoperative period.
Figure 7: (a) Incarceration of the brachial artery and median nerve at the fracture site. (b) Patency of the brachial artery restored after release. (c) Median nerve released

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In a systematic review of the literature, cases where there was no return of pulse after closed reduction in pink, pulseless supracondylar fractures had a 70% rate of arterial injury.[28]

Favorable long-term outcomes have been reported by those proposing immediate vascular exploration in terms of pulse, upper limb perfusion, neurologic status, range of motion, and grip strength.[32],[33] Patency rates of the reconstructed artery show mixed results with some describing higher rates of reocclusion[19] than others.[29],[34] In a pooled analysis of 54 vascular interventions from various studies, White et al. showed a 91% arterial patency rate based on normal Doppler vascular examination and forearm pressures at final follow-up.[28] The authors recommended vascular exploration in all cases where a pulse was not restored following fracture reduction.

The argument of the “Pulse School” is to prevent complications including cold intolerance, limb length discrepancy, exercise-induced ischemia, compartment syndrome, VIC, and amputation. However, children who underwent immediate intervention also experienced complications including VIC,[13],[29] claudication,[9] poor limb growth, myositis ossificans,[35] scar hyperesthesia, and osteomyelitis of the distal humerus.[8]

Observation (“The Perfusion School”)

Spontaneous restoration of the radial pulse and perfusion is known to occur after fracture reduction without vascular exploration. Two theories have been proposed to explain this phenomenon.

First, transient spasm in the brachial artery that is relieved by fracture reduction and the vessel reverts to its normal patency after a period of time.[9],[26],[27],[29],[36] Several studies recommend waiting for 30 min to an hour before arterial exploration under the same anesthesia to allow for the potential spasm to resolve.[29],[36] Others describe postoperative monitoring and return to the operating theater if the pulse fails to appear within 24–48 h.[9]

Second, the rich collateral circulation around the elbow and forearm can maintain distal flow even when the brachial artery is occluded.[19],[37],[38] Based on the relative diameters of the brachial artery and the collateral vessels, it has been estimated that the blood flow to the arm would experience a 90% reduction (200 ml vs. 20 ml/min) if the brachial artery was completely occluded.[31] Other authors present angiographic evidence of adequate collateral flow following brachial artery occlusion.[9] Presumably, the collateral blood vessels expand considerably in diameter in response to the occlusion. In one study, a collateral vessel was large enough to be mistaken for the brachial artery.[19] The principal collateral vessels around the elbow accompany the ulnar and radial nerves. Any accompanying damage to these nerves can endanger collateral flow.[31]

Choi et al. reviewed a series of 24 children with pink, pulseless supracondylar fractures undergoing reduction and pinning (21 closed, 3 open reductions). The hand remained perfused in all cases with one child undergoing cubital fossa exploration to mobilize the brachial artery. None required a vascular repair.[26]

In an intermediate-term study of vascular status and function, 36 children with a pink, pulseless hand underwent closed reduction and pinning alone, followed by close observation for 1–3 days. Five patients (of 20 available) had a brachial artery occlusion on Doppler at follow-up, but none developed ischemic sequelae, and all had a palpable radial pulse. The authors found that complete median nerve palsy was predictive of brachial artery occlusion.[39]

Matuszewski described 67 patients with an absent radial pulse with 32 having pale, cold hands at presentation. A radial pulse was restored in 26 patients after closed reduction and percutaneous pinning (CRPP) at a mean time of 25 min (2–65 min). A further six patients had a pulseless, pink hand after CRPP. The radial pulse returned within a maximum of 3 days in this group. A follow-up ultrasound showed good vascular status and there was no vascular insufficiency or growth disturbance. The remaining 35 children with absent pulse and poor perfusion postreduction required vascular exploration.[35]

Weller et al.[14] reported on 20 patients with a perfused but pulseless hand after CRPP who were observed by careful inpatient monitoring. Only one of these patients developed late vascular compromise approximately 9 h after the initial procedure, requiring exploration. All of the remaining 19 patients regained a palpable radial pulse before discharge or at the first postoperative visit.

When the decision is made to observe a pulseless but well-perfused hand, frequent and careful monitoring of the neurovascular status of the limb becomes mandatory.[13],[40] The classic signs of vascular insufficiency and/or impending compartment syndrome are well known. “The five Ps” include pulse (by palpation and Doppler), pallor (or delayed capillary refill), pain (with passive movements or rest pain), paresthesia or altered sensation, and paralysis. In addition, “the three As,” namely agitation, anxiety, and increasing analgesic requirement are specific to children.[41] Children with a pulseless supracondylar fracture have a higher risk of compartment syndrome. However, the pathogenic mechanisms for muscle ischemia are not restricted to vascular insufficiency alone. Therefore, compartment syndrome can occur even in a well-perfused limb and needs to be monitored, independent of the vascular status.


  Complications Top


Late vascular occlusion,[26] persistent brachial artery stenosis,[19] compartment syndrome,[24] VIC,[29] chondrolysis of the distal humerus, and osteonecrosis of the trochlea[39] are problems that occur with greater frequency in the pulseless pediatric supracondylar fracture than its normally perfused counterpart. Longer-term radiological follow-up is therefore recommended when there is evidence of perioperative vascular compromise.


  Conclusion Top


The pulseless supracondylar fracture in a child represents a unique management problem for the orthopedic surgeon where clear and timely decision-making is of the essence. There is a wide clinical spectrum ranging from the child with a Dopplerable pulse and well-perfused hand who may be managed with observation after CRPP to the pale, cold hand even after reduction, which clearly requires immediate arterial exploration. Many children will fall in between these two extremes and these situations should be managed based on the presence of associated clinical signs and imaging findings. Every child needs close monitoring until a palpable pulse is restored and the perfusion status confirmed.

Management will also vary according to the institutional setup and facilities available. Given the relative frequency of supracondylar fractures in children, every orthopedic surgeon should have access to pediatric vascular expertise (either in-house or available on-call). This could be a pediatric, plastic, vascular, or microvascular hand surgeon. The common clinical scenarios must be discussed beforehand and an appropriate treatment plan generated for each. The implications for diagnostic results (oxygen saturation, Doppler) must be agreed upon. This avoids any hesitation or doubt when the child presents to the emergency department. Emergency staff and junior doctors must be educated in this regard and advised to seek senior help at the earliest.

Closed reduction and postoperative observation for 24–48 h may be sufficient in the majority of cases, but one must not hesitate to open the fracture site, explore the artery, and decompress the forearm compartments where necessary.

In conclusion, a combination of history, clinical examination, and diagnostic methods must be used to decide the need for close observation or vascular exploration and repair.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Abstract
Introduction
Vascular Anatomy...
Associated Neuro...
Clinical Examination
Diagnosis
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