Clin Orthop Surg.  2013 Mar;5(1):74-81. 10.4055/cios.2013.5.1.74.

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

• Soh RC
• Tawng DK
• Mahadev A

• KMID: 1402329
• DOI: http://doi.org/10.4055/cios.2013.5.1.74

Abstract

BACKGROUND
The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus.
METHODS
A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair.
RESULTS
In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise.
CONCLUSIONS
The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Keyword

Supracondylar humeral fracture; Pulseless hand; Pediatric; Pulse oximetry; Vascular repair

MeSH Terms

Brachial Artery/*injuries/surgery
Child
Child, Preschool
Female
Hand/*blood supply
Humans
Humeral Fractures/complications/*surgery
Male
*Oximetry
Pulse
Retrospective Studies
Vascular System Injuries/*diagnosis/surgery

Figure

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  Fig. 1 Good waveform on pulse oximeter

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  Fig. 2 Poor waveform on pulse oximeter.

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  Fig. 3 Subject 12 (Table 1), preoperative film (A) and postoperative film (B). Note the fine jagged edge of the fracture site in the anterior humerus. Radiological indices are restored.

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  Fig. 4 Subject 21 (Table 1), preoperative film (A) and postoperative film (B).

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  Fig. 5 Algorithm for the management of a pulseless pink hand.

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