Necessity of Vascular Surgical Intervention in Pulseless Supracondylar Fractures in Children

Background Supracondylar fractures of the distal humerus are common and potentially severe injuries in pediatric trauma. These fractures can be complicated by impaired vascular supply, with vascular compromise reported in 10-25% of grossly displaced cases. The injury to the brachial artery may occur via traction, external compression (swelling, bony displacement), or direct rupture by bone fragments, leading to diminished or absent pulsation in peripheral arteries (radial and ulnar), accompanied by alterations in skin temperature, color, and capillary refill.

Clinically, patients with absent radial pulses are categorized into two distinct presentations. The "pulseless pink" hand lacks a palpable radial pulse but remains warm and well-perfused with adequate capillary refill. Conversely, the "pulseless pale" hand presents with absent pulses, coldness, and overt signs of ischemia. While immediate anatomical reduction and fixation are universally indicated for both types, the subsequent vascular management-particularly for the "pulseless pink" presentation post-reduction-remains highly controversial. While some authors advocate for routine vascular exploration, others recommend an expectant approach unless frank ischemia develops.

Objectives The primary objective of this study is to evaluate the long-term clinical outcomes and safety of watchful waiting versus vascular surgical revision in patients with pulseless supracondylar fractures. The study aims to statistically confirm that a conservative approach in a well-perfused limb does not lead to an increased risk of long-term ischemic or growth-related complications.

Study Design and Methodology This is an observational, retrospective analysis of a large multicenter cohort incorporating data from 11 pediatric surgery and traumatology centers in the Czech Republic and Slovakia (2014-2024). Methodologically, the study integrates a historical retrospective cohort (2014-2018) with data extracted from prospectively maintained routine clinical registries (2019-2024).

The inclusion criteria comprise patients aged 0-15 years presenting with displaced supracondylar humerus fractures complicated by vascular compromise. The critical vascular assessment (pink vs. pale) determining cohort allocation is defined strictly after the closed reduction and K-wire fixation. Analyzed core variables obtained from routine medical records include demographics, injury parameters, Gartland classification, immediate post-reduction perfusion and neurological status, and surgical timing. Long-term clinical success is evaluated primarily using Flynn's criteria alongside the incidence of late ischemic complications (e.g., cold intolerance, claudication, growth arrest). The minimum required follow-up period for inclusion in the primary outcome analysis is 12 months.

Inclusion criteria

• Age 0 to 15 years at the time of injury.
• Isolated displaced supracondylar fracture of the distal humerus (Gartland type II or III).
• Absence of a palpable radial pulse documented immediately after closed reduction and K-wire fixation.
• Minimum documented clinical follow-up of 12 months.

Exclusion criteria

• Patients who regained a palpable radial pulse immediately after orthopedic reduction.
• Pathological fractures or fractures associated with systemic connective tissue disorders.
• Incomplete medical records preventing the assessment of the primary outcome at 1 year.
• Open supracondylar fractures of the distal humerus.
• Other associated injuries of the upper extremity.