ORIGINAL ARTICLE

Perfused, Pulseless, and Puzzling: A Systematic Review

of Vascular Injuries in Pediatric Supracondylar Humerus
Fractures and Results of a POSNA Questionnaire
Lydia White, MD, Charles T. Mehlman, DO, MPH, and Alvin H. Crawford, MD, FACS

appears pink and warm, suggesting the need for more aggressive
Background: Supracondylar humerus fractures that present with a vascular evalvation and vascular exploration and repair in selected
perfused, viable hand yet no pulse continue to be a source of cases. Moreover, patency rates for revascularization procedures
controversy. The purpose of this study was to conduct a systematic appear sufficiently high, making this intervention worthwhile.
review of the literature and perform a Pediatric Orthopaedic Society
of North America (POSNA) opinion poll regarding management of Key Words: supracondylar humeral fracture, vascular injury,
pulseless supracondylar humeral fractures in children. pulseless
Methods: A systematic review of the literature was conducted (J Pediatr Orthop 2010;30:328–335)
for relevant observational studies concerning neurovascular
injuries in supracondylar humerus fractures. Single case reports
and non-English language studies were excluded. Data were
pooled for defined subgroups and 95% confidence intervals were
reported. The results from the literature were then compared
S upracondylar humeral fractures are the most common
fracture about the elbow in children, and they have
been a source of controversy and debate among ortho-
to popular opinion via a POSNA-approved survey concerning
paedic surgeons for decades.1–8 This is in large part
management of pulseless supracondylar humerus fractures.
because of the significant complications that may occur in
Results: A total of 331 cases of pulseless supracondylar fractures
conjunction with supracondylar humeral fractures. Asso-
were identified from the literature, irrespective of perfusion
ciated complications may include stiffness, neurologic
status. In all, 157 fractures remained pulseless after closed
deficits, and deformity.7–9 However, vascular injury is
reduction and stabilization. Of the fractures that continued to be
arguably the most dreaded complication associated with
pulseless despite adequate reduction, 82% [95% confidence
this fracture pattern.7,10–13
interval (CI) = 0.82 (0.76-0.88)] were found to have a docu-
As many as 20% of patients with displaced
mented brachial artery injury. POSNA members presumed this
supracondylar humeral fractures may present with an
number would be 28% [95% CI = 0.28 (0.22-0.34)]. A total of
absent pulse.5,6,14–16 Little debate is generated concerning
98 perfused (aka pink) supracondylar fractures were identified.
the management of pulselessness in an unperfused, cool
Of these pulseless, perfused fractures, 70% [95% CI = 0.70
hand. In this setting, the literature supports urgent
(0.58-0.82)] had a documented brachial artery injury. POSNA
fracture reduction combined with stabilization and
members speculated that this number would be 17% [95%
arterial repair as indicated.9,11,17–20 However, no clear
CI = 0.17 (0.12-0.22). A total of 54 patients had minimum 1
consensus exists regarding the treatment of the patient
year follow-up data after vascular revascularization, and 91%
with an absent pulse and a warm, perfused hand.11,20,21
[95% CI = 0.91 (0.83-0.99)] of these patients had a patent artery
The purpose of this study was to conduct a systematic
based on vascular studies. POSNA members believed this
review of the literature regarding the incidence of arterial
number would be 55% [95% CI = 0.55 (0.48-0.62)].
injury in the setting of pulseless supracondylar humeral
Conclusions: Our study revealed that common dogma regarding
fractures in children. Furthermore, we aimed to correlate
watchful waiting of pulseless and perfused supracondylar fractures
this evidence from the literature with current practitioner
needs to be questioned. In the vast majority of published cases, an
opinion on arterial injuries associated with this fracture.
absence of pulse is an indicator of arterial injury, even if the hand

From the Division of Pediatric Orthopaedic Surgery, Cincinnati
Children’s Medical Center, Cincinnati Children’s Hospital Medical
Center, University of Cincinnati College of Medicine, Cincinnati, OH.
None of the authors received financial support for this study.
Reprints: Charles T. Mehlman, DO, MPH, Division of Pediatric
Orthopaedic Surgery, Cincinnati Children’s Medical Center, Cincin-
nati Children’s Hospital Medical Center, University of Cincinnati
College of Medicine, 3333 Burnett Avenue, Cincinnati, OH 45229-
3039. E-mail: Charles.mehlman@cchmc.org.
Copyright r 2010 by Lippincott Williams & Wilkins
METHODS
A systematic review of the literature was conducted
for relevant observational studies concerning vascular
injuries in pediatric supracondylar humeral fractures. The
electronic databases, PUBMED, Cochrane, and BMJ, were
investigated using the term ‘‘supracondylar fracture.’’
PubMed yielded 1447 hits with this phrase. When the
search was narrowed to include the words ‘‘vascular injury,’’
78 relevant articles were obtained from PubMed. The

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J Pediatr Orthop  Volume 30, Number 4, June 2010 Pediatric Supracondylar Humerus Fractures

phrase ‘‘supracondylar fractures and neurovascular injury’’
produced an additional 12 articles. Changing ‘‘injury’’ to
‘‘complications’’ did not obtain any extra articles. The
terms ‘‘Volkmann’s contracture’’ and ‘‘Volkmann’s ische-
mia’’ were also searched and led to the addition of 138 and
77 articles, respectively. Neither Cochrane nor BMJ
produced any articles concerning vascular complications
and supracondylar humerus fractures. The bibliographies
of pertinent articles were examined as well, and another 38
potentially applicable articles were found. Finally, the
references for the textbooks Skeletal Trauma in Children17
and Rockwood and Wilkins’ Fractures in Children9 were
evaluated with resulting recruitment of an additional 29
previously undetected articles. A total of 117 articles were
selected for review of full text, of which 19 met the
eligibility criteria for pulseless, perfused supracondylar
fractures and were completely reviewed by 2 authors (L.W.
and C.M.).14,15,20,22–37 Single case reports and studies with
inadequate description of patient population, injury, or
outcome were excluded. Additionally, only publications in
English were included. A summary of the literature
selection process is included in Figure 1.
Subsequently, a survey was conducted among pedia-
tric orthopaedic surgeons to determine their opinions on
the frequency of brachial artery injuries in supracondylar
humerus fractures and the success of arterial repairs. This
short survey was sent to the Pediatric Orthopaedic Society
of North America (POSNA) members and allowed
participants to enter their answers in an open-ended
fashion. These responses were collected and the mean
percentage for each question was determined.
RESULTS
Our systematic review of the literature identified 19
articles that addressed issues related to the management
of pulseless supracondylar humerus fractures.14,15,20,22–37
Eighteen of these articles represented case series reports
and 1 was a cross-sectional survey. Eight articles
specifically mentioned pulseless perfused fractures,
whereas 10 made no mention of the perfusion status of
the extremity. Table 1 summarizes aspects of the patient
population and study design for each article. Figure 2
represents a forest plot of the pooled data on brachial
artery injuries in each of the studies. Figure 3 depicts a
forest plot of brachial artery injury only from articles that
specifically mentioned perfused and pulseless fractures.
Figures 4 and 5 summarize the entire study data regarding
the cases of confirmed brachial artery injury, which is
consistently in the range of 70% or greater in the setting
of the pulseless supracondylar patient.
In summary, a total of 331 cases of pulseless
supracondylar fractures were reviewed, irrespective of
their perfusion status. One hundred and fifty-seven
remained pulseless despite adequate reduction. Eighty-two
percent of these fractures were found to have a documented

1447 initial hits

Search terms: “Supracondylar fracture”

372 articles with reference to vascular insult

Search terms: “supracondylar fracture”+

“vascular injury,” “vascular complication,” “neurovascular complication,” neurovascular
injury” “Volkmann’s contracture” “Volkmann’s ischemia”

117 chosen for full text review

Exclusions: Non-English studies, single case reports, studies with no description of

injury or outcome

19 met eligibility criteria

Inclusions: Pulseless supracondylar humerus fractures

FIGURE 1. Flow chart summary of literature search.

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White et al J Pediatr Orthop  Volume 30, Number 4, June 2010

TABLE 1. Summary of Studies Included in the Systematic Review

No. Color of Hand: Pink/
Author Year Study Type Cases Pale/Don’t Know Pulse Status Mean Follow-up Average Age
Campbell et al 1995 Case series 11 Don’t know ‘‘Vascular N/A 6.6
impairment’’
Clement and Phil 1990 Case series 9 Don’t know Not palpable 3y 6.5
Copley et al 1996 Case series 17 Don’t know Not palpable 28 mo 6
Dormans et al 1995 Case series 5 Don’t know ‘‘Vascular 2.3 y 9
injury’’
Garbuz et al 1996 Case series 22 16 pink 6 pale Not palpable 4.5 6.5
Gosens and Bongers 2003 Case series 10 4 pink, 6 pale Not palpable N/A N/A
Korompilias et al 2007 Case series 5 Pink Absent 34 mo 8.5
Kumar et al 2001 Case series 5 Don’t know ‘‘Compro- N/A 3-13
mised’’
Lewis et al 2003 Case series 8 Don’t know Reduced/absent 1y 5.25
Lipscomb and 1955 Case series 11 2 pink, 11 cyanotic Absent N/A N/A
Burleson
Louahem et al 2006 Case series 29 26 pink, 3 pale Not palpable N/A 7.5
Luria et al 2007 Case series 24 20 pink, 4 ischemic Weak/not 7y 6
palpable
Lyons et al 2000 Case series 12 Don’t know Not palpable N/A 5
Malviya et al 2006 Survey 81 Pink Not palpable N/A N/A
Noaman 2006 Case series 120 Don’t know Not palpable 26 mo 7
Rabee et al 2001 Case series 6 5 pink, 1 pale Not palpable, N/A 5.5
monophasic
signal
Sabharwal et al 1997 Case series 13 Pink Absent 31 mo 6.5
Schoenecker et al 1996 Case series 7 Pink Not palpable 3y 3-10
Shaw et al 1990 Case series 17 Don’t know Not palpable N/A N/A
mo indicates months; N/A, not applicable.

brachial artery injury. In contrast, spasm could be proven in
only 8% of the cases. Of the articles that specifically mention
perfused pulseless supracondylar fractures, 98 fractures were
identified. Of these pink, pulseless fractures, 70% had a
documented brachial artery injury whereas spasm was found
only in 9% cases.20,24,29,30,34–36
Overall, only 1 complication (osteomyelitis) resulted
from the open exploration.30 One case of Volkmann
contracture occurred as a result of delayed operative
intervention.14 With regard to reocclusion or stenosis of
arterial repairs, Sabharwal et al35 found that 5 of the 12
patients had reocclusion or stenosis on follow-up with
magnetic resonance angiography, Doppler ultrasound,
and forearm pressure measurements. However, other
articles report normal follow-up upper extremity Doppler
examinations27,30,33 and upper extremity pressures.30
A summary of the results for reported patency rates after
vascular follow-up are listed in Figure 6.

Study name Total Event rate and 95% CI

Campbell, 1995 3/6
Clement, 1990 9/9
Copley, 1996 5/5
Dormans, 1995 3/3
Garbuz, 1996 3 / 12
Gosens, 2003 6 / 10
Korompilias, 2007 4/4
Kumar, 2001 4/5
Lewis, 2003 8/8
Lipscomb 1955 7 / 11
Louahem, 2006 6/8
Luria, 2007 8 / 11
Lyons, 2000 3/4
Noaman, 2006 31 / 31
Rabee, 2001 6/6
Sabharwal, 1997 13 / 13
Shaw, 1990 3/4
Schoenecker, 1996 7/7
Total 129/157
0.00 0.50 1.50

*Totals reflect cases in which the condition of the artery was determined. None of the studies
performed further arterial evaluation if the pulse immediately returned after the first attempt of closed
reduction and stabilization.

FIGURE 2. Forest plot summary of studies regarding documented brachial artery injury in pulseless supracondylar fractures.

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J Pediatr Orthop  Volume 30, Number 4, June 2010 Pediatric Supracondylar Humerus Fractures

Study name Total Event rate and 95% CI

Garbuz, 1996 1/8

Korompilias, 2007 4/4
Louahem, 2006 3/5
Luria, 2007 7/9
Rabee, 2001 5/5
Sabharwal, 1997 13 / 13
Schoenecker, 1996 7/7
Total 40/57

0.00 0.50 1.00

*Totals reflect cases in which the condition of the artery was determined.
FIGURE 3. Forest plot summary of studies regarding documented brachial artery injury in pulseless and perfused supracondylar fractures.

Two hundred fifty-four pediatric orthopaedic sur-
geons responded to the survey regarding brachial artery
injuries in supracondylar fractures, achieving an approxi-
mately 40% response rate. The results of their responses are
listed in Table 2. When asked what percentage of the
pulseless supracondylar fractures had true brachial artery
injuries, the mean response was 28% [95% confidence
interval (CI) = 0.28 (0.22-0.34)]. The average answer for
the percentage of brachial artery injuries in perfused
pulseless supracondylar fractures was 17% [95% CI =
0.17 (0.12-0.22)]. Regarding pale, pulseless supracondylar
fracture, surgeons presumed that the artery was injured an
average of 65% [95% CI = 0.65 (0.71-0.59)] of the time.
Finally, the patency of brachial artery repairs was estimated
to be 55% [95% CI = 0.55 (0.48-0.62)] based on the aver-
age response. Finally, all results derived from the literature
are compared with the average opinion of POSNA
members and assembled into Table 3.
DISCUSSION
Treatment of supracondylar fractures has evolved
tremendously since Swenson first described his efforts
at percutaneous pinning in 1948.1–4 Despite the progress,
unanswered questions remain. A perfused, viable hand
with no pulse continues to be a gray area for which there
is no consensus on management. Our study has taken
currently available orthopaedic evidence and attempted
to zero in on this gray area. Both the reported rate of
arterial injury and the reported success rate of arterial
repair after this injury seem to be much higher than
commonly considered.
Since the 1950s, anecdotal experience regarding
the pulseless perfused upper extremity has been handed
down advising surgeons to take a watchful waiting
approach.19,28,38 These accounts provide reassurance that
the ‘‘pulse suddenly comes back’’28 or that collateral
circulation will be adequate.28 Historically, the need for a
patent brachial artery was put to the ultimate test in
World War II, when physicians actually ligated the
brachial artery to prevent hemorrhaging in military
arterial injuries. Of 2471 arterial injuries, DeBakey
and Simeone39 reported that only 5.5% were treated by
vascular repair. This treatment strategy led to an
amputation rate of 26.5%.40
Decades later, advancements in vascular surgery
were made, and surgeons became more aggressive in
attempting brachial artery repairs. These technical
advancements led to tangible improvements in clinical

Pulseless Supracondylar
Fractures
331

Closed Reduction with Return of No Return of Pulse after Closed

Pulse Reduction
174 157
(53%) (47%)

Surgical Exploration Observed

142 15
(90%) (10%)

Brachial artery injury Spasm

129 13
(129/157=82%)* (13/157=8%)*

*Since it was unknown whether the arteries in the observed group were in spasm or
injured, they were included in the denominator in order to give the most conservative
percentage estimate.

FIGURE 4. Flow chart treatment summary of all pulseless supracondylar fractures.

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White et al J Pediatr Orthop  Volume 30, Number 4, June 2010

Pink and Pulseless Supracondylar

Fractures
98

Closed Reduction with Return of No Return of Pulse after Closed

Pulse Reduction
41 57
(42%) (58%)

Surgical Exploration Observed

45 12
(79%) (21%)

Brachial artery injury Spasm

40 5
(40/57=70%)* (5/57=9%)*

*Since it was unknown whether the arteries in the observed group were in spasm or injured, they were
included in the denominator in order to give the most conservative percentage estimate.

FIGURE 5. Flow chart treatment summary of pulseless supracondylar fractures with pink, perfused extremities.

results. The amputation rate due to brachial artery
trauma decreased significantly from 26.5% in World
War II to 5.7% during the Vietnam War when prompt
routine repair was initiated.39–41 This wartime experience
provided evidence that results could be significantly
improved with a more aggressive approach to arterial
injury.
Other evidence in the literature also supports
prompt treatment of vascular injuries and cautions
that delayed treatment could prove to be devastating.
Ottolenghi42 warned that the rate of Volkmann ischemic
contractures increased steadily if vascular compromise
remained uncorrected after 24 hours of injury. Additional
complications of untreated vascular injuries appear later
in the treatment course and include forearm claudication,
cold intolerance, thrombus embolization, and retarded
development of the limb.13,27,43,44 Even in the setting
of good collateral circulation, Friedman and Jupiter45
reported 5 cases of untreated well-perfused vascular
injuries that resulted in long-term dysesthesia or loss of
function. Similarly, Shuck et al46 reported 2 cases where
a delay in arterial exploration resulted in permanent
weakness, despite the presence of excellent collateral
circulation.
With regard to the treatment of perfused pulseless
supracondylar fractures, more than half of the papers
located through our systematic review advocated for
immediate arterial exploration. In contrast, only 16%
of pediatric orthopaedic practitioners would take this
approach.32 Additionally, our survey results show that
pediatric orthopaedic surgeons estimate brachial artery
injury in 28% of pulseless supracondylar fractures,
whereas the literature average is greater than 80%. For
perfused pulseless supracondylar fractures, the survey
mean estimate for brachial artery injury was 17%
compared with the actual reported mean of 70% from
the literature. Reported patency rates were also higher
than estimated by current practitioners, with an arterial
repair success rate of greater than 90% as compared with
the survey opinion of a somewhat dismal 55%. These
comparisons highlight the discrepancy between the
available evidence and popular opinion.
Therefore, the most important take-home message
for practitioners is that an absence of pulse is a strong
indicator of arterial injury, even if the hand is perfused
and warm. In our systematic review, patients with no
pulse were overwhelmingly found to have true brachial
artery injury. In contrast, arterial spasm could be proven
in only 9% (13 of 142) surgically explored patients.
Therefore, we cannot always comfort ourselves with
the thought that the pulselessness in the supracondylar
patient will resolve because it is due to spasm.

4 Studies with Follow-up on

Patency Rates27, 30, 33, 35

54 Vascular Interventions

Normal Vascular Exam based on

Abnormal Vascular Exam at Follow-up
Doppler +/- Forearm Pressures
5 (9%)
49 (91%)

FIGURE 6. Flow chart of patency rates following brachial artery revascularization.

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J Pediatr Orthop  Volume 30, Number 4, June 2010 Pediatric Supracondylar Humerus Fractures

TABLE 2. POSNA Membership Supracondylar Survey Responses

Question 1. Among pediatric patients with a persistent pulseless (defined as no palpable radial pulse) 28% (238 responses)
supracondylar humeral fracture following appropriate reduction and internal fixation, what percentage do you 61% below 20%
think have true brachial artery injury (defined as transection, laceration, intimal tear, or entrapped artery)? 10% above 80%
Please answer this question based just on the ‘‘absent pulse’’ information alone i.e. no additional information
regarding distal perfusion is available

Question 2. Among pediatric patients with a pulseless (defined as no palpable radial pulse) supracondylar humeral 17% (242 responses)
fracture and a PINK (aka well-perfused) hand following appropriate reduction and internal fixation, what 78% below 20%
percentage do you think have true brachial artery injury (defined as transection, laceration, intimal tear, or 8% above 70%
entrapped artery)?

Question 3. Among pediatric patients with a pulseless (defined as no palpable radial pulse) supracondylar humeral 65% (242 responses)
fracture and a PALE (aka poorly perfused) hand following appropriate reduction and internal fixation, what 12% below 20%
percentage do you think have true brachial artery injury (defined as transection, laceration, intimal tear, or 47% above 80%
entrapped artery)?

Question 4. Among pediatric patients who are s/p brachial artery repair, what percentage do you think remain 55% (212 responses)
successful (i.e. patent) at a minimum of 2 years follow-up? 16% below 20%
30% above 80%
The values are presented in bold as a mean. Below each mean, a percentage for the extremes of the responses was presented to show trends.
POSNA indicates Pediatric Orthopaedic Society of North America.

Instead, the real reason for our assurance should be
reliance on collateral circulation. If we choose to treat
with close observation, we take a calculated gamble that
the rich vascular network about the elbow will provide
sufficient perfusion to the rest of the extremity. Unfortu-
nately collateral circulation is not always reliable, with
20% of the population having some variation in the
arterial anatomy of the upper extremity.47–49 Although
long-term complications are rare, delayed surgical inter-
vention has resulted in reported incidences of vasomotor
instability,50 limb length discrepancy,45 and Volkmann
contracture14 despite the supposed presence of collateral
circulation.
This review also suggests that routine arteriography is
not necessary because it only confirms a known diagnosis.
When the hand is pulseless, the artery is usually injured,
and the defect can be best viewed through direct surgical
exposure. Therefore, arteriography causes a delay in
treatment and usually does not change the management.
In addition, the small size of the artery in children
predisposes it to iatrogenic injury during arteriogra-
phy.43,51,52 A reliable noninvasive method available to the
surgeon in the operating room would be of great value.
Finally, this systematic review suggests that brachial
artery revascularization can be performed successfully,
with high patency rates. This finding corresponds to data
from the adult general and vascular surgery literature
regarding upper extremity trauma and forearm ische-
mia.43,53 In our study, the only paper supporting frequent
reocclusion and stenosis examined patients whose revas-
cularization procedure occurred later in the treatment
course (2 to 9 d after injury).35
There are limitations to the evidence conveyed in this
study, and the results of our research must be interpreted
within the context of the study design. Publication bias may
make the results of surgical treatment more likely to be
reported. Another limitation relates to the likelihood of
selection bias influencing retrospective cohort studies, the
predominant study design included in our meta-analysis.
Additionally, this study addressed brachial artery trauma
as a group. It did not distinguish between injury types such
as avulsion or thrombosis, but this differentiation could
have an impact on management and would warrant further
investigation. Finally, the articles in the review contain
heterogeneous descriptions for ‘‘perfused’’ and ‘‘pulseless.’’
However, the wording does not detract from our conclu-
sions, because the descriptions define the same clinical
picture. Most articles clearly state that the pulse was not
palpable, and all indicate that the status of the pulse was
worrisome on presentation. Also, many of the articles in
this review equate ‘‘pink’’ with ‘‘perfused.’’ Given the
variances in skin tones, we would encourage future authors
to avoid using these terms as synonyms. ‘‘Perfused’’
provides a more accurate description for a viable hand in

TABLE 3. Comparison of POSNA Survey Results and Systematic Review Results

POSNA Membership Opinion Meta-analysis Data
Rate or arterial injury in the setting of any pulseless supracondylar fracture? 28% 82%
Rate of arterial injury in the setting of pulseless and perfused fractures (aka pink)? 17% 70%
Rate of patent brachial artery repairs at follow up? 55% 91%
POSNA indicates Pediatric Orthopaedic Society of North America.

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White et al
FIGURE 7. Clinical photograph of intraoperative use of
ultrasound with color flow Doppler for a pulseless perfused
supracondylar humeral fracture patient. A pediatric radiologist
performs the study while a pediatric orthopedist positions the
previously reduced and pinned extremity. Brachial artery
injury was confirmed by this study and arterial exploration
and repair ensued.
all ethnic groups. Also, other measurements such as hand
temperature or capillary refill would have given further
objective data about the degree of ischemia.
Nevertheless, our systematic review reveals that
common pediatric orthopaedic dogma regarding watchful
waiting of reduced and stabilized pulseless, pink supra-
condylar fractures needs to be questioned. Based on the
available literature, an absence of pulse seems to be a
warning for arterial damage, even if the hand is perfused
and warm. Historically, reports of disastrous outcomes
after observation of these injuries have been infrequent.
However, data from this study clearly suggests that this
treatment strategy should be revisited. Over the years,
vascular repair techniques and diagnostic tools have
improved, but we have largely ignored these advance-
ments and let policies from the past dictate our decision
making process. A change in this doctrine should begin
with strong consideration for supplemental diagnostic
techniques such as postreduction and pinning ultrasound
with color flow Doppler. This tool has been proven to be
useful in determining the severity of arterial injury and
providing guidance for treatment and its use is illustrated in
Figure 7.40,54–60 Additionally, it is noninvasive and easily
attainable. Both the equipment and support staff (including
the technician and radiologist) are readily available at all
times at most institutions. As a last resort, this study
suggests vascular exploration may limit the chance for late
complications, and patency rates are reportedly success-
ful enough to make revascularization procedures worth-
while.
ACKNOWLEDGMENT
The authors thank Susan Foad for her generous help
in constructing the forest plots in Figures 2 and 3.
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J Pediatr Orthop  Volume 30, Number 4, June 2010
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