Journal of Pediatric Orthopaedics - 2026-01-01 - Journal Article; Observational Study
Intraoperative Duplex Ultrasonography for Decision-Making in Pediatric Supracondylar Fractures With Pink Pulseless Hand.
Muraoka T, Inui T, Ueno Y, Inoue S
Topics
Key Takeaway
Intraoperative duplex ultrasonography confirmed brachial artery flow in 8 of 10 pink pulseless hands after CRPP, guiding selective open exploration in only 2 cases with arterial spasm or kinking, with 100% neurovascular recovery by 6 weeks.
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Summary
This retrospective observational study evaluated intraoperative duplex ultrasonography (DUS) for real-time neurovascular assessment in 10 pediatric Gartland Type III supracondylar fractures presenting with pink pulseless hand at two Japanese referral centers from 2018–2024. After CRPP, DUS assessed brachial artery flow and median, radial, and ulnar nerve continuity; 8 of 10 patients had confirmed arterial flow and avoided open exploration, while 2 required open procedures for arterial spasm and kinking respectively, neither requiring vascular repair. All radial pulses returned within 3 days, all nerve palsies resolved within 6 weeks, and Flynn criteria scores were excellent in all patients at 6 months.
Key Limitation
The sample size of 10 patients is too small to determine the false-negative rate of DUS for clinically significant arterial injury requiring repair, which is the critical safety threshold for adopting this protocol.
Original Abstract
BACKGROUND
Pink pulseless hand (PPH) is a critical condition in pediatric Gartland type III supracondylar humeral fractures, raising concerns about neurovascular injury. While watchful waiting is often recommended, most cases do not require surgical intervention; however, some eventually require open procedures, and there remains a risk of missed cases. Intraoperative duplex ultrasonography (DUS) allows real-time neurovascular assessment; however, its intraoperative application remains unclear. The aim of this study was to describe the detailed methodology and clinical outcomes of intraoperative DUS in pediatric supracondylar fractures with PPH.
METHODS
This retrospective observational study included 10 pediatric patients with PPH due to Gartland type III supracondylar fractures, treated at 2 referral hospitals in Japan between 2018 and 2024. After closed reduction and percutaneous pinning, intraoperative DUS was used to assess brachial artery blood flow and the continuity of the median, radial, and ulnar nerves. The primary outcomes were the necessity of an open procedure and postoperative neurovascular recovery.
RESULTS
DUS confirmed intraoperative brachial arterial blood flow in 8 of 10 patients. Two patients required open procedures: one due to arterial spasm and the other due to arterial kinking, both of which resolved without requiring vascular repair. Three patients had median nerve palsy, and 1 patient had anterior interosseous nerve palsy. No neurovascular entrapment was observed, and nerve continuity was intact in all cases. Postoperatively, the radial pulse of all cases returned within 3 days, and all nerve palsy resolved within 6 weeks. Based on the Flynn criteria, all patients achieved excellent functional and cosmetic outcomes at 6 months.
CONCLUSION
Intraoperative DUS is a noninvasive and effective tool for real-time neurovascular assessment in Gartland type III supracondylar fractures with PPH. Its use should be considered in facilities with intraoperative ultrasonography, as it may optimize surgical decision-making by reducing unnecessary open procedures while ensuring optimal neurovascular outcomes.
LEVEL OF EVIDENCE
Level IV.