1906

C OPYRIGHT 2013

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Management of the Pediatric Pulseless Supracondylar

Humeral Fracture: Is Vascular Exploration Necessary?
Amanda Weller, MD, Sumeet Garg, MD, A. Noelle Larson, MD, Nicholas D. Fletcher, MD, Jonathan R. Schiller, MD,
Michael Kwon, MD, Lawson A.B. Copley, MD, Richard Browne, PhD, and Christine A. Ho, MD
Investigation performed at Texas Scottish Rite Hospital-Childrens Medical Center, Dallas, Texas

Background: Radically different conclusions exist in the pediatric orthopaedic and vascular literature regarding the
management of patients with a pink hand but no palpable radial pulse in association with a supracondylar humeral
fracture.
Methods: One thousand two hundred and ninety-seven consecutive, operatively treated supracondylar humeral fractures
in patients presenting to a level-I pediatric trauma center from January 2003 through December 2007 were studied
retrospectively. Clinical records were reviewed to determine vascular and neurological examination findings, Gartland
classification, timing of surgery, and postoperative complications.
Results: One thousand two hundred and sixty-six patients had a documented radial pulse examination at the time of
arrival in the emergency room; fifty-four (4%) of those patients lacked a palpable radial pulse. All fifty-four patients had type3 fractures. Five (9%) of the fifty-four patients underwent open exploration of vascular structures on the basis of clinical
findings of a pale hand, sluggish capillary refill, and/or weak or no pulse detected with use of Doppler ultrasound after
closed reduction and percutaneous pinning. All five underwent vascular surgery to restore blood flow (two primary repairs,
three saphenous vein grafts). Twenty (37%) of the fifty-four patients had a pulse documented with use of Doppler
ultrasound and a pink hand after closed reduction and percutaneous pinning, but the radial pulse remained nonpalpable.
These patients were observed in the hospital for signs of ischemia; one of the twenty patients required vascular repair
after developing a pale hand nine hours after closed reduction and percutaneous pinning, and the other nineteen patients
were also observed while they were in the hospital, and they all regained a palpable pulse either prior to discharge or by the
time of the first postoperative visit. When compared with the group of patients with type-3 fractures for whom data
regarding nerve examination were available, patients with type-3 fractures who lacked a palpable radial pulse had a higher
rate of nerve palsy postoperatively (31% versus 9%, p < 0.0001).
Conclusions: In this cohort, nearly 10% of patients who presented with a type-3 supracondylar humeral fracture and no
palpable radial pulse underwent immediate vascular repair to restore blood flow following closed reduction and percutaneous pinning. However, in our series, the lack of a palpable radial pulse after closed reduction and percutaneous
pinning was not an absolute indication to proceed with vascular exploration if clinical findings (i.e., Doppler signal and
capillary refill) suggested that the limb was perfused. Careful inpatient monitoring of these patients postoperatively is
mandatory to identify late-developing vascular compromise.
Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Disclosure: None of the authors received payments or services, either

directly or indirectly (i.e., via his or her institution), from a third party in
support of any aspect of this work. One or more of the authors, or his or
her institution, has had a financial relationship, in the thirty-six months
prior to submission of this work, with an entity in the biomedical arena
that could be perceived to influence or have the potential to influence
what is written in this work. No author has had any other relationships, or
has engaged in any other activities, that could be perceived to influence
or have the potential to influence what is written in this work. The
complete Disclosures of Potential Conflicts of Interest submitted by
authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2013;95:1906-12

http://dx.doi.org/10.2106/JBJS.L.01580

A commentary by Steven L. Frick, MD, is

linked to the online version of this article at
jbjs.org.

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he management of children who present pulseless (i.e.,

without a palpable upper-extremity distal pulse) secondary to a supracondylar humeral fracture remains
controversial. All agree that a patient who presents with no palpable radial pulse because of a supracondylar humeral fracture
requires timely reduction of the fracture1. However, controversy
continues regarding the decision to proceed with vascular exploration when a limb remains pulseless by palpation after closed
reduction and percutaneous pinning but has good clinical signs
of perfusion, such as brisk capillary refill, warmth, and pink hand
and fingers.
The practice of immediate vascular exploration in a limb
displaying signs of ischemia (coolness of the hand, paleness of
the limb, and no radial pulse detected on Doppler ultrasonography) is widely accepted2-4. Despite this consensus, variations in treatments exist in the management of a warm,
clinically well-perfused limb that lacks a palpable pulse. Some
surgeons have advocated for vascular exploration whenever the
radial pulse is nonpalpable after closed reduction and percutaneous pinning2,4-6. Others support emergent angiography5,7 or
color Doppler studies2 to evaluate the patency of the brachial
artery prior to any open surgical management. A third group
feels that closely observing this subgroup of patients in the
hospital with serial vascular examinations is a safe way to
manage the pink, warm distal extremity that lacks a palpable
pulse8-12.
This study examines the experience at a high-volume,
level-I pediatric trauma center with regard to the management of patients who present without a palpable radial pulse
as a result of a supracondylar humeral fracture. This is a
focused review of the short-term outcomes resulting from
close observation of patients lacking a palpable pulse after
undergoing closed reduction and percutaneous pinning at
our institution, and it is also an analysis of the decisionmaking processes that led to open exploration in this cohort.
Although a portion of this cohort has been described in a
previously published report by surgeons from the Department of Surgery at our institution (The University of Texas
Southwestern Medical Center), that report only focused on
patients who underwent vascular repair; it did not review any
patients managed solely by observation13.

P E D I AT R I C P U L S E L E S S S U P R A C O N D Y L A R H U M E R A L
F R A C T U R E : I S VA S C U L A R E X P L O R AT I O N N E C E S S A R Y ?

in this review. All fifty-four patients had a type-3 supracondylar humeral

14,15
fracture according to the Gartland classification system
. Fracture classification was confirmed by review of preoperative and postoperative radiographs by the senior author (C.A.H.).
Following closed reduction and percutaneous pinning, all patients
lacking a palpable radial pulse were monitored every six to eight hours in
the hospital for twenty-four to forty-eight hours and were only discharged
home with the approval of the attending surgeon. Postoperative serial
examinations included attempts to palpate a radial pulse, assessment of
warmth of the distal part of the extremity, assessment of capillary refill
time, a neurological examination, and Doppler examination if no palpable
radial pulse was present. These examinations were performed by various
providers, including orthopaedic residents, nurse practitioners, physician
assistants, and attending surgeons. The upper limb was placed in a posterior long arm splint after surgery, with the elbow flexed <90 and with
use of loose cast padding. The nursing staff was instructed to notify the
on-call provider immediately if any patient had an increase in pain or a
behavioral change postoperatively. All providers were instructed to loosen
the dressings, Ace wrap, or splint if the patient experienced increasing
pain that was not responsive to pain medication or had new neurological
symptoms and to notify the attending surgeon if these symptoms did
not resolve. Discharge from the hospital was at the discretion of the attending orthopaedist, with the decision to discharge the patient largely
based on the physical examination findings and on the comfort level of the
patient.
Each patient who initially presented without a palpable radial pulse
underwent a neurological examination; an analysis of postoperative complications, patient demographics, mechanism of injury, time from injury to
presentation, time from injury to surgery, and length of hospital stay; and a
postoperative physical examination. Three categories were used to describe
the mechanism of injury: low energy (e.g., a ground-level fall or a fall from a
short distance), medium energy (e.g., a fall from playground equipment or a
trampoline injury), or high energy (involvement in a motor-vehicle collision
or a fall from a height). The Fisher exact test was used to compare the
demographics of the fifty-four patients who had a type-3 fracture and no
palpable radial pulse with the 819 patients who had a type-3 fracture and a
palpable radial pulse upon presentation to the emergency department.
Significance was set at p < 0.05.
The decision to consult with the Division of Vascular Surgery was
made at the discretion of the attending surgeon on the basis of the findings
from each patients postreduction vascular examination. Operative reports
were reviewed to determine the type of vascular injury that was encountered as well as the type of repair that was performed by the vascular surgery
team.
Institutional review board approval was obtained for this study.

Source of Funding
There were no external sources of funding for this study.

Materials and Methods

database was created with use of Current Procedural Terminology (CPT)

codes 24538 and 24545 to identify all operatively treated supracondylar
humeral fractures that were treated at our center during the five-year period
from the beginning of 2003 through the end of 2007. A total of 1297 patients
met this inclusion criterion. Any patient receiving operative treatment prior to
arriving to our center was excluded.
Preoperative physical examination documentation was reviewed to
identify all patients who, at the time of presentation to the emergency department, lacked a palpable radial pulse secondary to a supracondylar
humeral fracture. The radial pulse was used for all preoperative and postoperative examinations because of ease of both palpation and localization of
Doppler signal, therefore standardizing and simplifying the assessment of
distal blood flow by residents, nurse practitioners, and physician assistants.
Fifty-four patients (of 1266 patients with a documented radial pulse examination) lacked a palpable radial pulse on presentation and were included

Results
ne thousand two hundred and sixty-six of the 1297 patients with an operatively treated supracondylar humeral
fracture had a documented radial pulse examination on arrival
at the emergency department. Of the 1266 patients, 873 had
Gartland type-3 fractures (displaced with no cortical contact),
and 393 had Gartland type-2 fractures (displaced with intact
posterior cortex). Fifty-four patients (4%) were documented as
having no palpable radial pulse. All of the patients who did not
have a palpable radial pulse had a Gartland type-3 supracondylar humeral fracture and underwent closed reduction and
percutaneous pinning except for one patient with an open
fracture, who had an open reduction. After closed reduction

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TABLE I Patients Requiring Vascular Surgery

Postreduction Examination

Surgical Finding and/or Intervention

Patient 1

Pink hand, no pulse detected with use

of Doppler ultrasound

Intimal tear resected with primary repair;

angiogram done

Patient 2

Brisk capillary refill, no pulse detected

with use of Doppler ultrasound

Patch angioplasty with saphenous graft

Patient 3

Sluggish capillary refill; no pulse detected

with use of Doppler ultrasound

Thrombosed brachial artery; saphenous

graft repair (interpositional)

Patient 4

Open fracture (Gustilo and Anderson grade II*);

pink hand, no pulse detected with
Doppler ultrasound

Brachial artery laceration with primary repair

Patient 5

Brisk capillary refill and normal (triphasic)

Doppler velocity waveform initially; cool, pale
hand 9 hrs postoperatively

Thrombosed brachial artery; saphenous

graft bypass (9 hrs after reduction)

*Gustilo and Anderson grade II indicates an open fracture in which the wound is >1 cm in length without extensive soft-tissue damage, flaps,
or avulsions.

and percutaneous pinning, four patients underwent immediate

vascular exploration; twenty-six patients had a restored palpable radial pulse; twenty had a pink, perfused hand and were
without a palpable radial pulse but a pulse could be detected
with use of Doppler ultrasound; and four did not have a welldocumented record with regard to whether or not they had
immediate postoperative vascular examination (Fig. 1). One of
the twenty with a pink, perfused hand and a radial pulse that
could only be detected with use of Doppler ultrasound had late
deterioration and underwent delayed exploration and brachial
artery reconstruction, making a total of five patients who ultimately had vascular surgery. There were no patients with a
nonpalpable radial pulse after closed reduction and percutaneous pinning who preoperatively had had a palpable radial
pulse. We were unable to retrospectively analyze descriptives
regarding the quality and strength of Doppler sounds, and thus
we restricted our categorization of radial pulses detected with
Doppler ultrasound to present or absent. All four patients
who underwent immediate vascular exploration had no radial
pulse detected with Doppler ultrasound following reduction
and fixation. In all cases, the vascular surgery team was consulted prior to making the decision in favor of exploration; no
attempt was made by the orthopaedist to perform vascular
exploration without input from a vascular surgeon except for
Patient 4, who had an open fracture with an already exposed
brachial artery (Table I).
The incidence of nerve palsy was 31% (seventeen of fiftyfour patients) in the group lacking a palpable radial pulse as
compared with 9% (seventy of the 800 for whom detailed
preoperative neurological examination data were available) in
the group of patients with type-3 fractures and a palpable pulse
(p < 0.0001, Table II). All nerve injuries were managed with
observation until resolution, with no documented permanent
nerve injury. Preoperative examination revealed that fifteen
patients (27.8%) with a nonpalpable radial pulse had nerve
injuries. Postoperative examinations revealed that seventeen

patients (31%) had nerve injuries. Preoperative examination

revealed twelve anterior interosseous nerve palsies, one posterior interosseous nerve palsy, one ulnar nerve palsy, four
median nerve sensory deficits, one radial nerve sensory deficit,
and one ulnar nerve sensory deficit (some patients had multiple nerve palsies). One of the four patients who underwent
immediate vascular exploration was identified as having anterior interosseous nerve palsy postoperatively.
The patients who presented with no palpable pulse underwent surgery significantly sooner than those with a palpable
pulse (mean time from injury, 8.4 hours versus 16.8, respectively; p < 0.0001). There was no correlation between mechanism of injury (low energy, medium energy, or high energy)
and presence of a palpable pulse (Table III). The group without
a palpable radial pulse had a slightly longer hospital stay than
did the group with a palpable pulse (mean, 25.9 hours versus
21.2 hours, respectively; p = 0.0248).

Fig. 1

Summary, method of treatment, and outcome of patients who had no

palpable radial pulse at the time of presentation to the emergency department. Asterisk indicates the four patients who had immediate exploration and the one patient who had delayed exploration (thus, a total of five
open vascular explorations).

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TABLE II Incidence of Sensory or Motor Nerve Injury (p < 0.0001)

Pulse

Neurologically Intact

Nerve Injury

Nonpalpable (n = 54)

37 (69%)

17 (31%)

Palpable (n = 800)*

730 (91%)

70 (9%)

*Detailed preoperative neurological examination was only available for 800 of the 819 patients with a Gartland type-3 supracondylar humeral fracture and a palpable pulse.

TABLE III Mechanism of Injury (p < 0.4724)

Pulse

High Energy

Medium Energy

Low Energy

Nonpalpable
(n = 54)

3 (6%)

23 (43%)

28 (52%)

31 (4%)

290 (37%)

463 (59%)

Palpable
(n = 784*)

*Mechanism of injury was only available for 784 of the 819 patients with a Gartland type-3 supracondylar humeral fracture and a
palpable pulse.

All twenty patients who had a pulse detected with use of

Doppler ultrasound but no palpable radial pulse after closed
reduction and percutaneous pinning were observed in the
hospital postoperatively with use of serial vascular examinations. One patient had a cool, pale hand with no detectable
pulse on Doppler ultrasound approximately nine hours after
the initial closed reduction and percutaneous pinning. This
patient returned to the operating room for emergent vascular
exploration (Table I). All of the remaining nineteen patients
who were observed in the hospital after closed reduction and
percutaneous pinning regained a palpable radial pulse either
prior to discharge or by the first postoperative clinic visit.
One four-year-old girl developed evidence of forearm
ischemia that was not diagnosed until the first outpatient followup visit. Preoperatively, the patient was documented as being
able to wiggle fingers with normal motor ability and had
sensation to light touch. The patient had a cool, pink hand
and a radial pulse that was not palpable but that could be
detected on Doppler ultrasound, and she was taken to the operating room eight hours after the injury. Initially after closed
reduction and percutaneous pinning, the radial pulse remained
nonpalpable but could be detected with use of Doppler ultrasound and the hand was pink and warm; the patient was subsequently observed by means of multiple physical examinations
during which it was documented that the hand was pink, capillary refill was brisk, a palpable radial pulse had returned, and all
sensory and motor nerve distributions were intact. The patient
was also documented to have adequate pain control and did not
complain of an appreciable increase in pain with finger manipulation while in the hospital, and an orthopaedic provider
documented no concern for compartment syndrome at the time

P E D I AT R I C P U L S E L E S S S U P R A C O N D Y L A R H U M E R A L
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of discharge. The child was discharged from the hospital and, at

some point after discharge, presented to an outside emergency
department for evaluation; however, the records of this encounter were not available to us. The patient was evaluated in
our clinic one week after the hospital discharge and was found to
have circumferential skin necrosis under the splint and loss of
motor and sensory function to the hand; the radial pulse remained palpable and the hand was pink with brisk capillary
refill. The patient was diagnosed with a Volkmann ischemic
contracture and was referred to the hand surgery service for
further care.
Discussion
he problem of managing a pink, pulseless supracondylar
humeral fracture is one that has been debated throughout
the pediatric orthopaedic literature. Despite this ongoing debate, a definitive treatment strategy has yet to be established.
This review represents an analysis of almost 1300 surgically
treated supracondylar humeral fractures from a large-volume
pediatric trauma center.
While a portion of our series has been previously published by our institutions vascular surgeons13, that series was
composed of patients with any pediatric elbow trauma, not just
a supracondylar humeral fracture, and it only evaluated the
cases in which the orthopaedist requested a consult from the
vascular surgery team. That report does not provide insight
into the management that led to the orthopaedists decision to
consult the vascular surgeon. Their series also included patients
who underwent closed reduction and percutaneous pinning at
outside hospitals and were transferred to our hospital purely
for vascular surgery intervention, and these cases were therefore not included in this series of supracondylar humeral
fractures treated operatively at our institution. The vascular
surgery authors were not consulted on patients who may have
had transient ischemia of the hand from arterial spasm or small
intimal flaps without thrombosis. Those authors concluded
that Absence of wrist pulses after orthopedic fixation should
prompt immediate brachial artery exploration, which is contrary to the findings in our series and contrary to our orthopaedic
surgery experience.
We found that 4% of all patients who were surgically
treated for supracondylar humeral fractures at our institution
presented to the emergency department with no palpable pulse.
This group made up 6% of all of the type-3 Gartland supracondylar humeral fractures. These numbers are consistent with
previous studies analyzing vascular injury with this fracture,
which ranged from 2.6% to 20%5,7,16-25. Of our patients who
presented with no palpable radial pulse, 9% underwent open
vascular exploration and all patients who underwent exploration had an arterial injury that was repaired. In this series, all
patients who were evaluated intraoperatively by the vascular
surgery team had a no radial pulse detected with use of Doppler
ultrasound after closed reduction and percutaneous pinning
(although three did have pink hands), leading us to identify
Doppler status as the variable that determined the decision to
consult with a vascular surgeon. White et al.2 also found a high

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rate of arterial injury in those patients (82%) who underwent

vascular exploration. However, our data revealed that one of
twenty (5%) of the patients with a pink, pulseless distal part of
the upper extremity had a brachial artery injury requiring
exploration and repair, whereas White et al.2 found this number to be 70%. Their study did not specify that the Doppler
examination was used in their patients without a palpable radial pulse. In our review, all patients with a pink hand but no
palpable radial pulse who were observed in the hospital did
have a pulse detected on Doppler ultrasound after closed reduction and percutaneous pinning, although it was not palpable initially.
After undergoing closed reduction and percutaneous
pinning, three patients had a pink, warm hand but no pulse
detected with palpation or with use of Doppler ultrasound.
After a vascular surgery consultation, all three of the patients
underwent open vascular exploration and brachial artery repair
and/or reconstruction by the vascular surgeons. The need for
vascular repair is debatable since, clinically, the patients had
warm, perfused hands despite the absence of a pulse. Blakey
et al. stated that more often decompression of the brachial
artery, rather than repair, is adequate to restore bloodflow 26.
Sabharwal et al. reported a high rate of reocclusion and residual
stenosis of the brachial artery after a revascularization procedure in such patients, who often maintain perfusion in the limb
through robust collateral vasculature10. However, Reigstad et al.
reported normal vascular and neurological outcomes after
open exploration and repair of the brachial artery and believed
that this procedure added minimal risk to the patient27. Finally,
Griffin et al. confirmed that, even in the vascular literature, the
necessity of repairing vascular injuries in patients with pulseless
pink hands is highly debatable, concluding that repair is required in some cases but whether or not all these injuries need
operative management. . .has not yet been proven.11
Since our patients treated with observation after closed
reduction and percutaneous pinning did not have any further
vascular studies conducted, we cannot definitively explain the
return of the palpable pulse. However, two major theories exist in
the current literature. One theory argues that, because of the rich
collateral flow about the elbow and forearm, distal pulses can
remain palpable and a limb can remain warm and perfused even
after a brachial artery injury4,6,8,10,12,16. Another theory suggests that
the brachial artery may be in spasm while the fracture is displaced
and, if given time after reduction, will revert to its former level of
patency and distal pulses will return4,6,16,22,23.
Our review also reported one case of ischemia of the
forearm with development of contracture. The diagnosis was
not made until the patient returned to the outpatient clinic for
follow-up. The most likely causes of forearm ischemia after
a supracondylar humeral fracture or any extremity injury are
arterial occlusion or injury, compartment syndrome, or both26.
We concluded that, given the clinical scenario for this particular patient, the forearm ischemia was likely caused by a missed
compartment syndrome. As noted by Blakey et al., if the critical
ischemia was caused by a vascular injury, this would have been
accompanied by absent distal pulses, severe pain, and declining

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neurological status26, none of which were observed in this patient. However, diagnosing compartment syndrome in the
pediatric population can be difficult because symptoms can
manifest more slowly, and children often do not or cannot express the typical symptoms of pain that are seen in the adult
population28,29. Whether it is due to vascular insult or excessive
hemorrhage and/or swelling, there is an increased risk of the
development of compartment syndrome in patients who present
with an absent radial pulse and supracondylar humeral fracture14,26,27. Efforts should therefore be made to prevent forearm
ischemia as a result of compartment syndrome, and, to this end,
postoperative observation is critical as is educating the parents
to recognize symptoms of impending compartment syndrome
after discharge. Unfortunately in this case, the compartment
syndrome was not recognized or treated in a timely manner,
resulting in an ischemic contracture.
In our cohort, there were significantly more nerve palsies
observed in the patients without a palpable radial pulse on presentation as compared with the number observed in the patients
with a type-3 supracondylar fracture who did have a palpable
radial pulse (31% versus 9%, respectively; p < 0.0001). Other
retrospective studies have documented similar rates of neurological injury in patients with displaced supracondylar humeral
fractures19,30-32. However, those studies did not analyze the incidence of neurological deficits in the patients presenting to
the emergency department with an ipsilateral supracondylar
humeral fracture and no palpable radial pulse. This emphasizes
the need for a thorough prereduction neurological examination in patients who present with no palpable radial pulse after
a supracondylar humeral fracture, as these patients have a
much higher risk of neurological injury33.
As is the case with any retrospective study, this study
does have some weaknesses. It relies exclusively on chart
documentation for its data, and some data points are not
documented for every patient. Despite this, our study analyzes such a large volume of patients that valid conclusions
can still be made regarding the management of the pulseless
limb. Another drawback to the study is the short-term followup that plagues any study looking at acute care in the trauma
setting. The majority of our patients who undergo closed reduction and percutaneous pinning of a supracondylar humeral fracture are discharged from the clinic as soon as the
pins have been removed and the child has regained full range
of elbow motion, which allows for only two to three months
of follow-up in most cases. Also, a power analysis was not performed in this cohort; however, we believe that, because of the
size of our cohort, we were able to make clinically relevant conclusions regarding this very clinically relevant dilemma.
In his annotation addressing two papers that discuss
neurovascular injuries in association with supracondylar humeral fracture, Robb12 noted that the incidence is not established and the functional outcome in children who had a pink,
pulseless hand, but in whom no intervention was undertaken,
are [sic] also unknown in the population as a whole. Our study
does shed some light on the incidence of the pink, pulseless
hand, but we are in agreement that it would be beneficial to

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perform additional long-term outcome studies on these pulseless patients who are treated expectantly.
In conclusion, this study demonstrated that 9% of patients
who presented with a Gartland type-3 supracondylar humeral
fracture and without a palpable radial pulse underwent vascular repair to restore blood flow. All patients who underwent
exploration had no Doppler pulses after closed reduction and
percutaneous pinning, and all patients had an arterial injury that
was repaired. In our series, the absence of a palpable pulse after
closed reduction and percutaneous pinning was not an absolute
indication to proceed with vascular exploration if clinical findings
suggested that the distal part of the forearm and hand were well
perfused (i.e., a Doppler signal and a brisk capillary refill), although these patients should be admitted and closely observed
postoperatively with multiple serial examinations. An absent
radial pulse by palpation in a patient with a type-3 supracondylar humeral fracture can indicate substantial vascular and
neurological injury; however, in our experience, patients with
no palpable radial pulse but with a perfused limb (i.e., warm,
pink, and with brisk capillary refill) and a pulse detected with
Doppler ultrasound after closed reduction and percutaneous
pinning can be closely observed postoperatively rather than being
managed with immediate open vascular exploration, whereas the
patient with no radial pulse detected with Doppler ultrasound
after closed reduction and percutaneous pinning should raise a
high degree of suspicion for arterial injury, especially considering
the cases of all four patients in this series who underwent immediate revascularization and had no radial pulse detected with
Doppler ultrasound after fracture stabilization. n

Sumeet Garg, MD
Pediatric Orthopaedics and Spine Surgery,
Childrens Hospital Colorado,
13123 East 16th Avenue, Box 060,
Aurora, CO 80045

Amanda Weller, MD
Center for Sports Medicine,
University of Pittsburgh,
3200 S. Water Street,
Pittsburgh, PA 15203

Richard Browne, PhD

Department of Research,
Texas Scottish Rite Hospital for Children,
2222 Welborn Street,
Dallas, TX 75219

A. Noelle Larson, MD
Department of Orthopedic Surgery,
Mayo Clinic, 200 1st Street S.W.,
Rochester, MN 55905
Nicholas D. Fletcher, MD
Emory Department of Orthopaedics,
59 Executive Park South NE,
Atlanta, GA 30329
Jonathan R. Schiller, MD
Department of Orthopaedics,
University Orthopedics,
Inc., 2 Dudley Street, Suite 200,
Providence, RI, 02905
Michael Kwon, MD
Department of Orthopaedics,
St. Christophers Hospital for Children,
3601 A Street,
Philadelphia, PA 19134
Lawson A.B. Copley, MD
Christine A. Ho, MD
Department of Orthopaedics,
University of Texas Southwestern Medical School,
Texas Scottish Rite Hospital-Childrens Medical Center of Dallas,
1935 Medical District Drive,
Dallas, Texas 75235.
E-mail address for C.A. Ho: Christine.ho@childrens.com

References
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P E D I AT R I C P U L S E L E S S S U P R A C O N D Y L A R H U M E R A L
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