The decision of whether to undertake surgical exploration for SHFs is a subject of some debate presenting with a PPH [10-11]. Some clinicians recommend aggressive exploration and vascular reconstruction [3, 8-10, 12-14] while others recommend close observation after urgent CRPP [4-7, 11, 15-20]. The present study demonstrates the benefits of a strategy of close observation following CRPP for the treatment of SHFs presenting with a PPH.
The traditional conservative strategy of close observation has been used for SHFs since 1950s and relies on collateral circulation of the elbow joint [10, 17, 23-25]. Studies have demonstrated that the limb can kept alive with ligation of the injured brachial artery [26-28]. Strong collateral circulation has been identified using arteriography or ultrasound around the elbow after SHFs . Furthermore, CFDU also detected collateral circulation around the elbow even though the radial pulse was not palpable.
Many studies have described good results of this strategy and few complications [5-6, 15, 19, 29]. Choi et al reported that, among patients treatment for absent distal pulse following displaced SHFs, CRPP resulted in a good rate of return of palpable pulse after surgery or achievement of a pulseless but well-perfused status . Good outcomes were achieved without surgical exploration and no patients developed compartment syndrome. Scannell et al described that CRPP for the treatment of perfused pulseless hand following displaced SHFs resulted in an immediate return of palpable pulse in 20% of patients, with normal radial pulse returning in all patients eventually . However, patent brachial arteries occurred in almost 75% of patients and brachial artery occlusion in 20%; collateral vessels were also found, severe arterial stenosis occurred in one patient, and cold intolerance during participation in ice hockey was reported in one patient. At an average of 20 months follow-up, there were no differences in arm circumference or length, elbow motion, muscle endurance, or grip strength between the injured and uninjured sides. Louahem et al treated 68 patients with vascular compromise (63 of whom with pulseless perfused hand) with CRPP followed by close observation. Forty-two patients had a palpable radial pulse immediately after CRPP, eighteen experienced return of radial pulse from a few hours to 11 days postoperatively. Three patients required immediate surgical exploration for ischemic signs after unsuccessful reduction, which revealed incarceration of the brachial artery between fragments. With an average of 8.4 years of follow-up, all patients achieved normal circulatory status including a palpable radial pulse. No complications such as limb length discrepancy, cold intolerance, or claudication were observed .
Our results agree well with those of the above described studies; all 13 patients who presented with a PPH underwent urgent CRPP. Immediate return of radial pulse was observed in most cases, good capillary refill was detected in those where radial pulse was not palpable, and all patients had a palpable radial pulse at the final follow-up with no complications observed.
Despite the outcomes of conservative management, many surgeons—especially vascular or microsurgical surgeons—tend to recommend surgical exploration and vascular reconstruction after CRPP for a PPH, with good results reported [9, 13-14]. Immediate surgical exploration before fracture reduction has even been recommended , although disadvantages of the procedure have been reported to include a long scar and the occurrence of re-occlusion and stenosis of the brachial artery [21, 28].
Surgical exploration is recommended for three main reasons: the first is that ligation of an injured brachial artery is considered to be associated with a high amputation rate based on war-time reports [10, 31]. However, these cases are very different to SHFs, in which the arm can be kept alive even with ligation of the brachial artery due to the collateral circulation [17, 26-28]. Two of our cases underwent CRPP nearly 2 days after injury because of neglect of artery compromise and late referral; however, the pulse recovered in 6 hours in both. This confirms the suggestion from previous studies that collateral circulation is sufficient to support the vitality of a PPH following SHFs, even without fracture reduction.
The second reason is the concern that delayed vascular exploration and reconstruction for a PPH following SHFs will lead to compartment syndrome , Volkmann ischemic contractures , vasomotor instability , forearm claudicating [27, 35], cold intolerance [5, 36], thrombus embolization , or retarded development of the limb . Blakey et al reported a high incidence of compartment syndrome associated with a PPH following SHFs , and the incidence has been reported to increase from 0.2%–4.5% in cases with co-existing neurovascular compromise . However, the cases in Blakey’s study were referred in a mean time of 3 months (4 days to 3 years) after injury, with no further pre-referral information reported . Other studies have shown compartment syndrome following SHFs to be associated with over-swelling, delayed fracture reduction, and elbow flexion of more than 90° absence of radial pulse alone is not an indication for exploration if there are no other signs of ischemia [40-42]. All cases of retarded development involve the lower limb, and are therefore not related to SHFs . Furthermore, the main area of potential growth in the upper limb is not the elbow . Other complications that have been reported such as vasomotor instability, forearm claudicating, and cold intolerance were either from case reports or a single case in a series [5, 27, 34-36].
The third reason for recommending surgical exploration is the lack of long-term follow-up data and sufficient cases to support the superiority of conservative management, which results in an arm relying on collateral circulation only [9, 21-22]. However, collateral circulation around the elbow after SHFs has been shown to be sufficient to maintain the limb, with good long-term results [6, 15].
Making the decision of whether to perform surgical exploration requires accurate evaluation of the vascular compromise. There are several ways to evaluate such compromise, including arteriography, CFDU, computed tomography angiography, and magnetic resonance imaging, with the first two being used most often in clinical work. Arteriography can reveal the type of vascular compromise such as compression, entrapment, obstruction, or disruption; performed intra-operatively this approach can avoid unnecessary exploration . Pre-operative arteriography has no benefit because it only confirms a known diagnosis and will delay exploration without usually contributing to decisions regarding clinical management [10, 21]. The disadvantages of arteriography include its invasive nature and the risk of hemorrhage at the puncture site, allergic reaction to the contrast agent, and temporary loss of distal pulse . In contrast, CFDU is noninvasive and easily attainable. A comprehensive pre-operative physical examination is sufficient for assessing compromise of the brachial artery , but post-operative CFDU is useful for determining the severity of arterial compromise and informing treatment . In our center, we do not perform vascular exploration where CFDU does not show disruption of the brachial artery and perform post-operative CFDU to reassess the vascular status where aggravation of artery compromise occurred during CRPP and to confirm the continuity of the artery. We believe that intra-operative CFDU immediately after CRPP is beneficial for deciding whether to perform surgical exploration. In our practice, vascular exploration is performed if disruption of the artery is revealed by CFDU; otherwise, close observation will be carried out.
A survey by the British Society for Children’s Orthopedic Surgery showed that only 16% of members would perform vascular exploration immediately after CRPP in the case of a PPH . A recent systematic review comparing two different strategies suggested that CRPP should be the first-line approach for SHFs with either a pale or pink pulseless hand. In the case of pale pulseless hands, there is a chance that radial pulse may return after CRPP; otherwise, immediate vascular exploration is strongly indicated. In a PPH, the traditional strategy of close observation should not be revisited as long as there are no signs of deterioration of the vascular status .
The present study has some limitations which should be acknowledged, including the retrospective analysis of data, lack of sufficient cases, and lack of results of final and intra-operative CFDU. Future studies are warranted involving larger cohorts recruited from multiple centers, and the development of an animal model would be beneficial to study the collateral circulation of the elbow and long-term effects of ligation of the brachial artery on limb function and development.