Pulseless Pink Hand after a Gartland III Supracondylar Fracture
A 6-year-old boy is brought to a district hospital after falling from monkey bars onto his outstretched hand. He has a swollen, deformed elbow with a 2 cm abrasion over the olecranon but no open wound. The hand is pink and warm with capillary refill under 2 seconds and oxygen saturation 99%, but no radial pulse is palpable and Doppler detects only a faint signal. He will not flex the distal phalanx of the thumb or index finger, and sensation is reduced in the median distribution. Radiographs show a Gartland type III supracondylar fracture with posterolateral displacement. The nearest paediatric orthopaedic surgeon is 3 hours away by road, and the anaesthetist on site is not comfortable with paediatric airways. The boy has been fasting for 4 hours.
1. How would you classify and prioritise this injury, and what would you do about the absent pulse?
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This is a Gartland type III (completely displaced) supracondylar fracture with a pulseless pink hand and an anterior interosseous nerve palsy. The pulseless pink hand is a problem of timing rather than an immediate indication for vascular exploration: in most children the brachial artery is kinked or in spasm over the proximal fragment, and flow returns once the fracture is reduced. The priority is urgent reduction and pinning, not angiography.
Immediate steps: analgesia, splint in 20-30 degrees of flexion (never hyperflexion, which further occludes the brachial artery), NPO, IV fluids, and clear documentation of the pulse and perfusion with a marked site. Arrange transfer to a centre with paediatric orthopaedic and vascular capability. If the hand becomes white, cold, or capillary refill exceeds 2-3 seconds at any point, that converts to a limb-threatening emergency requiring exploration or revascularisation rather than transfer.
2. Justify whether you would transfer or treat locally, and what you would communicate to the receiving centre.
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The anaesthetist on site cannot manage a paediatric airway and the surgeon is 3 hours away, so the safest course is splinting and transfer, not a heroic local procedure. Transfer to the paediatric centre allows reduction under general anaesthesia with an image intensifier and immediate vascular surgery back-up. If a local surgeon competent in paediatric supracondylar pinning were available, reduction before transfer would be ideal because it decompresses the artery, but it should not be attempted by an inexperienced operator in a child with a pulseless limb.
Communicate directly with the receiving consultant: age and weight, mechanism, Gartland III, pulseless pink hand with only a faint Doppler signal, anterior interosseous nerve palsy, no open wound, time of injury, fasting status and allergies. Send copies of the radiographs. Give IV antibiotics if the abrasion over the olecranon communicates with the joint. Monitor perfusion hourly during transfer and ensure the escort can escalate if the hand becomes ischaemic.
3. Describe your reduction and fixation technique and the post-operative plan, including management of the nerve injury and pin removal.
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Under general anaesthesia and image intensifier, apply longitudinal traction with the elbow extended, correct medial or lateral translation, then flex and apply thumb pressure over the olecranon to reduce posterior displacement, checking the anterior humeral line and Baumann angle. Avoid hyperflexion so that the pulse is maintained. Fix with two lateral divergent pins or crossed medial and lateral pins; crossed pins are more stable but risk ulnar nerve injury, so a medial pin should be placed through a small incision with the nerve protected. Recheck the pulse after reduction and after pinning.
If the pulse remains absent but the hand stays pink and warm, observe with hourly vascular checks and Doppler, and obtain a vascular opinion; explore if perfusion deteriorates. The anterior interosseous nerve palsy is usually a neuropraxia and is managed expectantly with documentation and review; exploration is unusual. Remove pins at 4 weeks, then mobilise, and warn the family about loss of reduction and about cubitus varus.