Management of Pulseless pink hand after fixation of supracondylar humerus fracture in children.  Controversial topic indeed. I Will provide you some literature on this

1. June 2010.  Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire.


This study by pediatric orthopaedic society of north America concluded that common dogma regarding watchful waiting of pulseless and perfused supracondylar fractures needs to be questioned. In the vast majority of published cases, an absence of pulse is an indicator of arterial injury, even if the hand appears pink and warm, suggesting the need for more aggressive vascular evalvation and vascular exploration and repair in selected cases. Moreover, patency rates for revascularization procedures appear sufficiently high, making this intervention worthwhile.


2. May 2011. Management of acute 'pink pulseless' hand in pediatric supracondylar fractures of the humerus. Ramesh P, Avadhani A, Shetty AP, Dheenadhayalan J, Rajasekaran S. FROM Ganga hospital stated that that the management of a persistent pink pulseless hand remains a 'watchful expectancy'. Surgical exploration should be recommended only if there is either severe pain in the forearm persisting for more than 12 h after the injury or if there are signs of a deteriorating neurological function.

3. Jan 2010. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. Choi PD, Melikian R, Skaggs DL

This study from California stated that the perfusion status of the hand at time of presentation correlating significantly with the ultimate need for vascular repair. In patients presenting with a well-perfused hand, fracture reduction alone was sufficient treatment in all 24 (of 24) cases, and no patients developed compartment syndrome. Nearly half of these patients still had an absent palpable pulse but well-perfused hand after closed reduction, yet did well clinically. Patients presenting with a poorly perfused hand are at high risk for vascular repair and compartment syndrome.

4. J Bone Joint Surg Br. 2009 Nov;91(11):1487-92.

Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. Blakey CM, Biant LC, Birch R.

This study from London stated that urgent exploration of the vessels and nerves in a child with a 'pink pulseless hand', not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia.

5. Int Orthop. 2009 Feb;33(1):237-41. Epub 2008 Mar 26.

Treatment of pink pulseless hand following supracondylar fractures of the humerus in children.


Korompilias AV et al. this study from Greece stated that Surgical exploration for the restoration of brachial artery patency should be performed, even in the presence of viable pink hand after an attempt at closed reduction.

Recommended treatment options include observation, immediate exploration of the artery , exploration if the pulse has not recovered by 24 h, immediate angiography  and transfemoral brachial artery urokinase thrombolysis .

However based on the above review of literature we can lay down few guidelines for your case

1. How was the perfusion at the time of presentation? If poor perfusion – may require exploration; if good perfusion – wait and watch

2. Amount of pain the child is experiencing now. If Significant pain (unresponsive to analgesia) – explore; if child comfortable – observe

3. Any associated neurological symptoms. If yes – explore; if no – wait and watch

4. Persistent and increasing pain with a progressive nerve lesion was indicative of critical ischemia that required urgent exploration of the vessel and nerve.

Disclaimer - Every case is different and requires personal skill and judgement. The current review does not try to replace the better judgement of the treating Surgeon