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Neglected clubfoot: Patho-anatomy and clinical features

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 2-5|Mandar Agashe Authors : Mandar Agashe [1*] Director, Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Maharashtra, India Address of Correspondence Dr Mandar Agashe Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Mumbai, India. Email: mandarortho@gmail.com Abstract Neglected clubfoot […]

Pink Pulseless hand – Evaluation and Decision making: Is there a Consensus?

Vol 1 | Issue 1 | July-Sep 2015 | page:19-22 | Venkatadass K. Authors : Venkatadass K[1]. [1] Consultant Paediatric Orthopaedic Surgeon, Ganga Medical Centre & Hospitals, Coimbatore, India. Address of Correspondence Dr. K. Venkatadass Ganga Medical Centre & Hospitals, Coimbatore, India. Email- venkatpedortho@gmail.com Abstract Background: The standard of care for the initial treatment of pulseless supracondylar fracture […]

Neglected clubfoot: Patho-anatomy and clinical features

Pink Pulseless hand – Evaluation and Decision making: Is there a Consensus?

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Neglected clubfoot: Patho-anatomy and clinical features

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 2-5|Mandar Agashe

Authors : Mandar Agashe [1*]

Director, Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Maharashtra, India

Address of Correspondence
Dr Mandar Agashe
Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Mumbai, India.
Email: mandarortho@gmail.com

Abstract

Neglected clubfoot still remains a great problem in developing countries like India especially in the rural population with limited access to modern healthcare. It is the most common congenital problem leading to locomotor disability, so much so that the government of India has, in recent years added congenital clubfoot in one the eight notifiable conditions at birth with the hope of eliminating the scrouge of neglected clubfoot. With the popularity of the Ponseti method, more and more cases of congenital clubfoot are being treated at the time when they should be ideally treated- ie neonatal period and early infancy. However there are still some lacunae in the healthcare delivery system in India, leading to persistence of these neglected cases in rural population. The obstacles of poverty, lack of awareness and lack of medical facilities in accessible locations means that treatment is either not initiated or incompletely performed.
Since the deformity in neglected cases is a complex three-dimensional one, it is essential to understand the pathoanatomy of the same before embarking on the treatment. In this article, we deal with the detailed pathoanatomy as well as the clinical features related to neglected clubfeet.
Keywords: Congenital talipes equino varus, clubfeet, neglected

Introduction:
Neglected clubfoot still remains a great problem in developing countries like India especially in the rural population with limited access to modern healthcare[1,2]. It is the most common congenital problem leading to locomotor disability, so much so that the government of India has, in recent years added congenital clubfoot in one the eight notifiable conditions at birth with the hope of eliminating the scrouge of neglected clubfoot. With the popularity of the Ponseti method, more and more cases of congenital clubfoot are being treated at the time when they should be ideally treated- ie neonatal period and early infancy[1]. However there are still some lacunae in the healthcare delivery system in India, leading to persistence of these neglected cases in rural population. The obstacles of poverty, lack of awareness and lack of medical facilities in accessible locations means that treatment is either not initiated or incompletely performed[3,4].
Since the deformity in neglected cases is a complex three-dimensional one, it is essential to understand the pathoanatomy of the same before embarking on the treatment. In this article, we deal with the detailed pathoanatomy as well as the clinical features related to neglected clubfeet.

Pathoanatomy
The pathological anatomy of the neglected clubfoot can be divided into that related to bone and joints and that related to soft tissues (ligaments, muscles and tendons).

Bones and joints[5,6] [Figures 1,2,3]
The talus is the bone which is most affected in neglected clubfoot [blue arrow]. The talus is severely plantarflexed. The body is small and altered in shape. The talus becomes severely inverted in the ankle mortice. The trochlea is shorter than normal. Only the posterior portion of the talus articulates with the tibia in the ankle joint while the anterior portion is just covered with thin and stretched out ankle joint capsule. Normally, the posterior-most portion of the talus is extra-articular. However in neglected clubfeet with severe planter-flexion, the posterior portion of the talus becomes intra-articular and is covered by joint capsule. The neck of the talus develops significant medial angulation and the head becomes wedge shaped. There are two surfaces of the talus- the anterolateral and anteromedial. The anterolateral surface of the talus is left uncovered by the medially displaced navicular and is now covered by just thin joint capsule which is stretched out, and the skin. This is the part which is palpable just underneath the skin. The anteromedial surface now articulates with the navicular which is displaced medially and proximally.
The navicular is also very severely affected in neglected clubfeet [white arrow]. It is flattened or wedge-shaped and medially displaced, adducted and inverted. It articulates with the anteromedial surface of the talus and in some severe cases, even has a pseudo-articulation with the medial malleolus. The enlarged tibialis posterior is attached to a wide area on the navicular along with the medial malleolus.
The calcaneus also undergoes a significant alteration [black arrow]. The body of the calcaneus is severely plantarflexed and medially bowed. It is adducted and the lateral process of the calcaneum is under the talus, rather than being lateral to it. In severe neglected cases, the body of the calcaneus also undergoes severe changes, leading to it being bean-shaped rather than rectangular on the axial plane. The axes of the calcaneum and talus are parallel to each other. The cuboid is also medially displaced at the calcaneo-cuboid joint so that only the medial surface of the anterior process of the calcaneum articulates with the cuboid.
The cuneiforms and metatarsals also undergo secondary changes though to a lesser extent than the talus, calcaneum and navicular. The cuneiforms are medially displaced and have very haphazard articulations with the navicular and the cuboid. The metatarsals are shortened.
The talonavicular joint is entirely medially displaced. This articulation is between the anteromedial surface of the talus and the proximal surface of the navicular. There develop pseudoarticulations between the navicular and the tibia (at the medial malleolus) and also between the navicular and the calcaneum. In some cases, there is a fibrous band which is formed between the navicular and the calcaneum, almost like a fibrous calcaneonavicular bar.
The three talcalcaneal joints (anterior, middle and posterior) are also very abnormal. The anterior facet remains very narrow while the middle facet is variable. The posterior facet is short. The sustentaculum tali is left uncovered to a large extent. In very severe neglected clubfeet, the talo-calcaneal joints are almost in the weight bearing axis due to the severe inversion so that the talus assumes the weightbearing position.
The calcaneocuboid joint orientation is very important for the treatment of neglected clubfeet. The calcaneocuboid joint is very obliquely placed with the cuboid being subluxed anteriorly and medially while the lateral aspect of the calcaneum is left uncovered. The other joints of the foot (ie the intercuneiforms and intermetatarsals) follow the course of the main joints of the midfoot and hindfoot. The point to remember is that the first two metatarsals are severely pronated while the lateral three metatarsals are supinated. The degree of pronation will determine the cavus, which in turn will determine the fate of the foot in terms of whether the child walks on the lateral border or the dorsal surface.

Pathoanatomy of soft tissues (ligaments, muscles and tendons)[5-7]
The soft tissues in clubfeet also undergo a significant amount of secondary changes. They are subclassified as:
1) Changes in muscles:
The triceps surae and the tendoachilles is the most severely affected amongst all muscle tendon units in neglected clubfeet. The severity of neglected clubfoot depends mainly on the amount of shortening of the tendoachilles.Both the triceps surae and the tendoachilles are foreshortened and the tendon is significantly longer than the muscle. The tendoachilles is inserted medially on the calcaneus and is one of the deforming forces to pull the heel in varus.
Amongst the other muscle tendon units affected, the tibialis posterior is very important. The tibialis posterior becomes very broad and hypertrophied and is inserted over a very broad area on the inferomedial surface of the navicular and the medial cuneiform. This is the most important cause of supination of the foot. In some very severe cases, the tibialis posterior also seems to have an additional thick fibrous band which is attached to the cuboid, which pulls the cuboid medially. This itself leads to the significant displacement of the calcaneocuboid joint, which is seen in some cases.
The tibialis anterior undergoes some amount of hypertrophy. This is more apparently seen in incompletely treated clubfeet, in which the tibialis anterior causes a dynamic supination deformity during the swing phase of gait. The other muscles of the flexor compartment of the foot also undergo foreshortening with resultant clawing.
2) Changes in ligaments and other soft tissues:
The plantar fascia is very tight and results in the cavus component of the deformity. The amount of tightness of the plantar fascia and the cavus, decide how the child walks in neglected clubfeet[4-6]. If the cavus is moderately severe, the child walks on the lateral border of the foot. However if the cavus is exceedingly severe, the child starts walking on the dorsal surface of the foot, making normal ambulation exceedingly difficult.
In the ligaments, the deep layer of the deltoid ligament is very thick and forms a part of the pseudoarticulation between the medial malleolus and the medially displaced navicular. The tibianavicular and the calcaneonavicular ligaments are thickened and shortened. The ligaments on the medial, plantar and the posterior aspect of the foot undergo severe thickening with shortening and are the main tethers against effective closed manipulative treatment of neglected feet. Amongst them, the medial talo-calcaneal ligament and the plantar calcaneonavicular ligaments are very important. The eponymous “knot of Henry” becomes a thick fibrous band which extends from the undersurface of the navicular till the plantar surface of the medial cuneiform and the talus in neglected clubfeet.
Thus to conclude, neglected clubfoot is a three dimensional deformity, with severe secondary changes in bones, muscles, tendons and ligaments, all of whom have to be corrected for effective clinical management.

Clinical features
The neglected clubfoot, by definition is a foot which has experienced no or minimal surgical or non-surgical management[6] [figure 4]. In this case, the deformity starts increasing after the child starts weightbearing. This is because the structures which are never meant to bear the weight of the body are now in a weight bearing position, the weightbearing starts happening on the side and dorsum of the foot and secondary contractures start developing on the plantar-medial and posterior side of the foot. There is usually a large bursa or callosity at the lateral aspect of the foot, which on prolonged weight-bearing leads to skin breakdowns, ulcerations and infections. It is often difficult or impossible to wear normal shoes for ambulation.

Patterns of deformity[6]
Just like clubfoot deformity in the neonatal and infantile period, there are different patterns of deformity in a neglected clubfoot. Though all the major components of the deformity, ie cavus, forefoot adductus, heel varus and equinus are present in all patients, the exact combination is the main causative factor for a particular type of deformity. As a result, there are various feet with different grades of stiffness, mobility and deformity. This led a few investigators to subclassifiy the deformities in neglected clubfeet into three patterns of deformity since the treatment modality followed and prognosis depends on each of these patterns.
1) Moderately flexible: The foot can be considerably corrected to neutral position
2) Moderately stiff: There is some correctability but not to neutral position and with moderate deformity persisting
3) Rigid: There is almost no correction of deformity.
The classification can be applied either to the entire foot, or separately to the midfoot and hindfoot. Of course, the standard classifications of Pirani[8] and Dimeglio[9] can still be used additionally.
As explained previously, the degree of cavus determines whether the child walks on the lateral border of the foot or the dorsum of the foot. In lesser degree of cavus, the child walks on the lateral border while in greater degree of cavus the child walks on the dorsal surface itself. In the presence of this severe cavus, it is very difficult to appreciate the amount of equinus actually present. This usually gets unmasked once the cavus and adductus gets corrected.

Socio-economic factors
The kids with neglected clubfeet eventually learn to walk with no or some modified footwear[6]. However, it is a condition which is fraught with numerous struggles. This deformity poses a significant disability in young children, preventing access to education and social activity[10]. Many of them are outcast or even deemed as “cursed” with very little social interaction due to the obvious grotesque deformity[6]. Social stigma of having “reverse feet” is also very great, and many girls find it difficult to get married due to this[4]. They are unable to squat for toileting purposes which is an essential function especially in rural population[3,4]. There is significant pain, difficulty in locomotion over long distance, with frequent skin breakdowns, infections and callosities. The skin breakdowns and infections can sometimes be so severe that it may lead to amputations.

Conclusion
Congenital clubfoot is a complex problem which requires proper understanding of the anatomy as well as realistic goals for treatment before embarking on attempting to treat it.

References

1. Gadhok K, Belthur MV, Aroojis AJ, Cook T, Oprescu F, Ranade AS, Morcuende JA. Qualitative assessment of the challenges to the treatment of idiopathic clubfoot by the Ponseti method in urban India. Iowa Orthop J. 2012;32:135-40.
2. Lohia LK, Meena S, Kanojia RK Comparative study of complete subtalar release and Joshi’s external stabilization system in the management of neglected and resistant idiopathic clubfoot..Foot Ankle Surg. 2015 Mar;21(1):16-21.
3. Shingade V, Shingade R, Ughade S Single-stage correction for clubfoot associated With myelomeningocele in older children: early results Curr. Orthop. Practice 2014;25(1),64-70.
4. Shingade V, Shingade R, Ughade S. Correction of neglected or relapsed clubfoot deformity in an older child with single stage procedure: Early results. Curr. Orthop Practice. 2012; 23(2), 122-129.
5. Ponseti IV. Congenital clubfoot: Fundamentals for treatment. Oxford: Oxford University Press: 1996.
6. Penny JN. The neglected clubfoot. Techniques in Orthopaedics Vol 20. Philadelphia: Lippincott Williams & Wilkins Inc.; 2005: 153–166.
7. Scott WA, Hosking SW, Caterall A. Clubfoot. Observations on the surgical anatomy of dorsiflexion. J Bone Joint Surg (Br) 1984;66: 71-6.
8. Pirani S. A reliable and valid method of assessing the amount of deformity in the congenital clubfoot. Presented at the Pediatric Orthopaedic society of North America, May 2004; St. Louis.
9. Demiglio A, Bensahel H, Souchet P, et al. Classification of clubfoot. J Pediatr Orthop (B) 1996;4:129-136.
10. Owen RM, Penny JN, Mayo A, Morcuende J, Lavy CB. A collaborative public health approach to clubfoot intervention in 10 low-income and middle-income countries: 2-year outcomes and lessons learnt. J Pediatr Orthop B. 2012 Jul;21(4):361-5.
11. Sengupta A. The management of congenital talipes equinovarus in developing countries. Int Orthop 1987;11: 183-187.

How to Cite this Article: Agashe M. Neglected clubfoot: Patho-anatomy and clinical features. International Journal of Paediatric Orthopaedics Jan-Apr 2016;1(2):2-5.

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Pink Pulseless hand – Evaluation and Decision making: Is there a Consensus?

Vol 1 | Issue 1 | July-Sep 2015 | page:19-22 | Venkatadass K.

Authors : Venkatadass K[1].

[1] Consultant Paediatric Orthopaedic Surgeon, Ganga Medical Centre & Hospitals, Coimbatore, India.

Address of Correspondence
Dr. K. Venkatadass
Ganga Medical Centre & Hospitals, Coimbatore, India.
Email- venkatpedortho@gmail.com

Abstract

Background: The standard of care for the initial treatment of pulseless supracondylar fracture of the humerus is emergency closed reduction and percutaneous pin stabilization. Some of these patients remain pulseless even after closed reduction and pin fixation with a well perfused hand. The management of this so-called pink pulseless hand still remains controversial. The options described in the literature are either of the two extremes of just observation or exploration of the vessel and vascular repair if needed. There are no clear guidelines on when to explore a pink pulseless hand. This article reviews the current literature on this gray area with recommendations on the process of evaluation and decision-making in pink pulseless hand.
Keywords: Supracondylar humerus fracture, vascular injury, pink pulseless hand.

Introduction
The incidence of vascular injuries associated with displaced supracondylar fractures of humerus in children is about 10-20% [1,2,3]. It is reported to be more common in extension type fractures due to the close proximity of the proximal fragment to the neurovascular bundle [4,5]. In a child presenting with a pulseless supracondylar humerus fracture an urgent closed reduction with percutaneous pin stabilization is recommended. In majority of these patients the injured limb gets back the pulse and the hand appears well perfused after closed reduction and pin fixation. These patients are then treated as any other patient with supracondylar fracture humerus without any additional special precaution [3]. There is no confusion in the literature regarding the management of those patients in whom the limb remains pulseless, pale and unperfused after a closed reduction and stabilization [3]. Emergency exploration of the artery and arterial repair if needed to get back the circulation of the affected limb is the current recommendation. But there is still no consensus on the management of those limbs, which remain pulseless after closed reduction and pinning, but are pink and well perfused. The main reason for this confusion is lack of details of natural history of this entity [2]. The current literature on this enigmatous situation has been reviewed and a recommendation based on the available literature and our experience for the management of pink pulseless hand in supracondylar fracture humerus is presented.

Mechanism of vascular injury
The mechanism of injury to the neurovascular structures following supracondylar fracture of the humerus has been described in great detail by Meyerding as early as 1936 [6]. He was the first to study the configuration of the fracture in detail and propose that in extension type supracondylar fractures, the injuring force carries the distal fragment posteriorly stripping the posterior periosteum. The sharp anterior fragment pierces the anterior periosteum and brachialis and injures the neurovascular bundle, which lies in close proximity anteriorly. The vascular insult could either be due to compression from the fragment, spasm or thrombosis or rarely complete arterial transection. Most times the absence of pulse might just be due to the compression of grossly displaced fragments. A gentle closed reduction would relieve the compression and artery becomes pulsatile again. Louahem et al. [7 described 26 patients with a pink pulseless hand in a series of 210 patients with severely displaced supracondylar fractures. In 21 cases, the pulses returned immediately after closed reduction of the fracture.

Collateral circulation
The exuberant collateral circulation around the elbow has been credited with maintaining the vascularity of the limb in patients managed without vascular exploration [8]. The radial recurrent artery arises distal to the elbow and anastomoses with the radial collateral branch of the profunda brachii. The superior ulnar collateral artery is the other main descending collateral. It arises from the brachial artery, a little below the middle of the arm and anastomoses with the posterior ulnar recurrent and inferior ulnar collateral arteries [8].

What is pink pulseless hand?
There is variable use of this terminology in the literature. Some authors use this terminology to label those supracondylar fractures presenting without a pulse with a well perfused hand. While there is no controversy regarding the management of these fractures, more than 50% of these pink pulseless limbs would turn pulsatile just after closed reduction. The limb appearing pink and perfused on presentation mainly depends on the time duration since injury, as it needs some time for the collateral circulation to be established. None of the authors had looked into the time since injury and its correlation to perfusion status at presentation. Ideally, a pink pulseless limb is one that remains pink and well perfused without a palpable pulse following closed reduction and pinning of a pulseless supracondylar fracture [2]. These are the ones that pose management controversy as to whether it needs urgent exploration for the vessel or a closed monitoring for the vascular status and just observation. Though there is some evidence in the literature supporting immediate exploration, more recent evidence seems to be in favour of in-patient observation and close monitoring [3].

Role of Doppler
There has been increased interest in the role of colour Doppler in the process of evaluation and decision making for pink pulseless hands. White et al has recommended the use of colour Doppler to assess the severity of arterial injury following closed reduction and pinning to decide on further management. A colour Doppler evaluation of the brachial artery would help to differentiate between spasm, thrombosis and complete transection. It is important to remember the fact that there is no question of brachial artery injury in this scenario and the real issue is about the adequacy of the collateral circulation to maintain the viability and function of hand. Doppler evaluation of the brachial artery might infact increase the number of explorations of the artery. Valentini et al has reported the use of color-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) of the hand as an additional tool for evaluation in all their patients with pink pulseless hands [9]. In their series, all seven patients with pink pulseless hand were found to have brachial artery injury by Doppler and all of them were treated by arterial repair. But, there are no clear guidelines on severity of arterial injuries on colour dopper and their management. Using Doppler to assess the radial artery in a pink pulseless hand helps to assess the adequacy of the collateral circulation. Weller et al [10] in their series of 54 pulseless supracondylar humerus fractures have documented that 26 patients regained the pulse after closed reduction, 20 remained pulseless after closed reduction but radial artery Doppler signals were picking up and 4 others had absent pulse as well as Doppler signals. All four were taken up immediate surgical exploration and found to have arterial injury requiring repair. All 20 patients who had pulse detected by Doppler but had no palpable radial pulse were observed. One of the 20 developed late ischaemia after nine hours and was taken up for surgical exploration. Shah et al have included triphasic radial artery doppler signal in their algorithm for decision making in pink pulseless limbs and recommends immediate surgical exploration for patients who do not have triphasic radial artery doppler signals.

Proponents for Immediate Exploration
White et al [11] after a systematic analysis of pink pulseless supracondylar fractures have concluded that there is significant arterial injury in 70% of patients and thus vascular exploration may limit the chances of late complications in these patients. They have also stated that with reported patency rates of more than 90% it is worthwhile considering exploration and arterial repair in these patients. Korompilias et al. [7] reported on five patients with a pink pulseless hand and recommended vascular exploration for the restoration of brachial artery patency, even in the presence of a viable well-perfused hand after an attempt at closed reduction. Copley et al [13] in their series of 17 patients with pulseless supracondylar fractures had a return of pulse in 14 of them following closed reduction. All the three patients were taken up for exploration and 2 of the fourteen patients who developed loss of pulse over the next 24 hours were also explored. They recommend immediate exploration if pulse is absent after closed reduction as a measure towards prevention of late complications. Blakey et al. found that twenty three of twenty-six patients with a pink, pulseless hand following initial management had some evidence of ischemic contracture, and they advocated for urgent exploration when the pulse does not immediately return after closed reduction [14]. Mangat et al [15] reported on the predictive value of co-existing median or anterior interiosseous nerve injury after studying a series of patients with nerve injury who underwent exploration. A significant relationship was found between preoperative median and anterior interosseous nerve deficits and vascular entrapment and tethering of the nerve at the fracture site. The authors recommended early exploration for patients with a Gartland type-III supracondylar fracture when they have coexisting anterior interosseous or median nerve palsy as the benefits of exploration outweigh the disadvantages. In a recent study by Scannell et al [17], the authors have tried to correlate the presence of median or anterior interosseous nerve with patency of brachial artery at long term follow-up in 20 twenty patients. In their series, median nerve palsy had good prediction of brachial artery occlusion while anterior interosseous nerve palsy did not predict brachial artery occlusion.

Proponents for Observation
Many authors are in favour of observation and close monitoring of the vascular status for pink pulseless hands. In contrast to the general belief that the literature in vascular surgery would be more in favour of arterial exploration, the recent papers in vascular surgery are recommending observation in case of pink pulseless hands [3]. Choi et al [18] presented the largest series of 33 patients with pink pulseless hands and concluded that in patients presenting with well perfused hand, fracture reduction and pinning alone would be sufficient treatment. Scannell et al [17] have reported the long term results of their series of 20 patients of pink pulseless hand that were treated by observation. All 20 had good functional outcome except one who had chondrolysis of the distal humerus. They also recommended long term follow-up of these patients for radiographic evidence of osteonecrosis as three of their 20 patients with pink pulseless hands developed avascular necrosis of the trochlea. Weller et al [10] in their analysis of 20 patients with pink pulseless hands have concluded that lack of palpable radial pulse is not an absolute indication for arterial exploration if Doppler signals and capillary refill is good suggesting a well perfused hand. Matuszewski [19] has published his follow-up results of pulseless supracondylar humerus fractures have concluded that children who, after satisfactory closed reduction, have a well-perfused hand but absent radial pulse do not necessarily require routine exploration of the brachial artery. Sabharwal et al [20], in their follow-up study patients with pulseless supracondylar fracture who were treated with arterial exploration and revascularisation found a high rate of asymptomatic reocclusion and residual stenosis and hence opined that collateral circulation would have been adequate to maintain a viable extremity. Garbuz et al [21] in 1996 presented the outcome of treatment of supracondylar fractures with absent radial pulse from the Hospital for Sick Children, Toronto. In their series of 22 patients, five had pink perfused pulseless hands who were managed by close observation and all had excellent functional outcomes. They concluded that absent pulse is not an absolute indication for exploration, provided the hand remains well perfused and compartment syndrome does not develop.

Is there a Consensus?
Though the literature is filled with publications on pink pulseless hand in supracondylar fractures, there still seems to be no consensus on the management of this condition. The AAOS guidelines [22] for the management of supracondylar fractures of humerus in children published in 2010 stated that ”We cannot recommend for or against open exploration of the antecubital fossa in patients with absent wrist pulses but with a perfused hand after reduction of displaced pediatric supracondylar humerus fractures” as there was no strong evidence supporting either observation or exploration. Five years down the line, the question still remains unanswered as far as evidence goes. But, what has changed over the years is that now we have more objective ways of assessing the perfusion rather than just relying on pink colour of the hand and capillary refill. The use of Doppler ultrasound and pulseoximeter signals to assess the perfusion of limb have come into vogue [23]. The presence of associated median nerve injury is more predictive of a significant arterial injury and hence these patients should be considered for exploration.
Hence in the present scenario, three factors needs to be considered in the decision making process of pink pulseless hand:
1.Presence of radial artery Doppler signals
2.Presence of good pulseoximeter waveforms and oxygen saturation >95%.
3.Intact Median Nerve function.

If all the three criteria are met, the recommendation is to observe the child closely for circulation and symptoms of compartment syndrome. If all three are absent, it is an indication of poor perfusion and it is an indication for arterial exploration. The combination of absence of radial artery Doppler signals and absence of pulse oximeter signals again indicates poor perfusion and favors exploration. There is no evidence to comment on other scenarios of either isolated median nerve palsy or isolated absence of radial artery Doppler signals or pulse oximeter signals and their combinations. There are no studies, which have documented all these factors for all their patients, and we are not sure whether a limb can have absent radial artery Doppler signals with good pulse oximeter waveforms. These would rather be hypothetical situations and if someone comes across such a situation in clinical practice, the best would be to individually assess the case and decide for exploration versus observation. However, considering the complications and the reported incidence of significant arterial injuries up to 70% in patients without a positive radial artery Doppler signal, it may be a safer option to consider exploration in these patients. The use of Doppler of the brachial artery to know the severity of the arterial injury and taking it as a sole factor for considering exploration is not justifiable, as the limb can still have good collateral circulation. Thus in conclusion both clinical and diagnostic methods have to be taken into account while making a balanced decision in terms on observation or surgical exploration of a pink pulseless hand [3,24].

References

1. Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM. Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996; 10:410–415.
2. Robb JE. The pink, pulseless hand after supracondylar fracture of the humerus in children. J Bone Joint Surg Br. 2009 Nov;91(11):1410-2.
3. Badkoobehi H, Choi PD, Bae DS, Skaggs DL. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Joint Surg Am. 2015 Jun 3;97(11):937-43.
4. Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE (2009) Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop 33(1):237–241.
5. Matuszewski Ł. Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children. Eur J Orthop Surg Traumatol. 2014 Dec;24(8):1401-6.
6. MEYERDING HW. Volkmann’s ischemic contracture associated with supracondylar fracture of humerus. Journal of the American Medical Association, 1936:106:1139-1144.
7. Louahem DM, Nebunescu A, Canavese F, Dimeglio A. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive
strategy? J Pediatr Orthop B 2006; 15(1):51–57
8. Ramesh P, Avadhani A, Shetty AP, Dheenadhayalan J, Rajasekaran S. Management of acute ‘pink pulseless’ hand in pediatric supracondylar fractures of the humerus. J Pediatr Orthop B. 2011 May;20(3):124-8.
9. Benedetti Valentini M, Farsetti P, Martinelli O, Laurito A, Ippolito E. The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children. Bone Joint J. 2013 May;95-B(5):694-8.
10. Weller A, Garg S, Larson AN, Fletcher ND, Schiller JR, Kwon M, Copley LA, Browne R, Ho CA. Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary? J Bone Joint Surg Am. 2013 Nov 6;95(21):1906-12.
11. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010 Jun;30(4):328-35.
12. Korompilias AV, Lykissas MG, Mitsionis GI, Kontogeorgakos VA, Manoudis G, Beris AE. Treatment of pink pulseless hand following supracondylar fractures of the humerus in children. Int Orthop. 2009 Feb;33(1):237-41.
13. Copley LA, Dormans JP, Davidson RS. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention. J Pediatr Orthop. 1996 Jan-Feb;16(1):99-103.
14. Blakey CM, Biant LC, Birch R. Ischaemia and the pink, pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg Br. 2009 Nov;91(11):1487-92.
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How to Cite this Article: Venkatadass K. Pink Pulseless hand – evaluation and decision making: Is there a consensus?. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):19-22.

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Neglected clubfoot: Patho-anatomy and clinical features

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Pink Pulseless hand – Evaluation and Decision making: Is there a Consensus?

Authors : Venkatadass K[1].

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