1 Fracturas supracondileas complejas del humeroSimon P Aristizabal L Ortopedia y Traumatología UPB

2 Déficit Neurológico

3 Déficit Neurológico Meta-análisis 5154 fracturasFracturas en extensión 13% (34% Interóseo anterior, luego radial y mediano) Fracturas en flexión 17% (91% cubital). Algunas series de las fx en exension reportan como mas comun la lesion del radial.. Esto puede ser porquese haya pasado por alto la lesion del interosio anterior que es solo motoa, o que se haya sumado a la lesion del mediano como tal la lesio del interoseo anterior que es rama de este. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop 2010;30: Pooled data from 5,148 patients and 5,154 fractures was used in this study. There was a 13% rate of pre-operative neurapraxia for extension-type fractures (most common injured nerve was AIN – 34% of cases) and a 17% rate in flexion-type fractures (most common injured nerve was ulnar nerve – 91% of cases). Medial [distal] entry carried a 4% risk to the ulnar nerve and lateral [distal] entry conveyed a 3% risk of median nerve injury. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop 2010;30:

4 Déficit Neurológico Que hacer con los déficit neurológicos primarios y secundarios? Como abordar la lesión cubital postquirúrgica? Usualmente resuelven espontáneamente Retiro del pin si en los Rx. se ve en la escotadura troclear Recomienda explorar y no solo retirar el pin Lyons JP, Ashley E, Hoffer MM: Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children's elbows. J Pediatr Orthop 1998; 18(1): Royce RO, Dutkowsky JP, Kasser JR, Rand FR: Neurologic complications after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop 1991; 11(2): 4 of 143 supracondylar fractures treated with K-wire fixation had neurologic complications after treatment. There were two late ulnar neurapraxias, and two direct nerve injuries during K-wire insertion, one to the ulnar and one to the radial nerve. All patients ecovered. The importance of a thorough initial neurological and vascular examination, as well as subsequent examinations immediately after treatment and during recovery is emphasized. Quoted a 2-3% incidence of iatrogenic nerve injury in displaced supracondylar umerus fractures. Lyons JP, Ashley E, Hoffer MM: Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children's elbows. J Pediatr Orthop 1998; 18(1): Of 375 supracondylar humerus fractures treated over 4 year period by closed or open reduction and percutaneous pinning, 19 patients with normal preoperative neurologic examinations developed postoperative ulnar nerve palsies. 17 patients were followed and all had complete return of function, although complete return of function took up to 4 months. Only 4 patients had medial pins removed prior to fracture union, and 2 others had exploration of the ulnar nerve demonstrating no interruption. The authors state that postoperative ulnar nerve palsies usually resolve spontaneously, and they believe that in most cases of postoperative ulnar nerve palsy observation is ppropriate. If the medial pin appears radiographically to be positioned in the ulnar notch, it may be appropriate to remove it and replace it more anteriorly if the pin is needed for stabilization of the fracture. Rasool MN: Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop 1998; 18(5): 6 cases of postoperative ulnar nerve palsy after cross pin fixation are described. Pain on extension of the small and fingers, and early clawing were important postoperative signs of ulnar nerve injury. Exploration revealed pin placement in the cubital tunnel in 5/6, in 2 the nerve was directly penetrated, and in 3 the cubital retinaculm was tethered and stretched tightly over the nerve. In the 6th case the nerve was anteriorly subluxated and fixed anterior to the medial epicondyle by the pin. After exploration and nerve decompression, 3 fully recovered, 2 partially recovered and one patient had no recovery. The author recommends exploration rather than simple pin removal. Rasool MN: Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop 1998; 18(5):

5 Déficit Neurológico Pronostico y cuanto esperar la recuperaciónExploración y neurolisis a los 5 meses Culp RW, Osterman L, Davidson RS, et al: Neural injuries associated with supracondylar fractures of the humerus in children. J Bone Joint Surg 1990; 72A: Culp RW, Osterman L, Davidson RS, et al: Neural injuries associated with supracondylar fractures of the humerus in children. J Bone Joint Surg 1990; 72A: 18 neural injuries in 13 children with supracondylar fractures; exploration and neurolysis are indicated if no evidence of neural function is present 5 months after injury.

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7 Déficit Vascular Indicación para arteriografíaGriffin KJ, Markar WS, Tang TY, Boyle JR, Hayes PD. The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. Eur J Vasc Endovasc Surg 2008;36: Explorar si persisten los signos de isquemia. La arteriografía fue poco útil. 7 pacientes, 3 con sección de la braquial, 4 con la braquial atrapada en el foco. Explorar si el pulso no regresa después de la reducción, la arteriografía no aporto nada al enfoque ni a la toma de decisión. Schoenecker PL, Delgado E, Rotman M, Sicard GA, Capelli AM: Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996; 10(6): Griffin KJ, Markar WS, Tang TY, Boyle JR, Hayes PD. The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children. Eur J Vasc Endovasc Surg 2008;36: Traditional review paper of the pulseless yet perfused hand. The authors conclude that angiography is of little use and that color flow duplex imaging deserves further study. The authors recommend exploration if signs of ischemia are present. Schoenecker PL, Delgado E, Rotman M, Sicard GA, Caplli AM: Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996; 10(6): Over a 12 year period, seven children had a pulseless arm and a seemingly viable hand after reduction and pinning of a type III supracondylar humerus fracture. 6 of 7 had no pulse prior to reduction. 4 had closed reduction while 3 had an open reduction. 6 patients underwent immediate exploration of the antecubital fossa, while one had arteriography followed by exploration (In discussion authors note arteriography is not helpful in these cases).The brachial artery was directly damaged or transected and underwent saphenous vein graft repair in 3 cases, and was entrapped in the fracture and dissected free in 4 cases. Distal pulses were reestablished in each case, and long term outcome was good. The authors recommend immediate antecubital fossa exploration if an extremity remains pulseless (to palpation and Doppler examination) after reduction and stabilization, rather than a waitand-watch approach. Shaw BA, Kasser JR, Emans JB, et al: Management of vascular injuries in displaced supracondylar humerus fractures without arteriography. J Orthop Trauma 1990; 4:25-29. 17 of 143 (11.9%) type III fractures had signs of vascular impairment, and reduction and Kwire fixation resulted in return of satisfactory blood supply in 14 of 17. The other three were treated with exploration of the brachial artery. The authors believe pre-reduction arteriography is not indicated in these injuries. Shaw BA, Kasser JR, Emans JB, et al: Management of vascular injuries in displaced supracondylar humerus fractures without arteriography. J Orthop Trauma 1990; 4:25-29. 17 pacientes, en 14 mejoraron luego de la reduccion, 3 no mejoraron y fueron explorados. No hubo indicación para arteriografía previa a reduccion.

8 Déficit Vascular Indicación para arteriografíaWhite LA, Mehlman CT, Crawford AH. Pulseless and Puzzling, Vascular Injuries in Supracondylar Humeral Fractures in Children: A Meta-Analysis of Observational Studies and Results of a POSNA Membership Survey. J Pediatr Orthop 2010;30: La arteriografia solo confirma un diagnostico que ya se sabe Retrasa el inicio del tratamiento efectivo White LA, Mehlman CT, Crawford AH. Pulseless and Puzzling, Vascular Injuries in Supracondylar Humeral Fractures in Children: A Meta-Analysis of Observational Studies and Results of a POSNA Membership Survey. J Pediatr Orthop 2010;30: This study pooled data from 313 pulseless supracondylar humeral fracture pts and polled the POSNA membership. There was a 40% response rate for the POSNA poll. Injury rates and brachial artery repair rates are noted below in the TABLE. This meta-analysis suggests that the common opinion of watchful waiting for pulseless and perfused (aka pink) supracondylars should be questioned. El calibre del vaso presenta riesgo de lesión iatrogénica

9 Déficit Vascular Indicaciones de exploración vascular19 pts con fracturas grado III y sin pulso Grupo 1: 11 pts fijación + observación Grupo 2: 8 pts fijación + exploración 4 del grupo 1 y 6 del grupo 2 tenían daño arterial. De estos 10 , 8 tenían lesión neurológica asociada Mangat KS, Martin AG, Bache CE. The pulseless pink hand after supracondylar fracture of the humerus in children: the predictive value of nerve palsy. J Bone Joint Surg-Br 2009;91-B: Mangat KS, Martin AG, Bache CE. The pulseless pink hand after supracondylar fracture of the humerus in children: the predictive value of nerve palsy. J Bone Joint Surg-Br 2009;91-B: These authors compared two management strategies for perfused but pulseless supracondylars: pinning and watchful waiting (11 pts) versus pinning and early exploration (8 pts). 4/11 pts in the watchful waiting group (who were later explored) and 6/8 pts in the early explore group tethering or entrapment of nerve and / or artery were found. Of these 10 pts, 8 out of 10 had concomitant nerve palsies (AIN or median nerve proper). The authors recommend exploration of pulseless and pink Gartland III fxs with coexisting median or AIN palsies

10 Déficit Vascular Indicaciones de exploración vascularMangat KS, Martin AG, Bache CE. The pulseless pink hand after supracondylar fracture of the humerus in children: the predictive value of nerve palsy. J Bone Joint Surg-Br 2009;91-B: Mangat KS, Martin AG, Bache CE. The pulseless pink hand after supracondylar fracture of the humerus in children: the predictive value of nerve palsy. J Bone Joint Surg-Br 2009;91-B: These authors compared two management strategies for perfused but pulseless supracondylars: pinning and watchful waiting (11 pts) versus pinning and early exploration (8 pts). 4/11 pts in the watchful waiting group (who were later explored) and 6/8 pts in the early explore group tethering or entrapment of nerve and / or artery were found. Of these 10 pts, 8 out of 10 had concomitant nerve palsies (AIN or median nerve proper). The authors recommend exploration of pulseless and pink Gartland III fxs with coexisting median or AIN palsies

11 Déficit Vascular La mano rosada sin pulso…26 niños remitidos a este centro por mano rosada sin pulso con seguimiento 15.5 años Tiempo de evolución al llegar, 3 meses 4 habían sido explorados en el memento del trauma 23 de los 26 tenían algún grado de contractura isquémica de los músculos de la mano y el antebrazo. Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: A highly selective series of 26 children with “pink pulseless hands” were reviewed and followed for an avg of 25 yrs (range 4 to 26 yrs). 4/26 children underwent immediate surgical exploration and treatment and 3 of 4 had satisfactory outcomes. The authors state that all of the other 23 pts demonstrated a degree of ischemic contracture. These authors conclude that “the pink pulseless” limb is ischemic. Persistent and increasing pain with a deepening nerve lesion indicate that there is critical ischemia and we recommend urgent surgical exploration of the vessel and nerve in this situation.” No ha duda que la mano palida sin pulso es una urgencias, sin embargo, la mano rosada sin pulso sigue siendo una controversia

12 Déficit Vascular La mano rosada sin pulso…Al llegar a este centro 15 tenían pulso ausente o apenas perceptible Solo 3 tenían pulso normal y eran de los que se habían explorado Se llevaron 21 a exploración 12 tenían la arteria atrapada en la cicatriz del tejido blando 9 tenían la arteria metida en el foco Todos recuperaran el pulso Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: A highly selective series of 26 children with “pink pulseless hands” were reviewed and followed for an avg of 25 yrs (range 4 to 26 yrs). 4/26 children underwent immediate surgical exploration and treatment and 3 of 4 had satisfactory outcomes. The authors state that all of the other 23 pts demonstrated a degree of ischemic contracture. These authors conclude that “the pink pulseless” limb is ischemic. Persistent and increasing pain with a deepening nerve lesion indicate that there is critical ischemia and we recommend urgent surgical exploration of the vessel and nerve in this situation.” No ha duda que la mano palida sin pulso es una urgencias, sin embargo, la mano rosada sin pulso sigue siendo una controversia

13 Déficit Vascular La mano rosada sin pulso…Todos tenían evidencia de fibrosis muscular Peor daño en el compartimiento flexor 9 manos tuvieron lesión de intrínsecos En 4 las contracturas no respondieron a férulas 22 niños necesitaron procedimiento paliativos Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: A highly selective series of 26 children with “pink pulseless hands” were reviewed and followed for an avg of 25 yrs (range 4 to 26 yrs). 4/26 children underwent immediate surgical exploration and treatment and 3 of 4 had satisfactory outcomes. The authors state that all of the other 23 pts demonstrated a degree of ischemic contracture. These authors conclude that “the pink pulseless” limb is ischemic. Persistent and increasing pain with a deepening nerve lesion indicate that there is critical ischemia and we recommend urgent surgical exploration of the vessel and nerve in this situation.” No ha duda que la mano palida sin pulso es una urgencias, sin embargo, la mano rosada sin pulso sigue siendo una controversia

14 LA MANO ROSADA SIN PULSO ES UNA MANO ISQUEMICADéficit Vascular La mano rosada sin pulso… 56 lesiones neurológicas 41 atrapados por la fibrosis isquémica de los músculos. 13 nervios atrapados en la fractura 2 seccionados por los pines de fijación Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: Blakey CM, Biant LC, Birch R. ischemia and the pink pulseless hand complicating supracondylar fractures of the humerus in childhood: long-term follow-up. J Bone Joint Surg-Br 2009;91-B: A highly selective series of 26 children with “pink pulseless hands” were reviewed and followed for an avg of 25 yrs (range 4 to 26 yrs). 4/26 children underwent immediate surgical exploration and treatment and 3 of 4 had satisfactory outcomes. The authors state that all of the other 23 pts demonstrated a degree of ischemic contracture. These authors conclude that “the pink pulseless” limb is ischemic. Persistent and increasing pain with a deepening nerve lesion indicate that there is critical ischemia and we recommend urgent surgical exploration of the vessel and nerve in this situation.” No ha duda que la mano palida sin pulso es una urgencias, sin embargo, la mano rosada sin pulso sigue siendo una controversia La foto es uno de lo casos ilustrativos que muestra alteraco en le, crecimiento. LA MANO ROSADA SIN PULSO ES UNA MANO ISQUEMICA

15 Déficit Vascular La mano rosada sin pulso…22 paciente sin pulso se llevaron a reducción cerrada 7 no recobraron (pálidos sin pulso) y se exploraron 15 recobraron la perfusión (10 con pulso y 5 sin pulso) Los 5 que no recobraron no tuvieron secuelas Garbuz DS, Leitch K, Wright JG: The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop 1996; 16: 22 of 326 patients with supracondylar humerus fractures presented without a radial pulse. 15 of 22 had a well perfused hand after closed reduction. 5 had a well perfused hand but no pulse, and none had any problem at final review. Seven patients had a cold white hand after closed reduction and pinning, and received open reduction and arterial exploration. The authors concluded that an absent radial pulse after closed reduction does not require routine exploration if the hand is well-perfused.

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17 Patrones Difíciles Flexión (2 – 11%)Mas probabilidad de reducción abierta De Boeck H. Flexion-type supracondylar elbow fractures in children. J Pediat Orthop2001;21: The author reports successful closed treatment of type III flexion-type injuries, although other authors have noted a higher likelihood these injuries will need open reduction. De Boeck H. Flexion-type supracondylar elbow fractures in children. J Pediat Orthop 2001;21:

18 Patrones Difíciles Oblicuidad coronal Oblicua medial Transversa puraOblicua lateral Alta La tvsa tiene mesno de 10o y las oblicuas mas de 10. La alta es por encima de la fosa olecraniana. Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent C, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop 2008;28: Retrospective study of 203 consecutive pts focusing on fracture patterns. The authors consider there to be 4 coronal and 2 sagittal patterns. Coronal obliquity of > 10 degrees and sagittal obliquity of > 20 degrees were associated with higher rates of malunion. This paper’s main point can be summarized as “all pediatric supracondylar humeral fracture patterns are not created equal”. Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent C, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop 2008;28:

19 Mas riesgo de mala uniónPatrones Difíciles Oblicuidad sagital Baja Mas riesgo de mala unión Alta La alta tiee mas de 20o en la lateral y la baja menos e 20 Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent C, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop 2008;28: Retrospective study of 203 consecutive pts focusing on fracture patterns. The authors consider there to be 4 coronal and 2 sagittal patterns. Coronal obliquity of > 10 degrees and sagittal obliquity of > 20 degrees were associated with higher rates of malunion. This paper’s main point can be summarized as “all pediatric supracondylar humeral fracture patterns are not created equal”. Bahk MS, Srikumaran U, Ain MC, Erkula G, Leet AI, Sargent C, Sponseller PD. Patterns of pediatric supracondylar humerus fractures. J Pediatr Orthop 2008;28:

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21 Indicación de Cirugía Fracturas tipo IIBaumman Grado de flexion del yeso Dametro el brazo y el antebrazo en Rx Grosor del acolchado del yeso Indice de la linea humeral 0, 1, 2 Fracturas tipo II 61 pacientes manejo no quirúrgico. Seguimiento promedio 41 días Los que no fallaron se tomaron como Grupo A (Controles) Los que fallaron se tomaron como Grupo B Fitzgibbons PG, Bruce B, Got C, et al. Predictors of failure of nonoperative treatment for type 2 supracondylar humerus fractures. J Pediatr Orthop 2011;31: Fitzgibbons PG, Bruce B, Got C, et al. Predictors of failure of nonoperative treatment for type 2 supracondylar humerus fractures. J Pediatr Orthop 2011;31: Providence, Rhode Island authors who looked at 61 Type II fxs that demonstrated an 80% success rate of non-operative treatment. They found that the degree of fx extension predicted failure of cast treatment. They suggested immediate pinning of those Type II where the capitellum extends beyond the anterior humeral line.

22 Indicación de Cirugía Fracturas tipo IILas tipo 2 pueden tratarse ortopédico excepto aquellos pacientes con índice de línea humeral 0 y los muy edematizados Fitzgibbons PG, Bruce B, Got C, et al. Predictors of failure of nonoperative treatment for type 2 supracondylar humerus fractures. J Pediatr Orthop 2011;31: Fitzgibbons PG, Bruce B, Got C, et al. Predictors of failure of nonoperative treatment for type 2 supracondylar humerus fractures. J Pediatr Orthop 2011;31: Providence, Rhode Island authors who looked at 61 Type II fxs that demonstrated an 80% success rate of non-operative treatment. They found that the degree of fx extension predicted failure of cast treatment. They suggested immediate pinning of those Type II where the capitellum extends beyond the anterior humeral line.

23 Indicación de Cirugía Simanovsky N, Lamdan R, Mosheiff R, Simanovsky N. Underreduced supracondylar fracture of the humerus in children: clinical significance at skeletal maturity. J Pediatr Orthop 2007;27: La función dependerá de a calidad de la reducción Poca remodelación del humero distal en > 6 años 80% del crecimiento es la fisis proximal en > 6 años Se debe lograr reducción anatómica en ambos planos Simanovsky N, Lamdan R, Mosheiff R, Simanovsky N. Underreduced supracondylar fracture of the humerus in children: clinical significance at skeletal maturity. J Pediatr Orthop 2007;27: This paper addresses issues related to sagittal and coronal alignment of supracondylar humeral fxs. These Israeli authors reviewed 223 supracondylar pts between 1996 and 2000 and found 30 that were underreduced. 73% (22/30) were followed until skeletal maturity or close to skeletal maturity. At final follow-up 77% were more than 5 degrees off on their Baumann’s angle (as compared to the opposite side), and 50% had limited elbow flexion. The abnormalities were such that only 31% of pts were aware of any difference in their elbows. The authors recommend achieving maximal anatomical position in the coronal and sagittal planes

24 Indicación de Cirugía Fracturas tipo II en flexiónReducen en extensión La inmovilización en un yeso en extensión es intolerable De Boeck H. Flexion-type supracondylar elbow fractures in children. J Pediat Orthop2001;21: Las tipo 2 en flexio son mejor manejadas con pines

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26 Momento del tratamientoEmergente, urgente o electivo? Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg-Br2006; 126 pts > 8h < 8h Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for ffffffffffffffffffffffffffffffffffffffff open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg-Br 2006; 126 pts treated early (< 8 hrs) were compared to 45 who had delayed treatment (> 8 hrs). No significant differences in complication rates were identified. A very high rate of open reduction was noted in both groups – an 11% rate in the early group and a 33% rate in the delayed group. These authors recommended treating such supracondylars at the earliest opportunity.

27 Momento del tratamientoEmergente, urgente o electivo? 158 fracturas tipo 3 21 fracturas antes de 8 horas Promedio para todos 21 horas No hubo correlación en malos resultados, complicaciones y tiempo operatorio con el tiempo de evolución antes de cirugía. Si no hay lesión vascular o nerviosa no es emergente Leet A, Frisancho J, Ebramzadeh E. Delayed treatment of type 3 supracondylar humerus fractures in children. J Pediatr Orthop 2002;22: Estudio con evidencia debil pero no se uede rendomizar por cuetiones eticas. Leet A, Frisancho J, Ebramzadeh E. Delayed treatment of type 3 supracondylar humerus fractures in children. J Pediatr Orthop 2002;22: Retrospective review of 158 type III fractures did not find any correlation between length of time between injury and surgical treatment with regard to increased operative time, need for open reduction, length of hospital stay or unsatisfactory result. 5 children had a nerve injury identified on initial examination, and no arm was poorly perfused. The average time from injury to surgery was 21.3 hours. 30 patients had poor results (>15 degrees loss of motion -17, pin tract infection-1, pin migration requiring general anesthetic for removal -1, malunion – 2 cubitus varus, postoperative neurapraxias -8 ulnar and 1 median). All nerve injuries resolved by 6 month follow-up. Delayed treatment is equivalent to emergent treatment in closed type III fractures with no associated neural or vascular injuries.

28 Momento del tratamientoEmergente, urgente o electivo? 43 Pts tratados en las primeras 12 horas 34 Pts tratados después de 12 horas Sibinski M, Sharma H, Bennet GC. Early versus delayed treatment of extension type-3 supracondylar fractures of the humerus in children. J Bone Joint Surg-Br 2006;88: Fracturas desplazadas no complicadas no tienen que ser tratadas en la noche. No definen claramente que es una Fx no complcada, pero reportan que los uni=cos dosptes que tu=vieron que atender de manera emergente fueron uno con riesgo de abrirse la piel y uno sin pulso al ingreso. Tuvieron pts con lesion neurologica asociada que no consideraron como fxs complicadas, Sibinski M, Sharma H, Bennet GC. Early versus delayed treatment of extension type-3 fffffffffffffffffffffffffffffffffffff supracondylar fractures of the humerus in children. J Bone Joint Surg-Br 2006;88:380- 381. 43 children whose type III fractures were treated within 12 hrs of injury were compared to 34 children treated greater than 12 hrs following injury. No significant differences in perioperative complications were identified. The authors concluded that uncomplicated supracondylar fxs could be treated early or delayed.

29 Métodos de reducción Tracción, alineación varo valgo, rotación, empujar olécranon, flexión, pronación del antebrazo

30 Métodos de reducción Fracturas en flexiónTracción con el codo extendido Alineación coronal con el intensificador Presión directa del fragmento desde anterior Corrección de la rotación De Boeck H. Flexion-type supracondylar elbow fractures in children. J Pediat Orthop2001;21: Aqui sale la manobra de reduccion de las de flexion

31 Métodos de reducción Para facilitar reducción…Utilizar un pin dorsal en el fragmento distal a manera de joystick. Archibeck MJ, Scott, SS, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: A technique of closed reduction and report of initial results. J Pediatr Orthop 1997;17: Retrospective review where 20 of 92 type III fractures were initially irreducible, and in 18 of these brachialis muscle interposition was diagnosed by physical examination (cubital fossa ecchymosis, dimpling of skin anteriorly over fracture site, palpable proximal fragment in subcutaneous tissues anteriorly) or intraoperative findings. Of these 16 underwent manipulation by a “MILKING MANEUVER” to free the impaled proximal fragment, and the maneuver was successful in 15, allowing closed reduction and pinning. Sawaizumi T, Takayama A, Ito H . Surgical technique for supracondylar fracture of the humerus with percutaneous leverage pinning. J Should Elbow Surg : 12:603-6.

32 Métodos de reducción Havlas V, Trc T, Gaheer R, Schejbalova A. Manipulation of pediatric supracondylar fractures of humerus in prone position under general anesthesia. J Pediatr Orthop2008;28:

33 Foto de si la reduccion es adecuada

34 Parámetros de reducciónPor debajo e los 4 años tiende a pasar mas anterior pero siempre tocando el capitelum Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint Surg 2009;91-A: Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint Surg 2009;91-A: Three observers measured 30 x-rays on two occasions for this study. The anterior humeral line passed thru anterior or middle third of the capitellum in 83% of pts. In children younger than 4 years of age the line tends to be “more anterior” and in older children the line tends to pass thru the central third of the capitellar center. Below is the authors’ measurement technique followed by x-rays of normal 3 ½, 4 ½, and 5-year-old kids. 3 años 4 años 5 años

35 Parámetros de reducción95% de los codos tienen un ángulo entre 64º y 81º Williamson DM, Coates CJ, Miller RK, et al: Normal characteristics of the Baumann (humerocapitellar) angle: An aid in assessment of supracondylar fractures. J Pediatr Orthop 1992; 12: Williamson DM, Coates CJ, Miller RK, et al: Normal characteristics of the Baumann (humerocapitellar) angle: An aid in assessment of supracondylar fractures. J Pediatr Orthop 1992; 12: The Baumann angle was evaluated in 114 normal children. The mean Baumann angle was 72° (standard deviation = 4°), and 95% of normal elbows had Baumann angles between 64° and 81°.

36 Parámetros de reducciónWilliamson DM, Coates CJ, Miller RK, et al: Normal characteristics of the Baumann (humerocapitellar) angle: An aid in assessment of supracondylar fractures. J Pediatr Orthop 1992; 12: The Baumann angle was evaluated in 114 normal children. The mean Baumann angle was 72° (standard deviation = 4°), and 95% of normal elbows had Baumann angles between 64° and 81°.

37 Parámetros de reducciónEl cubito varo es siempre consecuencia de no poder mantener una buena reducción? 63 pacientes con cubito varo Sin evidencia de inhibición de crecimiento Varo por reducción inadecuada por inclinación medial LaBelle H. Bunnel WP, Duhaime M, et al: Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop 1982; 2: LaBelle H. Bunnel WP, Duhaime M, et al: Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop 1982; 2: A review of 63 patients with cubitus varus deformities, in whom no growth inhibition was apparent. The primary cause of deformity was inadequate reduction with medial tilt. All patients had normal function, and osteotomy was performed to correct cosmetic defects. Results were unsatisfactory in 33%.

38 Parámetros de reducciónEl cubito varo es siempre consecuencia de no poder mantener una buena reducción? No quiere decir que no existan las barras fisiarias Niña con fractura a los 4 años Baumann postquirúrgico normal Cubito varo a los 3 años con Baumann de 96º Barra fisiaria del 35% en la tróclea Theruvil B, Kapoor V, Fairhurst J, Taylor GR. Progressive cubitus varus due to bony physeal bar in a 4-year-old girl following a supracondylar fracture: a case report. J Orthop Trauma 2005;19: Theruvil B, Kapoor V, Fairhurst J, Taylor GR. Progressive cubitus varus due to bony physeal bar in a 4-year-old girl following a supracondylar fracture: a case report. J Orthop Trauma 2005;19: This is a very well documented case of growth arrest / physeal bar formation following a Gartland II fracture sustained by a 4-year-old girl who fell 7 feet from the monkey bars. She was treated non-operatively (3 weeks in a cast). She initially had Baumann angles of 85 degrees on the injured side and 82 degrees on the un-injured side. By 3 yrs post-injury she had a 96 degree Baumann angle on the injury side. MRI demonstrated that she had a 35% physeal bar predominantly on the trochlear side.

39 Parámetros de reducciónCubito varo… Cosmético? Sobrecarga mecánica al LUCL Baumann entre 95º y 100º Inestabilidad posterolateral del codo Beuerlein MJ, Reid JT, Schemitsch EH, McKee MD. Effect of distal humeral varus deformity on strain in the lateral ulnar collateral ligament and ulnohumeral joint stability. J Bone Joint Surg-Am 2004;86-A: Beuerlein MJ, Reid JT, Schemitsch EH, McKee MD. Effect of distal humeral varus deformity on strain in the lateral ulnar collateral ligament and ulnohumeral joint stability. J Bone Joint Surg-Am 2004;86-A: Cubitus varus is NOT just cosmetic. Eleven cadaveric elbows were instrumented and studied and demonstrated that cubitus varus increases strain in the LUCL with corresponding increased ulnohumeral joint instability. Estimated varus deformities leading to these findings were Baumann angles in the 95 degree to 100 degree range. O’Driscoll SW, Spinner RJ, McKee MD, Kibler WB, et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg-Am 2001;83-A: Cubitus varus is NOT just cosmetic. 24 pts with cubitus varus (from fx or congenital anomaly) had PL elbow instability. Treatment consisted of lateral collateral ligament reconstruction and corrective osteotomy. O’Driscoll SW, Spinner RJ, McKee MD, Kibler WB, et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg-Am 2001;83-A:

40 Parámetros de reducciónCubito varo… Cosmético? Neuropatía cubital Luxación del tríceps y el cubital sobre el epicóndilo Spinner RJ, O'Driscoll SW, Davids JR, Goldner RD: Cubitus varus associated with dislocation of both the medial portion of the triceps and the ulnar nerve. The Journal of Abe M, Ishizu T, Shirai H, et al. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg-Am 1995;20:5-9. Spinner RJ, O'Driscoll SW, Davids JR, Goldner RD: Cubitus varus associated with dislocation of both the medial portion of the triceps and the ulnar nerve. The Journal of Hand Surgery 1999; 24A (4): Cubitus varus is NOT just cosmetic. The authors report 5 cases of cubitus varus associated with dislocation of the medial portion of the triceps tendon and the ulnar nerve over the medial epicondyle with elbow flexion. Symptomatic snapping of the triceps tendon can occur, as well as development of ulnar neuropathy. Abe M, Ishizu T, Shirai H, et al. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg-Am 1995;20:5-9. 15 pts were identified with this problem. Their average carrying angle was negative 2 degrees (or a Bauman angle of approximately 92 degrees).

41 Parámetros de reducciónCubito varo… Cosmético? 3 pacientes con cubito varo postraumático Resalto de la cabeza medial del tríceps Luxación del nervio cubital Inestabilidad posterior del hombro Gurkan, I, Bayrakci, K, Tasbas, B, Daglar, B, Gunel, U, Ucaner, A.. Posterior instability of the shoulder after supracondylar fractures recovered with cubitus varus deformity. J Pediatr Orthop 2002; 22(2): Gurkan, I, Bayrakci, K, Tasbas, B, Daglar, B, Gunel, U, Ucaner, A.. Posterior instability of the shoulder after supracondylar fractures recovered with cubitus varus deformity. J Pediatr Orthop 2002; 22(2): The authors report three patients with cubitus varus, snapping medial head of the triceps, dislocating ulnar nerve, and posterior shoulder instability believed to be related to excessive internal rotation of the humerus. Corrective osteotomy of the distal humerus resolved these problems. Por el componente angular y rotacional

42 Parámetros de reducciónCubito varo… Cosmético? Cien fracturas de condilo lateral Seis con antecedente de cubito varo traumático Davids JR. Maguire MF. Mubarak SJ. Wenger DR. Lateral condylar fracture of the humerus following posttraumatic cubitus varus.] J Pediatr Orthop 1994;.14: Explican que el cubioto varo expone a una fuerza aumentada cizallante y rotacional que con una caida simple puede aumentar tanto la transmision de carga que de para fraturar un condilo lateral. Davids JR. Maguire MF. Mubarak SJ. Wenger DR. Lateral condylar fracture of the humerus following posttraumatic cubitus varus.] J Pediatr Orthop 1994;.14: Cubitus varus is NOT just cosmetic. Six cases of lateral condylar fracture of the humerus in children with preexisting cubitus varus due to prior elbow fracture are presented. Biomechanical analysis suggests that both the torsional moment and the shear force generated across the capitellar physis by a routine fall are increased by varus malalignment. Posttraumatic cubitus varus may predispose a child to subsequent lateral condylar fracture and should be viewed as more than just a cosmetic deformity.

43 Parámetros de reducciónReducción abierta Las que no reducen cerrado Fracturas abiertas Lesión vascular asociada Lesión neurológica postreducción si no se logro reducir anatómico Reitman RD, Waters P, Millis M: Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001; 21: Reitman RD, Waters P, Millis M: Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001; 21: This retrospective review of 65 patients managed with open reduction and internal fixation described excellent results in 55%, good results in 24%, fair results in 4% and poor results in 12%. Postoperative stiffness was not common, as only six patients had loss of extension of 10 degrees or more. The surgical approach was made through the torn soft tissues without further destabilizing or devascularizing the fracture. Open reduction is indicated for fractures irreducible by closed means, open fractures, fractures associated with vascular compromise, and fractures with a postreduction nerve palsy when anatomic reduction is not obtainable.

44 Parámetros de reducciónAbordaje Según el desplazamiento Posteromedial abordan lateral Posterolateral abordan medial Fracturas en flexión abordan por medial Posterior puro abordan por anterior Lesión vascular siempre por anterior Reitman RD, Waters P, Millis M: Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001; 21: Entrar por el tejido desgarrado para evitar inestabilizar mas la fractura

45

46 Fijación con pines Que tiene que hacer los pines? Soporte varo y valgoSoporte flexión y extensión Soporte rotacional

47 Fijación con pines Que esta en contra de esto?Dirección y posición de los pines Paralelos, divergentes o cruzados Trazos de fractura Altas, oblicuas, conminutas Calidad de la reducción Malrotaciones (interna)

48 Fijación con pines Sabemos que…

49 Fijación con pines Además hay unos principiosHacer presa en ambas columnas proximal al foco de fractura. Tomar hueso suficiente en ambos fragmentos. Maximizar la separación de los clavos en foco de fractura.

50 Fijación con pines Así las cosas…Trazos mas simples y con buena presa en ambas columnas

51 Fijación con pines Así las cosas…Trazos que dificultan tomar bien las columnas

52 Fijación con pines Así las cosas… Trazos en principio inestables

53 Fijación con pines Así las cosas… No se confíe y verifiqueZenios M, Ramachandran M, Milne B, Little D, Smith N. Intraoperative stability testing of lateral-entry pin fixation of pediatric supracondylar humeral fractures. J Pediatr Orthop 2007;27:

54 Fijación con pines El cubital………………….Flexión >90º subluxa el cubital hacia anterior 18% de los menores de 5 años 7% entre los 6 y los 10 años Hiperflexión subluxa el cubital hacia anterior 43% de los menores de 5 años 20% de los 6 en adelante Zaltz I, Waters PM, Kasser JR. Ulnar nerve instability in children. J Pediatr Orthop 1996;16: Zaltz I, Waters PM, Kasser JR. Ulnar nerve instability in children. J Pediatr Orthop 1996;16: Elbow flexion greater than 90 degrees led to subluxation of the ulnar nerve anterior to the medial epicondyle in 18% of children age 5 or less, 8% of children age 6 to 10 years, and in 6% of children age 11 to 18 years. In hyperflexion the ulnar nerve subluxated to a position directly over the epicondyle in 43% of children less than 5 years old, 21% of 6 to 10 year olds and 20% of 11 to 18 year olds. Recommend insertion of lateral pin first and then extend the elbow some prior to insertion of medial pin Primero el lateral y luego extender y poner el medial

55 Mini-open para el pin medialFijación con pines Evitar la lesión Gosens T, Bongers KJ. Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury. 2003:34: Mini-open para el pin medial La bolita roja dice que no es tan cierto. El articulo reporta que con a literatura disponible no es vaible defnir cual tecnica es mas segura y que se necesitaria un estudio prospectivo con al menos 1000 pts para poder definir las diferencias en las ratas de complicacion entre las tecnicas. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after surgical treatment of displaced supracondylar fractures of the humerus: Number needed to harm, a systematic review. J Pediatr Orthop 2010;30: 32 studies contributing 2,639 patients were included in this pooled analysis. As compared to lateral pinning, crossed pinning was associated with a higher rate of ulnar nerve injury. The authors calculated the number needed to harm (NNH) such that for every 28 patients treated with crossed pinning, 1 ulnar nerve injury would occur. Gosens T, Bongers KJ. Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury. 2003:34: Between 1978 and 1997, 200 displaced fractures were treated by operative means. In 190 cases closed reduction and percutaneous pinning was performed. In 10 cases vascular impairment or unsatisfactory reduction necessitated open exploration. Functional and cosmetic success was achieved in 90% of all operated children. In 33 (16.5%) there was neurological impairment. All recovered without sequelae, except for one case. Transient Neurological problems are common in this fracture. A mini-open procedure is recommended for the ulnar Kirschner wire (K-wire) to prevent iatrogenic ulnar nerve injury. Barlas K. Baga T. Medial approach for fixation of displaced supracondylar fractures of the humerus in children. Acta Orthopaedica Belgica. 2005;71: The authors describe excellent results in 49 type III fractures after all were treated with crossed K wire fixation and all had a medial incision to place the medial K wire. There were no iatrogenic ulnar nerve palsies. 23% of fractures needed open reduction of the fracture and this was done through the same medial incision made for medial pin placement.

56 Fijación con pines Evitar la lesión DorganShannon FJ, Mohan P, Chacko J, D’Souza LG. Dorgan’s percutaneous lateral crosswiring of supracondylar fractures of the humerus in children. J Pediatr Orthop2004;24: Mostafavi HR, Spero C: Crossed pin fixation of displaced supracondylar humerus fractures in children. Clin Orthop Rel Res 2000; 376:

57 Inmovilización POP En que posición debe ir el codoNunca > 90º de flexión Aumento notable de la presión intracompartimental del antebrazo Battaglia, T, Armstrong, D, Schwend, R. Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus. J Pediatr Orthop 2002;22: This study evaluated forearm compartment pressures in 29 children with supracondylar humerus fractures. The effect of elbow flexion on post-reduction pressures was also evaluated; flexion beyond 90° produced significant pressure elevation. We conclude that forearm pressures after supracondylar fracture are greatest in the deep volar compartment and closer to the fracture site. To avoid unnecessary elevation of pressures, elbows should not be immobilized in >90° of flexion after these injuries. Mapes R, Hennrikus W. The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children. J Pediatr Orthop 1998;18: After closed reduction and percutaneous K-wire fixation of displaced extension supracondylar fractures, vascular safety is enhanced by extending the elbow and supinating the forearm. The ideal position of elbow immobilization depends on the amount of swelling and the presence of a radial pulse. The pulse disappeared by Doppler at a range of 70 to 130 degrees of elbow flexion. Battaglia, T, Armstrong, D, Schwend, R. Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus. J Pediatr Orthop 2002;22: Mapes R, Hennrikus W. The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children. J Pediatr Orthop 1998;18:

58 Inmovilización POP Inmovilizacion POPCuantas semanas inmovilizado y cuando quitar los pines? 5 a 6 semanas Ponce BA, Hedequist DJ, Zurakowski D, Atkinson CC, Waters PM. Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures. J Pediatr Orthop 2004;24: These researchers compared 52 pts who had early follow-up (less than or equal to10 days) versus 52 pts who had their follow-up at a time between > 10 days after and at the time of pin removal. 6 complications occurred in the early group and these were attributed to pin configuration. 2 complications occurred in the later f/u group. The authors concluded that pinned supracondylars do NOT need to be followed up until the time of pin removal (i.e. 3 to 5 weeks after surgery). Ponce BA, Hedequist DJ, Zurakowski D, Atkinson CC, Waters PM. Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures. J Pediatr Orthop 2004;24:

59 No hay diferencias sostenidas a mediano ni largo plazoFisioterapias No hay diferencias sostenidas a mediano ni largo plazo Wang YL, Chang WN, Hsu CJ, Sun SF, Wang JL, Wong CY. The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J Orthop Trauma 2009;23: These authors analyzed 45 kids with uncomplicated supracondylar fxs and 16 with lateral condyle fxs. Elbow ROM was measured with a goniometer until 90% or greater of the uninjured side was achieved. It took about 5 to 6 weeks for full motion to be achieved following cast removal, and this was WITHOUT any formal physical therapy. Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint SurgAm 2010;92: Prognostic Level I study published in American JBJS that documents what many orthopaedists have seen in their own practices … that most of the elbow motion following this injury returns within the first 4 weeks after cast removal with additional small gains taking almost up to one year. Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop2005;25: Small prospective randomized controlled trial (21 kids in one group, 22 kids in the other group) of therapy versus no therapy for pinned supracondylar fracture patients. As compared to the “no-PT pts” the pts who received physical therapy had 15 degrees more 12 weeks post-injury and 10 degrees more 18 weeks. At one year followup the groups were NOT different. The authors concluded that in uncomplicated supracondylar humeral fractures physical therapy is NOT indicated. Wang YL, Chang WN, Hsu CJ, Sun SF, Wang JL, Wong CY. The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J Orthop Trauma 2009;23: Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint SurgAm 2010;92: Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop2005;25:

60 Conclusiones Este atento a la lesión neurológica, sobre todo si esta acompañada de alteración vascular Evalúe la personalidad de la factura para ofrecerle el mejor método de fijación con la técnica adecuada Sea juicioso con la critica de la reducción No hay un solo patrón de pinado que necesariamente se adapte a todos los trazos Wang YL, Chang WN, Hsu CJ, Sun SF, Wang JL, Wong CY. The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J Orthop Trauma 2009;23: These authors analyzed 45 kids with uncomplicated supracondylar fxs and 16 with lateral condyle fxs. Elbow ROM was measured with a goniometer until 90% or greater of the uninjured side was achieved. It took about 5 to 6 weeks for full motion to be achieved following cast removal, and this was WITHOUT any formal physical therapy. Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint SurgAm 2010;92: Prognostic Level I study published in American JBJS that documents what many orthopaedists have seen in their own practices … that most of the elbow motion following this injury returns within the first 4 weeks after cast removal with additional small gains taking almost up to one year. Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop2005;25: Small prospective randomized controlled trial (21 kids in one group, 22 kids in the other group) of therapy versus no therapy for pinned supracondylar fracture patients. As compared to the “no-PT pts” the pts who received physical therapy had 15 degrees more 12 weeks post-injury and 10 degrees more 18 weeks. At one year followup the groups were NOT different. The authors concluded that in uncomplicated supracondylar humeral fractures physical therapy is NOT indicated.

61 JA!

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63 Déficit Vascular Regreso el pulso luego de la reducción o no?33 pacientes no tenían pulso (2.6%) 24 bien perfundidos 75% recupero el pulso el otro 25% no se documento. Buen resultado en todos, no molestias en ninguno 9 mal perfundidos, solo 2 recuperaron pulso con la reducción, 2 recuperaron perfusión sin pulso y 5 fueron llevados a reparación vascular Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010;30:50-56. Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop 2010;30:50-56. These Southern California researchers determined that 2.6% (33/1,255) supracondylar fx pts present without a pulse. 24 of the pts were considered to be pulseless and well perfused at presentation and 100% (24/24) remained well perfused immediately following reduction and internal fixation while 58% (14/24) were also noted to have a palpable pulse following reduction and internal fixation. At an average of 8 week f/u at least 4 more of these pts had a palpable pulse documented, THUS 75% (18/24) of the perfused and pulseless normalized following reduction and fixation. The other 6 perfused and pulseless pts who never had a documented return of pulse suffered no known ill effects of their injury. Only 2 of 9 of the pulseless and POORLY perfused pts had both return of perfusion and pulse following reduction and fixation. Another 2 of 9 pts had satisfactory perfusion but no immediate palpable pulse after CRPP surgery. The other 5 of 9 pts were all explored / repaired with good results. Perfused and pulseless pts were operated at an avg of 10.7 hrs (range 4 h to 24 h) following injury while the pulseless and poorly perfused pts were operated at an avg of 7.3 hrs (range 3 hrs to 12 hrs) following injury. THIS IMPORTANT PAPER TELLS US THAT A SIGNIFICANT PERCENTAGE OF PULSELESS PTS IMPROVE FOLLOWING REDUCTION AND FIXATION.

64 Déficit Vascular Regreso el pulso luego de la reducción o no?17 pacientes 14 recuperaron pulso con la reducción 3 no recuperaron pulso se exploraron y requirieron reparación vascular 2 de los que habían recuperado el pulso lo perdieron en antes de 36 horas Se les hizo arteriografía y requirieron reparación, uno desarrollo Volkmann Copley, L, Dormans, J, Davidson, R. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: Toward a goal of prevention. J Pediatr Ortho 1996;16: Copley, L, Dormans, J, Davidson, R. Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: Toward a goal of prevention. J Pediatr Ortho 1996;16:99-103 17 of 128 consecutive children with type III supracondylar humeral fractures had absent or diminished (detected with Doppler but not palpable) radial pulses on initial examination. Fourteen of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each was explored immediately and found to have a significant vascular injury requiring repair. Two of the 14 children who had initially regained their pulses had a progressive postoperative deterioration in their circulatory status during the first h, including loss of the radial pulse. Both had arteriograms that identified vascular injuries and underwent exploration and bypass grafting. One of these two children had been transferred 48 h after injury, resulting in delay of management of his vascular impairment. Despite exploration, vascular repair, and fasciotomy, he ultimately developed Volkmann's ischemic contracture. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children.

65 Déficit Vascular Es seguro dar alta al pte que no tiene pulso pero la mano se ve viable 313 manos rosadas sin pulso 157 persistían sin pulso luego de la reducción White LA, Mehlman CT, Crawford AH. Pulseless and Puzzling, Vascular Injuries in Supracondylar Humeral Fractures in Children: A Meta-Analysis of Observational Studies and Results of a POSNA Membership Survey. J Pediatr Orthop 2010;30: White LA, Mehlman CT, Crawford AH. Pulseless and Puzzling, Vascular Injuries in Supracondylar Humeral Fractures in Children: A Meta-Analysis of Observational Studies and Results of a POSNA Membership Survey. J Pediatr Orthop 2010;30: This study pooled data from 313 pulseless supracondylar humeral fracture pts and polled the POSNA membership. There was a 40% response rate for the POSNA poll. Injury rates and brachial artery repair rates are noted below in the TABLE. This meta-analysis suggests that the common opinion of watchful waiting for pulseless and perfused (aka pink) supracondylars should be questioned

66 Para Responder Indicacion de Cx Fx tipo IIIEsta claro que las tipo 3 tienen pero resultado si se tratan no quirurgico??? Pirone AM, Graham HK, Krajbich JI: Management of displaced extension- type supracondylar fractures of the humerus in children. J Bone Joint Surg 1988; 70A: In this retrospective study of 230 patients with type III supracondylar humeral fractures, closed reduction and casting resulted in significantly fewer good results and more complications. Percutaneous pinning provided the highest number of good results and is recommended as the treatment of choice for most fractures. Skeletal traction, however, provided acceptable results in some patients who had significant soft-tissue swelling.