A 9 years old girl Falling in home Pain swelling of elbow Neurology normal weak radial pulse

What do you recommend for diminished or absent radial pulse? Emergent vascular consult Early closed reduction followed by vascular consult Early closed reduction and observation Early CRIF and observation Angiogram and early exploration other

Management of Pulseless Pink Hand in Pediatric Supracondylar Fractures of Humerus. Sabharwal, S. M.D., F.R.C.S.(C) *; Tredwell, S. J. M.D., F.R.C.S.(C) *; Beauchamp, R. D. M.D., F.R.C.S.(C) *; Mackenzie, W. G. M.D., F.R.C.S.(C) +; Jakubec, D. M. M.D. *; Cairns, R. M.D., F.R.C.P.(C) ++; LeBlanc, J. G. M.D. [S] Based on this study, early revascularization of a pulseless otherwise well-perfused hand in children with type 3 supracondylar fractures, although technically feasible and safe, has a high rate of asymptomatic reocclusion and residual stenoses of the brachial artery. Therefore a period of close observation with frequent neurovascular checks should be completed before more invasive correction of this problem is contemplated

Vascular Injuries and Their Sequelae in Pediatric Supracondylar Humeral Fractures: Toward a Goal of Prevention. J Pediatr Orthop B. 2012 Mar;21(2):121-6 Copley, Lawson A. M.D.; Dormans, John P. M.D.; Davidson, Richard S. M.D.  : Between 1988 and 1994, 128 consecutive children with grade III supracondylar humeral fractures presented for treatment at our hospital. Seventeen 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 of these three children 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 24-36 h, including loss of the radial pulse. Both of these children had arteriograms that identified vascular injuries. Both 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. All five children with significant vascular injuries had absent or diminished radial pulses on presentation. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children

What do you recommend for treatment with good pulse Early closed reduction followed by elective orif Emergent crif Emergent orif

Percutaneous fixation Lareal pins Two parallel Two divergant Three pins Cross lateral and medial pins Two three

FIGURE 1. Biomechanical Analysis of Lateral Pin Placements for Pediatric Supracondylar Humerus Fractures. Hamdi, Amre; Poitras, Philippe; Louati, Hakim; Dagenais, Simon; DC, PhD; Masquijo, Julio; Kontio, Ken; MD, FRCS Journal of Pediatric Orthopaedics. 30(2):135-139, March 2010. DOI: 10.1097/BPO.0b013e3181cfcd14 FIGURE 1. Four pin configurations tested in extension, varus, valgus, and external/internal rotations. The most lateral pin was placed parallel to the lateral humeral cortex whereas the other pin was varied from parallel 1 to maximum divergence.4 © 2010 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2

FIGURE 1 Intraoperative Stability Testing of Lateral-Entry Pin Fixation of Pediatric Supracondylar Humeral Fractures. Zenios, Michalis; Ramachandran, Manoj; Milne, Ben; Little, David; Smith, Nicholas Journal of Pediatric Orthopaedics. 27(6):695-702, September 2007. DOI: 10.1097/BPO.0b013e318142566f FIGURE 1 . Stress films taken in theatre after fixation with 2 lateral wires demonstrating rotational instability. The fracture is well aligned on external rotation (A), but the fracture gap opens up on internal rotation (B). © 2007 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2

Intraoperative Stability Testing of Lateral-Entry Pin Fixation of Pediatric Supracondylar Humeral Fractures. Zenios, Michalis FRCS (Orth); Ramachandran, Manoj FRCS (Orth); Milne, Ben MBBS; Little, David FRACS(Orth), PhD; Smith, Nicholas FRACS supracondylar fractures that are rotationally stable intraoperatively after wire fixation are unlikely to displace postoperatively. Only a small proportion (26%) of these fractures were rotationally stable with 2 lateral-entry wires.

A Systematic Review of Medial and Lateral Entry Pinning Versus Lateral Entry Pinning for Supracondylar Fractures of the Humerus. \Brauer, Carmen Alisa MD, MSc, FRCSC *; Lee, Ben Minsuk MD +; Bae, Donald S. MD +; Waters, Peter M. MD +; Kocher, Mininder S. MD This systematic review indicates that medial/lateral entry pinning, of pediatric supracondylar fractures, remains the most stable configuration and that care needs to be taken regardless of technique to avoid iatrogenic nerve injury and loss of reduction 2012 Lippincott Williams & Wilkins, Inc

Iatrogenic Ulnar Nerve Injury After the Surgical Treatment of Displaced Supracondylar Fractures of the Humerus: Number Needed to Harm, A Systematic Review. Slobogean, Bronwyn L. PA-C *; Jackman, Heather MD, FRCSC +; Tennant, Sally BSc, MBBS, FRCS (Tr & Orth) ++; Slobogean, Gerard P. MD, MPH [S]; Mulpuri, Kishore MBBS, MS (Ortho), MHSc (Epi) Conclusions: The results of this review suggest that there is an iatrogenic ulnar nerve injury for every 28 patients treated with the crossed pinning compared with the lateral pinning

If you recommend ORIF Posterior approach Anterior approach Medial approach Lateral approach

Comparison of anterior and lateral approaches in the treatment of extension-type supracondylar humerus fractures in children. Ersan O, Gonen E, İlhan RD, Boysan E, Ates Y. anterior incision when open reduction is needed in pediatric supracondylar fractures offer the advantage of a smaller scar and easy access to structures that might be injured between the fractured fragments J Child Orthop. 2010 April; 4(2): 143–152.

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review Juan Pretell Mazzini, 1 Juan Rodriguez Martin,2 and Eva María Andres Esteban3 Our results suggest that a combined antero-medial approach could be the method which allows the achievement of better functional and cosmetic outcome according to Flynn’s criteria. Time to union, as well as post-surgical complications, should not be an issue regarding surgical approaches used for open reduction and pinning in these fractures.

What do you recommend for extension deformity due to under reduction

Underreduced Supracondylar Fracture of the Humerus in Children: Clinical Significance at Skeletal Maturity. Simanovsky, Naum MD *; Lamdan, Ron MD *; Mosheiff, Rami MD *; Simanovsky, Natalia MD + We retrospectively reviewed 223 pediatric cases of supracondylar fractures of the elbow treated in our hospital between the years 1996 and 2000. Results: In 30 patients, we found some degree of underreduction of the extension component of the fracture. Twenty-two of them were followed and evaluated at or close to skeletal maturity Eleven patients (50%) had limited elbow flexion, and 7 (31%) were aware of this deficit. Most of the underreductions occurred when reduction was attempted in the emergency department, when the angulation was not appreciated, and when the cast was applied without any reduction attempt

AAOS Guideline of The Treatment of Pediatric Supracondylar Humerus Fractures

We suggest nonsurgical immobilization of the injured limb for patients with acute (e.g. Gartland Type I) or non displaced pediatric supracondylar fractures of the humerus or posterior fat pad sign Strength of Recommendation: Moderate

2. We suggest closed reduction with pin fixation for patients with displaced (Gartland Type II and III, and displaced flexion) pediatric supracondylar fractures of the humerus. Strength of Recommendation: Moderate

3. The practitioner might use two or three laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin. Strength of Recommendation: Limited

4. We cannot recommend for or against using an open incision to introduce a medial pin to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Strength of Recommendation: Inconclusive

5. We are unable to recommend for or against a time threshold for reduction of displaced pediatric supracondylar fractures of the humerus without neurovascular injury. Strength of Recommendation: Inconclusive

6. The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus with varus or other malposition after closed reduction. Strength of Recommendation: Limited

7. In the absence of reliable evidence, the opinion of the work group is that emergent closed reduction of displaced pediatric supracondylar humerus fractures be performed in patients with decreased perfusion of the hand. Strength of Recommendation: Consensus

8. In the absence of reliable evidence, the opinion of the work group is that open exploration of the antecubital fossa be performed in patients who have absent wrist pulses and are underperfused after reduction and pinning of displaced pediatric supracondylar humerus fractures. Strength of Recommendation: Consensus

9. 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. Strength of Recommendation: Inconclusive

10. We are unable to recommend an optimal time for removal of pins and mobilization in patients with displaced pediatric supracondylar fractures of the humerus. Strength of Recommendation: Inconclusive

11. We are unable to recommend for or against routine supervised physical or occupational therapy for patients with pediatric supracondylar fractures of the humerus. Strength of Recommendation: Inconclusive

12. We are unable to recommend an optimal time for allowing unrestricted activity after injury in patients with healed pediatric supracondylar fractures of the humerus. Strength of Recommendation: Inconclusive 13. We are unable to recommend optimal timing of or indications for electrodiagnostic studies or nerve exploration in patients with nerve injuries associated with pediatric supracondylar fractures of the humerus. 14. We are unable to recommend for or against open reduction and stable fixation for adolescent patients with supracondylar fractures of the humerus.

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