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Urgently, within 6-8 hours
4%
60/1516
First case the following morning (~6 am)
1%
12/1516
8 hours after his last meal
0%
6/1516
Emergently, as soon as the operating room allows
94%
1429/1516
As a scheduled procedure the following day with a vascular surgeon present
2/1516
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The patient has a pulseless and cold extremity following a type III supracondylar humerus fracture. He should be taken to the operating room on an emergent basis for closed reduction and percutaneous pinning. Type III supracondylar humerus fractures can be associated with a vascular injury in up to ~15% of cases. These vascular injuries are most often transient and improve following reduction and stabilization of the injury. Patients with pulseless and perfused hands should be taken to the operating room urgently (same day) while those with pulseless and poorly perfused hands should be taken to the operating room on an emergent basis. Following reduction and pinning, the vascular status of the extremity should be assessed and if the patient has persistently poor perfusion, vascular exploration is recommended. Wingfield et al. review supracondylar humerus fractures in the pediatric population. They note that supracondylar humerus fractures that are associated with neurologic and/or vascular injuries should be treated with timely reduction via closed techniques. They discuss that if closed reduction fails, reduction via open techniques is indicated. They conclude that open reduction if indicated, has been reported to yield good outcomes in patients in whom closed reduction fails. Sanders et al. review the AAOS guidelines for supracondylar humerus fractures with vascular injury voted on by a panel of pediatric orthopedic surgeons. The panel made the "always appropriate" recommendation that patients without a palpable pulse, even in the setting of a perfused hand, should be admitted to observation after surgery for at least 24 hours. Reitman et al. performed a retrospective review of open reduction and pinning of 65 patients with type III supracondylar humerus fractures. They noted that 46 (71%) of these fractures were irreducible, 16 (24%) had associated vascular compromise, eight (12%) were open, and one was associated with a postreduction nerve palsy and nonanatomic reduction. Of these, 79% of the elbows were rated good or excellent, three (9%) were rated fair, and four (12%) were rated poor at ~6 months post-op. The authors concluded that satisfactory results can be obtained in severely displaced fractures managed with an open reduction. Figure A reveals a displaced type III supracondylar humerus fracture Incorrect Answers: Answer 1: Patients with pulseless but perfused hands may be taken to the OR on an urgent basis (within 6-8 hours). This patient has a poorly perfused hand and requires emergent treatment. Answer 2: This patient has a poorly perfused hand and requires emergent treatment. Answer 3: Traditional NPO times may be overridden in cases of life or limb-threatening emergencies. The case should be discussed with anesthesia to review risks/benefits and ensure appropriate aspiration precautions. Answer 5: This patient has a poorly perfused hand and requires emergent treatment.
4.9
(7)
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