Características del tratamiento quirúrgico de las fracturas de paleta

!"#
$! % &! ' ())*+,--(
!
" . .
/ 012 34
#$
%
& &
5 61 ,--,
37
(
9
78 @
( 97
78
H
, 7 /7
19
: 7
1@
; 8 7
9H
< @9
00394 @@
=
@C
' (# )*+*,*-+ ./*+0 # #
@C
' 1# *,2 ,,,*-+ 0# #
@C
37
37
Queda constancia de nuestra gratitud a todas las personas que colaboraron directa o
indirectamente con la elaboración de este trabajo, en especial al jefe del servicio de ortopedia y
traumatología del HCPNP, al jefe de registros médicos y archivos del HCPNP y HEP, al Dr.
Waldemaro Fernández que impulsó constantemente este trabajo al igual que al Dr. Carlos
Castillo que desinteresadamente nos ayudó en la obtención y procesamiento de las fotografías, a
la Lic. Claudia Mejía por su apoyo constante en la elaboración y correcciones en la preparación
del informe final, y a todos los niños que sufrieron este tipo de lesiones, que con su dolor nos
enseñan a perfeccionarnos cada día.
34/ 560*0 7 8 ,20 0+ 3
(
!"# $! % &! ' ())*+,--(
1
34/ 560*0 7 8 ,20 0+ 3
Las fracturas en la paleta humeral de los niños, son una de las lesiones más frecuentes, alcanzan
casi 30% del total de fracturas, algunas son de necesidad quirúrgica, por la posibilidad de
limitaciones marcadas que alteran el desarrollo normal del niño.
Se estudiaron las fracturas descritas entre 1997 y el 2001 en el Hospital Central de la Policía
Nacional del Perú (HCPNP) y el Hospital de Emergencias Pediátricas (HEP) -Ministerio de
Salud; con un diseño retrospectivo, transversal, descriptivo y observacional, para evaluar las
características básicas de estas poblaciones. Los datos estadísticos fueron evaluados con el
sistema SPSS 9.0 considerándose como significativo un p< 0.05.
Se encontraron 129 pacientes, 94 del HEP; de los cuales 80% eran varones con una edad
promedio de 6.9 años. La fractura más frecuente fue la supracondílea (68.9%) mediante el
mecanismo de extensión (93%) en el codo izquierdo (58.13%). El tiempo pre hospitalario fue en
promedio 3.069 días siendo mayor en el HEP, probablemente por la elevada incidencia de
tratamiento empírico pre hospitalario (41.8%). El tiempo pre operatorio fue mayor en el HCPNP
con 6 días, frente a 1 del HEP, al igual que el post operatorio y la estancia total hospitalaria, ya
que en el HCPNP esta lesión no es considerada una urgencia y el paciente tiene un mayor tiempo
de observación post quirúrgica (4 días en promedio). Solo hubieron 5% de complicaciones
predominando las infecciones y luego las neurológicas (2 lesiones del cubital), todas resueltas
satisfactoriamente. El abordaje de elección fue según el tipo de fractura predominando el
posterior (65.99%)con alambres de Kirschner cruzados (68.9%). La inmovilización post
quirúrgica fue en promedio 23 días, de preferencia con yeso tubular braquio- palmar (78.29%).
Solo 27% recibió rehabilitación especializada. Los familiares afrontaron los gastos en 41.8%,
seguidos por el seguro escolar (31%).
Palabras claves: codo, niños, fracturas, incidencia, alambres de Kirschner, tratamiento,
complicaciones, costos.
34/ 560*0 7 8 ,20 0+ 3
9
!"# $! % &! ' ())*+,--(
:
34/ 560*0 7 8 ,20 0+ 3
78
78
0 ),0 2/ + +*;< 0+ =//+ ,/+0> 4+0
0 0 2+ + /0 ?@A 0 0 ),0 /*/6 0* B++
(C@:DB(D# 0 E+< 2+4 5 ,60< +,++ F ), 0 ,+
2E/ *0 (?A 0 0 ),0 *+,0 + 4 +*;0 + G
5 H ;0< 0++ 9GA 0 ),0 B2+4< (CC9DB1D# I2 ,+)*/
0 2J4 )*/+ F 0 ),0 + , ,+ /,2 /0 ),+/+
+ 0F *+/ F + B9D#
+ +0 /*< 0 ),0 2/ + *+ F *)* + 00
,,0*,0 ,+ ,*-+ 0 *0< /*+ 00 0 /5 K*6
04E+ ,+ 20** + 0 *+< 04E+ 6,*-+ , +, ,*+ B6+ D< 04E+ ,+,* 0 0 B/.*,0 200D *+,0
/5 */+< 04E+ ,,* ,+-/*, 0> )*+ 0 0 ),0
F + L 0,0 /,0 /+ 0+ /*+ + /*+0
F*E4*,0#
0 /5 */+ ,+, 0 ,,0*,0 ,*+ F 0 0/ 0
,*4 + ,+0 20**0 *)+0 + + , +,*-+
, , * +,*-+ 0 + +0 0#
34/ 560*0 7 8 ,20 0+ 3
@
!"# $! % &! ' ())*+,--(
?
34/ 560*0 7 8 ,20 0+ 3
( 97
78
( 97
78
0 ),0 + , 0+ =//+ ,/+0# ++ 5 00 0*/+ F
0+ =*//+ ?@A 0 ),0 + /*/6 0* + +*;0# 2+4 5
2+ +,++ F 0 ),0 0,+0 0+ (?#?A 0 0 ),0 +
*+)+,*# + 4 G H ;0 0+ 9GA 0 0 ),0 + 0 /*/60
0 0 F 0+ /0 ),+0 + 0F *+/#
9! &" >
0*)*,,*-+ 0*)*,,*-+ + 2E/ *0 /*J +, + /M)*0*0
0M 0*)*,< 0*+ /64 + 0 0 0,0 )*0*0 0M+# ,*/
0 */ 0, + 0*)*, 5 0 K*0 *4M)*,/+ 0 0 ?
/00 , ,+ *60*+#
*,-+* /* 0 0*4*+ + 0*)*, 5 0 K 5 0 @ ;0 < 0
0 )/ 0 * ,+ 0*)*,,*-+ /*+0 F 0 0,0 0 ++
)/+ + 0 +E, 0*)*,,*-+# -, 0 0*4*+ 0 0 H ;0< 0 /M0 ,/E+ + 0 C 5 (G ;0# *,-* 0 E*/ ,*-+ + 0*)*,0<
+ 0 N 5 C ;0#
,*/ 5 -, 0 )0*++ 0 (G ;0< , 0.0 0 +
/6*.+ *,-+* )/+ , *+,* )*0*0 *0 2E/#
)*0*0 0 )0*+ ,+ /M)*0*0 + 0 (1 5 (9 ;0< )*+/+ *,-+*
/* 0 )0*+ 6F )*+ + 0 (: 5 (H ;0# B*4# (D
34/ 560*0 7 8 ,20 0+ 3
H
!"# $! % &! ' ())*+,--(
,*,,*-+ , , 0 /5 *, 5 0)*,*+ *+,0 **4 +6J 5 /+ + ,0 6F * 6F*# *+ /64 6F
* 6F* ,* 0*4+0 *0F/* ,/ 0 ) 5 ,*,,*-+#
B*4# 1D
! N
34/ 560*0 7 8 ,20 0+ 3
( 97
78
" #$ 0)*,* *0 2E/ 0 *+*, 0K /60 *,-+*0# ,M0
*, *+K, .,++ 5 ,0 ,+* 0 ,/ ,E *#
=*0+ 0 F0 400 + ,M0 5 2E/< + +* 5 0*> 0, *-4*, 00 F0 /*+ *4+0*, 0*+0 + ,#
*)+0 +0 *-4*,0 0+ 00 ,/ 5 *4+-0*, ),0 2/# M+4 I/+ B*4# 9D 0 /5 E* /*+
+ , ,,*-+ + ), 0,+ 2/# 0 M+4 0
)*+* ,/ )/ *+0,,*-+ + J K.0 )0*0 ,*/ 5 + + +*, L +4**+ 2E/ K*0 + +
*4) + 0*# =*0+ 0 M+40 5 +0 ,/ M+4 *,-+*
*)*0** /* + +* ,+* 5 + +* 2/ 0,*0 *60*+ F *+ **0 0,)*,0 F 0*K+ /*0/#
0 /5 */+ 5 4+ 5 * *4)0 ,/*K0 ,*0 ,+ /5 ),** 0 0*+0 + ,#
0 /.0 00 ,/+ 0+ 0++,* /4+.*, 5 0+4)
0,*/+ + 0F0 /5 *+/0#
34/ 560*0 7 8 ,20 0+ 3
C
!"# $! % &! ' ())*+,--(
% &' ' (
) 0 0 +*+ ,/ /++*/*+ K K4 *,,*-+# 5 F
++ F 0 0 *+,/+ ,+ 5 + 0 *4 + + +*;0 ,/ + +*;0#
/* /++*+ , ,//+ =+* 5 +6J + 0*+,*-+
,/# /L K,*-+ 0 ,/M+ ,+ , ,+ #
9! !%
*0; 2/ ,/+ 0 ,/+0 )0 +*0 +
4 , /+0 ( //# 00 + 0 ,*-+ ,+< B*4# :D 0 0 0* )0 ,++ 5 +* )0 ,+* B1?D
(G
34/ 560*0 7 8 ,20 0+ 3
( 97
78
* #$ +
0 ), , /+ /M0 ),+ + 0F0 *+/0 */ ., K*# + ,0* 9GA 0 ),0 + 0 /*/60 + 0
4 + /M0 ),+ B(<1<1HD# =*0+ 0 *0 ),0 0,+0<
+*+ /,+*0/> 0 ),0 + =+0*-+ + C?A 0 ,00< 5 0
),0 + )=*-+< 0 ,0 ,+0*5+ /+0 :A#
) 0 ),0 0,+0 + ,* 2*=+0*-+ )=*-+ ,# 0*-+ 0 0 + , ,+ 5 /+ 5 , + 2*=+0*-+ , ,+ 5 .,++ 5 , + 2*)=*-+# ,+ *+,*/+ +
*/ ., K* F 0 *4/+0 + 0+ =0 5 + + +
0 )J0 +0*-+ 0 F 0+ 0/*0 ,*0 00 ,,*+0#
, ?>
=*0 + *04 *K/+ 0*+0 +K*00 0,*0 ),0
0,+0 B+ H 5 (@#@AD# /6 +,+ F + @C ,*+0 ,+
),0 * < 1: B:(AD K*+ 0*+0 +K*00# 00 :@A *+*,+ +K*
* 5 91A +K* ,6*# 0 0*+0 +K* /*+ 0+ 0,*0 0J/*+0 -0 0 /,0# +K* ,6* 0 0*+ + 0,* ,+
0 ),0 + )=*-+# * ,*+ F +K* F /M0 ),+/+
0 0*+ 0 + -0 +*> F 0 +K* 0 /+ /< 0 0*-+ 0
*4+0*, =/*+ )= 4 4 5 )= )+ +*,#B1ND#
?!>
34/ 560*0 7 8 ,20 0+ 3
((
!"# $! % &! ' ())*+,--(
+F 0 0*+0 K0,0 + 0 * 0*-+ 0+ 0*4+*)*,*K0< ;
/++ 0 0 60K + /+0 (A ,00B1CD# * 6F*
4+/+ 0 4* /E0, 6F*< F */ 0 04 /+
+0 0*+ *#
F 0 , 4+/+ =*0* + 0J/*+ +* 0 +
,/0*-+ F *0/*+5 **4,*-+ +6J 5 F 0 0,*+ ,* ),#
&
,0*)*,+ *,,*-+ 0J/*+ 0 )4/+0#
0 ),0 0,+0 + =+0*-+ 0+ 0/+ ,0*)*,0 04E+ 0 + B9GD +
* ,0 + 0J0#
* ,0 ,+ K +4,*-+ *+4* ,*, 0*#
* ,0 ,//+ 0J0< 4+/+ -0 /*#
9! !% @A
-
0 2*0* +*; F 0) + , ,+ 5 / /+< ,+ , + =+0*-+ 5 F +*+/+ 0*+ *++0 */+,* )+,*+ +*K 0 *,,*-+#
#. + * ),< + * * 26 + +4 /K*/*+ 0 0*0+#
+ * < */+,* )+,*+ 0 K*+,* /+ *++
*+*,* /K*/*+#
+ * 5 *+,,* 0 *++0 /M0 0 60K +
)/* /,#
0 /5 */+ *J + =/+ +K0, ,/ *+/*#
# '
6M 0*,* *+/*/+ *4)0 + )+ 5 < 0* 0 +,0*
6*,0# + * ,*-+ 0 K*0*6 M*/+ + 0 * 5 6M+
00 0 0*4+0 5 +0 /*+ *4+-0*, ,*0#
) 9! % > B9# <C
+ +4,*-+ 0* )4/+ *0> 04E+ +4 B9(D< 0* 0
/+ 1GO + F* ,,*-+< + 0 *+/K**J,*-+ 4 5 ,/* 9 0/+0#
(1
34/ 560*0 7 8 ,20 0+ 3
( 97
78
/ +
9! % > B9# DC
+ 4+ /*+ 0 *4 0* 0 25 + +4,*-+ /+ (GO + *4) < ,+*< 0* 26* + 0K*,*-+ +4 + K K4 0
6M *J + /+*6 ,,*-+# * 0 *J + /+*6 ,,*-+<
66/+ ), 0 KK *+06< /*K , 0 6M *J +
)*L,*-+ ,+ /6 P*0,2+< *+/K**J,*-+ ,+ )=*-+ NG CGO#
34/ 560*0 7 8 ,20 0+ 3
(9
!"# $! % &! ' ())*+,--(
0 1
++ $!
9! % > B9# *C
00 *++ 0J/*+< + 25 ,+, + 0 60 )4/+
=*/ 5 *0< *++ 4+ *04 0*-+ + K0,< /*+ /M0
, 0 ,,*-+ , 5 )*L,*-+ ,M+ ,+ /60#
2 +++ $!
% >
0 , ,,*-+ ,M+ + 5 0F.*, ,++ B*4# ND B91D<
0*+ 0 E*/ F *+ /L0 00 B99D#
,,*-+ 6*< 0M *+*, + ,00 F =*0 + 0*-+ K0, +K*0< + ), =0< + 0 *J + ,,*-+ , ,>
0*0 ,*+0 *+*,+ 00 0*/*0 + /60 B,,*-+ 6* ,D
,+ *04 F + ,,*-+ 6* 0 0*6 6+ + ,6*0 K0 0*#
(:
34/ 560*0 7 8 ,20 0+ 3
( 97
78
3 )4 &
% ?!>
+ 0 *0< 40 5 0640< */ )+/+ 0 /5 <
04+ + *0F/* QR/++#
,//*0 K0, 0 */ F 6 0 K< L+ ,+ 0 00
*).*,0 0 6 K ,,*-+ ,M+ 5 < 0 0*6 F =*0 +
,//*0 K0, 0*+ F 4 4+0 20 0 ,*+ ,+
,*-+ 0+0*6**< 0 6 0 K /*+,*0/+#
A !A#>
*+,*+,* K* /,2 , 0 6*,,*+0< + /* 0 +
(@A< 0*+ +K* *< ,/E+/+< /M0 ),< 04* /*+ 5
)*+/+ ,6*#
7*//+ 0 /5 ),+/+ 0*-+ +K* + -0 +*
F 0 + / +K* /*+< 0 0 + +K* / 5 0 KE ,+ )+,*-+ 0 )=0 4 +*,#
34/ 560*0 7 8 ,20 0+ 3
(@
!"# $! % &! ' ())*+,--(
!E! !
6*0 K0 0 )/* /0 ),+ F , 4 + ), ,< 4+/+ ,/ 0 + ,,*-+ *+,# ,0 ),+
0 ,*-+ ,4 ,,*/*+ F K,*+ 0 )/* F
4+/+ + ,0 */*,*+0 )+,*+0#
5 9! A >
00 ),0 0+ *K/+ ,/+0< ,+ + (1 5 (?#NA ),0 , + +*;0 B9:D#
A>
0 , 0/L+ 0,+ ,+ +6J 0*+< 0
, + )J + K F K0*+ ,-+*#
$A>
4E+ SR6 0 + ,0*)*, +
T
(?
* , *+,/< + 0J< ,+0K+ 0)*,* *,< /*+ 0 ,+0K#
34/ 560*0 7 8 ,20 0+ 3
( 97
78
T
* , ,/< F 0 =*+ 20 0)*,* *,< ,*/
0 0J /M0 + # /*+ *L,*-+ 0 ,,*-+ 5 *L,*-+
,+ /6#
T
* , ,/ 0J /*)4/+*# /*+ 0 ,,*-+
5 )*L,*-+#
#A
0 )+/+/+ ,+*, 5 *-4*,< 5 F ,*/ 0M 6*+ 0*)*,
0 /+# + ,0 0 ,* 0 *4)0 6*,0<
4) 5 #
7>
5 0,*< 2,*+ 0K F ,,*-+ 6* 0 , ,/+6
F *+ +,0*0 K0,< 0* 0*-+ *+ /M0 9 0/+0 0 )*
L 0 /*+ ,+0K#
%>
0 ,/*,,*+0 /M0 ,/+0 0+ + +*-+ 5 ,6* K4#
6 ) 34/ 560*0 7 8 ,20 0+ 3
(H
!"# $! % &! ' ())*+,--(
7 (7 , $! &7 8
" (7 &7 , $! 97 8
9! A + /5 *+),+0< 0 0*0 0 6*,+ + /+0 1A< 4+/+ 0
(N
34/ 560*0 7 8 ,20 0+ 3
( 97
78
,+ K0*-+#
,0*)*,,*-+ 0 *.+*, ,-+* # *4+-0*, /6*.+ 0 ,+*, 5
*4M)*,#
/*+ 0 + * 0 0/+ *+/K**J,*-+< + * ,,*-+ 5
)*L,*-+ ,+ /60< + * < 0 6 *J + ,,*-+ 6* 5 )*L,*-+ ,+
/60# 6 *+/K**J , + 0 0 ,00 9 0/+0#
9! %A >
0 + 0*-+ *K/+ ),+< =*//+ (GA 0 ,00> 0 K*0
/5/+ + 0,+0 5 K+0#
>
,0 /M0 ),+ 0 + , F ,0 + K4 )J + K0*-+ 0 )4/+< ,/6*+ ,+ + ,+,,*-+ 0 )=0 +6J# * )J
0 *++0 0 ,*+ + =,*-+ ,#
$A>
4E+ $0 5 0 B9@D 0 ,0*)*,+ +
# 0J
# +*//+ 0J BU@ //D
# 0J BV @ //D
T
0*+ =,*-+ ,*
T
*,-+* ) *,,*-+
T
*,-+* + *,,*-+
T
=#
#A>
*4+-0*, 0 0+,*< 0 2*0* + , ,+ + )J + K4 6J< 25 *++0 */+,* )+,*+ /*+* /*#
*-4*,/+ 25 + /+ + /; *,-+* /* ,+ 0, , ,+ # + +*;0 /5 F;0 + E+ 25 ) 0*)*,,*-+< *4+-0*, 6 0 /5 ,*0#
34/ 560*0 7 8 ,20 0+ 3
(C
!"# $! % &! ' ())*+,--(
% 7 (7 , 7>
/*+ + 0J/*+# + 0J0 /+*//+
0J0 0 ,/*+ *+/K**J,*-+ ,+ , + CGO )=*-+ + 0/+
5 4 /K** K* *4*J# + ,00 0J/*+0 /50 0
,/*+ ,,*-+ 6* 5 )*L,*-+ ,+ /6 F =*0* ,*-+#
+ 0 *+,*0 ,/*,,*+0 0 +,+ 0*-+ +K* ,6*#
9! %A + ),0 =//+ 0< 4+/+ ,+,,*-+ 0K 0
/E0,0 =+00 +6J# /*+ 0 *+/K**J,*-+ ,+ /K**J,*-+
/+#
! $ 0 ),0 2/ + 0 +*;0< 0+ + +*40 ,/ 2/+*
/*0/# + 2*0*< /*+< ,/ /5 0 ),0<
6*- 26 0* ,+0K< /*+ ,,*+0 5 /+*,*+0< ,+ 0
,+0,+0 )/*0 5 */*,*+0 6,*-+ F 0) 00 0*+0#
6*6*4) /M0 +*4 +,+ +00 06 /*+ F*E4*, 0 ),0< 0 /+ (NN@ + ,2*+0+ +0 26 + W0, ,0 )/,*-+ 0*+ + + +*;XB@D# 4 0220 F*.+ 6*, + (C(G + 0*
+/8F*E4*, 0 ),0 ,* *0 2/ B?D# 4+0 6L0 + K*L /+ /6*.+ + 0K F*E4*,/+ 0 6/< + * * BHD
+ **J ,,*+0 0F.*,0 ,4* )/* + (C99# *0+BND 5
1G
34/ 560*0 7 8 ,20 0+ 3
( 97
78
K BCD 6*,+ + S 00 0,*K0 6L0 + (C1H 5 (C91 06 ),0 , + +*;# 6/0 K* 0 6L0 + B(GD F*+ + (C9C + 0
/*+ ,+ ,,*-+ F K 0 +/6#
0 ,*.+ + ., 0 @G0# 0*4 0< F , */ *++ 0*0/*J 5 ,/+ 0 ),0 + 0 +*;0< ,+ 6 W,0 + 0 +*;0X
# $ +/ I+< ,+ 0 =*+,* + 0* *;0 *YR Z
B:D# 0 6 0 F*JM0 + 0 ,0 *,0 =,0*K/+ ),0 +
+*;0 20 ., 0 0+0# + ,+ *)+0 0 F
)+*J+ 0 /< 20 4 ; 1GGG + ),0 + +*;0 ,RY 5
+ B((D 0 /* 0+,* 0* 00 0*+0#
+ E< 0 +,+0 06 0* 0 6/< 0 /++ (C::
,+ 0*0 6,2* + +*K0* ,*+ 5 + ,0 #
*0.0 Q* 0 * W,0 2/ + 0 =/* *0XB(1D< #
0*0 0 *44*+0+ ,+ 0 0*0 W, 0 )*0*0 F )/+ , + +*;XB(9D + (C:N> # K*+ 4* 5 0 0*0 W,0 , ,+0*,*-+ ),0 + +*; /*+ 0,,*-+ ,* 2/XB(:D + (C@:# # +*F K ,+ 0 0*0 W,0 ,XB(@D + (C@?> # E J ,M+0 5 0 6L W,0 ,+0*,*-+
K*,*0 + +*; 5 0 /*+X + (C@HB(?D> # I2-FJ Q*K*0 5 0
0*0 ,0 , + +*;0 Z + (CH(B(HD< # 0 00 2MKJ 5 0
0*0 W /*+ 0 0,0 ), , + 0* J6*0
5JX< (C?:B(ND> # ) K 5 0 0*0 W ), + )*0*0 *0 2E/ + X (CH9B(CD> # K 0+,*0 5 0 0*0 W,0 , +
+*;0 + (CN@ Z (CCG + X + (CC(B1GD> # , 0 4 5 0 0*0
W,0 ([9 *0 2E/X (CC:B1(D> 0*0 # *, 5
W+,*+,* ),0 *)*0**0 + (G ;0X (CC9B11D 5 E*//+ #
I04** 5 0 0*0 W/*+ F*E4*, 0 ),0 0,+0 + +*;0
X 1GGG B19D#
34/ 560*0 7 8 ,20 0+ 3
1(
!"# $! % &! ' ())*+,--(
11
34/ 560*0 7 8 ,20 0+ 3
, 7 /7
, 7 /7
0 6L 0 * 60K,*+< 0,*K< +0K0 5 0,**K B,+,*
,/E+/+ ,/ 0* 0,**K D# + 04+ 0 ,+K* + +
0* ,/*K *++ ,*+ 0 00 4 +* + <
)+ +* + BD#
0+ 0*< 04E+ ,0*)*,,*-+ +M+J /** + 0 4
*+K0*4,*-+ B1:D< 0 + *0; 0* *+K0*4,*-+ +
=*/+ +0,,*+< 5 F + 0 ,+05 +*+4+ 0*,*-+< 0*+ 0 60K+
0*,*+0 5 =*0+0< + K,0 *++,*+/+ *+K0*4< 5 0
/*,*+0 0 *J+ + 0 KJ#
+ 0*4*+ 0* + 0M +,0* ,, + /0 +* + + *0;
00*, /0< 0 F 0 +*J 6,*-+< 0 ,* +*K0 ,/ + + 0,* 5 */#
K*0- K,*-+ ,+*, 5 *-4*, 0 0 ,00< 00 00
)+ 4*00 + + *+0/+ K* * K*< + 0 ;0 (CCH 5
1GG( + 0* + *, ,*+ E 5 + 0* /4+,*0 *M*,08 #
0 K*60 0/*0 0* )+ 20* )+,*< < 0=< 4
=0*,*-+< * J ),< /,+*0/< */ 5 0 F*E4*, 20**J,*-+< 0 )*=*0 +*6*-*,< * 6L< ,/*,,*+0 5 0
F*E4*,0< .,+*, F*E4*,< *+/K**J,*-+ 5 0 F*E4*,< */0 *0<
34/ 560*0 7 8 ,20 0+ 3
19
!"# $! % &! ' ())*+,--(
*/ 5 4 * < * 26**,*-+ ,*+ 5 )+ 4
,*/*+#
,0/*+ 0 0 *J + + ,/ +*/ /*+ 60 0 =, ))*, 1GGG *,0) 5 +M*0*0 00 0 *JM
/*+ 4/ 00*, C#G ,M+0 ,/ 0*4+*)*,*K + K U G#G@#
,+ 5 K,*-+ 6L *+K0*4,*-+ 0 KM ,6 0 5, 5 + ,0 *+K0*4,*-+ 0 000 0,,*+0 5 *+K0*4# 6,*-+ 5, 0K ,4 ,/*. .*, 5 +4
/60 20*0 5 +* 04 ), /*,*+ #
0 ,*6*- +* ,*6*M 6+)*,* 4+ ,/,* ,*+ 0*
*, *+*,/+ 2,* 0 6L# 0 ,*6*+ )+0 =+0
*J,*-+ 0 *+K0*4,*-+#
1:
34/ 560*0 7 8 ,20 0+ 3
: 7
: 7
*J+ (N? *+K+,*+0 F*E4*,0 /*+ ),0 2/ + *+*,< ?C + 0* + *, BD 5 ((H ,00
+ 0* /4+,*0 *M*,0 BD#
00< 0 6*,+ 0 2*0*0 ,+*,0 ,/0 (1C ,*+0< 9@ 5 C: #BM)*, (D
:1;+& 9+<=1+(>&+?@ 9# , A(,&+?@
+ 4 0*< 0 +,++ (G: 2/60 5 1C /L0< B 1N
2/60 5 N /L0> H? 2/60 5 (H /L0D BM)*, 1D> /*
+,+ ). ?#C@ ;0 B H#NC ;0> ?#? ;0D *+*)*,M+0 + +4
+ 0 (H ;0 5 1 ;0# BM)*, 9D
34/ 560*0 7 8 ,20 0+ 3
1@
!"# $! % &! ' ())*+,--(
:1;+& " 9+<=1+(>&+?@ A1 <#B
:1;+& % 9+<=1+(>&+?@ A1 #99
K ), 60K/0 @: 0*+0 + 2/ ,2
B:(#NAD 5 H@ 0*+0 + *JF* B@N#1AD# BM)*, :D
:1;+& * 9+<=1+(>&+?@ A1 ,9 #&=9
4E+ J ), ,0*)*,/0 G: *0 0,+0< *,+<
1?
34/ 560*0 7 8 ,20 0+ 3
: 7
*, 5 0> ,+ 0 0*4*+0 *0*6,*+0 0,+ NC ,00 B?N#CAD<
*,+0 9: ,00 B1?#9@AD< *,0 @ ,00 B9#NHAD 5 0 ( ,0 BG#HHAD#
BM)*, @D# + *0*6,*-+ 20*0< 0 +,+- + 1( ),0
0,+0 B?GA + 0 20*D< N ),0 *,+0 B11#N@AD< @ ),0
*,0 B(:#1GAD 5 ( ), ,0*)*, ,/ 0 B1#N@AD> 5 + ?N
0,+0 BH1#9GAD 5 1? *,+0 B1H#?@AD#
:1;+& / =+A< 9# 1&=>1
+ F 0 )* =0*,*-+ -0 0 +,+- N ,00 ),0 =00
F F*K ?#1GA #
/,+*0/ 0*-+ /M0 ),+ ) , ,+ +6J + =+0*-+< N:
,00 B?@#((AD< 04* , ,+ +6J + K< 9: ,00 B1?#9@AD> 4
, ,+ +6J + )=*-+ ? ,00 B:#?@AD 5 K4 ,+ @ ,00 B9#CHAD#
*/ + 4 ,*+ 0 4 ,,*+ 20 ,+
20**< 2/0 / */ 20** 5 2/0 +,+ F /* 0 9#G? 0< 0*+ 0 +40 + /+0 ( 20 (@ 0<
00 0 K+ 04E+ 20*< + +,+/0 + /* (#? 0<
0*+ +4 + /+0 ( 20 C 0< C ,00 B1@AD 4+ 4 9 /M0 0# + < /* 0 20**0 ) 9#?(HG 0< 0*+ +4 + /+0 ( 5 (@ 0< :@ ,00 B:H#NAD 4+ 4 9 /M0 0#
BM)*, ?D
34/ 560*0 7 8 ,20 0+ 3
1H
!"# $! % &! ' ())*+,--(
:1;+& 0 =+#)A A1# C -<A+=,1+
*/ F*E4*, ) )*+* 0 *+40 20* 20 //+
, F*E4*,< +,+M+0 + /* 1#:(N 0< 0*+ +4 +
/+0 ( 20 (N 0# + *0*6,*-+ 20*0 0 +,+- F + /* ) ?#11N 0< 0*+ +4 + /+0 ( 20 (N 0<
0*+ N9#9A B9G ,00D 0 4 9# + < /* ) (
< 0*+ +4 + /+0 ( 5 9 0< 0*+ 1#(1A 4 9# BM)*, HD
:1;+& 2 =+#)A A1# D>+1E1:+&
*/ 0 F*E4*, 0 )*+*- ,/ +0,* + ,*-+ 5 >
0 +,+- ,/ /* (#H@ 0< 0*+ +4 + /+0 ( 5 (1
0# + *0*6,*-+ 20*0 2/0 + + /* :#GN@ 0<
0*+ +4 + ( 5 (1 0< 9( ,00 BN?#((AD )+ 0 4 9#
+ < 0 +,+- + /* 0+,* 0 F*E4*, G#NC 0< 0*+ 1N
34/ 560*0 7 8 ,20 0+ 3
: 7
+4 /+0 + 20 (1 0< 0 : ,00 B:#19AD )+ 0 4 9# # BM)*, ND
:1;+& 3 =+#)A A<= D>+1E1:+&
0+,* 0 ,*+0 ) + /* :#(N 0 0*+ /M=*/ 9G
0 5 /+*/ ( # + *0*6,*-+ 20*0 +,+/0 + +
/* (G#9: 0< 0 0 ,00 )+ 0 4 9# 0*+ +4 + : 5 9G 0> + +,+/0 + /* (#NC 0< 0 (: ,00
B(:#NCAD ). 4 9# < +4 ) ( (9 0# BM)*, CD
:1;+& 5 #<=@&+ -<A+=,1+
+ F 0, 6/0 *K0 ,,*+< +,+/0 H ,00
B@#:1AD< 1 + 5 @ + # BM)*, (GD
34/ 560*0 7 8 ,20 0+ 3
1C
!"# $! % &! ' ())*+,--(
:1;+& 6 A1(,#)< 9#1+F9< 9#, &&+9#@=#
0 2,20 ,+0*0 ,/ 6/0 *K0 ,,*+ )+ 9
*+),,*+0 B1#91AD< ( F 0 /+*)0- +0 , F*E4*, 5 1 F 0 /+*)0+
4 , F*E4*,< 1 +0 0*+0 +K* ,6* B(#@AD 4 ,
F*E4*,< 5 1 ),0 * /*0 , ,,*+# 0 0 ,00 K*+
K,*-+ )K6# BM)*, ((D
:1;+& =+A< 9# A1(,#)< 9#1+F9< 9#, &&+9#@=#
/*+ F*E4*, ) K + : ,40< +,+M+0 + F @: ,00 B:(#NGAD ,*6*+ /*+ /*, BW20X W06XD< 9: ,00
B1?#9@AD + ,*6*+ +< 9: ,00 B1?#9@AD 0 0 ,,- 0 ). 50
6F*8/< 5 H ,00 B@#:1AD 50 ,/# BM)*, (9D
*J *0*6,*-+ 20*0 0 +,+- + 1G ,00 B@H#(:AD
,+ ).< (1 ,00 B9:#1NAD ,+ /*+ /*,< 1 ,00 B@#H(AD 0*+ /*+ 5
00 ( ,0 B1#N@AD ,+ 50 6F*8/#
+ 0 00 )+ /*,< :1 ,00 B::#?NAD> +< 91 ,00
B9:#G:AD> ). 50< (: ,00 B(:#NCAD 5 50 6F*8/ + ? ,00 B?#9NAD#
BM)*, (1D
9G
34/ 560*0 7 8 ,20 0+ 3
: 7
:1;+& " =1=)+#@= A1# D>+1E1:+&
:1;+& % =+A 9# =1=)+#@= A1# D>+1E1:+&
)*=*0 +*6*-*, 0 *J 0 + :9 ,00 B99#9AD< + 0 9
,00 BN#@HAD 5 + < :G ,00 B:1#@@AD< + 0 0 ,00 0 **J,)0*+ (# 4+,*-+ (4# +0 *+*,* ,*4# BM)*, (:D
:1;+& * >< 9# A1+,B+< @=+(+?=+&
0 6L0 0K*+ + ,*-+ ,+ * ),< 6L 0* 5 ,,*-+ ,M+ 0 *J + ),0 0,+0< 6L 0 *J
34/ 560*0 7 8 ,20 0+ 3
9(
!"# $! % &! ' ())*+,--(
+ ),0 *,-+* 5 6L /* 0 *J- + ),0 *,#
+,+/0 N@ ,00 B?@#NCAD ,+ 6L 0*< 9? ,00 B1H#CGAD ,+
6L < : ,00 ,+ 6L /* B9#(GAD 5 : ,00 B9#(GAD ,+ )*L,*-+
,M+# BM)*, (@D
:1;+& / =+A 9# (19G#
/. )*L,*-+ ,,*-+< ) /6 P*0,2+# 0 0 **J- 9
/+0 1 /60 ,J0 + NC ,00 B?N#CCAD< 1 /60 0 + 9N ,00
B1C#:AD 9 : /60 + ,+)*4,*-+ 04E+ J ),#BM)*, (?D
:1;+& 0 &@+:>1&+?@ 9# ,< ,)(1#<
0 /. *+/K**J,*-+ 0 F*E4*, F 0 **J+ )+ 50
,/ 6F*8/ + (G( ,00 BHN#1CAD 5 ). 50 6F*8/ + 1N
,00 B1(#HGAD# BM)*, (HD
91
34/ 560*0 7 8 ,20 0+ 3
: 7
:1;+& 2 +@)F+,+H&+?@ A<= D>+1E1:+&
*/ * ) + /* C?#N /*+0< 0*+ + NH#N:
/*+#< 0*+ 0 +40 + 9G 5 (NG /*+0 5 + (GG#1( /*+0< 0*+ 0
+40 + @G 5 :1G /*+0# BM)*, (ND
:1;+& 3 =+#)A A#1=1+
*/ *+/K**J,*-+ 5 * /* 00+0*0 ,*+,**+ + 0
0 ,00< +,+M+0 + /* 19#?C 0< + /* ) 9G#1N
0 +,+M+0 + +4 + ? 5 @G 0< + /* ) 1( 0#
BM)*, (CD
34/ 560*0 7 8 ,20 0+ 3
99
!"# $! % &! ' ())*+,--(
:1;+& 5 =+#)A 9# 1#=+1 9# ,)(1#<
+ (GGA 0 ,00 /* 00+0*0 0 *- + ,+0*0
=+0 5 + + 0 ,*+0#
9? ,00 B1H#CGAD ,*6*+ +,*-+ 0,**J + 26**,*-+
)0*,> + 9: ,00 BC:#:GAD< 5 + 0 1 ,00 B1#(1AD# BM)*, 1GD
:1;+& "6 1#-(+,+=&+?@ #<A#&+,+H9
0 ,00 /*+ )+ 0/*0 + @: ,00 B:(#N?AD 0 )/**0
,*+< 9@ ,00 B1H#9(AD + *,* BD< :G ,00
B9(#GAD 4 0, *# BM)*, 1( 5 11D
9:
34/ 560*0 7 8 ,20 0+ 3
: 7
:1;+& " ID>+J@ A: #, =1=)+#@=K
:1;+& "" ID>+#@ A: #, =1=)+#@= #@ #, -#AK
34/ 560*0 7 8 ,20 0+ 3
9@
!"# $! % &! ' ())*+,--(
9?
34/ 560*0 7 8 ,20 0+ 3
; 8 7
; 8 7
), + 2/< 0 + 40 -00 /M0 ),+0 + *+)+,*# 4+0 0 0 )*+ 0 ,/ ?@A 0 ),0 + /*/6
0* B(D< *+,0 2+4 B1D +0 26 9GA 0 ),0 + 4 G H ;0# + E< ** B9ND +0 ,/+ F 0 ), + +*;0 /M0 ),+
+,0* F*E4*, + < 0*,*-+ ,+)*/ # +M+J +
B,/+*,,*-+ 0+D#
+ 0 ;0 (CCH 5 1GG( 0 +,++ (N? ,*+0 0 + 1 ,+0
20**0< 0* + *, ,*+ E BD 5 0* /4+,*0 *M*,0 BD< ++,* *+*0* E< ,+ ?C 5
((H ,00 0,*K/+#
+,+ + /*+* 2/60 BNGAD< F ,*+,*+ ,+ 0
60K,*+0 ,/ 0 I04**B19D< Q+ B:1D 5 4B:9D< 66/+
0 ,,0*,0 ,*+J +0 6,*-+ + , +*; *+ *J
,*K*0 /M0 60,0 F 0 /L0< F *+ /5 *04 0)*
,,*+0#
/* +,+ ) ?#C@ ;0< /5 0*/* F )* 2+4
B1D< I04** B19D< Q+ B:1D 5 4 B:9D> + =*0*+ *)+,*0 0*4+*)*,*K0
+ /60 20*0#
K ),< 0 60K F @N#1A 0 0*+0 )+ + *JF* 5 :(#NA + ,2< + =*0*+ *)+,* 0*4+*)*,*K + 00<
34/ 560*0 7 8 ,20 0+ 3
9H
!"# $! % &! ' ())*+,--(
0 ,*+,* ,+ 0 0 6+*0 0 0 B19< 9N< :1< :9D 5 =*,0
=*0* + /5 ++,* 0 *00 5 F + /*++ 0 **, ,/
)+0 )+ + 0*,*-+ *4 ,/ *+*, K+ B:1D#
4E+ J ), +,+/0 F ), 0,+ , */
4 ?N#CA< 04* *,+ ,+ 1?#9A 5 0 *,0 ,+ 9#NHA< 00
),+,*0 ,*+,*+ ,+ 0 20 + 0 *0 ++ B(D< ,RY B((D<
2+4 B1D 5 0 B9< :< @< ?< H< N< C< (GD> F /6*.+ + =*0 *)+,* 0*4+*)*,*K
+ /60 20*0 0*0#
/,+*0/ ), 0 + ,*-+ ,+ J< + 0 ),0
0,+0< ,+ 6J + =+0*-+ ,+ */ 4 BC:A 0 ),0
0,+0D< 5 0 ? A + )=*-+ 0*/* 0 0 B(< 1< 9< :< @< 19< :1<D> 0
0*+0 + K 0+ 1?#9A 5 + K4 9#CHA< ,*+M+0 ,+ ), *,-+* 5 *, 0,*K/+< 5 *4 F ,0 +* 0*/*0 * /+* B(< 1< 9< :< N< C< ((D#
$! F $!
+ F ,0+ 0 ),0 =00 +,+/0 N ,00 F F*K+
?#1A < ? 0 * < ( ,0 * 5 0 + * 9< 00 1
E*/0 ,*+0 ,,*+0 M+0* BD 5 ,+ 0 0*+0 0*0./*,0
*/+,*#
9N
34/ 560*0 7 8 ,20 0+ 3
; 8 7
9! @%! '
+ 0 2J40 *+0+0 F +,+/0 0K*+< 0 ,,0*,0
*/ 20**< )*+* ,/ F +0, 0 ,,*+ 20 *+40 20*> */0 60K + /* 9#G? 0 ,+ +40 ( (@
0# + < /* 0 (#? 0< 0 0 =*, 0 /*K0<
*/ 0 * 6,*-+ F 0 /+L< , 0 /5 +*K , F 6,*-+ /*< /*K , ,0 + 0*-+ + 0 +*;0< 0 K+
M*/+ 0 +*0 + + 06,*/*+ 0> 5 + 04+ 4< +,*-+ + 0 60/+ 4* 20 ,,*-+ *+*K*
,0 , ), ,+-/*, )/** + 0 //+ + *+)*
/5/+# 0 ,+* 0 F 0, + < + */ 20** 0 9#? 0< 0*+ +4 + ( 5 (@ 0< F 25 F 0, F
:H#NA 0 ,*+0 4+ 0.0 9 0 0,* ,,*+< 0 0 =*, 0 /*0/0 0 /*K0 F + ,0 +*< */ ),
,,*+< 5 F 4+ 6,*-+ F 0 *+ + 0 ,+ 0 +*K
, 6L 5 /*0/ */ *++ 0 ,0/60 +*40 /5 +*J0 /*K 0+ )M,*/+ *+)+,*60 0 )00 /.*,0 +*00< /*,0 W200X F ++ *+*,* + /*+ 5 F 4< K )/** F 0 +
*+ 00 )K60< ,+ + ,+ 20**< 0 /*K +,+ F
:(#NA ,*+0 F 2 0)* 0 * 0*+0 , + */ 4 + /*, W20X +0 F* +,*-+ /.*,# 04+ ), */+,* 0 ,+-/*,< + ,+ ,+ /*0 ,+-/*,0 ,6* 0 400
F */*, /*+ 0 0 *+*,* 0+ F 6/ 0 W0,*+
0X< + K /L< 0 ,*.+ F ,+ + 06,*/*+ 0# 0 0
K*+,* ,+ *,*-+ 4 0, *< ,+ , +E/ ,*+0 0 *+,/+- 0*4+*)*,*K/+< + F /++ 0 ,,*+0<
34/ 560*0 7 8 ,20 0+ 3
9C
!"# $! % &! ' ())*+,--(
0*+ F + 26 6/ ,+-/*,< 0 ,*+0 + K0 + ,+
20**#
*/ F*E4*,< + *+40 20* 5 //+ ,*-+<
) + /* 1#: 0< 0*+ +4 + ( 5 (N 0# < *+ + /*
( < 0 ,* F ), + 2/ 0 ,+,* ,/ + /4+,*
F 6 0 +* *+/*< 0 0 ,*+,*+ ,+ /,20 0 0 B9< :<
N< ((< 19D< 0 /0 /50 0 6*+ ,//*00 0*0./*,0 ,*+ F
+ /*+ *+K+,*-+# + < 0 0*-+ + 0 ,+0* /4+,*<
/*K 0+,* 20** *+ + /* ? 0< 6* +E/
K ,*+0 5 *00*,*-+ 0 ,*+0< 0 ,0 0 *K F* /4 *+)+*#
*/ 0 F*E4*,< ++* 0 ,*-+ 20 20**< 0
+ /* (#H 0 ,+ +40 ( (1 0< + < /* 0 :#GN@ 0 6* F 0 0 20 0*,*-+ /0*0 + ,*+ , < + +*+4E+ ,0 ) +0 , > + < /* 0 G#N 0< 5 F 0 ,*+< 0* + 2 +* +*+4+
,/*,,*-+< /*0/ ,*4< 0 )+/+/+ ,,* ,/0 20* 5 6/0 ,+-/*,0#
*/ 20**J,*-+ ) + /* :#(N? 0< + < /* 0 (G#9 0< 0 0 =*, 0 J+0 0 + 0 0 +0
+*0< */ F*E4*, +4 5 60K,*-+ 0 F*E4*,< 0 +
*/ *K/+ K 0 4 , *K + + /+
0*4+*)*,*K ,00 20**0# + /* 0+,* 20** )
(#NC9 0 ,+ 0 (:#NCA ,00 0 , #
S0.< K-+ N ;0 F 0) ,< ,+ 5 /+ ,2#
60K )/* /,#
:G
34/ 560*0 7 8 ,20 0+ 3
; 8 7
, 0,+< 0J#
+,*+,* 34/ 560*0 7 8 ,20 0+ 3
:(
!"# $! % &! ' ())*+,--(
,,*-+ ,+ /60 P*0,2+
+,*+,* :1
34/ 560*0 7 8 ,20 0+ 3
; 8 7
0 6/0 *K0 ,,*+ B,/*,,*+0 04E+ 0 0D )+
*+),,*+0 B1#91AD + 9 ,00 + F 0 /+*)0- +0 , F*E4*, 5 1 F 0
/+*)0+ 4 , F*E4*,> + */ ,0 0 ,*)*,- ,/ + ,**0 F
/**- ,+ /*+ +*6*-*,< 0 0 ,00 0*0 )+ + ,**0 5 +
*+),,*-+ 2* * ), =0< 00 2J40 0M+ + ,*-+ ),+,* *+),,*+0 00#
+ 0 ,/*,,*+0 +,+ 0*/+ ) 0J/*+
)4/+ *0< ,,,*-+ *+, 0 /60< +*; K F 0
*+K+*#
+ 0 0*+0 +-4*,0 +,+/0 0 1 0*+0 +K* ,6*<
F*K+0 (#@A< /60 0*0 *+K+,*-+ F*E4*,< /60 +=*0
34/ 560*0 7 8 ,20 0+ 3
:9
!"# $! % &! ' ())*+,--(
K*+,*0 ,/*4)< 0 K* 0*4+*)*,*K/+ ,+ 0 2J40 + 0
*0 + 0 + 20 (?A 0*+0 +K*00< + *+,*/+ ,/
), +K* *< 04* ,6* 5 4 /*+< ,/ IY+ B9@D + (CC: + 0 0* + , (?1 ,*+0 ,+ ),0
0,+0 +,+- 19 0*+0 +K*00< (1 + +K* *< ? + ,6* 5 @
+ /*+< 0 ,0 : +K* ,6* )+ *4.+*,0< 0 K*+ +
/L 0+M+ + 0 : ? /00# 2+4 B1D< 5+0 B9?D 5 5, B9HD
/6*.+ ,+)*/ 0 00 5 44 F 0 0*+0 +K* ,6* 0+ 0 /M0
),+0 4 ,*4< ,+*< 0 0*+0 +K* * 0+ 0 /0
),+0 ,00 * ,,*+#
K*+,*/0 0*+0 K0,0 ,+0*,*-+ + 0+ 0*#
' ?
::
34/ 560*0 7 8 ,20 0+ 3
; 8 7
6%A A ! % &! ?
+ 0 0= 0/+ 0 *< 2 *+*,* + 0K*,*-+ + K4<
F =/+ ,+*,< E+ + 0 K*+,*#
)*=*0 +*6*-*, 0 *J + 99#9A 0 ,00< + 0 0
,+0*4+- + :A 0 ,*+0 5 + + :1#@@A 0 ,*+0< + 0 0
,00 0 **J ,)0*+ */ 4+,*-+ + 4/ *+*,* *+K+,*-+#
0 /5 */+ 0 )*=*0 +*6*-*, + 0 * ),0< /M0 F
0 + ,*4 ,/6/+ */*< 0*/ =*0 *04 *+),,*-+ B((D< + 34/ 560*0 7 8 ,20 0+ 3
:@
!"# $! % &! ' ())*+,--(
< 4+/+ 0 ,+*+ ,+ +*6*-*, 1 9 0 4 *+K+,*-+ K
< /*+0 F + < 0 )* K Q /*0/ */< 5 F ,*+ 0 +,+ 20**J#
0 6L0 K*+ *, ,*-+ ,+ * ),< )**.+0 6L 0* * Q+ < 0 ,* + + +4\ *+4 +*K
,0 0 ),0 0,+0< + 6L 0 ),0 *,-+* 5 + /* 0 ),0 *,< ,/ ,/*++ I+
B9D 5 ,2L*+ B9ND< 00 6L0 /*+ K, 0 2//0 5 ,*++ K*0*-+ * + ,,*-+ /5 +-/*,< 4*+ 0 +K*0 5 K00#
,/+ 04E+ I04** B19D 0 )*+ 6L0 +*0< + 0 *+
=*+,* 06 0#
/. )*L,*-+ **J ) + 0 0 ,00 /6 P*0,2+< 0
0 **J 9 /+0< */ ) ,+ 1 /60 ,J0 *+,*/+ +
),0 0,+0 + ?N#CCA 0 ,00< 0 0 /. F *,*+/+
0 **J< 5 F /* 00+0*0 /5 /; ; ,4 ,,*/*+> 0M + *0,0*-+ , 6 0 0*,*-+ 0 ,K0< L/
R440 B9CD +0 *, F )*L,*-+ ,+ 0 ,K0 0 0 ),*K 0*+0
* + 5 0 ),0 0,+0 2E/ + +*;0# 0 ,K0
0 K*+ 0 0*+0 *4.+*,0 +K* ,6*< )* + **J ,K /* )/ *+* 5 0* 0 6 0< , + 6 0 + 2*)=*-+
+ 0 *+0,*-+# /6*.+ &*+0 B:GD +0 26 F + 00 0*0 **J+
/0 ,K.*,0 /0- F 0* 6*+ / /M0 06 )*L,*-+ 0+ 0
,K0 ,J0< 0 ,K0 0 0+ 04+ /M0 06 5 + 0 *)+,*
/0* */# *+4 B::D +,+ + 00 0*0 00 0*/*0
+ ,K0 0 5 ,J0 + ),0 0,+0# 0 /60 0 0
**J+ ,,*-+ + ),0 *,-+* 5 *,< ,/ ,+0 0*
B:(D< 5++ B:1D 5 Y0 B:9D#
*< +*; @ ;0 F 0) , ,+ 5 +6J *JF*
0*,*-+ *+K+,*-+ F*E4*,
:?
34/ 560*0 7 8 ,20 0+ 3
; 8 7
, 0,+#
+)*4,*-+ 0 /60#
34/ 560*0 7 8 ,20 0+ 3
:H
!"# $! % &! ' ())*+,--(
Q*0 #
+,*-+ */+ /, /*+ ,M+ 0 ),0 2/< F +,+/0 + : ,00 B9#(GAD 0 *J0 + < 0
,/ *+B:@D +0 26 F + + K*0*-+ (NC ),0 0,+0 ,+
/*+ ,M+ N@A K*+ =,+0 00# 2+4 B:?D /6*.+ +0 *,
F 6* 0 0*60 0*+0 +K* ,6* ,, 0 /60< 0 )*6
0 0 1 /60 ,M+0 0> +, B:HD< +0+ B:ND< I5 B:CD
)+*J+ + /0 *,*+ F 0 0 6 /** 0 ,,*-+ 0* 0 6*+ +
M+4 I/+ /+ :] 5 P* B@GD )* F .,+*, *+ + ,K +*JL 4 5 0 /5 0* + 0 ,+ ,+ + *++0*)*, */M4+0#
S4< K-+ H ;0 F 0) + , ,+ 5 / /+
*JF*#
:N
34/ 560*0 7 8 ,20 0+ 3
; 8 7
K*+,* )/* +*K , *JF#
*4+-0*, , 0 ,+#
34/ 560*0 7 8 ,20 0+ 3
:C
!"# $! % &! ' ())*+,--(
,,*-+ ,+ /60 P*0,2+ ,J0
,,*-+ ) ,M+#B K*+,* */4+ *++0*)*,D#
@G
34/ 560*0 7 8 ,20 0+ 3
; 8 7
H S4 0 /*0/ #
*/ 0 * F 0 6K + /* ) C? /*+0< 0*+ + NH /*+0 5 + (GG /*+0< + =*0*+ *)+,* 0*4+*)*,*K +
0< +* ,+ 0 0 ,+0 B19D#
/. *+/K**J,*-+ 0 F*E4*, )+,* 0 50 6 6F*
/ ,+ (G( ,00 BHN#1CAD 5 F + 0 +*;0< 0 ,M,< *+/K**J,*-+ 0
*),* 5 ++ + *04 .=* *+K+,*-+ F*E4*,#
*/ *+/K**J,*-+ 5 * /* ,*+,*+ + 0 0 ,00< /* 0 19#? 0< + 0 + , /5 B9G#1N 0D 6M0*,/+ K/+ ,*+0 /+L0 + ,+0 =+ F *)*, *0/*+* */
+ 0 ,*0# 0 0 *0 0 *J+ + ,+0* =+# 0 /5 */+
*J * /* 00+0*0 5 0 +0 + 0 9 0/+0<
5 F 0 /**M +*; + /K**J,*-+ /+< 5 + +4 *, /5 + /+ */ 0*6 ,/ ,/*+ +0+ B:ND#
26**,*-+ ,*+ 6 *J0 *+/*/+ 0.0 * /* ,/ ,+0L ,2L*+ B9ND# /* 26**,*-+ 0,**J
B*+*, + 0,**0 + /*,*+ )0*, 5 26**,*-+D 0 0 60K- +
1H#CA 0 ,00 5 0/+ + < 0 0 6 F 0 +,*-+ 0
4* 0 ,*+0 0 +0,/*< + ,/6* + + 26 0K*,*
26**,*-+< 00 ,*+0 0+ *K0 0 ,+0 0 0 *+*,
26**,*-+ 0+ + 0 /*,**< /+ 0 ,00 /*+<
4+/+ 0 0 *4+ 0 04+ ,*-+#
,0 /*+ 0 ),0 2/ + 4 0* 0
0/* + :(#N?A 0 *0 0< + 9(@ 0 ,00 4 0,
* 5 + + 1H# 9 A + *,*# 5 F 0, F
+*/+ 4 0, *< /,20 ,*+0 ,+ +,0* F*E4*, +
+ 0< 6* 0 ,00 /*+ 5 0*//+ L6+ 34/ 560*0 7 8 ,20 0+ 3
@(
!"# $! % &! ' ())*+,--(
06,*/*+ 0 B+M+J ,/+*,,*-+ 0+D< 0 6 0, F ,0*
9GA 6,*-+ + F 2, + 4+ 0)J 0,*+ 0 0*-+ 0*//+ L 5 , 0 */*,*+0 F ,/;+ 0 * ),0#
@1
34/ 560*0 7 8 ,20 0+ 3
< < T
0 ),0 + 2/ 0+ /M0 ),+0 + K+0< 0 ?
;0 #
T
),< ,+ /5 ),+,*< 0 *JF*#
T
J ), /M0 ),+ 0 0,+< 04* *,+* 5
4 *,#
T
0 ),0 0,+0 ,*0 /,+*0/ =+0*-+< 0+ /,2
/M0 ),+0 F 0 ,*0 /,+*0/ )=*-+#
T
*/ 20** ,*+ ,+ ), + 2/< 0 /5 + ++,* *+*0* < F + ++,* *, ,*+
E#
T
5 /5 ),+,* ,*+0 F 0*0 0 /*,0 W200X< + 6,*-+ #
T
0+,* 20** + 0 /+ F + #
T
), + 2/ 0 +*;0< 0 ,+0* ,/ + 4+,* + 5 ,/ + 0*-+ F 0 4/ + #
T
+ 6,*-+ 0*< 0 0*+0 K0,0 5 +K*00 , 0
),0 + 2/< 0+ *+),+0#
T
0 6/0 *K0 0 ),0 + 2/ B,/*,,*+0D< 0+
0*/*0 + /60 *+0*,*+0#
34/ 560*0 7 8 ,20 0+ 3
@9
!"# $! % &! ' ())*+,--(
@:
T
)*=*0 +*6*-*, 0*4 0*+ 0 */*< + /60 *+0*,*+0#
T
6L /M0 ),+ + 0 ),0 2/< + J
),* 0* 0,+0< *,+0 5 /* *,0#
T
/* 00+0*0 /M0 0 0 /6 P*0,2+< )/ ,J
K.0 J ),#
T
*+/K**J,*-+ 0 F*E4*, /M0 ),+< 0 50
6F*8/ 6#
T
* /* 00+0*0 0 *J + 0 ,+0*0 =+0<
, 0/+ 0 ,*4#
T
25 + 26**,*-+ **4* 0,**00< + #
T
)/** 0 *+,* 4+*0< + 0/* 0 400 F */*, /*+
0 4#
T
4 0, 4* ,6 + ,+L 0*4+*)*,*K 6,*-+< F 0)
0 * 0*-+#
34/ 560*0 7 8 ,20 0+ 3
00394
00394
Hanlon. CR; Estes WL; Fractures in childhood: A statistical analysis. Am J,: Surg. 87:
312 – 323, 1954.
Cheng, J.C.; Shen, W.Y. Limb fracture pattern in diferent pediatric age groups: A study
of 3500 children. J. Orthop. Trauma. 7: 15 – 22, 1993.
Buhr, A.J.; Cooke, A. M. Fracture patterns. Lancet 1: 531 – 536, 1959.
Puntnam Blount A.B; M.D. F.A.C.S. Fracturas en los niños. Edit. Intermédica Buenos
Aires. Argentina 1979.
Hutchinson, J., On certain obscure sprains of the elbow occurring in young children.
Ann.Surg. 2: 91, 1885.
Ashhurst, A.P.C.: An anatomical and surgical study of fractures of the lower end of the
humerus. Philadelphia. Lea & Febiger 1910.
Carli. C.: Wire traction for supracondylar fracture of the elbow in children (Trazione col
filo nelle fratture sovracondiloide di gomito del bambino) Chir. D. Org.d. movimento,
18: 311. 1933.
Allison, N.: Fractures about the elbow. JAMA, 89: 1568,1927.
Sever, J.W., Fracture of the elbow. JAMA 98:1737, 1932.
Dunlop j. Trans condylar fractures of the humerus in childhood. J. Bone & joint Surg.,
21: 59, 1939.
Roockwood and Green, Fractures in Children. 4th edition in CD. Lippincott – Raven
34/ 560*0 7 8 ,20 0+ 3
@@
!"# $! % &! ' ())*+,--(
Publishers 2000.
Villa Crespo Moisés. Fracturas del humero en su extremidad articular del codo.
UNMSM. T. Br. Lima 1944.
Ríos Higginson Arístides. Fracturas de la epífisis que forman la articulación del codo en
el niño. UNMSM T.Br. 1948.
Severino Aguirre Pedro.: Fracturas de codo de consolidación defectuosa en el niño: su
tratamiento por la resección total o parcial de la paleta humeral. Lima UNMSM T.Br.
1954.
Navarrete Carmelino Enrique.: Fracturas de codo. Lima UNMSM T.Br. 1956.
Lazarte Cárdenas Raúl.: Fracturas de consolidación defectuosa en el niño y su
tratamiento. Lima UNMSM T. Br. 1957.
Bohórquez Valdivieso Nora.: Fractura de codo en niños – Callao. Lima UNMSM T.Br.
1971.
Rosales Chávez Israel.: El tratamiento de la luxación y fractura antigua de codo en el
Hospital Loayza. Lima UNMSM T.Br. 1964.
Fave Bustamante Alfredo.: Las fracturas de epífisis distal del húmero en el HMC. Lima
UNMSM T. Br. 1973.
Asencios Villavicencio Eva.: Fracturas de codo en niños en los años 1985 – 1990 en el
HDAC” Callao UNMSM T. Esp. 1991.
Poco Paredes Edgar.: Fracturas del 1/3 distal del húmero. Lima UNMSM 1994.
Ordaya Luces Ricardo.: Incidencia de fracturas epifisiarias durante 10 años. Lima
UNMSM T.Esp. 1993.
Basagoitia Cárdenas Luis.: Manejo quirúrgico de las fracturas supracondileas en niños.
Lima UNMSM T. Esp. 2000.
Hernández Sampieri Roberto. Metodología de la Investigación. México D.F. 2da.
Edición Edit. Mac Graw Hill 1998.
Mormontoy Laurel Wilfredo. Elaboración del protocolo de Investigación. Lima. 2da.
Edición. Boehringer Ingelheim. 1994. (pag. 35).
Siberstein et al. Some Vagaries of the capitellum J. Bone and join surgery 61A: 244
–247. 1979.
Litchtenberg RP.: A study of 2532 fractures in children. Am journal surgery 87: 330 –
338. 1954.
Graham et al Supracondylar osteotomy of the humerus for correction of cubitus varus. J
pediatric orthoped., 10: 228 – 231. 1990.
Hernandez et al. Corrective osteotomy for cubitus valgus deformity. J.pediatric
orthopedic., 14: 487 – 491. 1994.
Gartland. Managment of supracondylar fractures in humerus in children Surgical
gynecol obstetr.: 109: 145 – 154. 1954.
Rang M.: Children’ fractures. Philadelphia, JB. Lippincott, 1983.
Dodge HS., Displaced supracondilar fracture of the humerus in children. Tratment with
Dunlop traction. JBJS 54A: 1408 – 1418, 1972.
@?
34/ 560*0 7 8 ,20 0+ 3
00394
Kramhoft M; et all: Displaced supracondilar fractures of the humerus in children. Clin
Orthop 221: 215 – 220, 1987.
Flint JC; et al. Prevention and treatment of fractures of the lateral humerla condyle in
children. JBJS 57A: 1087 – 1092. 1975.
Woods, GM; Tullos HG;. Elbow inestability in medial epicondyle fracture. Am J sports
Med. 5: 23 – 30, 1977.
Brown IC, Zinnar DM. Traumatic and iatrogenic neurological complications after
supracondylar humerus fracture in children. J.Pediatric Orthop 1994, 16(5): 678 – 9.
Lyons JP; Ashley E; Hoffer MM;: Ulnar nerve palsies after percutaneous cross pinning
of supracondylar fracture in children elbow. J Pediatr Ortoph 1998, 18(6): 824.
Royce RO; Dutkowsky JP;: Neurologic complications after K-wire fixation of
supracondylar humerus fracture in children. J Pediatr Orthop 1991, 11(2): 191 – 4.
Tachdjan, MS; Ortopedia Pediátrica- Fractura supracondílea del Húmero. Volumen 4.
Pag. 3288 – 3336, 1994.
Skaggs David. Operative treatment of supracondylar fractures of de humerus in
children: The consequences of pin placement. JBJS (am) 83: 735 – 740 2001.
Zionts LE; Mc Kellop HA; Torsional strength of pin configurations used to fix
supracondylar fractures of the humerus in children. JBJS 76: 253 – 56, 1994.
Farsetti P; Long term results of treatment of fractures of medial humeral epicondyle in
children. JBJS (am) 83: 1299 –1305 (2001).
Flynn JC; Prevention and treatment of non union of slightly displaced fractures of the
lateral humeral condyle in children. JBJS 57: 1087 – 92. 1975.
Fawles JV; Displaced fractures of medial humeral condyle in children. JBJS 62: 1159 –
63. 1980
Topping RE; Blanco IS; Davis TJ; Clinical evaluation of crossed –pin vs. lateral –pin
fixation in displaced supracondylar humerus fractures in children. J Pediatr Orthop
1995 15(4): 435 – 9.
Arino VL; Lluch EE; Percutaneus Fixation of supracondylar fractures of the humerus in
children. JBJS 59(7): 914 – 916. 1977.
Cheng JC; Lam TP; Chen WY. Close reduction and percutaneous pinning for type III
displaced supracondylar fracture of the humerus in children from Hong Kong. J orthop
Trauma 1995; 9(6): 511 – 5.
France J; Strong M; Deformity and function in supracondylar fracture of the humerus in
children variously treated by closed reduction and splinting, traction and
percutaneous pinning. J Pediatr Orthop 1992, 12(4): 494 –98.
Aronson DD; Prager BI; Supracondylar fractures of the humerus in children. A modified
technique for closed pinning. Clin Orthp. 1987 Jun 219: 174 –78.
Boyd DW, Aronson DD.Supracondylar farctures of the humerus: a prospective study of
percutaneus pinning. J Pediatr Orthop 1992 12(6): 789 – 94.
Kallio PE; Faster BK; Difficult supracondylar elbow fractures in children: Analysis of
percutaneous pinning technique. J pediatr orthop 1993 13(2): 270.
34/ 560*0 7 8 ,20 0+ 3
@H
!"# $! % &! ' ())*+,--(
@N
34/ 560*0 7 8 ,20 0+ 3
=
=
= ( $A G
D +*K0* ,*+ 5 + ,0#
6D *+*0* E#
,D 0* + *, ,*+ E#
D 0* /4+,*0 *M*,0#
D * 00+0*0#
)D + 0 *,*#
= , 9& A (D ^^^^^^^
1D /6^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
9D ^^^^^^^^^^^^^^^^^^
34/ 560*0 7 8 ,20 0+ 3
@C
!"# $! % &! ' ())*+,--(
:D # +*, ^^^^^^^^^^^^^^^^^^^^^^^^^^^
@D 0* B^D B^D
?D ,2 ,,*+ ^^^^[ ^^^^[ ^^^^
HD ^^^^^^ ;0#
ND = B^D B^D
CD =0*,*-+ * B^D B^D 4 ^^^^^^^^^^^^
(GD J ,+* B^D +,+ B^D 0*+,+ B^D *,+ B^D
*, B^D B^D
((D ,+*0/ ), =*-+ B^D =+0*-+ B^D Q B^D Q4 B^D ,*-+ B^D
B^D
(1D 0**J,*-+
*/ # F=# ^^^^ 0#
*/ 0# F=# ^^^^^ 0#
*/ 20**J,*-+ ^^^^^ 0#
(9D /*,,*+0
+0 0# * B^D B^D K0, B^D K*0 B^D ^^^
0.0 0# * B^D B^D K0, B^D K*0 B^D ^^
(:D /*+ # `=# B^D /*, B^D ). B^D 50 ,/ B^D (@D )*=*0 +*6*-*, * B^D B^D ,M ^^^^^^^^^^^^^^^^^^
(?D 6L *J * B^D B^D 0* B^D +* B^D ^^
(HD .,+*, F*E4*, P*0,2+ 0 B^D J0 B^D ^^^^^^^^^
(ND * *+/K**J,*-+ 0# F*E4*, "0 ,/ B^D ). B^D +B^D
(CD */ *+/K**J,*-+ ^^^^^^ 0#
1GD */ * ^^^^^^^^ /*+0#
1(D */ * ^^^^^^ 0#
11D 4 * B^D ,+0* =+ B^D
19D 26**,*-+ * B^D B^D
1:D `*.+ ,0 /*+ B^D 4 0, B^D /** B^D 0
?G
34/ 560*0 7 8 ,20 0+ 3