闭合复位克氏针内固定治疗肱骨髁上骨折术后摄片的必要性和内固定松动的风险因素分析

Feasibility of reducing perioperative radiography--analysis of risk factors for internal fixation loosening after closed reduction and internal fixation with Kirschner wire for supracondylar fracture of the humerus in children

目的探究闭合复位克氏针内固定治疗肱骨髁上骨折术后摄片的必要性和内固定松动的风险因素。方法回顾性分析2019年1月1日至2021年12月31日复旦大学附属儿科医院骨科采用闭合复位克氏针内固定治疗的502例肱骨髁上骨折患者资料。男307例,女195例;年龄为(60.0±27.2)个月;骨折Gartland分型:Ⅱ型224例,Ⅲ型278例。随访中有52例发生松动(设为内固定松动组),余未发生内固定松动的460例设为内固定未松动组。测量并比较患者在术中与术后围手术期的肘关节X线片上克氏针间夹角(夹角1、夹角2)、克氏针有效固定比值(比值1、比值2、比值3)、干骺端骨干角α、肱骨远端前倾角β。收集其他可能影响内固定松动的数据,利用logistic回归分析肱骨髁上骨折闭合复位内固定术后出现内固定松动的危险因素。结果术中、术后围手术期X线片示,克氏针间夹角1、夹角2(26.58°±14.22°vs.26.75°±10.70°,41.85°±8.67°vs.41.31°±7.79°)、克氏针有效固定比值1、比值2、比值3(0.904±0.182vs.0.887±0.206,0.897±0.119vs.0.895±0.142,0.890±0.035vs.0.889±0.076)、干骺端骨干角α(86.25°±2.74°vs.85.52°±1.86°)、肱骨远端前倾角β(31.04°±0.97°vs.29.54°±0.45°),以上项目术中与术后围手术期比较差异均无统计学意义(P>0.05)。通过logistic回归分析显示,骨折部位(P=0.032)、骨折分型(P=0.041)和术后感染(P=0.004)是造成内固定松动的危险因素。结论肱骨髁上骨折闭合复位克氏针内固定术在围手术期间固定牢靠,无骨折移位的风险,术后可考虑不再摄X线片。随访中内固定松动的风险与骨折部位、骨折分型和术后感染呈正相关。

Objective To explore the necessity of perioperative radiography by analyzing the risk factors for internal fixation loosening after closed reduction and internal fixation with Kirschner wire for supra-condylar fracture of the humerus in children.Methods Retrospectively analyzed were the 502 patients with supracondylar fracture of the humerus who had been treated at Department of Orthopedics,Children's Hospital of Fudan University by closed reduction and internal fixation with Kirschner wire from January 1,2019 to December 31,2021.There were 307 boys and 195 girls,with an age of(60.0±27.2)months.There were 224 Gartland typeⅡsupracondylar fractures and 278 Gartland typeⅢsupracondylar fractures.Follow-ups revealed internal fixation loosening in 52 cases(set as a loosening group)and no internal fixation loosening in the other 460 cases(set as a non-loosening group).The angles between Kirschner wires(angle 1 and angle 2),the effective fixation ratios of the Kirschner wire(ratio 1,ratio 2,and ratio 3),the metaphyseal shaft angleα,and the distal anteversion angle of the humerusβwere measured on the perioperative and postoperative elbow X-ray films and compared.Other data affecting the internal fixation loosening were collected.Multiple logistic regression was used to analyze the risk factors for internal fixation loosening after closed reduction and internal fixation of supracondylar fracture of the humerus.Results There were no significant differences between the intraoperative and postoperative data in the angle 1 or angle 2 between Kirschner wires(26.58°±14.22°versus 26.75°±10.70°;41.85°±8.67°versus 41.31°±7.79°),the effective fixation ratio 1,2 or 3 of Kirschner wire(0.904±0.182 versus 0.887±0.206;0.897±0.119 versus 0.895±0.142;0.890±0.035 versus 0.889±0.076),the metaphyseal shaft angleα(86.25°±2.74°versus 85.52°±1.86°),or the distal anteversion angle of the humerusβ(31.04°±0.97°versus 29.54°±0.45°)(all P>0.05).Multiple logistic regression analysis showed that fracture site(P=0.032),fracture classification(P=0.041)and postoperative infection(P=0.004)were the risk factors for internal fixation loosening.Conclusions As supracondylar fractures of the humerus remain stable in the perioperative period with little risk of fracture displacement or internal fixation loosening after closed reduction and internal fixation with Kirschner wire,postoperative radiography is not necessary.The risks for internal fixation loosening are positively correlated with fracture site,fracture type and postoperative infection.