儿童四肢长骨骨折弹性髓内钉内固定术后骨折延迟愈合的原因及治疗探讨

Causes and treatments of delayed fracture union after elastic stable intramedullary nailing internal fixation in children with long bone fractures of extremities

目的探讨应用弹性髓内钉(elastic stable intramedullary nailing,ESIN)技术治疗儿童四肢长骨骨折后出现骨延迟愈合的原因及预后,为骨折延迟愈合的治疗提供临床经验。方法回顾性分析江西省萍乡市人民医院小儿外科2015年7月至2020年4月应用ESIN技术治疗四肢长骨骨折,且术后复查发现骨折延迟愈合的9例患儿临床资料,收集患儿年龄、受伤机制、骨折部位、手术方式、出院后管理及后期康复情况等资料,收集针对骨折延迟愈合的原因进行相应治疗后的结果。结果9例患儿中,男6例,女3例;学龄前期(4~6岁)1例,学龄期(7~12岁)6例,青春期(13~18岁)2例;骨折部位:肱骨1例、尺桡骨2例、股骨2例、胫骨4例;高能量损伤(包括车祸伤、高处坠落伤和重物砸伤)7例,低能量损伤(摔伤、扭伤等)2例;开放性损伤3例,闭合性损伤6例;切开复位4例,闭合复位5例。9例患儿经处理后骨折均已完全愈合,愈合时间6~21个月,平均愈合时间10.5个月。2例尺桡骨双骨折延迟愈合患儿经延长石膏固定时间、制动后骨折愈合;2例胫骨骨折延迟愈合患儿经支具保护下适当负重后骨折愈合;1例股骨骨折延迟愈合患儿经取出ESIN改髋人字管型石膏外固定后骨折愈合;1例胫骨、1例肱骨及1例股骨延迟愈合患儿经抗感染、患肢制动后骨折愈合;1例胫骨延迟愈合患儿经断端自体骨植骨+石膏固定处理后骨折愈合。结论不同部位不同类型骨折后骨延迟愈合的治疗方式不同,本组病例采用了加强固定、增加断端应力刺激、抗感染、植骨重建等方法,均达骨性愈合。去除引起延迟愈合的因素、稳定骨折端是治疗成功的关键。

Objective To explore the causes and outcomes of delayed fracture union after elastic stable intramedullary nailing(ESIN)for pediatric long bone fractures of extremities to minimize the occurrence of this complication and provide clinical rationales for managing delayed fracture union.Methods From July 2015 to April 2020,clinical data were retrospectively reviewed for 233 children with long bone fractures of extremities after ESIN.Nine cases of delayed fracture union were found during follow-ups.Age,injury mechanism,fracture site,surgical approach,post-discharge management and subsequent rehabilitation were recorded.For various causes of delayed fracture union,the corresponding treatment was offered.Results Two cases of delayed fracture union of double fracture of radius and ulna healed after prolonged plaster fixation and immobilization.Two cases of delayed tibial fracture union received proper weight bearing under brace protection.One case of delayed fracture union of femoral fracture healed after external fixation of hip with heriform plaster and removal of elastic intramedullary nail.One case of delayed fracture union of tibia(n=1),humerus(n=1)and femur(n=1)healed after anti-infection and immobilization of affected limb.One case of delayed tibial union underwent autologous bone grafting and plaster fixation.Conclusion Treatments of delayed bone union vary for different and different types of fractures.In this cohort,strengthened fixation,greater stress stimulation at broken end,anti-infection,bone graft reconstruction and other means have been adopted for attaining bone union.Removing the influencing factors of delayed healing and re-stabilizing fracture end are vital for successful treatments.