大龄儿童股骨颈骨折的治疗

Treatment of femoral neck fractures in adolescence

目的对年龄大于10岁、有移位的股骨颈骨折患儿，采用早期复位、关节囊减压、骨折解剖复位、坚强内固定术治疗，观察在降低或避免股骨头坏死发生的作用。方法13例有移位的大龄儿童股骨颈骨折。参照Delbet分型，Ⅰ型（股骨头骨骺滑脱）1例，Ⅱ型（经颈骨折）7例，Ⅲ型（股骨颈基底骨折）4例，Ⅳ型（股骨颈转子间骨折）1例。因Ⅰ、Ⅳ型仅各有1例，未包括在本研究内。余Ⅱ型和Ⅲ型的11例中，患儿的平均年龄为11岁4个月（9岁7个月～14岁）。男女之比为9：2。治疗方法是于伤后48h内在麻醉下，仅尝试一次闭合复位，以避免多次反复对位加重损伤致股骨头坏死。如闭合复位满意，用180针头抽吸关节囊内积血；如不成功，则立即行切开复位。当达到解剖复位后，用2～3枚空心螺钉固定，螺钉均不穿过骺板。结果11例中，2例为一次闭合复位成功，余9例一次闭合复位不满意后行切开复位。11例患儿均获得随访，平均随访时间为37个月，全部患儿的骨折均愈合，11例无股骨头坏死发生。本组Harris评分平均为96～100分。11例Trendelenburg征均阴性，无下肢不等长和髋内翻，家长对治疗结果满意。结论大龄儿童股骨颈骨折的治疗，在伤后48h内，经一次闭合复位或切开复位，使骨折达到解剖复位、空心螺钉固定；抽吸或直视下清除关节囊内瘀血，缓解、降低关节囊内压力，可以避免股骨头颈部血运的再损伤，减少和降低股骨头坏死的发生率。

Objective To investigate the therapeutic results of femoral neck fractures in adolescence. Methods From March of 2001 to February of 2004, 13 older children with femoral neck fractures with displacement were treated in our hospital. According to Delbet classification, type Ⅰ in 1, type Ⅱ in 7, type Ⅲ in 3, type Ⅳ in 1. Type Ⅰ and Ⅳ were excluded in this study. There were 9 boys and 2 girls with a mean of 11.4 years old. Manipulative reduction was attempted only once under satisfactory anesthesia within 48 hours after injury to prevent damage to the blood supply. If the reduction is successful, aspirate the hematoma from the hip capsule, immediate open reduction if unsuccessful and the fractures were immobilized by 2 or 3 hollow-screws. Cares were taken not to penetrate the premature physeal. In follow-up period, avascular necrosis （AVN） was investigated according to the Ratliff classification. Results Of the 11 cases, 2 received closed reduction, and the other 9 underwent operative fixation. Hinges between the proximal segment of the fractures and the hip capsule were seen during operation, they might result in the closed reduction failure. The average hematoma aspirated from hip capsule after closed reduction was 25ml, while the figure is 40 in open reduction. The implants were removed 10- 14 months after surgery. All 11 patients were followed up （mean time 37 months）. All fractures healed without AVN. The Harris score was 96 - 100 in the group, Trendlenburg signs were all negative, limb length discrepancy and coax vara were not noted, the parents were satisfied with the outcomes. Conclusions This study shows that closed or open reduction and hollow-screw fixation to treat femoral fractures in adolescence can get the satisfactory results without occurrence of AVN.