不同复位质量的儿童肱骨髁上骨折对闭合穿针固定的要求

Pin fixation in supracondylar humeral fractures of children with different closed reduction quality

目的探讨不同复位质量的儿童肱骨髁上骨折闭合穿针固定后再移位原因并提出相应的预防措施。方法回顾2005年1月～2009年9月,采用闭合复位经皮穿针内固定治疗的603例Ⅲ型儿童肱骨髁上骨折患者,年龄1～14岁(平均7岁)。全部患者术中均获得解剖复位或功能复位。受伤至手术的时间:1周以内者507例,解剖复位435例,功能复位72例;超过1周者96例,解剖复位50例,功能复位46例。分别于术后3d、10d、3周或4周拍片复查。骨折位置与术中位置不符者归为再移位病例,共36例。按照Sankar分类,穿针失误26例,发生再移位17例,无穿针失误577例,发生再移位19例。107例无穿针失误的功能复位2枚穿针38例,再移位9例;3枚穿针69例,再移位3例。对于上述分类统计的数据采用x2检验进行统计学分析,P<0.05被认为具有统计学差异。结果伤后1周内治疗者解剖复位率(86%)明显高于1周后治疗者(52%)。穿针失误的再移位率(65%)明显高于无穿针失误者(3.3%);对于无穿针失误的功能复位者,2枚针的再移位率(24%)明显高于3枚针(4.3%),差异均具有统计学意义。结论对于儿童Ⅲ型肱骨髁上骨折应尽早闭合复位经皮穿针内固定,这样有利于实现解剖复位,增加内在稳定性。对于解剖复位者,避免穿针失误,即可获得骨折位置的稳定。而对于功能复位者,3枚针固定的稳定性优于2枚针。

Objective To identify the causes leading to re-displacement after pin fixation of supracondylar humeral fractures in children with different closed reduction quality and to present methods for prevention. Methods 603 cases of type Ⅲ supracondylar humeral fractures that had been treated with percutaneous pin fixation were evaluated. The average age was seven years old （ranging from one to 14 years old）. Pin configuration, intraoperative alignment after fixation, change in alignment were examined during follow-up. All achieved anatomic or functional reduction. Postoperative re-diplacement occurred in 36 cases, in which 17 cases were from 26 cases identified as pin-fixation errors according to Sankar classification, and 19 cdases were from 577 cases identified as no pin-fixation errors. There were 435 cases of anatomic reduction and 72 cases of functional reduction in 507 cases treated within one week, 50 cases of anatomic reduction and 46 cases of functional reduction in 96 cases treated over one week. Among the 107 cases of functional reduction without pin-fixation errors, there were nine displacement cases from 38 cases with two-pin fixation, three displacement cases from 69 cases with three-pin fixation. The data was analysed by Z2 test, P 〈 0. 05 was selected as significantce. Results The rate of anatomic reduction was higher in cases treated within one week （86%） than that in cases over one week （52%）. The rate of postoperative displacement was higher in cases with pin-fixation errors （65%） than that in cases without pin-fixation errors （3.3%）. When the functional reduction was analysed alone, the rate of postoperative displacement was higher in cases with two-pin fixation （24%） than that in cases with three-pin fixation （4.3%）. There were statistic differences in data above. Condusions Early treatment was recommended for type D[ supracondylar humeral fractures to obtain anatomic reductions. The stability can be maintained for the anatomic reductions if the pin-fixation errors are avoided. For the functional reduction, the stability with three-pin fixation ia better than that with two-pin fixation.