儿童陈旧性孟氏骨折的手术治疗

Missed Monteggia fractures in children： pathological mechanism and surgical treatment

目的探讨尺骨截骨后成角延长钢板内固定或单臂外固定两种方法治疗儿童陈旧性孟氏骨折的疗效及相关影响因素。方法回顾性分析2005年7月至2011年6月收治的儿童陈旧性孟氏骨折患儿19例，男11例，女8例。BadoⅠ型13例，Ⅲ型6例。按照尺骨截骨后固定方法分为钢板内固定组（12例，治疗时平均年龄为5．3岁，受伤时间平均为6．8个月；BadoⅠ型9例，Ⅲ型3例）和单臂外固定组（7例，治疗时平均年龄为11．8岁，受伤时间平均为16．6个月；BadoI型4例，Ⅲ型3例）。对两组患儿的年龄、受伤时间、术后并发症、肘关节与前臂旋转功能、骨折愈合时间等指标进行比较。结果19例患儿均获随访，平均10个月（6-36个月）。术后钢板内固定组1例发生桡骨头再脱位，单臂外固定组1例发生筋膜室综合征。钢板内固定组、单臂外固定组两组患儿除1例外，术后屈肘功能平均120°（110°-130°），前臂旋前功能均有15°（10°-20°）的受限。尺骨截骨成角延长后的愈合时间：钢板内固定组平均8周（6-15周），单臂外固定组平均22周（10-44周）。按Nakamura等影像学评估标准：钢板内固定组优11例（图1），差1例；单臂外固定组7例均为优。结论尺骨截骨成角延长是治疗儿童陈旧性孟氏骨折矫正尺骨骨折后畸形的关键，截骨后的两种固定方法不同、目的相同。术前评估最重要：年龄小、受伤时间短患儿选择钢板内固定，而对年龄大、受伤时间长者选择单臂外固定。

Objective To evaluate and compare the outcomes of missed Monteggia fractures in children treated with ulnar angulation-distraction osteotomy and plate fixation or external fixation. Methods Nineteen patients, including 11 boys and 8 girls who presented with missed Monteggia fracture, were reviewed from July 2005 to June 2011. Twelve children （Group A） were treated with ulna angulation osteotomy and plate fixation, and 7 cases （Group B） with ulna angulation-distraction osteotomy and external fixator. Thirteen patients were classified as type Bado I, and six as type Bado III. The age, the delay from injury to surgery, complications, elbow and forearm function, and the healing time of the osteotomy were compared. Results All 19 patients were followed up. The duration of missed dislocation was from 6 to 36 months （mean, 10 months）. Redislocation of the radiocapitellar joint occurred after surgery in one case in group A. Forearm compartment syndrome occurred in one case after surgery in group B. All patients, except one, regained full elbow flexion in group A and B, various forearm pronation limitation were noted in all patients （mean, 15°）. The average healing of osteotomy of group A and B was 8 weeks （6-15 weeks） and 22 weeks （10-44 weeks）. Conclusion The ulnar angulation-distraction osteotomy could correct the ulnar deformity in children of missed Monteggia fractures, which is the key issue to be corrected. Both of the fixation strategies can obtain the same treatment results. Preoperative assessment is most important, plate internal fixation was recommended for young age and short delay cases, on the contrary, we prefer to choose external fixator.