儿童陈旧性孟氏骨折不同手术方式的临床疗效探讨

Exploration of the outcomes of different operative methods for old Monteggia fractures in children

目的探讨3种不同手术方式治疗陈旧性孟氏骨折的临床疗效。方法回顾性研究了2006至2012年，在我科接受手术的55例陈旧性孟氏骨折患者的病例。按Bado分型，I型33例，II型2例，III型20例。入院时，7例患儿有桡神经损伤症状。治疗前3组患者在年龄、性别、受伤时间、骨折类型、伴随神经损伤与否等临床资料方面，差异无统计学意义（P＞0.05），具有可比性。根据入院后患者接受的手术方式将患者分为3组，其中A组：24例，行改良Hirayama尺骨截骨、掌长肌腱重建环状韧带术。B组：17例，行改良Hirayama尺骨截骨、克氏针固定肱桡关节术。C组：14例，行改良Hirayama尺骨截骨术。所有伴随桡神经损伤症状的患儿，均未给予特殊治疗。结果51例获得随访（随访率为92.7%），A组23例，B组16例， C组12例，随访7～32个月，平均18.27个月。所有切口均一期愈合，骨折按期愈合，损伤的桡神经获得恢复。A组出现2例不良并发症（8.7%）：1例前臂旋转功能受限（旋前75°，旋后45°），1例桡骨头半脱位；B组出现1例不良并发症（6.3%）：术后3周克氏针断裂；C组出现6例不良并发症（50.0%）：2例桡骨头半脱位，4例桡骨头全脱位。A组及B组不良反应发生率均少于C组，差异有统计学意义（P＜0.017），A组不良反应发生率少于B组，差异无统计学意义（P＝1.000）。术后6个月，A组患者肘关节MEPI积分较术前平均增加30分，高于B组16.3分（P＝0.000）及C组24.4分（P＝0.048），差异均有统计学意义，B组患者MEPI积分较术前平均增加16.3分，低于C组24.4分（P＝0.001），差异均有统计学意义。结论改良Hirayama尺骨截骨加掌长肌腱重建环状韧带术治疗儿童陈旧性孟氏骨折优于单纯行Hirayama尺骨截骨术及联合克氏针固定肱桡关节术。

Objective To explore the outcomes of 3 different operative methods in the treatment of old Monteggia fractures. Methods From 2006 to 2012, 55 patients with old Monteggia fractures underwent surgical treatment in our Department, whose clinical data were retrospectively studied. According to the Bado classiifcation system, there were 33 cases of type I, 2 cases of type II and 20 cases of type III. On admission, 7 children were diagnosed with radial nerve injury. Before the treatment, there were no signiifcant differences among the 3 groups in clinical data such as the age, gender, injury time, fracture type, with or without nerve injury and so on （ P〉0.05 ）, which were comparable. All patients were divided into 3 groups according to their different operative methods. Group A （ n=24 ） were treated with modiifed Hirayama ulnar osteotomy and annular ligament reconstruction with the palmaris longus tendon. Group B （ n=17 ） were treated with modiifed Hirayama ulnar osteotomy and Kirschner wire （ K-wire ） ifxation of the humeroradial joint. Group C （ n=14 ） were only treated with modiifed Hirayama ulnar osteotomy. No special treatment was given to the children with radial nerve injury. Results 51 patients were followed up for an average duration of 18.27 months （ range;7-32 months ）, and the follow-up rate was 92.7%. There were 23 cases in Group A, 16 cases in Group B and 12 cases in Group C. All incisions were primary healing, and fracture union was achieved on schedule. The symptoms of radial nerve injury were relieved. 2 patients in Group A had bad complications （ 8.7%）. Limited forearm rotation occurred to 1 patient （ 75° of pronation, 45° of supination ）, and radial head subluxation to the other. 1 patient in Group B had bad complications （ 6.3%）, whose K-wire was broken 3 weeks after the operation.6 patients in Group C had bad complications （ 50.0%）. Radial head subluxation occurred to 2 patients, and radial head dislocation to the other 4 patients. The incidences of adverse reaction in both Group A and Group B were lower than that in Group C, and the differences were statistically signiifcant （ P〈0.017 ）. The incidence of adverse reaction in Group A was lower than that in Group B, and the differences were not statistically signiifcant （ P=1.000 ）. The Mayo elbow performance index （ MEPI ） in Group A was increased by 30 points on average 6 months after the operation, when compared with that before the operation. This index was higher than that in both Group B （ 16.3 points ） （ P=0.000 ） and Group C （ 24.4 points ） （ P=0.048 ）, and the differences were statistically signiifcant. The MEPI in Group B was increased by 16.3 points on average, when compared with that before the operation. This index was lower than that in Group C （ 24.4 points ） （ P=0.001 ）, and the differences were statistically signiifcant. Conclusions The modiifed Hirayama ulnar osteotomy plus annular ligament reconstruction with the palmaris longus tendon is superior to only modified Hirayama ulnar osteotomy and modified Hirayama ulnar osteotomy plus K-wire fixation of the humeroradial joint in the treatment of old Monteggia fractures in children.