青少年屈曲型胫骨近端骨骺骨折的治疗体会

Treatment of flexion-type fractures of proximal tibial physis in adolescents

目的介绍青少年屈曲型胫骨近端骨骺骨折的临床特点及治疗，评价MRI在该骨骺骨折中的临床应用价值。方法2007年1月至2011年7月，我院共诊治屈曲型胫骨近端骨骺骨折7例，男6例，女1例，年龄11～16岁，平均（14．1±1．6）岁，体质量55．4～70．1妇，平均（60．8±4．5）k，平均体质量指数（BMI）24．3，左侧1例，右侧6例。体检患膝屈曲位，肿痛伴活动受限，2例患肢末梢冰凉，伴麻木感，足背动脉搏动较健侧减弱，足趾活动正常。膝关节X线片诊断为屈曲型胫骨近端骨骺骨折：Salter-HarrisI型2例、Ⅱ型5例。急诊完善术前MRI检查，2例原X线片诊断为Salter-HarrisⅡ型骨折，MRI显示骨折线延伸至关节面，且移位〉2mm，急诊行切开复位螺钉加压固定；其余5例均全麻下闭合复位交叉克氏钢针固定。术后平均随访时间16个月。对术后健侧、患侧膝关节活动度均值进行成组的t检验。结果2例可疑合并血管神经受压病例分别于伤后3．0h和4．5h行急诊手术，术后2h足趾恢复温暖红润，足背动脉搏动有力，术后第2天足趾麻木感均消失。所有患儿术后随访摄片提示骨折愈合好，患膝关节活动无明显受限，与健侧比较，差异无明显统计学意义（P〉0．05）。术后双下肢全长轴线片及双侧膝关节MRI对比，未发生膝关节内外翻、骨骺早闭及关节不稳定等并发症。结论胫骨近端骨骺骨折临床较少见，好发于肥胖青少年，建议术前常规完善MRI检查，可进一步明确骨折分型、关节面及骨骺损伤程度，在避免漏诊的同时可为手术方案的选择提供客观依据。该类型骨折即使得到及时合理的治疗，但作为骨骺骨折，仍有生长紊乱的潜在威胁，所有病例应继续随访至骨骺闭合。

Objective To explore the clinical characteristics and treatment of flexion-type fractures of proximal tibial physis in adolescents and assess the clinical application value of magnetic resonance imaging （MRI） in epiphyseal fractures. Methods From January 2007 to July 2011, 7 cases of flexion- type fractures of proximal tibial physis, were diagnosed and treated at our hospital. There were 6 males and i female with a mean age of 14. 1 （11-16） years. And the involved sides were left （n= 1） and right （n= 6）. Their mean weight was 60. 8 （55.4-70. 1） kg with a mean body mass index （BMI） of 24. 3. Physical examination indicated that all knees were in flexion position, painful and swelling with activity limitation. Two cases had cold and numb peripheral extremities with weaker dorsalis pedis artery pulse than normal side. However the activity of toe remained normal. Knee radiographs showed flexion-type fractures of proximal tibial physis. According to the classification of Salter-Harris epiphyseal fractures, there were Salter-Harris type I （n= 2） and type Ⅱ （n= 5）. Emergency MRI examination showed the fracture line extended to articular surface in 2 cases incorrectly diagnosed as Salter-Harris type Ⅱ by plain film. Both underwent open reduction and screws fixation while the reminder closed reduction and pin fixation under general anesthesia. The follow-up period was 16 months. Grouped t test was performed for the mean postoperative activity of bilateral knee joints. Results Emergency surgery were performed in 2 cases with suspected combined vascular and nerve compression at 3 and 4. 5 hours post- injury respectively. Two hours later, peripheral blood supply of affected extremity became normal with warm toes and strong arterial pulse. And toe numbness disappeared the next day. The follow-up plain film showed all of them recovered well, without significant limitation of affected knee. And there was no significant difference compared with unaffected side （P〉0. 05）. Radiology of lower extremities and postoperative bilateral knee MRI showed no complications of premature epiphyseal closure, genu valgum, genu varum or joint unstablity. Conclusions Flexion-type fractures of proximal tibial physis are uncommon and tend to occur more in obese adolescents. MRI examination should be recommended as a routine preoperative procedure. The cases of flexion-type fractures of proximal tibial physis should be followed up until epiphyseal closure due to potential growth disorders.