儿童肱骨髁上骨折合并肱动脉损伤的治疗

Treatment of Supracondylar Humerus Fracture with Brachial Artery Injury in Children

目的探讨儿童肱骨髁上骨折合并肱动脉损伤的诊治经验。方法回顾性研究2010年1月至2014年1月收治的10例GartlandⅢ型肱骨髁上骨折合并肱动脉损伤的病例资料。其中8例闭合性骨折均采用前臂外侧切开复位,经皮克氏针内固定。2例开放性骨折清创后,从骨折穿破皮肤处入路,复位后经皮克氏针固定。骨折复位固定后显露肱动脉损伤部位。6例肱动脉痉挛患儿首先解除机械性痉挛,再行局部热敷,药物罂粟碱外膜注射。4例肱动脉断裂者先取出血栓,2例动脉缺损在2 cm以内行断端吻合,2例血管损伤重,修整后动脉缺损5~7 cm,行自体大隐静脉移植,术后抗凝治疗1周。结果术后随访10~18个月,平均15个月。术后4~6周复查,10例肱骨髁上骨折伴肱动脉损伤的患儿均骨折愈合,肢端及前臂血循环恢复良好,无一例发生前臂缺血性肌挛缩。最后一次复查时,10例肘关节活动均良好,伸屈活动范围正常,桡动脉搏动正常,复查血管彩超吻合段血管无狭窄、无假性动脉瘤。结论肱动脉损伤是儿童肱骨髁上骨折最严重的并发症,对可疑有血管损伤者,应仔细连续动态观察,一旦确诊,手术应尽早进行,必要时请血管外科医生辅助手术,早期手术疗效较好。

Objective To discuss the treatment of Supracondylar humerus fracture with brachial artery injury in children. Methods Ten children suffered Supracondylar humerus fractures（Gartland Ⅲ）with brachial artery injury were treated by surgery from January 2010 to January 2014. Eight of them underwent open reduction through the radial approach and k-wire in-ternal fixation. The other two underwent open reduction through the wood approach and k-wire internal fixation. After that,the brachial artery could be explored clearly. Six cases without brachial artery rupture removed the mechanical compression of the brachial artery first,and then local warm compress and outer membrane injection of papaverine were used. The other four cases with brachial artery rupture underwent embolectomy. Two cases with defect less than 2 cm underwent anastomosis. Two cases with defect more than 2 cm underwent the great saphenous vein grafting. After surgery,anticoagulant therapy was used for one week. Results Ten children were followed up with an average duration of l5 months（ranged from 12 to 18 months）. Four to six weeks after operations,X-rays at 4 weeks after operation showed good fracture healing with good bony alignment. On the last follow up,clinical examination revealed a pain free,normal hand function with no vascular deficits. Doppler ultrasound exami-nation were performed and showed unremarkable results. Conclusion Brachial artery injury is one of the most serious compli-cations of supracondylar humerus fracture in children. The patients suspected to have vascular injury should be carefully ob-served. Once diagnose was determined,surgery should be performed as soon as possible. Vascular surgeons can join in the sur-gery if necessary. The efficacy of early surgical treatment is good.