两种手术方法治疗儿童不可复性肱骨髁上骨折的疗效比较

Limited open reduction with internal fixation versus closed reduction with external fixation in the treatment of irreducible supracondylar humerus fractures in children： an outcome comparison

目的 比较有限切开复位克氏针经皮内固定与闭合复位外固定支架外固定治疗儿童不可复性肱骨髁上骨折的疗效.方法 自2012年1月至2014年1月,我们共收治34例儿童不可复性Gartland Ⅲ型肱骨髁上骨折患儿,其中18例行有限切开复位克氏针经皮内固定（内固定组）,16例行闭合复位外固定支架外固定（外固定组）.比较两组患儿的手术时间、术中透视次数、骨折愈合时间、术后3d与2个月时Baumann角的变化及肘关节功能.结果 术后所有患儿均获得随访,时间为12-24个月,平均16.5个月.内固定组手术时间（49.1±6.6）min较外固定组（72.3±12.6）min短,术中透视次数（3.6±0.9）次较外固定组（10.1±2.0）次少,差异均有统计学意义（P＜0.05）.两组患儿均在术后4周获骨折临床愈合,术后2个月获骨性愈合.内固定组术后3d与2个月时Baumann角变化（2.4±1.3）°与外固定组（6.1±2.1）°比较,差异有统计学意义（P＜ 0.0001）.按照Flynn肘关节评分标准评定疗效：术后3个月内固定组优良率为27.8％（5/18）,外固定组为25.0％（4/16）;术后1年内固定组优良率为99.4％（17/18）、外固定组为81.3％（13/16）.两组患儿均无骨折延迟愈合、骨筋膜室综合征及医源性血管神经损伤等并发症.结论 有限切开复位克氏针经皮内固定与闭合复位外固定支架外固定治疗儿童不可复性Gartland Ⅲ型肱骨髁上骨折,骨折愈合时间相同,但前者可获得更满意的复位、更稳定的固定、更好的肘关节功能,而且手术时间短,术中透视次数少.

Objective To compare the clinical results of treating irreducible supracondylar humerus fractures （Gartland type Ⅲ） in children with limited open reduction and internal fixation versus closed reduction with external fixator.Methods The clinical data of 34 pediatric patients who had been treated for supracondylar humerus fractures （Gartland type Ⅲ） from January 2012 to January 2014 were available for retrospective analysis.Eighteen patients were treated with limited open reduction via a limited medial or lateral incision followed by percutaneous Kirschner wire fixation （internal fixation group）.The other 16 patients were treated with closed reduction followed by application of an external fixator （external fixation group）.Surgery time,intraoperative radiography frequency,fracture healing time,the change of Baumann angle at 3 days and 2 months postoperatively,and elbow function were compared between the two groups.Results All the patients received a mean follow-up of 16.5 months （range,12 to 24 months）.Compared with the external fixation group,the internal fixation group needed significantly shorter average surgery time （49.1 ± 6.6） minutes versus （72.3 ± 12.6） minutes and significantly lower average intraoperative radiography frequency （3.6 ± 0.9） times versus （10.1 ± 2.0） times （P 〈 0.05）.All the fractures achieved clinical healing at 4 weeks postoperatively and bone union at 2 months postoperatively.The change of Baurnann angle between 3 days and 2 months postoperatively was （2.4 ± 1.3）° on average in the internal fixation group and （6.1 ± 2.1）° on average in the external fixation group,with a significant difference （P 〈 0.0001）.Evaluation of elbow function using the Flynn elbow scoring system at 3 months postoperatively revealed a 27.8% （5/18） good to excellent rate in the internal fixation group and 25.0% （4/16） in the external fixation group.The good to excellent rate increased to 99.4%（17/18） in the internal fixation group and to 81.3% （13/16） in the external fixation group at 12 months postoperatively.There were no complications such as delayed union,compartment syndrome or iatrogenic lesions to vessels and nerves.Conclusion In the treatment of pediatric irreducible supracondylar humeral fractures （Gartland type Ⅲ）,both limited open reduction with internal fixation and closed reduction with external fixation can lead to fracture healing within similar time.Limited open reduction with internal fixation can achieve more satisfactory reduction and more stable fixation,and can result in shorter operative time,lower intraoperative radiography frequency and better elbow function.