超声技术引导闭合穿针保护尺神经治疗儿童肱骨髁上骨折

An ultrasound-assisted technique to protect ulnar nerve in blind-pinning of displaced pediatric supracondylar humerus fractures

目的探讨在治疗肱骨髁上骨折时利用超声技术探查尺神经的位置,以提高内侧穿针时尺神经安全性的效果观察。方法对我科于2012年2月至2014年5月收治的53例移位的肱骨髁上骨折患儿进行了肱骨内侧穿针的前瞻性研究。其中,男33例,女20例;年龄为1~13岁,平均为(5.3±0.4)岁。GartlandⅡ型18例,GartlandⅢ型35例。患儿均无尺神经损伤,开放复位4例,闭合复位49例。对患儿骨折复位后进行了交叉穿针技术固定,术中使用超声引导内侧穿针,以避免尺神经损伤。记录术中神经血管的状态和并发症情况,观察患儿愈合情况和愈合时间。超声观察术中、术后情况:术中尺神经和固定针的位置关系,术后有无尺神经损伤的临床症状和表现。结果术中使用超声检查,能够清楚地观察到肘管解剖形态,尺神经能得到清楚的显示。屈肘10°时,患儿使尺神经在肘管内松弛,在超声引导下顺利完成骨折内侧穿针。术中没有病例发生尺神经损伤。患儿术后均获得随访,随访时间为6~24个月,平均为(16.2±9)个月。患儿骨折全部愈合,愈合时间为2.7~3.1个月,平均为(2.9±0.2)个月。结论目前在操作技术上有较高的要求,但其可以准确地显示尺神经位置、引导穿针,可以有效地提高尺神经安全性,故我们认为超声技术是引导肱骨髁上骨折治疗时内侧穿针的有效工具。

Objective To improve the safety of ulnar nerve in the medial-pinning of displacedsupracondylar humerus fractures while utilizing ultrasound-assisted imaging to probe the location of the ulnarnerve. Methods Fifty-three children [including 33 boys and 20 girls with a mean age of 5.3±0.4 years old(range from 1-13 years old), with displaced supracondylar humerus fracture were prospectively studied fromFebruary, 2012 to May, 2014. There were 18 cases of Gartland type-Ⅱ fractures and 35 cases of Gartland type-Ⅲ fractures. Ultrasound was used to guide fracture reduction and percutaneous pinning to protect the ulnarnerve. Forty-nine fracture reductions were effectively accomplished with the assistance of ultrasound and openreduction was needed in 4 cases. With the assistance of intraoperative ultrasound, the pin was drilled to avoidthe ulnar nerve injury. The intraoperative neurovascular status and complications were recorded. The conditionof the healing and the healing time of the children were observed. The intraoperative and postoperativecondition of the ulnar nerve and the position of the fixed needle were observed by ultrasonography. The clinicalsymptoms and manifestations of ulnar nerve injuries were observed after operation. Results Elbow tunnelanatomical morphology could be clearly observed and ulnar nerve could be clearly displayed while undergoingultrasound in operation. With the elbow flexion of 10 degrees, medial pinning was effectively accomplished in53 fracture fixations and satisfactory results were confirmed by radiographs postoperatively. None suffered ulnarnerve dysfunction after using the ultrasound-assisted technique. All the patients were followed up for 6-24months(mean 16.2±9 months). All the fractures healed, and the healing time was 2.7-3.1 months(mean 2.9±0.2months). Conclusion Because the orientation of ulnar nerve could be detected accurately under ultrasound,the safety of ulnar nerve in the medial-pinning of displaced supracondylar humerus fractures could be improvedeffectively. Although technically demanding, ultrasound-technique may be an effective means to carry out themedial pinning in pediatric supracondylar humerus fracture.