3种不同方法治疗大龄儿童不稳定尺桡骨远端骨折的对比研究

Contrastive study of three different treatments of unstable distal ulna and radius fractures in older children

目的:比较手法复位石膏固定、闭合复位经皮克氏针固定、切开复位接骨板联合弹性髓内针内固定治疗大龄儿童不稳定尺桡骨远端骨折的临床疗效。方法:回顾性分析2014年1月至2017年12月南京医科大学附属儿童医院骨科收治并获随访的110例大龄儿童不稳定尺桡骨远端骨折的临床资料。男73例,女37例;年龄(11.6±2.3)岁(10~14岁)。按照治疗方式不同,分成手法复位石膏固定组(手法复位组48例)、闭合复位经皮克氏针固定组(经皮克氏针组,35例)与切开复位接骨板联合弹性髓内针内固定组(切开复位组,27例)。3组患儿骨折复位术后均采用肘下短臂前后石膏托外固定,骨折愈合后拆除石膏,行患肢腕关节功能训练。对3组患儿的手术时间、治疗费用、骨折愈合时间、骨折再移位率及腕关节功能进行统计学分析。结果:3组患儿术前一般资料比较差异均无统计学意义(均P>0.05)。手法复位组、经皮克氏针组、切开复位组手术时间分别为(20.2±8.4)min、(35.4±12.2)min、(68.5±20.4)min,骨折愈合时间分别为(42.1±3.8)d、(44.2±4.3)d、(48.4±5.3)d,治疗费用分别为(2000.4±551.3)元、(8000.2±1151.6)元、(20010.7±2453.3)元。3组手术时间及治疗费用比较差异均有统计学意义(χ^2=11.226,F=58.427,均P<0.05)。患儿均获6~18个月[(11.2±3.7)个月]随访。术后3个月随访时腕关节功能按Berton愈后评价标准,手法复位组、经皮克氏针组、切开复位组优良率分别为89.6%(43/48例)、91.4%(32/35例)、92.6%(25/27例)。手法复位组有6例患儿术后2周内出现骨折再移位。出现针尾激惹症状4例(经皮克氏针组3例,切开复位组1例)。患儿骨折均顺利愈合,随访过程中均未发现骨不连及医源性神经损伤等并发症。结论:手法复位石膏固定、闭合复位经皮克氏针固定、切开复位接骨板联合弹性髓内针内固定治疗大龄儿童尺桡骨远端骨折,术后腕关节功能评估上无差异。手法复位术后骨折再移位率高;切开复位手术创伤大,治疗费高;闭合复位经皮克氏针具有微创、手术时间短、骨折再移位率低等优点,是治疗大龄儿童不稳定尺桡骨远端骨折的优先选择。

Objective To compare the clinical effect of manual reduction and plaster fixation,closed reduction and percutaneous K-wire fixation,as well as open reduction plate and elastic intramedullary pin fixation in the treatment of unstable distal ulna and radius fractures in older children.Methods The clinical data of 110 cases treated in Department of Orthopedics,Children′s Hospital of Nanjing Medical University from January 2014 to December 2017,for unstable fractures of the distal ulna and radius were retrospectively reviewed.There were 73 males,37 females,aged from 10 to 14 years[(11.6±2.3)years old].According to the different treatments,the 110 cases were divided into 3 groups which included manual reduction group(48 patients),closed reduction and percutaneous K-wire fixation group(35 patients,K-wire fixation group)and open reduction with plate and elastic stable intramedullary nail fixation group(27 patients,open reduction group).All cases were treated with plaster external fixation.After the fracture healing,the plaster was removed and then exercises were begun.The data of operative time,fracture healing time,displacement rate and wrist function after treatment were recorded in the three groups and compared statistically.Results There was no significant difference in general data between 3 groups before operation(all P>0.05).For the manual reduction group,K-wire fixation group and open reduction group,the operation time was(20.2±8.4)min,(35.4±12.2)min and(68.5±20.4)min,respectively;the clinical fracture healing time was(42.1±3.8)d,(44.2±4.3)d and(48.4±5.3)d;the cost of treatment was(2000.4±551.3)Yuan,(8000.2±1151.6)Yuan and(20010.7±2453.3)Yuan,respectively.There were significant differences in operation time and cost treatment among the 3 groups(χ^2=11.266,F=58.427,all P<0.05).The Berton score of excellent and good were 89.6%(43/48 cases),91.4%(32/35 cases)and 92.6%(25/27 cases)3 months later after surgery in the manual reduction group,K-wire fixation group and open reduction group.The mean follow-up was(11.2±3.7)months(range 6-18 months).In the manual reduction group,there were 6 cases with fracture displacement within 2 weeks after the manual reduction.There were 3 cases with symptoms of caudal irritation in K-wire fixation group,which happened in 1 case in the open reduction group.No complications such as nonunion and iatrogenic nerve injury were found during the follow-ups.Conclusion There is no significant difference in the wrist function among the 3 methods for the treatment of distal radius and ulna fractures in older children.The manual reduction therapy has a high fracture displacement rate.The open reduction therapy causes maximal operative trauma and costs highly.The percutaneous K-wire method is minimally invasive and has shorter operative time and a lower fracture displacement rate.Therefore,percutaneous K-wire is the optimal treatment for distal ulna and radius fractures.