闭合复位与桡侧交叉克氏针治疗儿童GartlandⅢ型肱骨髁上骨折

Efficacies of closed reduction and percutaneous radial crossed pinning of Gartland typeⅢsupracondylar humeral fractures in children

目的评价闭合复位与桡侧交叉克氏针治疗儿童GartlandⅢ型肱骨髁上骨折的疗效,分析影响其预后的相关因素。方法回顾性分析2013年1月至2016年5月北京儿童医院骨科收治的198例GartlandⅢ型肱骨髁上骨折,其中192例采用闭合复位、桡侧交叉克氏针内固定,排除术前神经损伤3例,最终获得临床资料完整者180例。采用Flynn肘关节评分标准评价其治疗效果,对于可能影响其预后的因素:性别、年龄、左右侧、受伤机制、受伤至手术的时间、手术时间、拔出克氏针时间、体质量指数(BMI),采用均值比较或者卡方检验进行单因素分析,再采用多因素Logistics回归对可能的危险因素进行分析,明确影响其预后的因素。结果180例患儿手术时间25~162 min,平均68.2 min;住院时间2~7 d,平均3.6 d;随访时间18~48个月,平均30.6个月。Flynn功能标准评价优153例、良24例、可3例、差0例,优良率为98.3%(177/180);外观恢复标准评价优152例、良23例、可4例、差1例,优良率为97.2%(175/180)。术后出现肘内翻畸形2例,针道感染7例,无Volkmann挛缩和尺神经损伤。影响预后危险因素单因素分析显示年龄(t=-2.016,P=0.045)、手术时间(t=-5.530,P<0.001)、受伤机制(χ2=75.373,P<0.001)、受伤至手术的时间(χ2=9.449,P=0.009)与功能评价显著性相关;手术时间(t=-3.575,P=0.001)和受伤机制(χ2=102.350,P<0.001)与外观恢复评价显著性相关;多因素分析显示手术时间(OR=1.081,P<0.001)、受伤机制(OR=42.286,P<0.001)、受伤至手术的时间(OR=4.337,P=0.047)是功能恢复的独立危险因素;受伤机制(OR=74.850,P<0.001)是外观恢复的独立危险因素。结论采用闭合复位与桡侧交叉克氏针治疗儿童GartlandⅢ型肱骨髁上骨折,能减少尺神经损伤、肘内翻畸形和Volkmann挛缩等并发症,无切口、住院时间短,术后临床效果良好,值得推广。受伤机制、受伤到手术时间和手术时间会影响患儿肘关节功能预后,同时受伤机制也是影响外观恢复预后的独立危险因素。

Objective To review the outcomes of percutaneous radial crossed pinning of Gartland typeⅢsupracondylar humeral fractures and to analyze its prognostic factors.Methods From January 2013 to May 2016,a total of 198 children with Gartland typeⅢsupracondylar humeral fractures underwent percutaneous radial crossed pinning.Three cases were excluded due to preoperative nerve injury.Ultimately 180 children had complete clinical data.The outcomes were assessed according to the Flynn's criteria.The relevant prognostic factors,including gender,age,sideness,mechanism of injury,duration from injury to surgery,operative duration,duration from surgery to removing k-wire and body mass index(BMI),were analyzed.Mean comparison or chi-square test was employed for univariate and multivariate logistic regression analysis to identify possible risk factors.Results Functionally,the outcomes were excellent(n=153),decent(n=24),fair(n=3)and poor(n=0).Cosmetically,excellent(n=152),decent(n=23),fair(n=4)and poor(n=1).The complications included cubitus varus(n=2)and minor pin-sit infection(n=70).Univariate analysis revealed that age(t=-2.016,P=0.045),mechanism of injury(χ2=75.373,P<0.001),duration from injury to surgery(χ2=9.449,P=0.009)and operative duration(t=-5.530,P<0.001)were significantly correlated with functionality.And operative duration(t=-3.575,P=0.001)and mechanism of injury(χ2=102.350,P<0.001)were significantly correlated with cosmetics.Multivariate logistic regression analysis indicated that mechanism of injury(OR=42.286,P<0.001),duration from injury to surgery(OR=4.337,P=0.047)and operative duration(OR=1.081,P<0.001)were independent risk factors of functionality while mechanism of injury(OR=74.850,P<0.001)was an independent risk factor of cosmetics.Conclusions Lateral cross-wiring technique is feasible for percutaneous fixation of displaced supracondylar humeral fractures in children.It provides excellent fracture stability,decent union rate and acceptable complication rate with a minimal risk of iatrogenic nerve injuries.Mechanism of injury,duration from injury to surgery and operative duration are independent risk factors of functionality while mechanism of injury is an independent risk factor of cosmetics.