儿童肱骨髁上突四例报道及文献复习

Supracondylar process of the humerus in children:four case reports and literature review

目的探讨儿童肱骨髁上突的临床和影像学表现以及诊疗方法,并结合相关文献,对此病进行全面阐述,以提高认识。方法回顾性分析2016年1月—2019年6月复旦大学附属儿科医院骨科4例肱骨髁上突患儿的临床资料;在PubMed、中国知网、万方数据库、维普数据库中,以“肱骨髁上突/supracondylar process”和“儿童/pediatric”为关键词进行检索所获得的1篇9例中文文献和4篇4例英文文献,共报道13例,结合本中心接诊的4例患儿临床资料,对该病进行分析总结。结果本中心报道4例肱骨髁上突患儿,男3例、女1例,平均年龄为4.5岁。其中1例年龄4岁男孩行骨突、Struther韧带及附近骨膜切除术,术中发现骨突有韧带(Struther’s ligament)与内上髁相连,并形成髁上孔,肱动脉或正中神经穿行其间,术后病理证实为肱骨髁上突,随访3.5年未见复发;其余3例患儿门诊平均随访2.5年,未见增大和产生压迫症状。文献报道的13例患儿,年龄2岁~11岁,平均5.3岁;男6例,女3例;6例临床有症状的患儿(6例均有疼痛、4例有正中神经卡压症状)行手术治疗,术后均痊愈且无复发;另外7例保守观察者,未见髁上突增大及临床有疼痛或神经压迫症状。肱骨髁上突在X线及三维CT重建显示肱骨下段前内侧源于骨皮质的鸟嘴样骨性突起,容易误诊为外生性骨软骨瘤,两者的区别在于,肱骨髁上突的密度稍低于骨皮质,无髓腔及软骨帽,尖端常指向关节,骨软骨瘤具有骨皮质和骨髓腔,且均与母骨连续,尖端有软骨帽,轴心常背离关节。结论肱骨髁上突是一种先天性骨发育变异,属于返祖性骨性结构,儿童肱骨髁上突在临床上尤其需要与骨软骨瘤相鉴别。对无症状的肱骨髁上突患者通常不需要手术干预;而短期内快速增大,有神经、血管压迫症状者可行骨突、Struther韧带及附近骨膜切除,以利于根治和防止复发。

Objective This study explored the clinical and imaging features of the supracondylar process of the humerus in children,as well as the diagnosis and treatment methods,to improve clinicians'understanding of this disease.Methods A retrospective study was performed on four patients with the supracondylar process in our center from January 2016 to June 2019.Relevant pieces of literature on Pubmed,CNKI,Wanfang,and Weipu were reviewed.The key words were“supracondylar process”and“pediatric/children.”Nine cases reported in Chinese and four cases reported in English were found.Data on the clinical and imaging features,treatment,and prognosis were obtained and analyzed.Results Four cases of humeral supracondylar process were recorded in our center,including three boys and one girl(average age=4.5 years).One 4-year-old boy underwent surgical resection.During operation,the process,ligament,and shaft of the humerus formed a ring or canal through which the median nerve and the brachial artery(or a branch of it)were transmitted.We successfully resected the process and the ligament with its entire periosteum.Postoperatively,supracondylar was confirmed by histological examination.No recurrence was noted at follow-up throughout the subsequent 3.5 years.The remaining three patients were followed-up for 2.5 years on average,and no enlargement or compression symptoms were observed.According to the literature review,13 patients(6 boys and 3 girls;age=2-11 years)were included.Among the 13 patients,6 underwent surgery,all of whom manifested with pain and 4 showed symptoms of median nerve compression;the other 7 patients were treated conservatively.The prognosis of all these patients was good.The supracondylar process should be distinguished from osteochondroma.Literature review showed that the spur was oriented distally toward the elbow joint and without discontinuity in the cortex of the humerus.X-ray imaging revealed an intact underlying humeral cortex,in contrast to osteochondroma in which the tumor cortex was continuous with the humeral cortex,pointing away from the joint.Conclusions Supracondylar process is an anatomical variation and needs to be distinguished from osteochondroma.Surgery is warranted when growth is rapid and compression symptoms emerge,during which the process and the ligament with its entire periosteum should be resected entirely.