保守与手术治疗GartlandⅡ型儿童肱骨髁上骨折比较

Nonoperative versus surgical treatments of Gartland typeⅡsupracondylar humerus fracture in children

目的评价保守与手术两种方法治疗GartlandⅡ型儿童肱骨髁上骨折临床效果。方法回顾性分析北京儿童医院骨科2018年2月至2019年2月治疗的142例GartlandⅡ型儿童肱骨髁上骨折病例。纳入标准:骨折后初次治疗在本院且完成随访;X线诊断为GartlandⅡ型肱骨髁上骨折。排除标准:开放性、陈旧性及病理性骨折;伴有血管神经损伤的骨折;随访丢失或资料不全;合并重要脏器损伤;合并同侧肢体其他部位骨折。按照治疗方法分为三组,第一组为手法复位石膏固定保守治疗(保守组);第二组为经过手法复位石膏固定后因复位丢失再行手术治疗(复位丢失手术组);第三组为直接选择经皮穿针手术治疗(手术组)。评估三组间的临床特征、功能外观恢复及并发症情况,统计学分析组间比较采用方差分析;计数资料采用采用Fisher确切概率法。结果142例患儿均获得随访,随访时间6~12个月,平均(8.3±1.9)个月。按照初始治疗方案采用保守治疗的病例复位丢失率为19.8%,按照最终治疗方案采用手术治疗病例针道感染发生率为7.1%。三组病例骨折愈合时间比较差异无统计学意义(P=0.178),肘关节功能恢复时间比较差异有统计学意义(P=0.008),末次随访肘关节功能对比差异无统计学意义(P=0.776),末次随访肘关节外观比较差异无统计学意义(P=0.926)。末次随访时所有病例骨折全部愈合,无医源性血管、神经损伤,无Volkmann挛缩及肘内翻畸形。结论手法复位石膏固定及经皮外侧穿针手术两种方法治疗GartlandⅡ型儿童肱骨髁上骨折均可以取得良好的临床效果。选择保守治疗需密切随访,如复位丢失及时行手术治疗。如果不能保证密切随访,建议直接选择经皮穿针手术治疗。

Objective To observe the therapeutic effects of conservative and surgical treatment of Gartland typeⅡsupracondylar fracture of the humerus in children.Methods Clinical and radiographic information of 142 pediatric typeⅡsupracondylar humerus fracture that were treated in Beijing Children Hospital from February 2018 to February 2019 were reviewed.Inclusion criteria:the first treatment after fracture was in this hospital and the follow-up was completed.Gartland typeⅡsupracondylar fracture of the humerus was diagnosed from X-ray.Exclusion criteria:open fractures and pathological fractures,fractures with vascular nerve injury,missing or incomplete follow-up data,complicated with important organ damage,combined with other ipsilateral limb fractures.Three distinct groups of patients were identified:the patients who were treated nonoperatively(with closed reduction and casting);the patients who were initially treated nonoperatively but subsequently required surgery due to loss of reduction;and the patients who were treated initially with surgery.Treatment outcomes,as assessed by the final clinical and radiographic alignment,range of motion of the elbow,and complications,were compared between the groups to define clinical and radiographic features that related to success or failure of nonoperative management.Analysis of variance was used for comparison between groups.The Fisher exact probability method was used for counting data.Results All 142 children in this group were followed up for six to 12 months,arerage time was(8.3±1.9)months.The rate of reduction loss was 19.8%in patients treated conservatively according to the initial treatment.The incidence of needle infection was 7.1%inpatients treated with surgery according to the final treatment.There was no statistically significant difference in fracture healing time among the three groups(P=0.178),but the difference of function recovery time was statistically significant(P=0.008).There was no statistically significant difference in the loss of motion and carrying angle according to the Flynn criteria(P>0.05).At the last follow-up,all the fractures were healed without iatrogenic vascular and nerve injury,Volkmann’s contracture and cubit varus deformity.Conclusions Gartland typeⅡsupracondylar humerus fractures can be successfully treated nonoperatively or by surgery.The choice of conservative treatment requires close follow-up and timely surgical treatment if reduction is lost.If close follow-up is not possible,percutaneous k-wire is recommended.Surgical treatment can achieve satisfactory clinical results.