弹性髓内钉治疗儿童胫骨远干骺交界部骨折

Treatment of distal tibia diaphyseal metaphyseal junction fracture with elastic stable intramedullary nailing in children

目的评估弹性髓内钉(elastic stable intramedullary nailing,ESIN)治疗儿童胫骨远干骺交界部(distal tibia diaphyseal metaphyseal junction,DTDMJ)骨折的手术治疗效果及预后。方法回顾性分析2009年1月至2018年12月,我院行ESIN治疗的37例严重移位DTDMJ骨折的患儿,其中男21例,女16例;年龄5~11岁,平均8.8岁;体重20.5~49.5 kg,平均31.2 kg。所有DTDMJ骨折均选用微创闭合复位ESIN内固定治疗。末次随访时依据Tornetta踝关节功能评分标准评估术后伤肢功能。结果所有病例均闭合复位成功,无一例切开。2例粉碎性骨折行2枚ESIN固定后不稳定,于内侧附加1枚ESIN增加复位稳定性。7例腓骨远端骨折,邻近骺板,且复位后仍伴有明显内外翻畸形,选用闭合复位逆行ESIN固定。手术时间39~86 min,平均49.5 min;术中出血量10~30 ml,平均21.5 ml;住院时间5~9天,平均6.7天。随访时间13~42个月,平均21个月。骨折骨性愈合时间10~50周,平均12.5周。术后所有病例均未出现切口感染、神经血管损伤、下肢不等长、ESIN松动或折断等并发症。1例术后出现踝关节外翻(外翻6°),2例骨折延迟愈合(骨性愈合时间分别为32周、50周);患儿末次随访时,依据Tometta踝关节功能评分标准,优32例,良4例,可1例,差0例。结论儿童DTDMJ骨折大多数可行石膏托固定保守治疗,对于保守治疗失败或一些特殊的病例,如多发骨折或开放性骨折的患儿,可以选用ESIN固定,通过增加ESIN弧度及数量以增加固定后的稳定性。相对以其它固定方式,ESIN固定创伤小,操作简单,而且并发症少,效果好。

Objective To evaluate the effect and prognosis of elastic stable intramedullary nailing(ESIN)in the treatment of distal tibial metaphyseal junction(DTDMJ)fracture in children.Methods From January 2009 to December 2018,37 children with severe displaced DTDMJ fracture were treated with ESIN and analyzed retrospectively,including 21 males and 16 females.The age ranged from 5 to 11 years,with an average of 8.8 years.The body weight was 20.5-49.5 kg,with an average of 31.2 kg.All DTDMJ fractures were treated with minimally invasive closed reduction and ESIN internal fixation.At the last follow-up,functions of the injured limb were evaluated according to the Tornetta ankle function score.Results Closed reduction was successful in all cases without incision.Two cases of comminuted fractures were unstable after fixation with two ESINs,and the third ESIN was added to the medial side to increase the reduction stability.Seven cases with distal fibular fracture adjacent to the epiphyseal plate,accompanied by obvious varus deformity after reduction,were treated with closed reduction and retrograde ESIN fixation.The operation time was 39-86 min,with an average of 49.5 min;the intraoperative bleeding was 10-30 ml,with an average of 21.5 ml;the hospital stay ranged from 5 to 9 days,with an average of 6.7 days;the follow-up ranged from 13 to 42 months,with an average of 21 months;the time of bone healing was 10-50 weeks,with an average of 12.5 weeks.There were no complications such as incision infection,neurovascular injury,unequal length of lower limbs,loosening or breaking of ESIN in all cases.Ankle valgus(valgus 6°)was observed in 1 case,while delayed fracture healing in 2 cases(32 weeks and 50 weeks,respectively).Tometta ankle function score at the last follow-up:32 cases were excellent,4 cases were good,1 case was fair.Conclusions Most DTDMJ fractures in children can be treated conservatively with plaster fixation.However,ESIN fixation is recommended to increase the stability after fixation by increasing the radian and number of elastic nails for patients with multiple fracture or open fracture if conservative treatment fails.ESIN fixation achieves good effect with less trauma and simple operation.