儿童复杂肘关节骨折脱位的临床特点与治疗

Clinical characteristics and treatment of complex fracture-dislocations of the elbow in children

目的探讨儿童复杂肘关节骨折脱位的概念与临床表现、病理损伤特点、治疗方案与临床效果。方法回顾性收集2015年9月至2020年1月收治的34例复杂肘关节骨折脱位患儿资料,纳入标准为肘关节脱位合并尺桡骨近端一处或多处骨折,男25例、女9例;年龄(8.3±3.2)岁(范围5~16岁);左侧27例、右侧7例。致伤原因:玩滑板车摔伤16例、高处坠落伤10例、骑自行车摔伤5例及车祸伤3例。所有患儿均于急诊局麻下行手法复位纠正,复查肘关节正侧位X线片、CT扫描及肘关节MRI,评估骨折脱位的复位及韧带损伤情况;再根据合并骨折块的大小、移位程度及肘关节稳定性确定后续治疗方案:鹰嘴骨折采用切开复位克氏针张力带或接骨板固定,冠突骨折采用切开复位袢钢板固定,桡骨颈骨折采用闭合复位或切开复位联合克氏针或弹性髓内针固定。结果34例中经鹰嘴骨折脱位16例,内翻后内侧旋转不稳定1例,外翻后外侧旋转不稳定4例及分离型肘关节脱位13例。34例术后均获得随访,随访时间13(8,15)个月,骨折愈合时间(3.5±0.8)周,无内固定失效病例。2例肘关节脱位并桡骨颈骨折中1例出现桡骨头坏死、1例出现桡骨近端骺板早闭。末次随访时所有患儿无肘关节半脱位、脱位或不稳定,根据Mayo肘关节功能评分标准评定疗效,优25例、良5例、可3例、差1例,优良率为88%(30/34)。结论儿童复杂肘关节骨折脱位的临床特点为肘关节脱位合并尺桡骨近端一处或者多处骨折,临床表现以经鹰嘴骨折脱位及分离型肘关节脱位为主,大多通过骨折切开复位内固定可取得良好效果。

Objective To summarize and discuss the concept and clinical manifestations of complex fracture-dislocations of the elbow in children,and compare its injury characteristics,treatment and clinical effect with adults.Methods From September 2015 to January 2020,34 patients seen and treated at our institution for complex fracture-dislocations of the elbow were identified,and their medical records and radiographs were reviewed retrospectively.The inclusion criteria were elbow dislocation combined with one or more fractures at the proximal ulna and radius.There were 25 boys and 9 girls,with an average age of 8.3±3.2 years.The left arm was involved in 27 cases,and the right arm was involved in 7 cases.The causes of injury included falling from a scooter in 16 cases,falling from height in 10 cases,cycling in 5 cases and traffic accident in 3 cases.All patients were treated with closed reduction and the application of plaster under local anaesthesia in the emergency room.Then,X-ray,CT and MRI were performed to evaluate the fracture-dislocation and ligament injury.The following treatment plan was comprehensively evaluated according to the size and displacement of the combined fracture block and the stability of the elbow,for example,open reduction with K-wires and tension band or plate fixation for olecranon fracture,open reduction with loop plate fixation for coronal process fracture,closed reduction or open reduction with K-wires or elasticstable intramedullary nail for radial neck fracture.Results Among the 34 patients,there were 16 cases of transolecranon fracture-dislocation,1 case of varus posteromedial rotational instability,4 cases of valgus posterolateral rotatory instability and 13 cases of divergent dislocation of elbow.All patients were followed up for 13(8,15)months,and the average fracture healing time was 3.5±0.8 weeks,with no failure of internal fixation.In 2 cases of elbow dislocation combined radial neck fracture,one case had ischemic necrosis of the radial head and one case had early closure of epiphyseal plate of the proximal radius.At the last follow-up,all patients had no subluxation,dislocation or instability of the elbow.The therapeutic efficacy was evaluated at the final follow-up by the Mayo elbow performance score(MEPS)as excellent in 25 cases,good in 5 cases,fair in 3 cases,and poor in one case,with excellent and good rate 88%.Conclusion The complex fracture-dislocations of the elbow is rare in children.We have the opinion that the clinical characteristics are dislocation combined with one or more fractures of the proximal ulna and radius.Compared with adults,its pathological characteristics and the scope of injury are similar,but most of the injuries are mild.The clinical manifestations are mainly transolecranon fracture-dislocation and divergent dislocation of elbow.Good results can be achieved in most cases through open reduction with internal fixation for fractures.