基于X线影像判断儿童微小移位肱骨外髁骨折稳定性的可行性分析

Feasibility analysis of judging the stability of minimally displaced lateral humeralcondylar fractures based upon radiography in children

目的探讨基于X线影像判断微小移位型肱骨外髁骨折(minimally displaced lateral humeral condylar fractures,MDLHCF)稳定性的方法及可行性。方法分析2013年1月至2021年8月中国医科大学附属盛京医院收治的208例MDLHCF患儿的临床及影像学资料,其中男131例,女77例,平均年龄4.5岁。患侧为左侧118例,右侧90例。根据术前磁共振成像、术中肘关节造影、保守治疗骨折愈合过程评估骨折的稳定性,分析不稳定MDLHCF的X线片特征。采用χ^(2)检验或Fisher确切概率法进行单因素分析、多因素logistic回归分析危险因素。根据前述分析结果,请3名小儿骨科医生对其中40例肱骨外髁骨折的X线影像进行2次判定。采用Cohen'kappa系数评价结果的组内、组间一致性并计算各医生的敏感度、特异度和准确度。结果208例患儿中,术前磁共振成像102例,术中肘关节造影40例,保守治疗66例。根据本研究肱骨外髁骨折稳定性判断方法,稳定骨折患儿有163例,不稳定骨折45例,稳定骨折与不稳定骨折患儿除随访时间外,在性别、年龄、损伤侧别、Milch分型上差异无统计学意义。多因素logistic回归分析显示X线正位片骨折块整体外移或上移、内侧翘起,X线内斜位片骨折间隙前宽后窄或骨块前后移均提示不稳定。3名医生组内及组间检验具有中等以上的一致性(组间为0.576~0.763,组内为0.572~0.881)。结论基于X线片判断儿童MDLHCF的稳定性具有可行性,X线正位片显示远端骨折块整体外移或上移、内侧翘起,X线内斜位片显示骨折间隙前宽后窄或骨块前后移可提示骨折不稳定。

Objective To explore the feasibility and methods of judging the stability of minimally displaced lateral humeral condylar fracture(MDLHCF)based upon radiography.Methods From January 2013 to August 2021,retrospective analysis was conducted for 208 MDLHCF children.They were assigned into two groups of unstable fracture(n=45)and stable fracture(n=163).There were 131 boys and 77 girls with an average age of 4.5 years.And affected side was left(n=118)and right(n=90).The stability of MDLHCF was assessed by the results of magnetic resonance imaging(MRI),intraoperative elbow arthrography and conservative fracture healing.And χ^(2) and Fisher exact ratio tests were employed for univariate analysis and multivariate Logistic regression analysis for identifying the possible risk factors.Radiographic films of 40 MDLHCF patients were judged twice by three independent physicians.Cohen'kappa was utilized for evaluating inter/intra-observer reliabilities.Specificity,sensitivity and accuracy were calculated separately.Results Magnetic resonance imaging(MRI)(n=102),intraoperative elbow arthrography(n=40)and conservative fracture healing(n=66)were performed.No inter-group differences existed in gender,age,affected side or Milch system.Logistic multivariate analysis indicated that fragment of MDLCF moving outward,upward or its medial part curling upward in AP position and anterior fracture gap≥posterior fracture gap or fragment of LHCF moving outward or inward on internal oblique radiography all suggested suggest unstable MDLHCF.The inter/intra-observer reliabilities were at least moderate with a range of 0.576 to 0.763 and 0.572 to 0.881 respectively.Conclusions The stability of MDLHCF may be estimated based upon radiography safely and effectively.And fragment of MDLCF moving outward,upward or its medial part curling upward in AP position and medial fracture gap≥outward fracture gap or fragment of LHCF moving outward or inward on internal oblique radiography all hint at unstable MDLHCF.