闭合复位顺行弹性髓内钉和克氏针内固定治疗儿童桡骨远端骨干-干骺端交界区骨折的对比研究

A comparative of closed reduction anterograde elastic stable intramedullary nailing versus Kirschner wire fixation for distal radial diaphyseal metaphyseal junction fractures in children

目的比较闭合复位顺行弹性髓内钉(elastic stable intramedullary nailing,ESIN)和克氏针内固定治疗儿童桡骨远端骨干-干骺端交界区(diaphyseal-metaphyseal junction,DMJ)骨折的疗效。方法回顾性分析2019年9月至2021年9月在内蒙古医科大学第二附属医院儿童骨科医学中心接受闭合复位手术治疗的37例桡骨远端DMJ骨折患儿的临床资料。其中男23例,女14例;年龄7~14岁,平均年龄为10.3岁。根据使用的内固定材料将患儿分为髓内钉组(接受闭合复位顺行ESIN,15例)和克氏针组(接受经皮克氏针内固定,22例),记录并比较两组患儿手术时间、透视次数、骨折愈合时间及术后2、3、6、9个月腕关节活动度和上肢功能障碍(disabilities of the arm,shoulder and hand,DASH)评分,同时比较术后并发症发生情况。组间比较采用χ2检验或独立样本t检验。结果37例患儿均顺利完成闭合复位手术并获得完整随访。克氏针组和髓内钉组患儿的手术时间分别为(29.5±7.9)min、(29.3±3.6)min,差异无统计学意义(t=3.873,P=0.605);髓内钉组术中透视次数、骨折愈合时间分别为(25.0±6.5)次、(43.9±2.3)d,均少于克氏针组的(30.0±7.8)次、(45.6±2.3)d,组间比较差异有统计学意义(t=0.504,P=0.048;t=0.017,P=0.041)。髓内钉组患儿术后2个月的腕关节活动度较克氏针组好,DASH评分优于克氏针组,组间比较差异有统计学意义(均P<0.05),两组患儿术后3、6、9个月的腕关节活动度、DASH评分比较差异无统计学意义(均P>0.05)。所有患儿均无骨折再移位、延迟愈合、不愈合、神经或骺板损伤。随访期间克氏针组有3例发生针道感染,有2例在住院期间发现有肌腱损伤;髓内钉组有1例患儿在取出ESIN前,前臂旋后功能较健侧受限30°,并且出现了钉尾激惹,取出后功能及激惹处恢复正常。所有患儿术后3个月关节活动基本恢复正常。结论闭合复位顺行ESIN治疗儿童桡骨远端DMJ骨折微创、简单、安全、固定可靠,与克氏针内固定相比,康复更快,术后并发症发生更少,疗效令人满意,可作为治疗桡骨远端DMJ骨折的一种方式。

Objective To compare the efficacy of closed reduction(CR)anterograde elastic intramedullary nail versus Kirschner wire internal fixation in the treatment of distal radial diaphyseal-metaphyseal junction(DMJ)fractures in children.Methods From September 2019 to September 2021,retrospective analysis was conducted for the relevant clinical data of 37 children with distal radial DMJ fractures undergoing CR.There were 23 boys and 14 girls with an average age of 10.3(7-14)years.According to the modes of internal fixation,they were divided into two groups of elastic intramedullary nail(CR anterograde ESIN,n=15)and Kirschner wire(KW internal fixation,n=22).Operative duration,fluoroscopic frequency,fracture healing time,wrist joint range of motion and upper limb dysfunction score(DASH)at Month 2/3/6/9 at post-operation were compared between two groups.The incidence of postoperative complications was also recorded.And Chi-square or independent sample t test was employed for inter-group comparison.Results All of them successfully underwent CR with complete follow-ups.Operative duration for Kirschner wire and intramedullary nail groups was(29.5±7.9)and(29.3±3.6)min with no statistically significant difference(t=3.873,P=0.605).Intraoperative fluoroscopic frequency and fracture healing time were(25.0±6.5)sessions and(43.9±2.3)days in ESIN group.Both were significantly lower than those in KW group(30.0±7.8)sessions and(45.6±2.3)days with inter-group statistical significance(t=0.504,P=0.048;t=0.017,P=0.041).Wrist range of motion and DASH score of ESIN group were better than those of KW group at Month 2 postoperatively.And DASH score was better than that of KW group.There was inter-group statistical significance(all P<0.05),However,no inter-group statistical significance existed in wrist range of motion and DASH score at Month 3/6/9 postoperatively(all P>0.05).None had an onset of bone fracture displacement,delayed union,nonunion or injury of nerve or epiphyseal plate.In KW group,there were needle tract infections(n=3)and tendon injuries during hospitalization(n=2).One child in ESIN group had a 30 degree limitation of forearm supination as compared to healthy side before removing ESIN.There was nail tail stimulation.After removal,function and stimulation area normalized.All joint activities basically normalized at Month 3 post-operation.Conclusions For children with distal radial DMJ fractures,CR anterograde elastic intramedullary nailing is mini-invasive,simple,safe and reliable.As compared with KW internal fixation,it offers the advantages of a rapid recovery,a low incidence of postoperative complications and satisfactory therapeutic outcomes.It is an ideal treatment for distal radial DMJ fractures.