儿童肱骨髁上骨折160 例临床分析

目的分析儿童移位型肱骨髁上骨折几种治疗方法的疗效。方法160例随机分三组并进行相关治疗。A组54例，行闭合复位石膏托或夹板外固定；B组54例，行手术切开复位克氏针或可吸收螺钉内固定；C组52例，行C臂X线机透视下复位经皮交叉克氏针固定，并分析其疗效。结果随访4个月～6年，全部骨折完全愈合。A组：优32例，良20例，可2例；B组：优48例，良4例，可2例；c组：优48例，良3例．可1例。三种方法骨折愈合无明显差异。A组肘内翻、骨筋膜室综合征的发生率明显高于B、C二组，C组平均住院时间比B组少．差异有显著性（P〈0．05）；B、C二组医源性尺神经损伤的发生率高于A组，但统计学上无显著性意义。结论我们认为闭合手法复位交叉克氏针固定手术创伤小、住院时间短、并发症少，应为治疗儿童移位型肱骨髁上骨折理想的方法。     

闭合复位克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折

目的探讨闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折的疗效。方法对195例GartlandⅢ型儿童肱骨髁上骨折患者行闭合复位后,C臂机监视下先在肱骨髁外侧用2枚克氏针平行或交叉固定,再伸直肘关节到50°,保护尺神经下用1枚克氏针在内侧交叉固定,术后长臂石膏托固定于肘关节伸直70°制动3周。结果 195例均获随访,时间5~35个月。出现医源性尺神经损伤2例,肘内翻畸形需截骨矫形1例,肘部前侧局限性骨化4例。按Flynn标准评定疗效:优180例,良8例,一般6例,差1例,优良率为96.4%。结论闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折可有效减少医源性尺神经损伤,降低肘内翻畸形发生率,疗效满意。     

手术治疗儿童移位肱骨髁上骨折265例

目的回顾性总结儿童移位肱骨髁上骨折手术治疗的体会。方法选择1997年1月至2007年6月住院265例儿童移位肱骨髁上骨折采用切开复位克氏针内固定,石膏托外固定5~6周。结果本组265例全部获得随访,平均随访时间2年6个月,优237例,良26例,差2例,优良率99.2%。结论手术治疗儿童移位肱骨髁上骨折,复位准确,固定可靠,可有效防止并发症的发生。     

闭合复位经皮克氏针内固定治疗伸直型肱骨髁上骨折

目的 探讨闭合复位经皮克氏针内固定治疗儿童伸直型肱骨髁上骨折的疗效.方法 对29例伸直型肱骨髁上骨折患儿(Pirone分型:Ⅱb型8例,Ⅲ型21例)均作闭合复位、透视下经皮克氏针内固定,并予石膏托外固定.结果 26例获得随访,时间6～36个月.骨折均愈合,愈合时间6～8周,未出现缺血性肌肉挛缩.按Flynn标准评定疗效:优19例,良5例,可2例.结论 闭合复位经皮克氏针内固定治疗儿童重度移位的伸直型肱骨髁上骨折疗效较好.     

三种方法治疗儿童肱骨髁上骨折174例疗效分析

目的 :探讨不同方法治疗儿童肱骨髁上骨折的优点。方法 :从 2 84例中随机抽取三种方法治疗的病例各 5 8例 ,共计 174例 ,分三组 (手法复位石膏外固定为A组 ,桡侧交叉或平行克氏针固定为B组 ,双侧交叉克氏针固定为C组 ,分析其疗效。结果 :随访 10～ 2 8月 ,骨折完全愈合 ,参照邱耀元、葛宝丰[1] 的小儿肱骨髁上骨折治疗疗效评定 ,A组 :优 4 5例 ,良 13例。B组 :优 4 8例 ,良 10例。C组 :优 5 2例 ,良 6例。结论 :1、三种方法骨折愈合率无差异。 2、A、B二组肘内翻、筋膜室综合症的发生率明显高于C组 ,且统计学上有显著性意义 (P <0 .0 5 )。 3、C组神经损伤的发生率高于A、B二组 ,但统计学上无显著性意义 ,且此类神经损伤均在 3月内恢复。此类骨折的治疗一旦实施手术 ,双侧交叉克氏针固定可推首选     

不同外固定方法治疗肱骨髁上骨折临床疗效比较

目的：比较不同外固定方法治疗儿童移位性肱骨髁上骨折的临床疗效和肘内翻发生率：方法：226例移位性儿童肱骨髁上骨折患者,男134例,女92例;年龄5～12岁,平均8．58岁：手法复位后分别采用小夹板和塑形托板双重外固定治疗（A组）88例（男51例,女37例;年龄5．1～12岁）,小夹板外固定治疗（B组）74例（男44例,女30例;年龄5～11．8岁）,以及石膏托外固定治疗（C组）64例（男39例,女25例;年龄5．5～12岁）。观测3组骨折临床愈合时间、肘关节功能、肘内翻等指标,比较临床综合疗效及肘内翻发生率。结果：随访6个月～4年,平均25个月,参照疗效评定标准：A组优59例,良23例,差6例,优良率为93．18％;B组优37例,良29例,差8例,优良率为89．19％;C组优20例,良31例,差13例,优良率为79．69％：A、B、C三组肘内翻发生率分别为6．82％、17．57％、32．81％。A组临床疗效和肘内翻发生率分别与B、C组比较,差异均有统计学意义（P〈O．05）;B组与C组比较,差异亦有统计学意义临床疗效：A组优于B、C组,B组优于C组。肘内翻发生率：A组低于B、C组,B组低于C组。结论：三种外固定方法以小夹板和塑形托板双重外固定疗效最佳,此种外固定方法稳定性高、抗旋转作用强、可调性好、关节功能恢复快、肘内翻发生率低、临床疗效佳,小夹板和塑形托板双重外固定应作为治疗儿童肱骨髁上骨折的首选外固定方法.     

微创治疗儿童肱骨髁上不稳定骨折

目的 探讨以生物学固定及间接复位技术为基础,微创治疗儿童肱骨髁上不稳定骨折的临床疗效.方法 对86例儿童肱骨髁上不稳定骨折采用闭合复位,部分加内侧小切口,然后经皮克氏针交叉固定辅加石膏托外固定进行治疗.结果 术后随访时间为6个月至5年(平均2.5年),骨折全部愈合,平均愈合时间为1.2个月.参照Flum临床功能评定标准评定:优78例,良6例,可2例;优良率为98%.结论 以微创为原则闭合复位,经皮交叉克氏针内固定治疗儿童肱骨髁上不稳定骨折,该方法 符合生物学固定的观点,创伤小,并发症少,恢复快,疗效满意.     

闭合复位外侧经皮克氏针固定治疗小儿肱骨髁上骨折

目的探讨闭合复位外侧经皮克氏针固定治疗小儿肱骨髁上骨折的临床效果。方法采用在C型臂X线机透视下用手法闭合复位外侧经皮克氏针固定加石膏固定治疗小儿肱骨髁上骨折86例。结果随访6~12个月,按照Flum肘关节功能评分:优82例,良3例,可1例,优良率98.8%。结论闭合复位外侧经皮克氏针固定治疗小儿肱骨髁上骨折具有微创、操作简单、稳定性良好、骨折愈合快、并发症少等优点,适合临床开展。     

闭合复位治疗儿童Gartland Ⅱ型和Ⅲ型肱骨髁上骨折

目的:探讨儿童GartlandⅡ型和Ⅲ型肱骨髁上骨折闭合复位及固定的治疗方法。方法:自2004年1月至2011年12月收治儿童肱骨髁上骨折110例,男76例,女34例;年龄2～13岁,平均7岁;伸直型98例,屈曲型12例;GartlandⅡ型32例,GartlandⅢ型78例;伴有远折端旋转移位37例。分别在血肿内、臂丛及氯胺酮麻醉下,握持患肢的上臂及前臂对抗牵引,牵引数分钟后行手法闭合复位,经C形臂X线透视示骨折复位满意后用石膏托固定,对不稳定性骨折复位后经皮桡侧穿入1～2枚克氏针内固定再加石膏外固定。术后3～4周摄X线片,拆除石膏并拔出克氏针,开始康复锻炼。结果:110例均获随访,时间3～18个月,平均12个月,所有患儿获得骨性愈合,骨折愈合时间6～8周,平均6.9周。无一例出现肘内翻畸形、血管神经损伤或Volkmann挛缩等并发症。按Flynn标准评定疗效:优74例,良26例,可10例。结论:采用闭合复位石膏托外固定并对不稳定性骨折经皮克氏针内固定加石膏托外固定治疗儿童GartlandⅡ型和Ⅲ型肱骨髁上骨折是一种操作简单、创伤小、疗效较好的方法。     

肱骨近端复杂骨折内固定的临床应用研究

目的 探讨肱骨近端复杂骨折的手术方式.方法 2002年1月～2007年1月对70例肱骨近端三部分骨折患者分为4组.A组20例,行交叉克氏针加螺钉内固定;B组23例,行切开复位解剖钢板内固定;C组15例,行切开复位Ender氏针加张力带内固定;D组12例,行切开复位近端锁定钢板内固定.结果 70例均获得随访,随访10～19个月,平均11.5个月.术后采用Neer评分方法评定疗效.A组20例中优3例,良11例,可4例,差2例,优良率70.0%;B组23例中优5例,良12例,可3 例,优良率73.9%;C组15例中优7例,良5例,可2例,差1例优良率80.0%;D组12例中优5例,良5例,可1例,差1例,优良率83.3%.C、D组疗效明显优于A组和B组,差异有统计学意义(P<0.05);A组与B组及C组与D组疗效比较差异无统计学意义(P＞0.05).结论 肱骨近端锁定钢板治疗肱骨近端复杂骨折,内固定力学强度大,稳定性好,临床疗效满意,优于其他内固定方法.而Ender氏针加张力带固定也较为牢固,稳定性较好,临床疗效较满意.     

石膏或夹板外固定治疗移位肱骨髁上骨折近期临床疗效分析

目的：探讨手法复位石膏或夹板外固定治疗Gartland Ⅱ、Ⅲ型肱骨髁上骨折的临床疗效。方法：回顾性分析2007年3月至2009年9月应用手法复位石膏或夹板外固定治疗Gartland Ⅱ、Ⅲ型肱骨髁上骨折的病例资料,其中男18例,女15例;年龄3～12岁,平均6.4岁。骨折均为伸直型,Gartland Ⅱ型21例,Ⅲ型12例。分析术前、术后X线片,对肘关节功能进行Flynn肱骨髁上骨折分级评定,记录并发症的发生情况。结果：33例均获随访,时间3～12个月,平均6.8个月。33例均手法复位成功,14例有肘关节周围不同程度的张力性水疱,9例由于张力性水疱影响石膏或夹板外固定发生骨折再次移位,5例择期静脉麻醉下行闭合复位克氏针内固定,4例行尺骨鹰嘴骨牵引治疗。患儿最后一次随访时Flynn肱骨髁上骨折评定分级：优11例,良16例,一般4例,差2例。结论：手法复位石膏或夹板外固定仍是治疗肱骨髁上骨折的重要方法,肘关节过度屈曲位固定虽然可以提供骨折断端较稳定的固定,但一定要密切观察患肢远端血运及肘关节周围皮肤情况,及时调整治疗策略预防并发症。     

Results of treatment of displaced long bones fractures in children--comparison of different methods]

Authors compared functional results of treatment of 48 patients; 25 children with displaced supracondylar humeral fractures, 16 treated with skeletal traction (group I, mean age 7.9 year), 9 treated with closed reduction and percutaneous K-wire fixation (group II mean age 7.7 year), and 23 patients with displaced femoral shaft fractures, 10 treated with traction (group III, mean age 7.5 year), 13 treated with closed reduction and elastic intramedullary nailing. Good results after supracondylar humeral fractures were obtained in 37.5% of patients treated with traction and in 66.7% treated with percutaneous K-wire fixation, and after femoral fractures in 70% treated with traction and 84.6% treated with intramedullary nailing. The use of instrumental methods of treatment allowed to reduce significantly the duration of hospitalization (respectively: 19.8 vs. 6.4, and 28.5 vs. 9.5 days). In authors' opinion, a closed reduction secured by percutaneous K-wire fixation as well as a closed reduction with elastic intramedullary nailing are the methods of choice in treatment of discussed fractures in children.     

鹰嘴牵引加石膏固定治疗儿童肱骨髁上GartlandⅢ型骨折

目的 探讨鹰嘴牵引加石膏固定治疗儿童肱骨髁上GartlandⅢ型骨折的临床疗效。方法98例儿童肱骨髁上GartlandⅢ型骨折者均行尺骨鹰嘴牵引治疗3～5d后，在麻醉下手法复位加石膏外固定3～4周，并分期功能锻炼。结果98例均获随访，时间12～24个月，参照Flynnetal标准：优72例，良22例，可3例，差1例，优良率为95．9％。无严重肘内翻畸形发生。11例合并神经损伤患儿治疗后按Frankel分级：B级2例恢复至D级1例，1例无恢复；C级4例恢复至D级1例、E级3例；D级5例均恢复至E级。B级1例无恢复者术后3个月经对症治疗后恢复至D级。结论该方法操作简便，安全可靠，疗效确切，并发症少。     

Supracondylar fractures of the humerus in childhood: range of movement following the posterior approach to open reduction

The posterior approach for open reduction of supracondylar fractures of the humerus has been condemned for causing decreased elbow movement. This study investigates this by comparing the range of movement in children treated by posterior open reduction and Kirschner wiring with those treated by closed reduction and immobilization. A total of 65 children with severely displaced supracondylar humeral fractures have been reviewed.

There was some loss of movement in 66 per cent of the open reduction group and 42 per cent of the closed reduction group. The proportion losing more than 10 ° of movement was the same in both groups. The difference between the two groups was due to the increased numbers in the open reduction group who lost less than 10 ° of motion. Posterior open reduction of childhood supracondylar fractures is not associated with an important loss of elbow movement and need not be avoided on this account.     

Treatment of the displaced supracondylar fracture of the humerus (type III) with closed reduction and percutaneous cross-pin fixation

Forty-five consecutive patients treated for displaced supracondylar fractures of the humerus, Type III, by means of closed reduction and percutaneous crossed-pin fixation, were studied retrospectively. Thirty-three were available at an average of 33 months post-injury for clinical and radiographic follow-up of the affected and nonaffected extremities. Five additional patients returned radiographs for analysis. Baumann's angle and a lateral humeral capitellar angle were assessed and found to be useful clinical guides for assessing the adequacy of maintenance of fracture reduction. Based upon Flynn's criteria, 31 of 33 patients clinically assessed had a satisfactory result. Closed reduction with percutaneous pin fixation is believed to represent a safe, reliable, and efficient method of managing this difficult fracture.     

Kindliche suprakondyläre Oberarmfrakturen

Stage-adapted treatment for supracondylar humeral fractures in children is demonstrated with our own collective of patients. From 1997 to 2001, 88 children were treated for the diagnosis of supracondylar humeral fractures. The follow-up of 81 patients was possible (within 34 months). Based on the classification of von Laer, 36 stable injuries (types I and II) were treated conservatively on an outpatient basis and 52 unstable injuries (types III and IV) were treated operatively with a short stay in the hospital. The conservative treatment included immobilization in a cast or a Blount bandage. The operative treatment included closed or open reposition of the fracture and stabilization by crossed pinning (K-wires). Two of the conservatively treated type II fractures dislocated so that an additional operative treatment was necessary. Accompanying injuries besides the fracture were one primary vessel lesion and three traumatic nerve lesions. The follow-up according to Flynn's criteria showed 80% excellent, 19% good, and 1% fair results. The classification of von Laer can be recommended for stage-adapted treatment of supracondylar humeral fractures in children.     

Lateral-entry pin fixation in the management of supracondylar fractures in children

BACKGROUND: There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias. METHODS: A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures. RESULTS: Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors. CONCLUSIONS: In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins.     

Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture

BACKGROUND: There is an uncommon subset of supracondylar humeral fractures in children that are so unstable they can displace into both flexion and extension. The purposes of this study were to describe this subset of supracondylar fractures and to report a new technique of closed reduction and percutaneous pinning for their treatment. METHODS: In a retrospective review of 297 consecutive displaced supracondylar humeral fractures in children treated operatively at our institution, we identified nine that were completely unstable with documented displacement into both flexion and extension as seen on fluoroscopic examination with the patient under anesthesia. We used a new technique for closed reduction and fixation of these fractures, and then we assessed fracture-healing and complications from the injury and treatment. RESULTS: All nine fractures were treated satisfactorily with closed reduction and percutaneous pinning. The complication rate associated with these unstable fractures was no higher than that associated with the 288 more stable fractures. Seven of the nine fractures were stabilized with lateral entry pin placement, and two fractures were stabilized with crossed medial and lateral pins. None of the patients had a nonunion, cubitus varus, malunion, additional surgery, or loss of motion. CONCLUSIONS: In rare supracondylar fractures in children, multidirectional instability results in displacement into flexion and/or extension. This fracture can be classified as type IV according to the Gartland system, as it is less stable than a Gartland type-III extension supracondylar fracture. These fractures can be treated successfully with a new technique of closed reduction and percutaneous pinning, thus avoiding open reduction.     

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.