儿童肱骨髁上骨折闭合复位失败的处理与因素

Management and factors related to closed reduction failure of humeral supracondylar fracture in children

摘要:

［目的］探讨儿童肱骨髁上骨折闭合复位失败的处理与相关因素。［方法］回顾性分析本院 2019 年 6 月—2020 年 12 月治疗的儿童肱骨髁上骨折 375 例患者的临床资料。所有患者均行闭合复位，复位成功者行经皮交叉克氏针内固定术 （closed reduction）（CR 组），复位失败者改行切开复位+交叉克氏针固定（open reduction）（OR 组）。比较两组临床与影像资料。以 CR 是否成功分组比较和二元多因素逻辑回归分析术前资料，探讨 CR 失败的相关因素。［结果］ 375 例患者中，348 例 CR 成功， 占 92.80%；27 例 CR 失败改行 OR，占 7.20%。最终两组患儿均顺利完成骨折复位交叉克氏针固定。CR 组手术时间、术中透视次数、住院时间、早期并发症发生率、术后 1 d 的 VAS 评分均显著优于 OR 组 （P<0.05）。随访时间 14~46 个月，平均 （23.40±4.59） 个月。两组拆除石膏时间、恢复完全负重活动时间、末次随访时肘伸屈 ROM 和 Flynn 临床结果评级的差异均无统计学意义（P>0.05）。影像方面，两组术后均达到满意骨折复位，骨折愈合良好。末次随访时两组提携角和 Baumann 角的差异均无统计学意义 （P>0.05）。单因素比较，CR 组 BMI、骨折复杂程度、损伤至手术时间、损伤能量均显著低于 OR 组 （P< 0.05）。逻辑回归方面，骨折类型复杂 （OR=8.251，P=0.037）、损伤能量高 （OR=1.593，P=0.035）、损伤至手术时间长 （OR= 1.400，P=0.026）是儿童肱骨髁上骨折 CR 失败的独立危险因素。［结论］对儿童肱骨髁上骨折初次闭合复位失败者应及时更改为开放复位，仍可取得满意治疗效果。骨折类型复杂、损伤能量高和损伤至手术时间长是初次闭合复位失败的主要危险因素。

Abstract:

[Objective] To investigate the management and factors related to closed reduction failure of humeral supracondylar fracture in children. [Methods] From June 2019 to December 2020, a total of 375 children with supracondylar fracture of humerus were treated in our hospital. All patients underwent closed reduction (CR) firstly. If the CR proved successful, the patients had percutaneous cross Kirsch- ner wire for internal fixation conducted (the CR group) , while the unsuccessful patients underwent open reduction (OR) and cross Kirsch- ner wire fixation (the OR group) . The clinical and imaging data were compared between the two groups. In addition, univariate comparison and binary logistic regression analysis of preoperative data based whether CR successful were performed to search the factors related to CR failure. [Results] Among 375 patients, 348 patients had CR performed successfully, accounting for 92.80%, whereas 27 patients got CR failed to change OR, accounting for 7.20%. Finally, all patients got fracture reduction and cross Kirschner wire fixation successfully in both groups. The CR group proved significantly superior to the OR group in terms of operation time, intraoperative fluoroscopy times, hospital stay, incidence of early complications and VAS score 1 day postoperatively (P＜0.05) . All the patients were followed up for 14~46 months, with an average of (23.40±4.59) months. There were no statistically significant differences between the two groups in the time to remove the plaster splint, the time to resume full weight-bearing activities, elbow flexion-extension ROM and Flynn's scales at the latest follow-up (P＞ 0.05) . Radiographically, satisfactory fracture reduction achieved in all children of both groups, with sound fracture healing, whereas no sig- nificant differences in carrying angle and Baumann angle between the two groups at the last follow-up (P＜0.05) . Regarding to univariate comparison, the CR group had significantly less BMI, fracture complexity, time elapsed between injury and surgery, as well as damage ener- gy extent than the OR group (P＜0.05) . As results of logistic regression, fracture complexity type (OR=8.251, P=0.037) , damage energy (OR=1.593, P=0.035) , and duration from injury to operation (OR=1.400, P=0.026) were independent risk factors for CR failure of supracon-dylar humeral fractures in children. [Conclusion] The children who fail to initial closed reduction of humeral supracondylar fracture should be changed to open reduction in time, and still archive satisfactory results eventually. The fracture complexity, high energy injury and long duration from injury to operation are the main risk factors for the failure of initial closed reduction.