2013AAOS：不同年龄段幼儿肱骨髁上移位骨折的临床特征差异

引言：肱骨髁上骨折中，Gartland 3型是最难处理的一类。本研究旨在探讨发生3型肱骨髁上骨折的幼儿与3岁以上儿童病例临床表现上是否存在显著差异。
方法：我们收集了2000年到2012年共10年期间一家三级儿童创伤中心诊治的146例3型肱骨髁上骨折病例。将这些病例按年龄分为幼儿组（年龄在3岁以下）及儿童组（年龄在3岁以上）。收集并比较两组病例下述相关因素：人口统计学资料、可疑儿童虐待、合并损伤、受伤机制、创伤发生的位置、骨折移位类型、内固定针数量以及不同固定针之间的结构形式、术后Baumman角以及肱骨前缘线、术后并发症、再手术、是否遵医嘱复查及术后随访时间等之间的差异。
结果：本组病例分别有73例在受伤时的年龄小于或大于3岁。幼儿组和儿童组病例在合并损伤、可疑儿童虐待、创伤发生的位置、术后肱骨前缘线以及内固定针的数量等方面差异显著。儿童组病例合并损伤的发生率更高（p=0.0469）。幼儿组病例中，幼儿组共有6例存在合并损伤，其中3例（50%）桡动脉博动减弱且伤肢手部颜色青紫、2例（33%）合并桡骨远端骨折、1例（17%）合并股骨骨折。幼儿组病例无合并神经损伤者。儿童组有7例（37%）患儿合并骨间前神经损伤，3例（16%）合并桡动肪博动减弱伴伤肢手部颜色青紫，3例（16%）合并桡骨远端骨折，3例（16%）合并骨间后神经损伤，3例（16%）合并尺骨骨折。幼儿组病例怀疑存在儿童虐待者比例较儿童组更高（p=0.0334），其中幼儿组为8例（11%），而儿童组为1例（1%）。幼儿组病例的损伤更多发生于家庭室内环境下（50例，68%），而儿童组病例的损伤更多发生于室外（47例，64%）（p=0.0001）。儿童组病例所使用的内固定针数量多于幼儿组病例：幼儿组和儿童组分别有35例（48%）和42例（58%）用量为2根；两组分别有38例（52%）和42例（58%）用量为3根。幼儿组病例无使用4根内固定针者，而儿童组则有7例（10%）内固定针用量为4根。儿童组病例术后肱骨前缘线通过肱骨干中1/3者比例更高（p=0.0097）。
结论：本研究结果显示不同年龄段儿童3型肱骨髁上骨折病例之间在合并损伤、可疑儿童虐待、创伤发生的部位以及内固定针用量等方面均存在明显的差异。我们认为在幼儿病例应考虑其损伤为非意外原因所导致。由于对幼儿病例进行神经功能的评估较儿童患者更为困难，因此我们认为可能低估幼儿病例存在神经损伤的可能性。尽管幼儿病例手术中所使用的内固定针数量更少，但这并不意味着其骨折较儿童病例更为稳定，其原因在于不同的医师对于内固定针的应用可能存在习惯性方面的差异。儿童组病例术后肱骨前缘线通过肱骨干中1/3者比例更高的现象与年龄相关的骨折复位目标相一致，因为在幼儿肱骨前缘线在肱骨干前中1/3之间范围内存在较大的变异。以后需要更大样本量的研究来进一步证实本研究的相关发现。
与骨折相关的拓展阅读：

• Injury：关节外胫骨远端骨折的手术选择：MIPPO vs ORIF
• AAOS：多次细菌培养或可提高骨折内固定术后感染诊断率
• AAOS：抗骨质疏松治疗可降低髋部骨折老年女性的死亡风险
• Osteoporos Int：糖皮质激素使用增加骨折风险
• JCEM：腹部脂肪的减少增加骨折风险
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Displaced Supracondylar Humerus Fractures in Toddlers: Are They Different?
INTRODUCTION
Gartland type 3 is the most troublesome type of supracondylar humerus fracture. Our goal was to analyze clinically significant differences between toddlers and children over the age of three exclusively with type 3 fractures.
METHODS
A total of 146 patients with type 3 supracondylar humerus fractures were collected at a tertiary pediatric trauma center over a 12-year period (2000 to 2012). We divided the patients into two cohorts: toddlers (< 3 years old) and children over the age of three. We collected and compared factors such as demographics, suspected child abuse, associated injuries, mechanism of injury, physical location where the trauma occurred, types of displacement, number of pins and pin configuration, postoperative Baumman's angle and anterior humeral line, postoperative complications, return to surgery, compliance with scheduled follow up and follow-up time between the two groups.
RESULTS
Seventy-three patients were less than three years old and 73 were older than three. There were significant differences between the two groups in the rate of associated injuries, suspected child abuse, location where the injury occurred, postoperative anterior humeral line and number of pins used in surgery. The older group was more likely to have associated injuries (p=0.0469). In the toddlers group, three patients (50%) had a decreased radial pulse with a pink hand, two (33%) had an associated distal radius fracture and one (17%) had an associated femur fracture. There was no associated nerve injuries reported in the toddlers group. In the older children group, seven patients (37%) had an anterior interosseous nerve injury, three (16%) had decreased radial pulse with a pink hand, three (16%) had an associated distal radius fracture, three (16%) had a posterior interosseous nerve injury and three (16%) had an associated ulna fracture. Cases of suspected child abuse were more frequent in the toddler group than the older group (p=0.0334). There were eight (11%) suspected cases in the toddlers group versus one (1%) in the older group. Injuries were more likely to happen in the home environment than outside the home in toddlers (50 patients, 68%) compared to the older group (p=0.0001) where injuries were more likely to occur outside the home environment (47 patients, 64%). On average, a greater number of pins was used in the older group (p=0.0088).Two pins were used in 35 (48%) of the toddlers and 24 (33%) of the older children; three pins were used in 38 (52%) of the toddlers and 42 (58%) of the older group. The four-pin configuration was not used in the toddler group, but was used in seven (10%) of the older children. The older group was more likely to have the anterior humeral line crossing the middle 1/3 postoperatively (p=0.0097). {nextpage}
CONCLUSION
This study provides novel insight into differences between age groups in type 3 supracondylar humerus fracture patients. The data reveals differences in associated injuries, suspected child abuse, location where the trauma occurred and number of pins used. We suggest that nonaccidental causes should be considered in toddlers. We believe that the associated injuries in the toddler group could be underestimated since neurologic assessment in toddlers is more challenging than in older children. The difference in number of pins used does not necessarily imply that injuries are more stable in toddlers, as this finding may be confounded by surgeon preference for a particular pin configuration. The finding of the anterior humeral line crossing the middle 1/3 postoperatively in the older group is in accordance with age appropriate anatomical reduction goals, as normal relation with the anterior humeral line can vary between anterior and middle third in toddlers. Larger studies are recommended to further confirm these results.