Skaggs D L, Hale J M, Bassett J, Kaminsky C, Kay R M, Tolo V T
Division of Orthopedic Surgery, Childrens Hospital, Los Angeles, California 90027, USA.
J Bone Joint Surg Am. 2001 May;83(5):735-40.
The commonly accepted treatment of displaced supracondylar fractures of the humerus in children is fracture reduction and percutaneous pin fixation; however, there is controversy about the optimal placement of the pins. A crossed-pin configuration is believed to be mechanically more stable than lateral pins alone; however, the ulnar nerve can be injured with the use of a medial pin. It has not been proved that the added stability of a medial pin is clinically necessary since, in young children, pin fixation is always augmented with immobilization in a splint or cast.
We retrospectively reviewed the results of reduction and Kirschner wire fixation of 345 extension-type supracondylar fractures in children. Maintenance of fracture reduction and evidence of ulnar nerve injury were evaluated in relation to pin configuration and fracture pattern. Of 141 children who had a Gartland type-2 fracture (a partially intact posterior cortex), seventy-four were treated with lateral pins only and sixty-seven were treated with crossed pins. Of 204 children who had a Gartland type-3 (unstable) fracture, fifty-one were treated with lateral pins only and 153 were treated with crossed pins.
There was no difference with regard to maintenance of fracture reduction, as seen on anteroposterior and lateral radiographs, between the crossed pins and the lateral pins. The configuration of the pins did not affect the maintenance of reduction of either the Gartland type-2 fractures or the Gartland type-3 fractures. Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used. The use of a medial pin was associated with ulnar nerve injury in 4% (six) of 149 patients in whom the pin was applied without hyperflexion of the elbow and in 15% (eleven) of seventy-one in whom the medial pin was applied with the elbow hyperflexed. Two years after the pinning, one of the seventeen children with ulnar nerve injury had persistent motor weakness and a sensory deficit.
Fixation with only lateral pins is safe and effective for both Gartland type-2 and Gartland type-3 (unstable) supracondylar fractures of the humerus in children. The use of only lateral pins prevents iatrogenic injury to the ulnar nerve. On the basis of our findings, we do not recommend the routine use of crossed pins in the treatment of supracondylar fractures of the humerus in children. If a medial pin is used, the elbow should not be hyperflexed during its insertion.
儿童肱骨髁上移位骨折的公认治疗方法是骨折复位及经皮穿针固定；然而，关于钢针的最佳置入位置存在争议。人们认为交叉钢针构型在力学上比单纯外侧钢针更稳定；然而，使用内侧钢针可能会损伤尺神经。由于在幼儿中，钢针固定后总是用夹板或石膏固定，因此内侧钢针增加的稳定性在临床上是否必要尚未得到证实。
我们回顾性分析了345例儿童伸直型肱骨髁上骨折复位及克氏针固定的结果。根据钢针构型和骨折类型评估骨折复位的维持情况及尺神经损伤的证据。在141例Gartland 2型骨折（后侧皮质部分完整）患儿中，74例仅采用外侧钢针治疗，67例采用交叉钢针治疗。在204例Gartland 3型（不稳定）骨折患儿中，51例仅采用外侧钢针治疗，153例采用交叉钢针治疗。
前后位和侧位X线片显示，交叉钢针和外侧钢针在维持骨折复位方面无差异。钢针构型不影响Gartland 2型骨折或Gartland 3型骨折复位的维持。在仅使用外侧钢针的125例患者中未发现尺神经损伤。在149例未使肘关节极度屈曲而置入内侧钢针的患者中，4%（6例）出现尺神经损伤；在71例使肘关节极度屈曲而置入内侧钢针的患者中，15%（11例）出现尺神经损伤。穿针两年后，17例尺神经损伤患儿中有1例存在持续的运动无力和感觉障碍。
对于儿童Gartland 2型和Gartland 3型（不稳定）肱骨髁上骨折，仅用外侧钢针固定是安全有效的。仅使用外侧钢针可避免尺神经的医源性损伤。根据我们的研究结果，我们不建议在儿童肱骨髁上骨折治疗中常规使用交叉钢针。如果使用内侧钢针，在置入时肘关节不应极度屈曲。
