儿童肱骨髁上骨折移位时克氏针固定失败：原因与预防
Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention.
作者信息
Sankar Wudbhav N, Hebela Nader M, Skaggs David L, Flynn John M
机构信息
Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Wood Building, 2nd Floor, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
出版信息
J Bone Joint Surg Am. 2007 Apr;89(4):713-7. doi: 10.2106/JBJS.F.00076.
BACKGROUND
Although the results are generally good following pin fixation of supracondylar humeral fractures in children, occasionally there is postoperative displacement. The purposes of the present study were to identify the causes leading to loss of fixation after pin fixation and to present methods for prevention.
METHODS
We evaluated 322 displaced supracondylar humeral fractures that had been treated with percutaneous pin fixation. We examined fracture classification, pin configuration, intraoperative alignment after fixation, change in alignment after fixation, details of additional procedures, and final radiographic and clinical outcomes.
RESULTS
Adequate radiographs were available for 279 of the 322 fractures. Eight (2.9%) of the 279 fractures were associated with postoperative loss of fixation; all eight were Gartland type-III fractures. Seven of these eight fractures initially had been treated with two lateral-entry pins, and one had been treated with two crossed pins. In patients with Gartland type-III fractures, loss of fixation was successfully avoided more often when three pins were used (with fixation being maintained in thirty-seven of thirty-seven patients) as opposed to when two lateral-entry pins were used (with fixation being maintained in thirty-five of forty-two patients) (p = 0.01). In all cases, loss of fixation was due to technical errors that were identifiable on the intraoperative fluoroscopic images and that could have been prevented with proper technique. We identified three types of pin-fixation errors: (1) failure to engage both fragments with two pins or more, (2) failure to achieve bicortical fixation with two pins or more, and (3) failure to achieve adequate pin separation (>2 mm) at the fracture site.
CONCLUSIONS
Postoperative displacement following pin fixation of supracondylar humeral fractures in children is uncommon. In the present series, loss of fixation was most likely to occur when Gartland type-III fractures were treated with two lateral-entry pins. There were no failures when three pins were used. In all cases of failure, there were identifiable technical errors in pin placement.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.
背景
尽管儿童肱骨髁上骨折经克氏针固定后总体效果良好，但偶尔会出现术后移位。本研究的目的是确定克氏针固定后固定失败的原因，并提出预防方法。
方法
我们评估了322例采用经皮克氏针固定治疗的移位肱骨髁上骨折。我们检查了骨折分类、克氏针构型、固定后术中对线情况、固定后对线变化、附加手术细节以及最终的影像学和临床结果。
结果
322例骨折中有279例获得了足够的X线片。279例骨折中有8例（2.9%）出现术后固定失败；所有8例均为Gartland III型骨折。这8例骨折中有7例最初采用两根外侧入路克氏针治疗，1例采用两根交叉克氏针治疗。在Gartland III型骨折患者中，使用三根克氏针时更常成功避免固定失败（37例患者中有37例固定得以维持），而使用两根外侧入路克氏针时则不然（42例患者中有35例固定得以维持）（p = 0.01）。在所有病例中，固定失败均归因于术中透视图像上可识别的技术失误，而这些失误可通过适当技术避免。我们确定了三种克氏针固定失误类型：（1）未能用两根或更多克氏针固定两块骨折碎片；（2）未能用两根或更多克氏针实现双皮质固定；（3）未能在骨折部位实现足够的克氏针间距（>2 mm）。
结论
儿童肱骨髁上骨折克氏针固定术后移位并不常见。在本系列研究中，当Gartland III型骨折采用两根外侧入路克氏针治疗时，最有可能发生固定失败。使用三根克氏针时无一例失败。在所有失败病例中，克氏针置入均存在可识别的技术失误。
证据水平
治疗性III级。有关证据水平的完整描述，请参阅作者须知。
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