Flynn John M, Jones Kristofer J, Garner Matthew R, Goebel Jennifer
Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
J Pediatr Orthop. 2010 Jun;30(4):313-9. doi: 10.1097/BPO.0b013e3181d98f2c.
There has been a trend toward operative management of pediatric diaphyseal forearm fractures (DFFx). We studied our experience with surgical management of these injuries to assess indications, frequency, outcome, and complications.
One hundred forty-four consecutive children had surgical management of 149 DFFx over 11 years at our Level 1 pediatric trauma center. A chart/radiographic review established perioperative events, intraoperative findings, time-to-union, range-of-motion, and complications. We developed the Children's Hospital of Philadelphia Forearm Fracture Fixation Outcome Classification to assess postoperative outcomes.
Over 11 years, we treated 2297 DFFx; 155 of 2297 (6.7%) had surgical management. Six were lost to follow-up and excluded. A 7-fold increase in operative management was observed over the study period [2 of 143 (1.4%) vs. 28 of 270 (10.4%), P<0.001]. One hundred and three of 149 (69.1%) were treated with intramedullary nailing (IMN); 44 of 149 (29.5%) with plates; and 2 of 149 (1.3%) had combined plate/nail fixation. Thirty of 103 (29.1%) had the fracture site opened to pass the IMN; in 23 cases, open fractures were exploited to assist nail passage. When managed with IMN, open fracture sites showed slowed healing: union was 8.6 weeks for those opened intraoperatively and 6.9 weeks for those remaining closed (P<0.001). Fractures opened secondary to injury achieved union at 9.75 weeks which was significantly longer than those opened intraoperatively (8.6 wk, P=0.04) and those remaining closed (6.9 wk, P=0.001). Compartment syndrome occurred in 6.7% (2 of 30) treated with IMN within 24 hours of injury versus 0 of 73 treated later (P=0.026). Delayed union after IMN occurred in 6 children 10 years of age versus none less than 10 years of age. Poor/fair outcome of IMN increased with age [6 of 47 (13%) < or =10 y of age, vs. 17 of 56 (30%)>10 y of age, P=0.03]. Overall complication rate for IMN was 14.6% (15 of 103).
Our center has operatively managed DFFx with increased frequency over the past decade. IMN had a complication rate of 14.6% and was frequently not "minimally invasive." An open fracture site delayed healing. Compartment syndrome was more frequent when IMN was used the day of injury and older children had poorer outcomes and higher rates of delayed union.
Level III, Retrospective Comparative Study.
小儿尺桡骨干骨折（DFFx）的手术治疗呈上升趋势。我们研究了这些损伤的手术治疗经验，以评估其适应证、频率、预后及并发症。
在我们的一级儿童创伤中心，11年间144例连续儿童接受了149例DFFx的手术治疗。通过病历/影像学回顾确定围手术期事件、术中发现、愈合时间、活动范围及并发症。我们制定了费城儿童医院前臂骨折固定结果分类法来评估术后结果。
11年间，我们共治疗2297例DFFx；其中155例（6.7%）接受了手术治疗。6例失访被排除。在研究期间，手术治疗增加了7倍[143例中的2例（1.4%）对270例中的28例（10.4%），P<0.001]。149例中的103例（69.1%）采用髓内钉固定（IMN）；149例中的44例（29.5%）采用钢板固定；149例中的2例（1.3%）采用钢板/髓内钉联合固定。103例中的30例（29.1%）切开骨折部位以插入髓内钉；23例中，利用开放性骨折来辅助髓内钉插入。采用IMN治疗时，开放性骨折部位愈合减慢：术中切开的患者愈合时间为8.6周，未切开的患者为6.9周（P<0.001）。因损伤导致切开的骨折在9.75周愈合，明显长于术中切开的骨折（8.6周，P=0.04）及未切开的骨折（6.9周，P=0.001）。6.7%（30例中的2例）在受伤24小时内采用IMN治疗的患者发生骨筋膜室综合征（compartment syndrome），而73例后期治疗的患者中无1例发生（P=0.026）。10岁的6例儿童采用IMN治疗后发生延迟愈合，而10岁及以上儿童无1例发生。IMN治疗效果差/一般的比例随年龄增加而升高[47例年龄≤10岁的儿童中有6例（13%），56例年龄>10岁的儿童中有17例（30%），P=0.03]。IMN总的并发症发生率为14.6%（103例中的15例）。
在过去十年中，我们中心对DFFx的手术治疗频率增加。IMN的并发症发生率为14.6%，且通常并非“微创”。开放性骨折部位愈合延迟。受伤当天采用IMN治疗时骨筋膜室综合征更常见，年龄较大的儿童预后较差，延迟愈合率较高。
三级，回顾性比较研究。
