Liu Raymond W, Roocroft Joanna, Bastrom Tracey, Yaszay Burt
Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, OH, USA.
J Pediatr Orthop. 2011 Dec;31(8):818-24. doi: 10.1097/BPO.0b013e3182306884.
There has been an increasing trend toward referral of supracondylar humerus fractures in children to pediatric orthopaedic centers. The learning curve for treating this fracture is not well described.
We retrospectively reviewed all supracondylar fractures treated by 21 pediatric orthopaedic fellows over the 2003 to 2009 academic years, with attending cases from 2005 to 2007 to serve as a control. Type IIa, IIb, and III fractures were used in the case count of for each fellows, whereas only type III fractures were used to record fluoroscopy time, operative time, and for radiographic review. Nonideal reduction was defined as a Baumann angle outside the range of 64 to 81 degrees, or an anterior humeral line that does not intersect the capitellum.
Of the 654 total operatively treated fractures, fellows treated 479 total and 213 type III fractures. Backup attendings were present in the operating room for 39% of type III fractures in the first academic quarter before falling to a baseline of 10% to 20% during the remaining quarters. Fluoroscopy time and operative time were consistent for fellows throughout the year. Nonideal reductions increased notably at case 7, correlating with increased fellow independence in the operating room, with reversal of the trend at case 15. There were no differences in complication rates and no malunions requiring osteotomy.
In order to balance training and patient care, we recommend the availability of an attending backup surgeon for the first 15 cases of supracondylar humerus fractures treated by pediatric orthopaedic fellows.
Level III, retrospective comparative study.
儿童肱骨髁上骨折转诊至小儿骨科中心的趋势日益增加。治疗这种骨折的学习曲线尚未得到充分描述。
我们回顾性分析了2003至2009学年21名小儿骨科住院医师治疗的所有肱骨髁上骨折病例，并将2005至2007年主治医生治疗的病例作为对照。每位住院医师的病例数统计采用IIa型、IIb型和III型骨折，而仅用III型骨折记录透视时间、手术时间及进行影像学评估。复位不理想定义为鲍曼角超出64至81度范围，或肱前线未与肱骨小头相交。
在总共654例接受手术治疗的骨折中，住院医师共治疗479例，其中III型骨折213例。在第一学年季度，39%的III型骨折手术中有后备主治医生在场，之后各季度降至10%至20%的基线水平。住院医师全年的透视时间和手术时间保持一致。不理想复位在第7例时显著增加，这与住院医师在手术室的独立性增加相关，在第15例时趋势逆转。并发症发生率无差异，也没有需要截骨术的骨不连。
为平衡培训与患者护理，我们建议在小儿骨科住院医师治疗的前15例肱骨髁上骨折中，配备后备主治医生。
III级，回顾性比较研究。
