Kinney Matthew C, Nagle David, Bastrom Tracey, Linn Michael S, Schwartz Alexandra K, Pennock Andrew T
*Department of Orthopaedic Surgery, University of California†Department of Pediatric Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA‡Department of Orthopaedic Surgery, North Shore-LIJ Health System, Bay Shore, NY.
J Pediatr Orthop. 2016 Oct-Nov;36(7):661-6. doi: 10.1097/BPO.0000000000000532.
Displaced tibial shaft fractures are common in adolescent patients, yet there is no standardized management strategy. We compared surgical fixation and closed reduction and casting (CRC) of these fractures to assess treatment outcomes and determine predictors of failure.
We retrospectively reviewed all patients aged 12 to 18 who presented with a displaced tibial shaft fracture that required reduction over an 8-year period. Exclusion criteria included open fractures and lack of follow-up to radiographic union or to 6 months from the index procedure. Fractures were initially treated based on surgeon preference either with CRC or with immediate intramedullary nailing. Seventy-four patients met inclusion criteria: 57 were initially managed with CRC and 17 with operative fixation. Radiographic healing was defined as bridging of 3 cortices and adequacy of final alignment was defined as <5 degrees of angular deformity in both planes and <1.0 cm of shortening. Outcomes were analyzed both on intent-to-treat principles and by definitive treatment method.
Although all fractures in both groups achieved bony healing, 23 of the 57 patients who underwent CRC failed closed treatment and ultimately required surgery (40.3%). Multivariate analysis of patient and fracture characteristics revealed fracture displacement of >20% (odds ratio=7.8, P<0.05) and the presence of a fibula fracture (odds ratio=5.06, P=0.05) as predictors of closed treatment failure. Patients ultimately managed with intramedullary nailing trended toward increased adequacy of final alignment (92.5% vs. 72.4%, P=0.10) but required longer hospitalization (5.4 vs. 1.9 d, P<0.001) and had a higher incidence of anterior knee pain (20% vs. 0%, P<0.01). There was no significant difference between groups with respect to time to healing.
Treatment outcomes between initial operative fixation and closed reduction of displaced tibia fractures in adolescents are similar, but patients must be counseled about the high failure rates with CRC. Predictors of CRC failure include initial fracture displacement and the presence of a fibula fracture-these variables should be considered when selecting a treatment method.
Level III-Therapeutic study.
胫骨干骨折移位在青少年患者中很常见，但尚无标准化的治疗策略。我们比较了这些骨折的手术固定与闭合复位及石膏固定（CRC），以评估治疗效果并确定失败的预测因素。
我们回顾性分析了所有12至18岁因胫骨干骨折移位而需要复位的患者，研究时间跨度为8年。排除标准包括开放性骨折以及缺乏至影像学愈合或至初次手术6个月的随访。骨折最初根据外科医生的偏好，采用CRC或立即髓内钉固定进行治疗。74例患者符合纳入标准：57例最初采用CRC治疗，17例采用手术固定。影像学愈合定义为3个皮质连续，最终对线良好定义为两个平面的角畸形均<5度且短缩<1.0 cm。结果按照意向性分析原则和最终治疗方法进行分析。
尽管两组所有骨折均实现了骨愈合，但57例接受CRC治疗的患者中有23例闭合治疗失败，最终需要手术（40.3%）。对患者和骨折特征进行多因素分析显示，骨折移位>20%（比值比=7.8，P<0.05）和存在腓骨骨折（比值比=5.06，P=0.05）是闭合治疗失败的预测因素。最终采用髓内钉固定的患者最终对线良好的趋势增加（92.5%对72.4%，P=0.10），但住院时间更长（5.4天对1.9天，P<0.001），前膝痛发生率更高（20%对0%，P<0.01）。两组之间在愈合时间方面无显著差异。
青少年胫骨干骨折移位的初始手术固定与闭合复位的治疗效果相似，但必须告知患者CRC的高失败率。CRC失败的预测因素包括初始骨折移位和腓骨骨折的存在——在选择治疗方法时应考虑这些变量。
三级——治疗性研究。
