Bauer Jennifer M, Stutz Christopher M, Schoenecker Jonathan G, Lovejoy Steven A, Mencio Gregory A, Martus Jeffrey E
Monroe Carell Jr Children's Hospital at Vanderbilt Medical Center, Pediatric Orthopaedic Surgery, Nashville, TN.
Texas Scottish Rite Hospital for Children, Pediatric Orthopaedic Surgery, Dallas, TX.
J Pediatr Orthop. 2019 Jan;39(1):8-13. doi: 10.1097/BPO.0000000000000914.
The purpose of this study was to determine if routine use of an intraoperative internal rotation stress test (IRST) for type 3 supracondylar humerus fractures will safely improve maintenance of reduction.
An intraoperative protocol for type 3 supracondylar humerus fractures was adopted at our institution, consisting of fracture reduction, placement of 2 laterally based divergent pins, and then an IRST to determine the need for additional fixation with a medial column pin placed through a small open approach. Fractures treated with the prospective IRST protocol were compared with a retrospective cohort before adoption of the protocol (pre-IRST). The primary outcomes were differences in Baumann's angle, lateral humerocapitellar angle, and the rotation index between final intraoperative fluoroscopic images and radiographs at final follow-up. Secondary outcomes were complications such as iatrogenic nerve injury, loss of fixation, or need for reoperation.
There were 78 fractures in the retrospective cohort (pre-IRST) and 49 in the prospective cohort (IRST). Overall rotational loss of reduction (>6%), measured by lateral rotation percentage, and major rotational loss of reduction (>12%) were less common in the IRST cohort (6/49 vs. 27/78, P=0.007 overall; 0/49 vs. 8/78, P=0.02 major loss). There were no major losses of reduction for Baumann's angle (>12 degrees) in either cohort. There were 5 subjects in the pre-IRST cohort (6.4%) with a major loss of reduction of the humerocapitellar angle (>12 degrees) and none in the IRST cohort (P=0.16) Loss of proximal fixation with need for reoperation occurred in 3 fractures in the pre-IRST cohort, and none in the IRST cohort (P=0.28). There were no postoperative nerve injuries in either group.
Intraoperative IRST after placement of 2 lateral pins assists with the decision for additional fixation in type 3 supracondylar humerus fractures. This method improved the final radiographic rotational alignment, and was safely performed using a mini-open approach for medial pin placement.
Level III-prospective cohort compared with a retrospective cohort.
本研究的目的是确定术中常规使用内旋应力试验（IRST）治疗3型肱骨髁上骨折是否能安全地改善复位维持情况。
我们机构采用了一种3型肱骨髁上骨折的术中方案，包括骨折复位、放置2根外侧发散克氏针，然后进行IRST以确定是否需要通过小切口入路放置内侧柱克氏针进行额外固定。将采用前瞻性IRST方案治疗的骨折与该方案采用前的回顾性队列（术前IRST）进行比较。主要结局是末次术中透视图像与末次随访时X线片之间鲍曼角、肱骨小头外侧角和旋转指数的差异。次要结局是诸如医源性神经损伤、内固定失败或再次手术需求等并发症。
回顾性队列（术前IRST）中有78例骨折，前瞻性队列（IRST）中有49例骨折。通过外旋百分比测量，总体复位旋转丢失（>6%）和主要复位旋转丢失（>12%）在IRST队列中较少见（6/49对27/78，总体P=0.007；0/49对8/78，主要丢失P=0.02）。两个队列中鲍曼角（>12度）均无主要复位丢失。术前IRST队列中有5例患者（6.4%）肱骨小头角主要复位丢失（>12度），而IRST队列中无此情况（P=0.16）。术前IRST队列中有3例骨折出现近端内固定失败需要再次手术，而IRST队列中无此情况（P=0.28）。两组均无术后神经损伤。
在放置2根外侧克氏针后进行术中IRST有助于决定3型肱骨髁上骨折是否需要额外固定。该方法改善了最终的影像学旋转对线，并且通过小切口入路安全地进行内侧克氏针放置。
III级——前瞻性队列与回顾性队列比较。
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