Foran Ian, Upasani Vidyadhar V, Wallace Charles D, Britt Elise, Bastrom Tracey P, Bomar James D, Pennock Andrew T
*Department of Orthopaedic Surgery, University of California †Department of Orthopedics, Rady Children's Hospital and Health Center, San Diego, CA.
J Pediatr Orthop. 2017 Sep;37(6):e335-e341. doi: 10.1097/BPO.0000000000001001.
In 2015, a multicenter study group proposed a treatment algorithm for pediatric Monteggia fractures based upon the ulnar fracture pattern. This strategy recommends surgical stabilization for all complete ulna fractures. The purpose of this study was to evaluate whether an initial nonoperative approach to pediatric Monteggia fractures resulted in poorer outcomes and a higher rate of complications.
This institutional review board approved retrospective study evaluated all Monteggia fractures presenting to a level 1 pediatric trauma center between 2008 and 2014. Chart and radiographic reviews were performed on 94 patients who met inclusion criteria. The mean age was 5.5 years (range, 1 to 13 y). The mean clinical follow-up was 18 weeks. Major complications were defined as those requiring an unplanned second procedure (other than implant removal) or that may result in long-term disability (residual radial head subluxation/dislocation). Univariate (P<0.05) and Multivariate Classification and Regression Tree (CART) (P<0.05) analyses were used to identify variables associated with the need for surgical stabilization.
At final follow-up, there were no cases of residual radiocapitellar joint subluxation or dislocation and all fractures had healed. The majority (83%) of patients were successfully managed with a cast. Univariate analysis found Bado type and maximum ulna angulation as significant predictors (P<0.05), whereas the CART analysis found ulna angulation >36.5 degrees as the only primary predictor of requiring surgical stabilization. Overall, good outcomes were achieved in all patients with few major complications.
Although treatment algorithms are intended to minimize complications and maximize good outcomes, we believe that an unintentional consequence of the recently proposed pediatric Monteggia fracture treatment guideline may be the overtreatment of these injuries. In our cohort, the majority of patients were able to avoid the operating room and surgical implants without compromising outcomes or complications. This more conservative approach, however, requires close monitoring of patients in the first 3 weeks during which most reductions were lost.
Level IV-therapeutic studies, case series.
2015年，一个多中心研究小组基于尺骨骨折类型提出了小儿孟氏骨折的治疗算法。该策略建议对所有尺骨完全骨折进行手术固定。本研究的目的是评估小儿孟氏骨折的初始非手术治疗方法是否会导致较差的治疗效果和更高的并发症发生率。
本机构审查委员会批准的回顾性研究评估了2008年至2014年间在一级小儿创伤中心就诊的所有孟氏骨折患者。对94名符合纳入标准的患者进行了病历和影像学检查。平均年龄为5.5岁（范围1至13岁）。平均临床随访时间为18周。主要并发症定义为需要进行计划外的二次手术（植入物取出除外）或可能导致长期残疾（桡骨头残留半脱位/脱位）的并发症。采用单因素分析（P<0.05）和多因素分类与回归树（CART）分析（P<0.05）来确定与手术固定需求相关的变量。
在最后一次随访时，没有桡骨头关节残留半脱位或脱位的病例，所有骨折均已愈合。大多数（83%）患者通过石膏固定成功治疗。单因素分析发现巴多（Bado）分型和尺骨最大成角是显著的预测因素（P<0.05），而CART分析发现尺骨成角>36.5度是需要手术固定的唯一主要预测因素。总体而言，所有患者均取得了良好的治疗效果，主要并发症较少。
尽管治疗算法旨在尽量减少并发症并最大限度地提高治疗效果，但我们认为最近提出的小儿孟氏骨折治疗指南可能会导致这些损伤的过度治疗。在我们的队列中，大多数患者能够避免手术室治疗和手术植入物，而不影响治疗效果或增加并发症。然而，这种更保守的方法需要在最初3周内密切监测患者，在此期间大多数复位会丢失。
IV级——治疗性研究，病例系列。
