Pedreira Rachel, Cho Brian H, Geer Angela, DeJesus Ramon A
Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland, United States.
Division of Plastic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, United States.
J Hand Microsurg. 2018 Apr;10(1):6-11. doi: 10.1055/s-0037-1608743. Epub 2017 Dec 8.
The difficulties in surgical treatment of pilon fractures of the finger include fragment reconstitution and posthealing stiffness. In adults, external fixation with traction and early active range of motion (AROM)/passive range of motion (PROM) during healing is considered necessary for avoiding joint stiffness and attaining realignment. The authors present a unique approach to pediatric pilon fractures that uses open reduction and multivector external fixation with delayed AROM/PROM. Initial immobilization and significant traction allowed for joint realignment and prevented noncompliance with staged distraction. The authors believe this immobilization leads to a superior outcome because, unlike adults, children tend to avoid stiffness and a larger distraction force allowed for sufficient joint realignment to regain range of motion (ROM).
A right-handed 13-year-old boy sustained a right ring finger fracture and presented 12 days later. Radiographs revealed a comminuted Salter-Harris 4 fracture of the middle phalanx. The patient underwent open reduction and placement of multivector external fixation using a pediatric mandibular distractor/fixator. Significant traction was applied to distract the finger to length.
Hardware was removed 6 weeks postoperatively and AROM was initiated after splinting. The patient started PROM 8 weeks postoperatively. Strengthening was initiated 2 weeks later. ROM improved and rehabilitation was continued. The patient exhibited nearly equal grip strength 12 weeks postoperatively. At 14 months follow-up, radiographs showed complete healing and joint realignment. There was no deformity or pain and finger length was restored.
Management of pediatric pilon fractures is rarely described and presents unique considerations. Early-stage traction and immobilization using a multivector mandibular fixator/distractor is suitable in a child because noncompliance is avoided and there is a decreased risk for stiffness. Combining early immobilization with subsequent-staged AROM, PROM, and strengthening resulted in no loss of ROM and maintained articular symmetry.
手指pilon骨折的手术治疗难点包括骨折块重建和愈合后僵硬。在成人中，愈合期间采用牵引外固定及早期主动活动范围（AROM）/被动活动范围（PROM）被认为对于避免关节僵硬和实现复位是必要的。作者介绍了一种针对儿童pilon骨折的独特方法，即切开复位和多向量外固定并延迟进行AROM/PROM。初始固定和显著牵引可实现关节复位并防止不配合阶段性撑开。作者认为这种固定能带来更好的结果，因为与成人不同，儿童往往不易出现僵硬，且更大的撑开力可实现足够的关节复位以恢复活动范围（ROM）。
一名13岁右利手男孩右手环指骨折，伤后12天就诊。X线片显示中节指骨粉碎性Salter-Harris 4型骨折。患者接受切开复位，使用儿童下颌牵张器/固定器进行多向量外固定。施加显著牵引以使手指牵至正常长度。
术后6周取出内固定装置，夹板固定后开始进行AROM训练。患者术后8周开始PROM训练。2周后开始进行强化训练。ROM得到改善并继续康复治疗。术后12周患者握力几乎恢复正常。随访14个月时，X线片显示骨折完全愈合且关节复位。无畸形或疼痛，手指长度恢复正常。
儿童pilon骨折的治疗方法鲜有描述且存在独特的考量因素。在儿童中，早期使用多向量下颌固定器/牵张器进行牵引和固定是合适的，因为可避免不配合且僵硬风险降低。早期固定与后续分阶段的AROM、PROM及强化训练相结合，未导致ROM丧失并维持了关节对称性。
