Varga Marcell, Gáti Nikoletta, Kassai Tamás, Papp Szilvia, Pintér Sándor
Péterfy Hospital, Department of Pediatric Trauma Surgery, Budapest Department of Trauma Surgery, University Of Szeged, Hungary.
Medicine (Baltimore). 2018 Jun;97(24):e11167. doi: 10.1097/MD.0000000000011167.
Extensor pollicis longus tendon (EPL) injury is a potential complication of dorsal entry radial elastic nailing technique in children. The aim of this study was to investigate if intraoperative ultrasonographic guidance can reduce the risk of (EPL) injury.Correlation between sonographic and operative findings were examined first in 6 adult cadavers. Position of Lister's tubercle, EPL, and extraosseal end of the elastic nail were detected by ultrasound imaging during a minimally invasive dorsal entry nailing. Radial slope of Lister's eminence was determined as a safe and easily identifiable entry point for opening the medullary canal. Extraosseal ends of the nails were bended in a slight radial direction and cut immediately beneath the skin in a maximally palmar-flexed wrist position. Cadaveric dissections followed our procedures all correlated with ultrasonographic findings, we have not seen tendon damage, obstruction or friction by the implant's end.After cadaveric experiments, we began using intraoperative sonography for monitoring elastic nail insertion in pediatric radial fractures.Between January 2015 and November 2016, 77 pediatric closed diaphyseal radial fractures were operated by dorsal approach ESIN under intraoperative sonographic checking.Procedures were executed by 2 orthopedic surgeons experienced in ESIN technique with basic musculoskeletal ultrasonographic qualifications.Sonographic identification of EPL and Lister's tubercle in the transverse view was possible in all cases. Determination of the position of the nail end to EPL was also possible in all cases. Mean distance of the transverse view center of the EPL and nail was 0.49 cm (range 0.3-0.62 cm, SD = 0.66). Based on the sonographic transverse view, the operator decided repositioning the nails by 2 patients.We have not found EPL injury postoperatively. All patients were followed for at least 12 months after operations. Nails were removed in all children without further complications.Intraoperative sonography helps determining optimal insertion point and the risk of EPL injury may be reduced during dorsal entry approach.Although the procedure is relatively easy, authors take note that surgical and sonoanatomic knowledge, basic sonographic skills and experience in the ESIN technique are equally necessary for its successful application. A greater number of cases is necessary to confirm our initial promising experiences.
拇长伸肌腱（EPL）损伤是儿童桡骨弹性髓内钉背侧入路技术的一种潜在并发症。本研究的目的是探讨术中超声引导是否能降低EPL损伤的风险。首先在6具成年尸体上检查超声检查结果与手术结果之间的相关性。在微创背侧入路髓内钉固定过程中，通过超声成像检测Lister结节、EPL和弹性髓内钉骨外端的位置。Lister隆起的桡侧斜率被确定为打开髓腔的安全且易于识别的入点。将髓内钉的骨外端向桡侧轻微弯曲，并在腕关节最大掌屈位紧贴皮肤处切断。尸体解剖按照我们的操作步骤进行，所有结果均与超声检查结果相关，我们未发现植入物末端对肌腱造成损伤、阻塞或摩擦。尸体实验后，我们开始在儿童桡骨骨折弹性髓内钉植入术中使用术中超声进行监测。2015年1月至2016年11月，77例儿童闭合性桡骨干骨折采用背侧入路弹性髓内钉固定术，并在术中进行超声检查。手术由2名具有基本肌肉骨骼超声资质且有弹性髓内钉技术经验的骨科医生执行。在所有病例中，均能在横断面上通过超声识别EPL和Lister结节。在所有病例中也都能确定髓内钉末端与EPL的位置关系。EPL横断面中心与髓内钉的平均距离为0.49厘米（范围0.3 - 0.62厘米，标准差 = 0.66）。基于超声横断面图像，有2例患者的术者决定重新调整髓内钉位置。我们术后未发现EPL损伤。所有患者术后至少随访12个月。所有儿童均取出髓内钉，未出现进一步并发症。术中超声有助于确定最佳植入点，并且在背侧入路过程中可能降低EPL损伤的风险。尽管该操作相对简单，但作者指出，手术和超声解剖学知识、基本超声技能以及弹性髓内钉技术经验对于其成功应用同样必要。需要更多病例来证实我们最初的良好经验。
