Kumar Sachin, Mishra Arya, Odak Saurabh, Dwyer Jonathan
Royal Derby Hospital, Derby, United Kingdom.
University Hospital of Morecambe Bay, United Kingdom.
J Clin Orthop Trauma. 2020 Jul;11(Suppl 4):S456-S463. doi: 10.1016/j.jcot.2020.04.022. Epub 2020 Apr 26.
Radial Neck fractures are rare injuries in children. There is controversy surrounding their prognosis and management.
This review aims to produce an up-to-date summary to clarify prognostic factors and management principles, in the light of recent, better-quality evidence.
A systematic review was undertaken in accordance to PRISMA guidelines, applying pre-defined selection criteria. 6 papers were found suitable after quality assessment. All were observational cohort studies, one prospective and the rest retrospective. A semi-qualitative review was undertaken as heterogeneity, especially in the fracture classification and outcome assessment tools used, prevented quantitative synthesis.
Majority of these fractures occur at the metaphysis. Consistently good results are seen with simple immobilization in fractures angulated<30° with translation<50%, with nearly all achieving a good outcome. In more displaced fractures, results are poorer and only about 70% patients achieve a good outcome. Both higher fracture displacement and more invasive treatment are associated with worse outcomes, but also with each other. Associated injuries are common, with Proximal Ulna fractures being commonest (71%), but their effect on outcomes is unclear. Age more than 10 years is associated with worse displacement, more invasive treatment and worse results. There is much confounding among all these factors which remains to be convincingly addressed. An algorithmic approach is advisable for these fractures, with stepwise application of more invasive treatment only if less invasive methods fail. Percutaneous fixation with either K-wires or retrograde intramedullary elastic nails is acceptable. Fractures reduced closed in theatre fare better if fixed percutaneously to prevent re-displacement. Open treatment should be considered only if the fracture can't be reduced to within the displacement limits of angulation<30° and translation<50%. Incidence of serious complications is generally low (3-5%), but their effect on outcomes is unclear.
The treatment of higher-grade radial neck fractures is still controversial, needing further research, possibly through multi-center prospective data collection in pediatric fracture registries using validated outcome measures.
儿童桡骨颈骨折是罕见损伤。其预后和治疗存在争议。
本综述旨在依据近期质量更高的证据，对预后因素和治疗原则进行最新总结以阐明。
按照PRISMA指南进行系统综述，应用预先定义的选择标准。经质量评估后发现6篇论文合适。所有均为观察性队列研究，1篇前瞻性研究，其余为回顾性研究。由于存在异质性，尤其是在骨折分类和所使用的结局评估工具方面，无法进行定量综合分析，因此进行了半定性综述。
这些骨折多数发生在干骺端。对于成角<30°且移位<50%的骨折，单纯固定通常能取得良好效果，几乎所有患者都能获得良好结局。在移位更明显的骨折中，效果较差，只有约70%的患者能获得良好结局。骨折移位程度越高和治疗方式越具侵入性都与更差的结局相关，且二者之间也相互关联。合并损伤很常见，尺骨近端骨折最为常见（71%），但其对结局的影响尚不清楚。年龄超过10岁与更差的移位情况、更具侵入性的治疗及更差的结果相关。所有这些因素之间存在诸多混杂情况，仍有待令人信服地解决。对于这些骨折，建议采用算法式方法，仅在侵入性较小的方法失败时才逐步应用更具侵入性的治疗。使用克氏针或逆行髓内弹性钉进行经皮固定是可以接受的。如果在手术室中闭合复位的骨折经皮固定以防止再移位，效果会更好。仅当骨折无法复位至成角<30°且移位<50%的限度内时，才应考虑切开治疗。严重并发症的发生率一般较低（3 - 5%），但其对结局的影响尚不清楚。
较高等级桡骨颈骨折的治疗仍存在争议，需要进一步研究，可能通过在儿科骨折登记处使用经过验证的结局指标进行多中心前瞻性数据收集。
