Baghdadi Soroush
Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
J Pediatr Orthop. 2020 Sep;40(8):380-386. doi: 10.1097/BPO.0000000000001573.
Pediatric ipsilateral supracondylar humerus and forearm fractures (floating elbow), are historically reported to have a high rate of complications, including pediatric acute compartment syndrome (PACS). As a result, treatment paradigms for these types of injuries differ in the urgency, extent of fixation, and type of immobilization than if each fracture were treated in isolation. We aimed to systematically review the literature on pediatric floating elbow injuries and assess the reported risk of PACS along with risk factors for poor outcomes.
A systematic review was performed in November 2019 in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search of the PubMed and Embase databases was conducted for peer-reviewed literature between 1999 and 2019. Two reviewers filtered the results, looking for articles in English that reported >10 pediatric floating elbow cases. Primary outcomes were the rate and risk factors for developing PACS. Secondary outcomes included patient and injury characteristics, treatment strategies, other complications (eg, neurovascular injuries), and final outcomes.
The initial search yielded a total of 150 studies. Following review, 11 studies were included, with 433 patients available for review. The mechanism of injury was a fall in 96% of cases. Closed reduction and percutaneous pinning was the most common treatment performed for both fractures. Only 8/433 patients (2%) developed PACS. The incidence of a pulseless limb at presentation was 4%, and all patients regained a pulse following reduction. Three cases of iatrogenic ulnar nerve injury were reported in the setting of medial pin placement. Good to excellent results were reported in 83% to 100% of patients, based on the modified Flynn criteria.
Despite being limited to heterogenous and retrospective case series, the evidence reviewed in this study contradicts the current belief of a high risk of PACS or other complications in pediatric floating elbows. PACS is much more common with displaced fractures in the setting of delayed treatment. The rate of other complications is comparable to isolated supracondylar humerus fractures. Evidence supports treating these injuries in an urgent fashion in the setting of a displaced fracture, although fixation of both distal and proximal fractures is not supported by evidence. The outcomes of pediatric floating elbows are generally good and do not reflect the poor prognosis that adult floating elbows represent.
Level IV-systematic review of level IV studies.
小儿同侧肱骨髁上骨折和前臂骨折（浮动肘），历来报道其并发症发生率较高，包括小儿急性骨筋膜室综合征（PACS）。因此，与单独治疗每一处骨折相比，这类损伤的治疗模式在紧急程度、固定范围和固定类型上有所不同。我们旨在系统回顾有关小儿浮动肘损伤的文献，并评估报道的PACS风险以及预后不良的风险因素。
2019年11月按照PRISMA（系统评价和Meta分析优先报告项目）指南进行了系统评价。对1999年至2019年间的同行评审文献在PubMed和Embase数据库中进行了详尽检索。两名评审员对结果进行筛选，寻找报道超过10例小儿浮动肘病例的英文文章。主要结局是发生PACS的发生率和风险因素。次要结局包括患者和损伤特征、治疗策略、其他并发症（如神经血管损伤）以及最终结局。
初步检索共获得150项研究。经过评审，纳入11项研究，共433例患者可供分析。96%的病例损伤机制为跌倒。闭合复位经皮穿针是两处骨折最常用的治疗方法。仅8/433例患者（2%）发生PACS。就诊时无脉肢体的发生率为4%，所有患者复位后均恢复了脉搏。在内侧穿针时报道了3例医源性尺神经损伤。根据改良Flynn标准，83%至100%的患者报告结果为良好至优秀。
尽管本研究仅限于异质性和回顾性病例系列，但所回顾的证据与目前认为小儿浮动肘发生PACS或其他并发症风险高的观点相矛盾。PACS在延迟治疗的移位骨折中更为常见。其他并发症的发生率与单纯肱骨髁上骨折相当。有证据支持在移位骨折的情况下紧急治疗这些损伤，尽管远端和近端骨折的固定缺乏证据支持。小儿浮动肘的预后通常良好，并不像成人浮动肘那样预后不良。
IV级——IV级研究的系统评价。
