微创入路经皮内侧克氏针固定治疗儿童肱骨髁上骨折可能比以往认为的更安全。

A Mini-Open Approach to Medial Pinning in Pediatric Supracondylar Humeral Fractures May Be Safer Than Previously Thought.

机构信息

School of Medicine, Vanderbilt University, Nashville, Tennessee.

Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee.

出版信息

J Bone Joint Surg Am. 2022 Jan 5;104(1):33-40. doi: 10.2106/JBJS.21.00301.

DOI:10.2106/JBJS.21.00301

PMID:34673662

Abstract

BACKGROUND

Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning.

METHODS

Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded.

RESULTS

In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks.

CONCLUSIONS

The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

摘要

背景

小儿髁上肱骨骨折（SCHF）经复位后用光滑销钉固定。虽然外侧入路钢针固定（外侧固定）后部分 SCHF 可达到生物力学稳定，但部分 SCHF 中附加内侧入路钢针（交叉固定）可提供更好的稳定性。内侧入路钢针固定存在医源性尺神经损伤的风险。现有最佳证据估计交叉固定时医源性尺神经损伤的发生率约为 3.4%。在类似的研究中，外侧固定时医源性神经损伤（所有神经）的发生率估计为 1.9%。本研究旨在采用大型单中心单技术（微创）回顾性病例系列研究来确定交叉固定时医源性尺神经损伤的发生率。

方法

回顾性分析 2007 年至 2017 年采用微创经皮交叉固定治疗 SCHF 的患者。记录损伤特征、手术变量、固定技术以及医源性神经损伤等并发症。排除在其他医院接受手术治疗、无术后随访或因多发伤死亡的患者。

结果

本研究期间共确定 698 例接受交叉固定的患者。接受交叉固定的患者骨折严重，共发生 198 例术前神经血管损伤（28.4%），32 例（4.6%）出现皮瓣隆起，19 例（2.7%）发生开放性骨折。报告 3 例（0.43%）医源性神经损伤，均为尺神经损伤。3 例医源性神经损伤中，2 例尺神经症状在平均 15 周的随访时缓解。