Kraft Denver B, Moore Theresa J, Pargas Carlos, Rogers Kenneth, Thacker Mihir M
Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.
J Pediatr Orthop. 2023 Jan 1;43(1):1-6. doi: 10.1097/BPO.0000000000002265. Epub 2022 Aug 31.
Minimally displaced fractures of the lateral humeral condyle (LHC) may be treated nonoperatively in a long arm cast, but there is not a standardized evidence-based protocol. The aim of this study was to evaluate our nonoperatively treated LHC fractures, determine the risk of subsequent displacement, analyze our practice variability, and develop an evidence-based protocol to safely manage children with LHC fractures and to evaluate potential savings related to this analysis.
We retrospectively reviewed clinical and radiographic parameters of all patients with LHC fractures at our institution from 2009 to 2015. All patients treated nonoperatively initially were included. We recorded demographic data and calculated the number of visits, casts applied, and radiographs within the first 4 weeks. We also analyzed practice variation among 27 treating providers. The number of children with subsequent displacement needing operative fixation was determined. We also looked at the average duration for each follow-up visit and the charges/costs associated with casting and radiographs.
There were 271 children with LHC fractures treated nonoperatively. Twenty-one were excluded because of the lack of adequate radiographs. There were 157 boys and 93 girls (average age 6.7 y). According to the Jakob classification, fracture types were as follows: 1 (230), 2 (20), and 3 (0). Within the first 4 weeks, the average number of visits was 2.6 (range: 1 to 5), average number of casts was 2.4 (range: 1 to 4), and the average number of radiographs was 9.4 (range: 2 to 31). Only 3 patients with LHC fracture type Jakob 1 were taken to the operating room post injury (9, 12, and 15 d, respectively) for subsequent displacement.
Displacement in appropriately selected LHC fractures treated nonoperatively was rare (3/250, 1.2%) in this cohort, and the data question the need for multiple visits and radiographs in the first 4 weeks. Optimal follow-up (proposed follow-up at 10 to 15 d after injury and then 4 to 6 wk with radiographs, including an internal oblique view) would be safe, minimize waste, and result in better value-based care.
Level IV.
肱骨外侧髁（LHC）轻度移位骨折可采用长臂石膏非手术治疗，但目前尚无标准化的循证方案。本研究的目的是评估我们非手术治疗的LHC骨折，确定后续移位的风险，分析我们的实践差异，并制定循证方案以安全管理LHC骨折患儿，并评估与该分析相关的潜在节省费用情况。
我们回顾性分析了2009年至2015年在我院就诊的所有LHC骨折患者的临床和影像学参数。纳入所有最初接受非手术治疗的患者。我们记录了人口统计学数据，并计算了前4周内的就诊次数、石膏应用数量和X线片数量。我们还分析了27名治疗医生之间的实践差异。确定了后续需要手术固定的移位患儿数量。我们还研究了每次随访的平均时长以及与石膏固定和X线检查相关的费用。
271例LHC骨折患儿接受了非手术治疗。21例因缺乏足够的X线片而被排除。有157名男孩和93名女孩（平均年龄6.7岁）。根据雅各布（Jakob）分类，骨折类型如下：1型（230例），2型（20例），3型（0例）。在前4周内，平均就诊次数为2.6次（范围：1至5次），平均石膏应用数量为2.4个（范围：1至4个），平均X线片数量为9.4张（范围：2至31张）。仅3例雅各布1型LHC骨折患者在受伤后分别于9天、12天和15天因后续移位接受了手术治疗。
在该队列中，经适当选择的非手术治疗的LHC骨折移位罕见（3/250，1.2%），数据质疑了前4周内多次就诊和拍摄X线片的必要性。最佳随访方案（建议受伤后10至15天随访，然后在4至6周时拍摄X线片，包括内斜位片）将是安全的，可减少浪费，并带来更好的基于价值的医疗服务。
四级。
