Lightdale-Miric Nina R, Obana Kyle K, Fan Bensen B, Padilla Abigail N, Lin Adrian J, Bennett James T, Wren Tishya A L
Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles.
Keck School of Medicine, University of Southern California, Los Angeles, CA.
J Pediatr Orthop. 2023 Mar 1;43(3):129-134. doi: 10.1097/BPO.0000000000002343. Epub 2023 Jan 3.
Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal.
A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion.
Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients.
Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization.
III.
小儿急性孟氏骨折的治疗需要尺骨长度稳定，以维持桡骨头关节的复位。当需要手术治疗时，尺骨髓内固定可以埋入，也可以在石膏固定期间暂时经皮外露。作者推测，外露固定治疗孟氏骨折的效果与埋入固定相当，同时可避免二次手术取出内固定物。
对我们一级小儿创伤中心的急性孟氏骨折患儿进行回顾性研究。评估患者病历和X线片，记录年龄、骨折类型、骨折部位、巴多分类、治疗方式、并发症、石膏固定时间、骨折愈合时间、取出内固定物的时间以及活动范围。
59例接受手术治疗的急性孟氏骨折患儿（平均年龄6岁，范围2至14岁）中，15例（25%）采用埋入式髓内固定，44例（75%）采用石膏固定下的外露式髓内固定。埋入式和外露式髓内固定在术后石膏固定时间（39天对37天；P = 0.55）、骨折愈合时间（37天对35天；P = 0.67）、旋前/旋后活动度（137度对134度；P = 0.68）或屈伸活动度（115度对114度；P = 0.81）方面无显著差异。外露固定的再次手术率为4.5%（44例中有2例），而所有接受埋入固定的患者均需再次手术取出内固定物。
外露式髓内固定在治疗小儿急性孟氏骨折时，临床效果与埋入式内固定相当，同时无需二次手术取出内固定物，降低了手术和麻醉的相关风险及费用，但并发症发生率较高。开放性孟氏骨折或已知有延迟愈合风险的骨折类型，采用埋入式而非外露式髓内固定可能更有利于早期活动。
III级。
