|
|
儿童肱骨外髁骨折概述及治疗策略
|
Abstract:
肱骨外髁骨折是低龄儿童常见肘部损伤之一。损伤机制主要为肘关节伸直时前臂在内翻或外翻应力下发生。大部分情况下，X线可以明确诊断，但对于没有移位及外髁尚未骨化骨折，MRI或肘关节造影可以进一步明确诊断。对于骨折移位 ≤ 2 mm且关节面平整的患儿首选保守治疗。闭合复位经皮克氏针固定适用于骨折移位 > 2 mm且关节面铰链完整者。而骨折块移位 ≥ 4 mm伴骨折块翻转，关节面不平整者，首选切开复位内固定治疗。主要并发症包括畸形愈合、延迟愈合、鱼尾畸形、外侧过度生长及生长停滞。本文旨在对儿童肱骨外髁骨折进行全面概述，以提高广大基层医生对儿童肱骨外髁骨折的认识及为患儿选择最合理的治疗方式。
Humeral lateral condyle fracture is one of the most common elbow injuries in young children. The injury mechanism mainly occurs under varus or valgus stress of the forearm during elbow extension. In most cases, X-ray can confirm the diagnosis, but MRI or elbow arthrography can further confirm the diagnosis of fractures without displacement or ossification of the lateral condyle. Conservative treatment is the first choice for children with fracture displacement ≤ 2 mm and flat articular surface. Closed reduction and percutaneous Kirschner wire fixation suitable for patients with fracture displacement > 2 mm and intact articular surface hinge. Open reduction and internal fixation are the first choice for patients with fracture displacement ≥ 4 mm, inversion of fracture fragment and uneven articular surface. The main complications included malunion, delayed union, fishtail deformity, lateral overgrowth and growth arrest. This article aims to provide a comprehensive overview of pediatric humeral condyle fractures, in order to improve the understanding of primary care doctors towards pediatric humeral condyle fractures and to select the most reasonable treatment methods for children.
| [1] | Tan, S.H.S., Dartnell, J., Lim, A.K.S. and Hui, J.H. (2018) Paediatric Lateral Condyle Fractures: A Systematic Review. Archives of Orthopaedic and Trauma Surgery, 138, 809-817. https://doi.org/10.1007/s00402-018-2920-2 |
| [2] | Abzug, J.M., Dua, K., Kozin, S.H. and Herman, M.J. (2020) Current Concepts in the Treatment of Lateral Condyle Fractures in Children. Journal of the American Academy of Orthopaedic Surgeons, 28, e9-e19. https://doi.org/10.5435/jaaos-d-17-00815 |
| [3] | Beaty, J.H. (2010) Fractures of the Lateral Humeral Condyle Are the Second Most Frequent Elbow Fracture in Children. Journal of Orthopaedic Trauma, 24, 438. |
| [4] | Jakob, R., Fowles, J.V., Rang, M. and Kassab, M.T. (1975) Observations Concerning Fractures of the Lateral Humeral Condyle in Children. The Journal of Bone and Joint Surgery. British volume, 57, 430-436. https://doi.org/10.1302/0301-620x.57b4.430 |
| [5] | Milch, H. (1964) Fractures and Fracture Dislocations of the Humeral Condyles. The Journal of Trauma: Injury, Infection, and Critical Care, 4, 592-607. https://doi.org/10.1097/00005373-196409000-00004 |
| [6] | Pirker, M.E., Weinberg, A.M., Höllwarth, M.E. and Haberlik, A. (2005) Subsequent Displacement of Initially Nondisplaced and Minimally Displaced Fractures of the Lateral Humeral Condyle in Children. The Journal of Trauma: Injury, Infection, and Critical Care, 58, 1202-1207. https://doi.org/10.1097/01.ta.0000169869.08723.c8 |
| [7] | Weiss, J.M., Graves, S., Yang, S., Mendelsohn, E., Kay, R.M. and Skaggs, D.L. (2009) A New Classification System Predictive of Complications in Surgically Treated Pediatric Humeral Lateral Condyle Fractures. Journal of Pediatric Orthopaedics, 29, 602-605. https://doi.org/10.1097/bpo.0b013e3181b2842c |
| [8] | Song, K.S., Kang, C.H., Min, B.W., Bae, K.C., Cho, C.H. and Lee, J.H. (2008) Closed Reduction and Internal Fixation of Displaced Unstable Lateral Condylar Fractures of the Humerus in Children. The Journal of Bone and Joint Surgery-American Volume, 90, 2673-2681. https://doi.org/10.2106/jbjs.g.01227 |
| [9] | Xie, L., Tan, G., Deng, Z., Liu, X., Zhou, Y., Zhang, H., et al. (2022) Impacts of Fracture Types on Success Rate of Closed Reduction and Percutaneous Pinning in Pediatric Lateral Condyle Humerus Fractures Displaced >4 mm. Journal of Pediatric Orthopaedics, 42, 265-272. https://doi.org/10.1097/bpo.0000000000002093 |
| [10] | Mirsky, E.C., Karas, E.H. and Weiner, L.S. (1997) Lateral Condyle Fractures in Children: Evaluation of Classification and Treatment. Journal of Orthopaedic Trauma, 11, 117-120. https://doi.org/10.1097/00005131-199702000-00009 |
| [11] | Miller, J.S., Weishuhn, L., Goodrich, E., Patel, J., McCarthy, J.J. and Mehlman, C.T. (2023) Pediatric Lateral Humeral Condyle Fractures: Reliability of a Modified Jakob Classification System and Its Impact on Treatment Planning with or without Arthrography. Journal of Pediatric Orthopaedics, 43, 505-510. https://doi.org/10.1097/bpo.0000000000002459 |
| [12] | Ramo, B.A., Funk, S.S., Elliott, M.E. and Jo, C. (2019) The Song Classification Is Reliable and Guides Prognosis and Treatment for Pediatric Lateral Condyle Fractures: An Independent Validation Study with Treatment Algorithm. Journal of Pediatric Orthopaedics, 40, e203-e209. https://doi.org/10.1097/bpo.0000000000001439 |
| [13] | Wang, Y., Ji, L., Liu, S. and Liu, W. (2021) “Hand as Foot” Teaching Method for the Song’s Classification of Lateral Condylar Fractures over the Humerus in Children. Asian Journal of Surgery, 44, 1195-1196. https://doi.org/10.1016/j.asjsur.2021.05.053 |
| [14] | Lozoya, S.C., Báez, J.D.T., Flores, J.M.R., Ventura, J.M.B., Topete, O.A. and Juárez, A.A. (2018) Inter-and Intra-Observer Agreement in the Milch and Weiss Systems. Acta Ortopédica Brasileira, 26, 218-221. https://doi.org/10.1590/1413-785220182604191367 |
| [15] | Kraft, D.B., Moore, T.J., Pargas, C., Rogers, K. and Thacker, M.M. (2022) Minimally Displaced Lateral Humeral Condyle Fractures: Optimizing Follow-Up and Minimizing Cost. Journal of Pediatric Orthopaedics, 43, 1-6. https://doi.org/10.1097/bpo.0000000000002265 |
| [16] | Pannu, G.S., Eberson, C.P., Abzug, J., et al. (2016) Common Errors in the Management of Pediatric Supracondylar Humerus Fractures and Lateral Condyle Fractures. Instructional Course Lectures, 65, 385-397. |
| [17] | Marzo, J.M., dʼAmato, C., Strong, M. and Gillespie, R. (1990) Usefulness and Accuracy of Arthrography in Management of Lateral Humeral Condyle Fractures in Children. Journal of Pediatric Orthopaedics, 10, 317-321. https://doi.org/10.1097/01241398-199005000-00004 |
| [18] | Lari, A., Alenezi, A., Abughaith, J., AlShehawy, H., Hammady, W. and AlSaifi, S. (2022) Intraoperative Arthrography Favorably Impacts the Early Outcome of Operatively Managed Fractures of the Lateral Humeral Condyle Displaced 1-5 mm in Children. Journal of Orthopaedic Surgery and Research, 17, Article No. 569. https://doi.org/10.1186/s13018-022-03472-z |
| [19] | Qi, Y., Guo, L., Sun, M. and Wang, Z. (2021) Clinical Value of MRI in Evaluating and Diagnosing of Humeral Lateral Condyle Fracture in Children. Journal of Orthopaedic Surgery and Research, 16, Article No. 617. https://doi.org/10.1186/s13018-021-02726-6 |
| [20] | Guo, L., Li, X., Wang, Z. and Zhu, S. (2021) Accuracy of MRI and X‐Ray Measurement of Displacement Distance of Humeral Lateral Condyle Fractures. Orthopaedic Surgery, 13, 2018-2026. https://doi.org/10.1111/os.13116 |
| [21] | Wu, X., Li, X., Yang, S., Wang, S., Xia, J., Chen, X., et al. (2021) Determining the Stability of Minimally Displaced Lateral Humeral Condyle Fractures in Children: Ultrasound Is Better than Arthrography. Journal of Orthopaedic Surgery and Research, 16, Article No. 32. https://doi.org/10.1186/s13018-020-02174-8 |
| [22] | Temporin, K., Namba, J., Okamoto, M. and Yamamoto, K. (2015) Diagnostic Arthroscopy in the Treatment of Minimally Displaced Lateral Humeral Condyle Fractures in Children. Orthopaedics & Traumatology: Surgery & Research, 101, 593-596. https://doi.org/10.1016/j.otsr.2015.04.003 |
| [23] | 周益彪, 夏永杰, 邓超, 等. 肘关节镜辅助内侧铰链优先复位联合内固定治疗儿童肱骨外髁Song Ⅴ型骨折的疗效[J]. 中国骨与关节损伤杂志, 2024, 39(5): 481-484. |
| [24] | Andelman, S.M., Meier, K.M., Walsh, A.L., Kim, J.H. and Hausman, M.R. (2017) Pediatric Elbow Arthroscopy: Indications and Safety. Journal of Shoulder and Elbow Surgery, 26, 1862-1866. https://doi.org/10.1016/j.jse.2017.07.005 |
| [25] | Kang, M.S., Alfadhil, R.A. and Park, S. (2019) Outcomes of Arthroscopy-Assisted Closed Reduction and Percutaneous Pinning for a Displaced Pediatric Lateral Condylar Humeral Fracture. Journal of Pediatric Orthopaedics, 39, e548-e551. https://doi.org/10.1097/bpo.0000000000001319 |
| [26] | Lieber, J., Dietzel, M., Tsiflikas, I., Schäfer, J., Kirschner, H. and Fuchs, J. (2019) Therapieprinzipien und Outcome nach Frakturen des Condylus radialis im Wachstumsalter. Der Unfallchirurg, 122, 345-352. https://doi.org/10.1007/s00113-019-0605-0 |
| [27] | Knapik, D.M., Gilmore, A. and Liu, R.W. (2017) Conservative Management of Minimally Displaced (≤ 2 mm) Fractures of the Lateral Humeral Condyle in Pediatric Patients: A Systematic Review. Journal of Pediatric Orthopaedics, 37, e83-e87. https://doi.org/10.1097/bpo.0000000000000722 |
| [28] | Aibara, N., Takagi, T. and Seki, A. (2022) Late Displacement after Lateral Condylar Fractures of the Humerus. Journal of Shoulder and Elbow Surgery, 31, 2164-2168. https://doi.org/10.1016/j.jse.2022.06.003 |
| [29] | Bullmann, T., Stucki, C., Kaiser, N. and Ziebarth, K. (2024) Fractures of the Lateral Condyle of the Humerus in Children: High Risk of Secondary Dislocation with Conservative Treatment. Die Unfallchirurgie, 127, 522-530. https://doi.org/10.1007/s00113-024-01432-2 |
| [30] | Xie, L., Wang, J., Deng, Z., Zhao, R., Chen, W., Kang, C., et al. (2020) Treatment of Pediatric Lateral Condylar Humerus Fractures with Closed Reduction and Percutaneous Pinning. BMC Musculoskeletal Disorders, 21, Article No. 707. https://doi.org/10.1186/s12891-020-03738-9 |
| [31] | Jacobsen, M.G. and Andersen, M.J. (2022) Current Concepts in Pediatric Lateral Humeral Condyle Fractures. Ugeskrift for Læger, 184, V12200939. |
| [32] | Tippabhatla, A., Torres-Izquierdo, B., Pereira, D.E., Goldstein, R., Sanders, J., Bellaire, L., et al. (2024) Closed Reduction Techniques Are Associated with Fewer Complications than Open Reductions in Treating Moderately Displaced Pediatric Lateral Humeral Condyle Fractures: A Multicenter Study. Journal of Pediatric Orthopaedics, 44, e865-e870. https://doi.org/10.1097/bpo.0000000000002777 |
| [33] | Stein, B.E., Ramji, A.F., Hassanzadeh, H., Wohlgemut, J.M., Ain, M.C. and Sponseller, P.D. (2017) Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated with Lower Rates of Open Reduction and Infection than Pin Fixation. Journal of Pediatric Orthopaedics, 37, 7-13. https://doi.org/10.1097/bpo.0000000000000579 |
| [34] | Bloom, T., Chen, L.Y. and Sabharwal, S. (2011) Biomechanical Analysis of Lateral Humeral Condyle Fracture Pinning. Journal of Pediatric Orthopaedics, 31, 130-137. https://doi.org/10.1097/bpo.0b013e3182074c5b |
| [35] | 白恒安. 儿童肱骨外髁骨折不同手术内固定方式的有限元分析及研究[D]: [博士学位论文]. 延安: 延安大学, 2024. |
| [36] | Raghavan, R., Jones, A. and Dwyer, A.J. (2019) Should Kirschner Wires for Fixation of Lateral Humeral Condyle Fractures in Children Be Buried or Left Exposed? A Systematic Review. Orthopaedics & Traumatology: Surgery & Research, 105, 739-745. https://doi.org/10.1016/j.otsr.2019.03.007 |
| [37] | Ormsby, N.M., Walton, R.D.M., Robinson, S., Brookes-Fazakerly, S., Yuen Chang, F., McGonagle, L., et al. (2016) Buried versus Unburied Kirschner Wires in the Management of Paediatric Lateral Condyle Elbow Fractures: A Comparative Study from a Tertiary Centre. Journal of Pediatric Orthopaedics B, 25, 69-73. https://doi.org/10.1097/bpb.0000000000000226 |
| [38] | Qin, Y., Li, Z., Li, C., Bai, S. and Li, H. (2017) Unburied versus Buried Wires for Fixation of Pediatric Lateral Condyle Distal Humeral Fractures. Medicine, 96, e7736. https://doi.org/10.1097/md.0000000000007736 |
| [39] | Silva, M. and Cooper, S.D. (2015) Closed Reduction and Percutaneous Pinning of Displaced Pediatric Lateral Condyle Fractures of the Humerus: A Cohort Study. Journal of Pediatric Orthopaedics, 35, 661-665. https://doi.org/10.1097/bpo.0000000000000376 |
| [40] | Silva, M., Paredes, A. and Sadlik, G. (2017) Outcomes of ORIF > 7 Days after Injury in Displaced Pediatric Lateral Condyle Fractures. Journal of Pediatric Orthopaedics, 37, 234-238. https://doi.org/10.1097/bpo.0000000000000640 |
| [41] | 余向阳, 吴改革, 汪航, 等. 螺钉及克氏针内固定治疗儿童肱骨外髁骨折疗效的Meta分析[J]. 中国骨伤, 2024, 37(4): 399-405. |
| [42] | Jiang, L., Wu, J., Li, M., Liu, X., Luo, C. and Qu, X. (2019) Cannulated Screw and Kirschner Fixation for the Treatment of Medial and Lateral Malleolar Epiphyseal Fractures in Children: A Retrospective Study of 36 Cases. Journal of Orthopaedic Surgery and Research, 14, Article No. 254. https://doi.org/10.1186/s13018-019-1287-6 |
| [43] | Gilbert, S.R., MacLennan, P.A., Schlitz, R.S. and Estes, A.R. (2016) Screw versus Pin Fixation with Open Reduction of Pediatric Lateral Condyle Fractures. Journal of Pediatric Orthopaedics B, 25, 148-152. https://doi.org/10.1097/bpb.0000000000000238 |
| [44] | Cardona, J.I., Riddle, E. and Kumar, S.J. (2002) Displaced Fractures of the Lateral Humeral Condyle: Criteria for Implant Removal. Journal of Pediatric Orthopaedics, 22, 194-197. https://doi.org/10.1097/01241398-200203000-00012 |
| [45] | Sorenson, S.M. and Hennrikus, W. (2015) Pain during Office Removal of K-Wires from the Elbow in Children. Journal of Pediatric Orthopaedics, 35, 341-344. https://doi.org/10.1097/bpo.0000000000000269 |
| [46] | Bernthal, N.M., Hoshino, C.M., Dichter, D., Wong, M. and Silva, M. (2011) Recovery of Elbow Motion Following Pediatric Lateral Condylar Fractures of the Humerus. Journal of Bone and Joint Surgery, 93, 871-877. https://doi.org/10.2106/jbjs.j.00935 |
| [47] | Leonidou, A., Chettiar, K., Graham, S., Akhbari, P., Antonis, K., Tsiridis, E., et al. (2014) Open Reduction Internal Fixation of Lateral Humeral Condyle Fractures in Children. a Series of 105 Fractures from a Single Institution. Strategies in Trauma and Limb Reconstruction, 9, 73-78. https://doi.org/10.1007/s11751-014-0193-z |
| [48] | Li, W.C. and Xu, R.J. (2011) Comparison of Kirschner Wires and AO Cannulated Screw Internal Fixation for Displaced Lateral Humeral Condyle Fracture in Children. International Orthopaedics, 36, 1261-1266. https://doi.org/10.1007/s00264-011-1452-y |
| [49] | Shirley, E., Anderson, M., Neal, K. and Mazur, J. (2015) Screw Fixation of Lateral Condyle Fractures: Results of Treatment. Journal of Pediatric Orthopaedics, 35, 821-824. https://doi.org/10.1097/bpo.0000000000000377 |
| [50] | Takada, N., Otsuka, T., Suzuki, H. and Yamada, K. (2013) Pediatric Displaced Fractures of the Lateral Condyle of the Humerus Treated Using High Strength, Bioactive, Bioresorbable F-u-HA/PLLA Pins: A Case Report of 8 Patients with at Least 3 Years of Follow-Up. Journal of Orthopaedic Trauma, 27, 281-284. https://doi.org/10.1097/bot.0b013e318269ba8e |
| [51] | Sharma, K., Mansur, D., Khanal, K. and Haque, M. (2015) Variation of Carrying Angle with Age, Sex, Height and Special Reference to Side. Kathmandu University Medical Journal, 11, 315-318. https://doi.org/10.3126/kumj.v11i4.12540 |
| [52] | Cates, R.A. and Mehlman, C.T. (2012) Growth Arrest of the Capitellar Physis after Displaced Lateral Condyle Fractures in Children. Journal of Pediatric Orthopaedics, 32, e57-e62. https://doi.org/10.1097/bpo.0b013e31826bb0d5 |
| [53] | Takagi, T., Bessho, Y., Seki, A. and Takayama, S. (2021) Characteristics of Cubitus Varus Deformity after Lateral Condylar Fracture of the Humerus. The Journal of Hand Surgery (Asian-Pacific Volume), 26, 218-222. https://doi.org/10.1142/s2424835521500211 |
| [54] | Park, H., Hwang, J.H., Kwon, Y.U. and Kim, H.W. (2015) Osteosynthesis in Situ for Lateral Condyle Nonunion in Children. Journal of Pediatric Orthopaedics, 35, 334-340. https://doi.org/10.1097/bpo.0000000000000353 |
| [55] | Liu, T.J., Wang, E.B., Dai, Q., Zhang, L.J., Li, Q.W. and Zhao, Q. (2016) Open Reduction and Internal Fixation for the Treatment of Fractures of the Lateral Humeral Condyle with an Early Delayed Presentation in Children: A Radiological and Clinical Prospective Study. The Bone & Joint Journal, 98, 244-248. https://doi.org/10.1302/0301-620x.98b2.34429 |
| [56] | Agarwal, A., Qureshi, N., Gupta, N., Verma, I. and Pandey, D. (2012) Management of Neglected Lateral Condyle Fractures of Humerus in Children: A Retrospective Study. Indian Journal of Orthopaedics, 46, 698-704. https://doi.org/10.4103/0019-5413.104221 |
| [57] | Narayanan, S., Shailam, R., Grottkau, B.E. and Nimkin, K. (2014) Fishtail Deformity—A Delayed Complication of Distal Humeral Fractures in Children. Pediatric Radiology, 45, 814-819. https://doi.org/10.1007/s00247-014-3249-9 |
| [58] | Lehnert, S.J., Wanner, M.R. and Karmazyn, B. (2017) Fishtail Deformity of the Distal Humerus: Association with Osteochondritis Dissecans of the Capitellum. Pediatric Radiology, 48, 359-365. https://doi.org/10.1007/s00247-017-4029-0 |
| [59] | Skak, S.V., Olsen, S.D. and Smaabrekke, A. (2001) Deformity after Fracture of the Lateral Humeral Condyle in Children. Journal of Pediatric Orthopaedics B, 10, 142-152. https://doi.org/10.1097/01202412-200110020-00012 |
| [60] | Pribaz, J.R., Bernthal, N.M., Wong, T.C. and Silva, M. (2012) Lateral Spurring (Overgrowth) after Pediatric Lateral Condyle Fractures. Journal of Pediatric Orthopaedics, 32, 456-460. https://doi.org/10.1097/bpo.0b013e318259ff63 |
