191例儿童肘关节创伤X线诊断及预后评估

目的：回顾性研究儿童肘关节创伤X线诊断,方法：收集儿童肘关节创伤X线资料191例,其中骨骺损伤60例,髁上骨折112例,肘关节脱位12例,尺骨鹰嘴骨折并桡骨小头骨折2例,和桡骨小头脱位5例。结果：肘关节囊脂肪垫X线征阳性109例;53例骨骺分离合并有干骺端骨折;髁上骨折愈合复便发现肘内翻畸形24例,骨化性肌炎11例,结论：肘关节囊脂肪垫X线征阳性是肘关节骨折或脱位的一个重要间接征象,出现率达575;肘关节骨骺损伤中大多数合并有干骺端骨折（88．3％）;髁上骨折肘内翻发生率低,而骨化性肌炎较常见。     

闭合复位穿针治疗小儿肱骨髁上骨折25例分析

目的探讨小儿肱骨髁上骨折治疗方法的选择及闭合复位内固定并发症的预防。方法回顾性分析25例明显移位的小儿肱骨髁上骨折采用在C臂下闭合复位交叉克氏针治疗的临床效果。结果随访时间3—24个月,平均9个月。骨折均在6周内愈合,关节功能无限制,无明显肘内外翻畸形。1例术后尺神经支配区感觉减退,拔除克氏针后消失,无1例感染。结论移位明显的肱骨髁上骨折,复位容易,但固定及维持复位困难,手法复位石膏或夹板外固定虽是首选治疗方法,但石膏或夹板固定不牢固,易出现松动甚至可造成血管及神经损伤,而切开复位更易进一步造成软组织创伤,组织粘连,最终导致关节僵直功能障碍。本组C臂下闭合复位交叉克氏针治疗移位明显的肱骨髁上骨折避免了上述缺点,而且方法简单。     

儿童肱骨远端全骨骺分离骨折

目的 为了提高对儿童肱骨远端全骨骺分离骨折的认识,减少误诊及相关并发症的发生。方法 回顾性分析了我院1983年－1999年收治的21例该病患儿的临床资料及随访结果。由于各种原因切开复位内固定治疗12例,9例经闭合复位外固定治疗。其中,在处理前仅有12例为正确诊断或近似诊断。结果 随访1－5年,平均9．5年。14例外观和功能恢复满意,5例有不同程度肘内翻畸形（2例已截骨矫形）,2例肘关节活动明显受限,肱骨远端明显畸形。结论 该病误诊率较高,仔细分清幼儿及儿童肱内骨上头骨化中心和桡骨的关系是正确诊断的关键;解剖复位对于预防肘内翻很必要。     

小切口张力带内固定治疗儿童肱骨髁上骨折

目的探讨采用肱三头肌两侧小切口入路交叉克氏针加桡侧钢丝张力带治疗儿童完全移位肱骨髁上骨折的临床疗效。方法收集2005年6月~2015年11月收治的儿童完全移位肱骨髁上骨折61例,男性47例,女性14例;年龄3~13岁,平均8.5岁。摔伤55例,道路交通伤6例。其中闭合性骨折59例,开放性骨折2例;右侧50例,左侧11例;伸直型57例,屈曲型4例。应用肱三头肌两侧小切口入路,桡侧克氏针张力带内固定治疗,术中置管引流,术后无需外固定,早期功能锻炼。结果本组均在门诊摄X线片随访,随访时间3~36个月,平均20个月。X线片显示61例均解剖复位,骨折平均愈合时间为8周,无肘内翻畸形发生。根据Flynn评定标准,优42例,良16例,可2例,差1例,优良率达95%。结论肱三头肌两侧小切口入路交叉克氏针加桡侧钢丝张力带治疗儿童完全移位肱骨髁上骨折,具有操作简单、固定可靠、肘关节功能恢复满意等优点,是治疗儿童肱骨髁上骨折的一种有效方法。     

可吸收棒内固定治疗儿童陈旧性GartlandⅢ型肱骨髁上骨折

目的评价町吸收棒内固定治疗陈旧性GartlandⅢ型儿童肱骨髁上骨折的可行性及疗效。方法采用直径为2mm或1．5mm的超高分子聚-DL-乳酸（PDLLA）可吸收棒治疗陈旧性GartlandⅢ型儿童肱骨髁上骨折56例。经肘后正中“S”形切口,从肱三头肌两侧暴露,外侧由肱三头肌、肱桡肌间隙进入,内侧由肱三头肌与肱肌间隙进入,不破坏肌纤维及伸肘装置。切开复位后2～3枚钉棒内固定,术中检查稳定性是否良好,术后行长臂石膏托外固定3～4周,2～3周后间断拆石膏进行关节功能训练,每3～4周定期复查X线片,观察骨折愈合情况。结果本组56例得到完全随访,术后平均随访19个月（3～36个月）,术后X线片示骨折解剖复位38例,无术后骨折再移位。骨折全部愈合,无伤口感染,无Volkmann缺血性挛缩、骨化性肌炎及继发性尺神经损伤,发生肘内翻畸形3例;术前检查有神经损伤症状的患者均在2个月内恢复,无后遗症;按Flynn肘关节评定标准,本组优49例、良4例、可3例,优良率为94．6％。结论PDLLA可吸收棒内固定治疗儿童陈旧性GartlandⅢ型肱骨髁上骨折,固定牢靠,效果理想,不影响骨骺发育。因避免了再次手术取内固定,患者家属乐于接受,满意度高。     

Multidetector computed tomography diagnosis of adult elbow fractures

Purpose: To assess acute phase multidetector computed tomography (MDCT) findings in elbow traumas.

Material and Methods: Fifty-six patients (32 M, 24 F, age 16 to 88 years, mean 44 years) underwent MDCT of the elbow due to an acute trauma during a time period of 34 months.

Results: A total of 65 fractures and 3 main fracture types were established: 16 (25%) ulnar coronoid process fractures, 13 (20%) radial head fractures, and 12 (18%) humeral supracondylar fractures. Three main injury mechanisms were falling (38 (68%) patients), falling from high places (6 (11%) patients), and traffic accidents (5 (9%) patients). In 6 (11%) patients, MDCT revealed 13 occult fractures in the elbow joint compared to primary radiography. In four (7%) patients a displaced fracture fragment was detected in primary radiography, but the origin of the fragment was unclear. In all four cases, MDCT revealed the origin of the fragment.

Conclusion: Radiography remains the primary imaging modality in elbow trauma, but in complex fracture patterns, where the extent of the fractures and the position or origin of dislocated fragments is not clear by radiography, the MDCT is a recommended complementary examination.     

髋臼骨折CT与X线平片检查比较

目的探讨CT与X线平片检查在髋臼骨折诊断中的临床应用价值。方法对照分析18例髋臼骨折CT、X线平片及临床治疗随访资料。结果18例髋臼骨折中前壁骨折4例,前柱骨折4例,后壁骨折2例,后柱骨折2例,复杂骨折6例。伴有盆腔内软组织肿胀11例。其中X线平片误漏诊4例。CT检出骨碎片27块,X线平片检出12块,其中关节腔内游离骨碎片CT检出17块,X线平片检出4块。股骨头脱位7例,伴股骨头骨折3例,其中X线平片漏诊1例。结论CT显示关节腔内碎骨片,确定骨折分型及了解盆腔软组织受损情况优于X线平片检查。     

儿童Gartland Ⅲ型肱骨髁上骨折克氏针外侧进针的疗效

 目的 探讨外侧进针方式对克氏针治疗Gartland Ⅲ型儿童肱骨髁上骨折疗效的影响。方法 回顾性分析北京儿童医院2017-02至2019-02收治并采用外侧平行克氏针和外侧扇形克氏针两种进针方式的138例Gartland Ⅲ型儿童肱骨髁上骨折病例资料,其中平行组为外侧平行克氏针固定(65例),扇形组为外侧扇形克氏针固定(73例)。评估两组间的临床特征、末次随访的功能及外观评分,并进行统计学分析。结果 共134例获得随访,随访时间6~24个月(平均16个月)。两组病例临床特征无统计学差异,术后根据Flynn功能标准,平行组优良率为93.7%,扇形组优良率为90.3%,差异无统计学意义;根据Flynn美观标准,平行组优良率为92.1%,扇形组优良率为90.1%,差异无统计学意义。所有病例术后未出现骨折再移位、医源性神经损伤、肘内翻等并发症。结论 对于GartlandⅢ型儿童肱骨髁上骨折,克氏针外侧平行与外侧扇形两种进针方式均能取得良好的手术效果及预后。     

Internal rotation angle measurement of the elbow with 3D reformatted CT image

The examination of internal rotation angle at the elbow is difficult on conventional radiographs. The angle of internal rotation has been measured with three dimensional reformatted CT image of GE CT/T9800. The angle of internal rotation with the cubitus varus deformity was measured both preoperatively and postoperatively. Postoperatively the angle of internal rotation became equal on both sides. Three dimensional CT reconstruction is useful in determining the internal rotation angle of elbow.     

改良French内固定术治疗儿童肘内翻畸形的临床观察

目的探讨改良French内固定术治疗儿童肘内翻畸形的效果。方法儿童肘内翻畸形37例均行髁上楔形截骨术治疗,采用改良French内固定(A组)13例,单纯交叉克氏针内固定(B组)12例和钢板内固定(C组)12例,比较3组治疗前后肘关节活动度、提携角的变化及肘关节功能评价。结果 37例全部获得随访,随访时间2年～5年3个月。术后截骨处均在3个月左右骨性愈合,无一例再次出现肘内翻畸形,无神经损伤、感染等并发症。改良French内固定组优良率92.3%,显著优于单纯交叉克氏针内固定组和钢板内固定组(P<0.05);术后2年肘关节活动度(162.8±8.6)°,提携角(10.2±1.5)°,分别优于单纯交叉克氏针内固定组和钢板内固定组(P<0.05)。结论改良French内固定术治疗儿童肘内翻畸形,手术操作简单,局部创伤小,并发症少,取出内固定简单,术后肘关节活动度和提携角增加,临床效果满意,是一种安全、有效、较理想的肘内翻矫形方法。     

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.     

Three-dimensional reformations of computed tomography in the assessment of facial trauma

Three-dimensional (3D) computed tomography (CT) reformations were obtained in 15 patients presenting with facial injuries of differing severity. The 3D images were compared with standard radiographs and high resolution CT, including multiplanar reformations, and assessed under the headings of fracture detection, extent and displacement using a simple scoring system. 3D was valuable in severe trauma with multiple fractures, providing a clear demonstration of fraction extent and fragment displacement. 3D was much less useful in minor trauma in which little or no fragment displacement had occurred, and demonstrated fewer fractures overall than either radiography or CT in all categories of facial injury. When used as part of a high resolution CT examination 3D imaging can provide useful information to both radiologist and surgeon in cases of severe facial trauma.     

Adequacy of plain radiography in the diagnosis of cervical spine injuries

Our hypotheses were (1) that plain radiography of the cervical spine in the evaluation of low risk patients with minor blunt trauma is accurate and (2) that computed tomography (CT) of the cervical spine in the evaluation of low risk patients is unnecessary. This study evaluates those hypotheses. We prospectively recorded findings of all patients with blunt trauma who underwent imaging over a period of 70 days. Injury status was determined by review of all radiographic studies obtained on each patient. Chart reviews were performed to determine mechanism of injury and neurological status. Patients were divided into three groups: very low risk, low risk, and high risk. Study end point was fracture. The study included 219 patients. The very low risk group had 107 patients, none of whom had fractures found on CT (projected specificity of plain radiography: 100%). The low risk group contained 78 patients who had no fractures seen on plain radiography or CT (specificity of plain radiography and CT: 100%). The high risk group consisted of 34 patients; 15 had fractures demonstrated on CT. Plain radiography missed one fracture out of 15. In low risk patients, plain radiography is an efficient diagnostic exam with a specificity of 100%. In high risk patients, plain radiography is a good adjunctive screening exam in conjunction with CT scan, with a sensitivity of 93.3% and specificity of 95%.     

Axial alignment of the lower limband its association with disorders of the knee

Lower limb alignment, including its load-bearing axis (LBA), is best appraised by standardized radiography. Rotational orientation, including patellar alignment, is best measured by computed tomography (CT) or magnetic resonance imaging (MRI). Normal limb alignment may be defined as the means ± 1 SD of healthy adult parameters. Ideally, the knee is centered on the LBA (hip-knee-ankle [HKA] angle, zero deviation from linearity), and the quadriceps-patella-tendon (Q angle) is aligned at 11° laterally. A common deformity is varus (bow-legged) with the knee center lateral to LBA. This can cause knee instability and subluxation when the anterior cruciate ligament is lax. Subluxation is accentuated in the varus oblique knee in which the joint surfaces have an exaggerated inward tilt. Arthritic knee patterns relate to alignment through cause or effect or both. In osteoarthritis (OA), varus knee degradation is focused medially. Surveys of OA patients reveal that femoral deformity is more frequently responsible for the varus than tibial deformity. Valgus deformity (knock-knee) is uncommon in OA and linked to inflammatory arthritis, renal rickets, and various dysplasias. Thus, surgical realignment of deformed knees should be based on correction at its source—the femur, the tibia, or both. The frequent patellar malalignment in OA is probably attributable to torsional abnormalities which may call for CT or MRI assessments. Arthritis progression is optimally defined by standardized radiography in which assessments are made of the maximally involved compartment (joint space loss, osteophytes, erosion, and subluxation—which correlate with HKA). New developments include blood and urine analysis for breakdown products of cartilage and bone.     

CT of fresh fractures of the carpal scaphoid with regard to attenuation changes and healing

Fourteen patients with fresh fractures through the waist of the carpal scaphoid were studied with repeated CT examinations to evaluate attenuation changes. Sclerosis, either absolute or relative, was found in a part of the proximal fragment in all cases except one. In spite of this all faractures healed without complications. Thus sclerosis of a part of the proximal fragment does not prognosticate non-union. Attenuation in the distal fragment and the area adjacent to the fracture in the proximal fragment diminished considerably. The identical reaction in these two areas suggests that the area adjacent to the fracture does not become devascularised, or is revascularised very quickly, which probably explains why the fractures heal in spite of proximal pole sclerosis.Correspondence to: P. Carlander     

Calculation of rotational deformity in pediatric supracondylar humerus fractures

Objective Supracondylar humerus fractures (SCHF) are common in the pediatric population. Cubitus varus deformity (CVD) is the most common long-term complication of SCHFs and may lead to elbow instability and deficits in throwing or extension. Distal fragment malrotation in the axial plane disposes to fragment tilt and CVD; however, no simple method of assessing fracture malrotation exists. This study tested a mathematical method of measuring axial plane malrotation in SCHFs based on plain radiographs. Design A pediatric SCHF model was made, and x-rays were taken at known intervals of rotation. Five independent, blinded observers measured these films. Calculated rotation for each data set was compared to the known rotation. The identical protocol was performed for an aluminum phantom. Results The reliability and agreement of the rotation values were good for both models. Conclusions This method is a reliable, accurate, and cost-effective means of calculating SCHF distal fragment malrotation and warrants clinical application. This study was conducted at the NYU Hospital for Joint Diseases. None of the authors received financial support for this study.     

Double line sign: a helpful sonographic sign to detect occult fractures of the proximal humerus

The aim of this study was to describe a new sonographic sign of bone fracture and to determine if it can be helpful in decreasing the number of missed fractures of the proximal humerus. Ultrasound (US) of the shoulder was performed in 57 consecutive patients with shoulder pain and/or disability following trauma. All cases were prospectively reviewed for the presence of a humeral fracture. Sonographic signs of fractures, with special emphasis on what was termed the ‘double line sign’ (DLS), were assessed. Plain radiography was considered the standard of reference and in equivocal cases magnetic resonance imaging (MRI). Twenty-eight patients had a tuberosity complex fracture, which were all detected at US examination. Sonographic features of a fracture were periosteal elevation, corticol bone discontinuity, step-off deformity or a combination of these findings. This study showed that in 26 (93%) patients an additional sonographic feature, a DLS, could be demonstrated. The DLS is a helpful and probably reliable sonographic sign to indicate a humeral fracture. High-spatial-resolution US substantially increases the detection of fractures of the proximal humerus and should be considered as an alternative diagnostic tool prior to computed tomography (CT), MRI and arthroscopy in patients with persisting shoulder pain and/or disability following trauma.     

Dental vertical root fractures: value of CT in detection

PURPOSE: To determine the value of computed tomography (CT) in the diagnosis of dental vertical root fractures relative to the value of conventional dental radiography. MATERIALS AND METHODS: Thirty-seven patients with 42 teeth in which vertical root fracture was clinically suspected underwent dental radiography and axial CT. Two radiologists evaluated the images independently and by consensus for a fracture line. The results were compared with intraoperative findings. RESULTS: Twenty-eight of the 42 teeth were proved intraoperatively to be fractured. The sensitivity and specificity averaged for the two reviewers in the assessment of vertical fractures were 23% and 70%, respectively, with dental radiography and 100% and 100%, respectively, with CT. Consensus reading showed sensitivities of 25% for dental radiography and 75% for CT. Eight (reviewer A) or nine (reviewer B) false-negative CT findings were encountered in cases in which metallic artifacts obscured parts of the root and in cases in which the root was very small in diameter. Interobserver agreement was 95% for dental radiography and 93% for CT. CONCLUSION: CT is superior to dental radiography in the detection of dental vertical root fractures.     

News briefs

Elbow fractures are common injuries in active patients. When the fracture is nondisplaced, nonoperative treatment is frequently successful. Because stiffness is a common complication, early mobilization is an important aim of treatment; this may necessitate surgical fixation. This article reviews the diagnosis and treatment of fractures of the distal humerus, lateral epicondyle, medial condyle, lateral condyle, olecranon, coronoid process, radial head, and radial neck, as well as supracondylar fractures and Monteggia's fracture.     

Diagnosis of acute fractures of the extremities: comparison of low-field MRI and conventional radiography

The aim of this study was to compare low-field MRI (0.2 T) and conventional radiography for the detection of acute fractures of the distal part of the extremities. X-ray and MRI examinations of 78 (41 fractures, 37 without fracture) patients with the clinical suspicion of an acute fracture in the distal part of the extremities were compared. Four experienced radiologists, two for each of the two modalities, independently analyzed the images. Interobserver variability and receiver operating characteristic (ROC) analysis for both methods were established. The MRI and conventional radiography revealed an accuracy of 81.4 and of 79.5%, respectively, in the detection of acute fractures. The diagnostic accuracy of MRI to detect fractures in the hand and forefoot proved to be significantly inferior to conventional X-ray examinations. On the other hand, MRI achieved a better accuracy for the examination of bones near a large joint. The interobserver variability for both methods was rated as moderate. In ROC analysis both methods were rated as good. There was no statistical difference of the accuracy between low-field MRI and conventional radiography in the detection of acute fractures of the distal part of the extremities. Consequently, a routine use of low-field MRI as an alternative to conventional radiography to diagnose acute fractures of the extremities seems not to be justified.