尺骨截骨位置不同对手术治疗儿童陈旧性孟氏骨折预后的影响

目的 探讨手术治疗儿童陈旧性孟氏骨折尺骨截骨点位置不同对疗效的影响。方法 回顾性队列研究。纳入2015年6月—2021年6月安徽省儿童医院骨科收治的68例儿童陈旧性孟氏骨折患者的临床资料,其中男42例、女26例,年龄3~12（6.6±2.4）岁。受伤至手术时间1~60个月,平均8.6个月。BadoⅠ型骨折60例,Ⅲ型8例。患儿均采用尺骨近端截骨矫形治疗,术中选择尺骨畸形最明显处截断尺骨,按照截骨点至尺骨近端间距占尺骨全长的比例不同分为3组,A组（占比≤25%）27例、B组（25%<占比<30%）20例、C组（占比≥30%）21例。观察指标：（1）对比3组患儿临床基线资料。（2）对比3组患儿手术时间,观察术后患肘肱桡关系恢复情况,尺骨截骨处愈合情况,以及并发症发生情况。（3）术后定期随访。取出内固定前,测量对比3组患儿肘关节旋前、旋后、伸肘、屈肘角度,采用Kim肘关节功能评分表评估并对比3组患儿肘关节功能;拆除内固定后,采用影像学Nakamura分级标准评估并对比3组患儿肘关节功能。结果 （1）3组患儿性别、年龄、患肢侧别、骨折分型、受伤至手术时间、术前患肢肘关节活动度等基线资料比较,差异均无统计学意义（P值均>0.05）。（2）3组患儿均顺利完成手术,A组手术时间为（100.6±31.7）min,B组为（133.0±24.2）min,C组为（94.9±28.6）min,差异无统计学意义（F=1.02,P=0.367）。术后第3天肘关节正侧位X线片示肱桡关系均恢复正常。A组有1例术后切口感染,予以抗感染治疗后愈合。68例患儿均获得随访,随访时间6~36个月,平均8.7个月。A组术后发生肱桡关节再脱位3例、半脱位3例,B组发生半脱位3例,C组发生半脱位2例、尺骨延迟愈合1例;3组间并发症发生情况比较,差异均无统计学意义（P值均>0.05）。3组患儿尺骨截骨处愈合时间比较,差异无统计学意义（F=0.01,P=0.989）。（3）3组患儿取出内固定前,肘关节旋前、旋后、伸肘、屈肘角度,以及Kim肘关节功能评定比较,差异均无统计学意义（P值均>0.05）。拆除内固定后,影像学Nakamura分级评定肘关节功能比较,3组间差异无统计学意义（Z=1.73,P=0.422）。结论 儿童陈旧性孟氏骨折采用尺骨近端截骨矫形治疗,术中选择尺骨畸形最明显处截断尺骨,尺骨截骨点位置的不同对患儿预后无明显影响。

Influence of different locations of ulna osteotomy points on the prognosis of children with missed Monteggia fractures

Objective To investigate the effect of different locations of ulnar osteotomy point on the curative effect of missed Monteggia fracture in children. Methods A retrospective cohort study was conducted to analyze the clinical data of 68 children with missed Monteggia fracture admitted to Anhui Provincial Children's Hospital from June 2015 to June 2021, including 42 males and 26 females aged 3-12 years old with an average of (6.6±2.4) years. The interval from injury to operation was 1-60 months (mean, 8.6 months). According to Bado classification, 60 cases were type Ⅰ, and 8 cases were type Ⅲ. All patients were treated with proximal ulna osteotomy. Intraoperatively, the ulna was truncated at the most obvious location of ulnar deformity. The patients were divided into three groups according to the ratio of the length from the proximal ulna to the osteotomy point to the length of the ulna,: group A (proportion≤25%, 27 cases), group B (25%Results (1) No substantial differences in gender, age, side of affected limb, fracture type, time from injury to operation, preoperative elbow motion of affected limb, and other basic data were observed among the three groups (all P values >0.05). (2) All children in the three groups successfully completed the operation. The operation time of groups A, B, C were (100.6±31.7), (133.0±24.2), and (94.9±28.6)min, respectively. No statistically significant differences in operation time were found in the three groups (F=1.02, P=0.367). Re-examination on the third postoperative day of the elbow joint anteroposterior and lateral radiographs showed that the brachioradial relationship was restored to normal. In group A, incision infection was found in one case during dressing change after operation, which healed after anti-inflammatory treatment. All 68 patients were followed up for 6-36 months with an average of 8.7 months. The postoperative redislocation of the brachioradialis joint occurred in three cases, and subluxation occurred in three cases in group A. Subluxation occurred in three cases in group B; subluxation in two cases and delayed ulna healing in one case were noted in group C; and no significant differences in the incidence of complications were found among the three groups (all P values >0.05). No significant differences in the healing time of ulnar osteotomy were noted in the three groups (F=0.01, P=0.989). (3) No significant differences in elbow pronation, supination, elbow extension, elbow flexion angles, and Kim elbow function were observed among the three groups before taking out the internal fixation (all P values >0.05). No significant differences in the postoperative radiographic Nakamura grading of elbow function were found among the three groups after the removal of internal fixation (Z=1.73, P=0.422). Conclusion In the surgical treatment of children with missed Monteggia fractures, when the ulna was truncated at the most obvious point of ulnar deformity, the choice of different osteotomy points has no significant effect on the prognosis.