本文選題：橈骨頸骨折 + 微創(chuàng)治療　； 參考：《蘇州大學(xué)》2016年博士論文

【摘要】：兒童橈骨頸骨折病例數(shù)量約占兒童肘部骨折病例數(shù)的5%-10%。橈骨頸的血供可能被外傷當時所受的暴力破壞,或者(和)被切開復(fù)位的手術(shù)創(chuàng)傷或者暴力的手法復(fù)位所影響,醫(yī)源性加重損傷橈骨頸的血供,導(dǎo)致兒童橈骨頸骨折的不愈合及橈骨小頭壞死等等并發(fā)癥。肘關(guān)節(jié)及前臂存在復(fù)雜的解剖,橈骨小頭與骨間后神經(jīng)(posterior interosseous nerve,PIN)關(guān)系密切,所以至今以來兒童橈骨頸骨折還是一個比較難以處理的問題。雖然治療方法各種各樣,但經(jīng)皮閉合復(fù)位固定的微創(chuàng)理念得到認可。本文比較了兒童橈骨頸骨折行Metaizeau治療法、經(jīng)皮克氏針撬撥復(fù)位法(percutaneous Kirschner’s wire leverage,PKWL)及兩種微創(chuàng)方法的結(jié)合,分析該微創(chuàng)治療方法的手術(shù)時間、術(shù)中注意事項及手術(shù)效果等。微創(chuàng)治療兒童橈骨頸骨折創(chuàng)傷小,效果佳,但骨間后神經(jīng)和橈骨頸關(guān)系密切,骨間后神經(jīng)的損傷成為兒童橈骨頸骨折手術(shù)治療多見的并發(fā)癥。通過對兒童橈骨頸的解剖研究,尤其是與骨間后神經(jīng)關(guān)系的研究,來減少甚至避免骨間后神經(jīng)的損傷,達到兒童橈骨頸骨折的最佳治療效果。第一部分骨間后神經(jīng)在橈骨近端后外側(cè)的解剖目的:骨間后神經(jīng)對上肢的功能有非常重要的作用,它營養(yǎng)并支配著前臂后部肌肉。橈神經(jīng)穿過肘關(guān)節(jié)囊前部,并分成橈神經(jīng)淺支和深支,橈神經(jīng)淺支在肱橈肌深面走行,橈神經(jīng)深支延續(xù)為骨間后神經(jīng)并穿過旋后肌管,環(huán)繞橈骨近端走行,到達前臂伸肌,發(fā)散開支配各肌。[1]雖然報道橈骨頭及橈骨頸骨折可導(dǎo)致骨間后神經(jīng)損傷,但骨間后神經(jīng)也可以為醫(yī)源性損傷,尤其是通過前路、側(cè)方及后外側(cè)入路顯露橈骨近端,甚至肘關(guān)節(jié)鏡檢查也可損傷骨間后神經(jīng)�？赏ㄟ^骨間后神經(jīng)相關(guān)解剖學(xué)的詳細學(xué)習(xí)而避免其損傷,至少可降低損傷發(fā)生率。Diliberti等稱旋前位可增加橈骨近端的安全區(qū)范圍,但骨間后神經(jīng)的定位沒有可靠的解剖學(xué)結(jié)構(gòu)來做參照,特別是兒童橈骨頸骨折病例,沒有既定的數(shù)據(jù)及結(jié)構(gòu)來參照。因此,本研究依據(jù)前臂的旋轉(zhuǎn),分析骨間后神經(jīng)與橈骨近端的位置關(guān)系的變化,定位骨間后神經(jīng)的走行,在微創(chuàng)治療兒童橈骨頸骨折時,特別是在撬撥復(fù)位過程中避免骨間后神經(jīng)的醫(yī)源性損傷。方法:解剖6具兒童尸體的上肢,年齡介于7-12歲。對每個標本,打開旋后肌淺層,保留骨間后神經(jīng)下方的旋后肌深層,顯露骨間后神經(jīng)。旋前狀態(tài)下,測量自肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨干后側(cè)骨皮質(zhì)中軸線交點的距離,測量自肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨外側(cè)骨皮質(zhì)中軸線交點的距離。旋后狀態(tài)下,測量自肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨干后側(cè)骨皮質(zhì)中軸線交點的距離,測量自肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨外側(cè)骨皮質(zhì)中軸線交點的距離。金屬線定位標記骨間后神經(jīng),對標本進行攝片檢查和三維ct檢查。結(jié)果:前臂于完全旋后位時,從肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨干后側(cè)骨皮質(zhì)中軸線交點的距離平均(32±5.9)mm,肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨外側(cè)骨皮質(zhì)中軸線交點的距離平均(19.5±3.0)mm。前臂位于完全旋前位,從肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨干后側(cè)骨皮質(zhì)中軸線交點的距離平均(39±8.3)mm,肱骨小頭遠端關(guān)節(jié)面至骨間后神經(jīng)越過橈骨外側(cè)骨皮質(zhì)中軸線交點的距離平均(22±3.3)mm。肘關(guān)節(jié)屈伸對這一距離沒有影響。橈骨長度平均(205.2±13.6)mm。前臂旋后位時,后側(cè)骨皮質(zhì)中軸線可在近端被安全暴露的范圍,占平均橈骨長度的(15.5±2.1)%;外側(cè)骨皮質(zhì)中軸線可在近端被安全暴露的范圍,占平均橈骨長度的(9.4±1.0)%。前臂旋前位時,該長度比例增至(18.8±3.1)%和(10.7±1.0)%。結(jié)論:旋前位有效地增加了骨間后神經(jīng)近端的安全區(qū)域范圍。因此,手術(shù)顯露橈骨頭時,前臂應(yīng)當置于旋前位,把骨間后神經(jīng)的損傷風(fēng)險降到最低。且在旋前位撬撥復(fù)位時,后側(cè)進針點到肱骨小頭關(guān)節(jié)面的距離盡量不超過橈骨總長的15%,外側(cè)進針點到肱骨小頭關(guān)節(jié)面的距離盡量不超過橈骨總長的9%。第二部分metaizeau法治療兒童橈骨頸骨折療效分析目的:在微創(chuàng)治療兒童橈骨頸骨折方法出現(xiàn)以前,對嚴重移位的兒童橈骨頸骨折絕大部分以手術(shù)切開復(fù)位克氏針固定方法為主。經(jīng)多年的臨床隨訪觀察,治療效果較差,特別是手術(shù)后患兒易出現(xiàn)橈骨頭骺缺血壞死改變、骺早閉、肘外翻、肘關(guān)節(jié)屈伸和前臂旋轉(zhuǎn)功能受限等。1980年metaizeau報道經(jīng)橈骨遠端骨皮質(zhì)置入髓內(nèi)釘,對橈骨頸骨折進行復(fù)位和固定,效果良好。分析我院采用metaizeau法治療傾斜移位30°以上的兒童橈骨頸骨折病例,結(jié)合治療效果及體會,研究metaizeau法治療傾斜移位30°以上的兒童橈骨頸骨折的臨床療效。方法:回顧性分析2008年8月至2010年2月采用metaizeau法治療傾斜移位30°以上的兒童橈骨頸骨折12例的臨床資料。取橈骨遠側(cè)生長板以上1~2.5cm處橈側(cè)背側(cè)縱切口,長1.5~2cm。逐層顯露橈骨遠側(cè)干骺端背側(cè)骨皮質(zhì),注意避開頭靜脈及橈神經(jīng)背側(cè)感覺支。骨皮質(zhì)開孔角度約30°,開孔不可過大,孔過大髓內(nèi)釘有松動可能,置入髓內(nèi)釘,注意髓內(nèi)釘頭端朝向橈側(cè)。逐漸推進髓內(nèi)釘至骨折斷端,一般髓內(nèi)釘?shù)竭_骨折斷端會遇到阻力,術(shù)中透視髓內(nèi)釘位置。當髓內(nèi)釘?shù)竭_骨折斷端后,稍后退髓內(nèi)釘,術(shù)者左手在皮外向內(nèi)上方擠壓骨折近端,可適當旋轉(zhuǎn)前臂,有助復(fù)位,固定橈骨小頭,繼續(xù)推進髓內(nèi)釘,使髓內(nèi)釘頭端穿入橈骨小頭,并將橈骨頭頂起復(fù)位。如果橈骨頸骨折仍有水平移位或不明顯的成角移位,適當旋轉(zhuǎn)髓內(nèi)釘,糾正橈骨頭的成角畸形與側(cè)方移位。術(shù)后屈肘90°,前臂中立位或旋后位石膏外固定,三角巾懸吊于胸前。約4周后解除外固定,進行功能鍛煉。術(shù)后3個月左右拔除髓內(nèi)釘。結(jié)果:10例metaizeau法成功復(fù)位患兒均在3月內(nèi)骨愈合。按metaizeau的整復(fù)標準,本組10例中,良好7例,較好2例,一般1例。經(jīng)適當功能鍛煉后,患肢外觀無畸形,肘關(guān)節(jié)活動范圍基本正常。術(shù)后隨訪3~12個月,平均9個月。根據(jù)tibone和stoltz的患肢臨床功能標準來評定,10例metaizeau法成功復(fù)位患兒優(yōu)8例,良2例。2例metaizeau法復(fù)位失敗患兒,1例患兒功能恢復(fù)優(yōu),1例患兒肘關(guān)節(jié)功能恢復(fù)可,x線復(fù)查示此患兒出現(xiàn)橈骨頸骨折斷端延遲愈合。結(jié)論:metaizeau法是一種微創(chuàng)的、行之有效的兒童橈骨頸骨折治療方法,但對于嚴重移位的橈骨頸骨折成功率不高。對于橈骨頸骨折成角移位60°以上者,metaizeau法復(fù)位失敗率較高,需切開復(fù)位,但切開復(fù)位橈骨頸骨折,易損傷橈骨頭頸的血液供應(yīng),造成橈骨頭的缺血壞死和骨折的不愈合,隨著兒童的成長,出現(xiàn)肘外翻并加重。此外,切開復(fù)位對肘關(guān)節(jié)周圍組織的干擾,可引起肘關(guān)節(jié)的功能受限。因此,對于兒童橈骨頸骨折的治療,除了metaizeau法,急需開創(chuàng)另外的微創(chuàng)方法來治療移位嚴重的兒童橈骨頸骨折。第三部分經(jīng)皮克氏針撬撥復(fù)位結(jié)合彈性髓內(nèi)釘固定技術(shù)治療兒童難復(fù)橈骨頸骨折目的:橈骨頸的血供比較脆弱,橈骨頸的血供可能被外傷當時所受的暴力破壞,可能被暴力的手法復(fù)位所影響,也有可能被切開復(fù)位的手術(shù)創(chuàng)傷所破壞,醫(yī)源性加重損傷橈骨頸的血供,導(dǎo)致兒童橈骨頸骨折的不愈合及橈骨小頭壞死等等并發(fā)癥。治療方案主要取決于橈骨頸骨折近端的成角和水平移位情況。目前整復(fù)的方式包括手法整復(fù),彈性髓內(nèi)釘復(fù)位固定技術(shù)(closeintramedullarypinning,cimp),經(jīng)皮克氏針撬撥技術(shù)(percutaneouskirschner’swireleverage,pkwl)等。在微創(chuàng)治療兒童橈骨頸骨折方法出現(xiàn)以前,對移位明顯的兒童橈骨頸骨折多以手術(shù)切開復(fù)位和/或克氏針固定為主,容易發(fā)生橈骨頭骺缺血壞死,骺板損傷早閉,關(guān)節(jié)內(nèi)鈣化等并發(fā)癥,療效優(yōu)良率僅在20%-50%之間,因此現(xiàn)在主張盡可能避免采用切開復(fù)位。我院采用經(jīng)皮克氏針撬撥復(fù)位結(jié)合彈性髓內(nèi)釘固定技術(shù)治療judetiii、iv型兒童橈骨頸骨折,現(xiàn)結(jié)合治療結(jié)果,來評估經(jīng)皮克氏針撬撥復(fù)位結(jié)合彈性髓內(nèi)釘固定技術(shù)治療judetiii、iv型兒童橈骨頸骨折的療效。方法:2010年6月至2013年12月共收治50例judetiii、iv型的橈骨頸骨折手術(shù)病例,平均年齡8.4歲,其中男31例,女19例;左側(cè)26例,右側(cè)24例。術(shù)中先行手法閉合復(fù)位,如閉合復(fù)位成功或使成角小于45°,使用橈骨髓內(nèi)釘固定及cimp技術(shù)復(fù)位固定。手法閉合復(fù)位失敗,行pkwl技術(shù),透視見移位的橈骨頸骨折尚未解剖復(fù)位,但成角小于45°,可使用彈性髓內(nèi)釘cimp技術(shù)幫助復(fù)位。術(shù)后長臂石膏固定于上肢功能位4-6周,拆除石膏后功能鍛煉。結(jié)果:50例judetiii、iv型橈骨頸骨折患兒中,11例橈骨頸骨折病人手法閉合復(fù)位成功,直接行彈性髓內(nèi)釘固定,5例通過cimp技術(shù)協(xié)助復(fù)位及固定,平均手術(shù)時間58分鐘;30例橈骨頸骨折病人,行經(jīng)pkwl技術(shù)復(fù)位成功行彈性髓內(nèi)釘固定,平均手術(shù)時間50分鐘;4例手法閉合復(fù)位失敗直接行切開復(fù)位彈性髓內(nèi)釘固定術(shù),平均手術(shù)時間80分鐘。8例合并尺骨近端骨折中2例同時行尺骨骨折切開復(fù)位內(nèi)固定,1例術(shù)前合并橈神經(jīng)損傷病例術(shù)后經(jīng)保守治療3月恢復(fù)正常。pkwl組與閉合復(fù)位髓內(nèi)釘及cimp組比較,手術(shù)時間無顯著性差異,pkwl組病例橈骨頸骨折成角度數(shù)較大,骨折移位程度較大,骨折成角度數(shù)與移位程度的比值較大。切開復(fù)位組與PKWL組、閉合復(fù)位髓內(nèi)釘、CIMP組比較,骨折的成角度數(shù)、移位程度及其比值無顯著性差異,但切開復(fù)位組手術(shù)時間較長。45例獲得隨訪,平均隨訪時間2年。所有病例骨折均愈合,平均愈合時間4.1個月,取內(nèi)固定平均時間為4.3個月。根據(jù)Tibone和Stoltz的臨床功能評價標準,3例切開復(fù)位者肘關(guān)節(jié)活動受限10°-20°不等,其余治療效果均優(yōu)。無其他并發(fā)癥發(fā)生。結(jié)論:至今兒童橈骨頸骨折一直是一個比較難以處理的疾病。單純手法整復(fù)及石膏固定治療兒童橈骨頸骨折的能力有限,可試用于治療骨折傾斜小于45°的橈骨頸骨折,或是配合其他復(fù)位方法使用。本組病例中橈骨頸骨折超過60°,或嚴重骨折嵌插,成角度數(shù)/移位程度90,通過CIMP技術(shù)行橈骨頸骨折復(fù)位失敗率高,可直接行PKWL技術(shù)復(fù)位骨折,再行CIMP技術(shù)輔助復(fù)位及固定復(fù)位的骨折。PKWL能整復(fù)大部分兒童橈骨頸骨折,包括那些經(jīng)CIMP復(fù)位失敗的病例,并可選擇順勢穿針固定兒童橈骨頸骨折。但這種經(jīng)皮克氏針貫穿橈骨頸骨折遠近端的固定限制了肘關(guān)節(jié)的早期活動及功能鍛煉,易引起肘關(guān)節(jié)僵硬。CIMP通過髓腔內(nèi)的彈性髓內(nèi)釘頂起橈骨頭,解除骨折嵌插,扶持骨折傾斜,實現(xiàn)兒童橈骨頸骨折的復(fù)位固定。CIMP術(shù)后拆除外固定后不限制肘關(guān)節(jié)的活動,這樣固定有利于肘關(guān)節(jié)的早期鍛煉。對于那些傾斜移位程度較大或嵌插較緊的橈骨頸骨折,建議先行PKWL技術(shù)復(fù)位橈骨頸骨折,再行CIMP技術(shù)固定橈骨頸骨折,PKWL配合CIMP技術(shù)可提高難復(fù)性橈骨頸骨折療效。近年來,我院根據(jù)既往的兒童橈骨頸骨折治療經(jīng)驗,對橈骨頸骨折成角移位超過60°,甚至嵌插嚴重的病例超過45°時,PKWL代替CIMP作為主要的復(fù)位方法。
[Abstract]:The blood supply of 5%-10%. radial neck in children's radius neck fracture cases, which accounts for the number of cases of children's elbow fractures, may be damaged by the violence at that time, or (and) the surgical trauma or violent manipulation of the open reduction. The iatrogenic aggravation of the blood supply of the radius and neck causes the nonunion of the fracture of the radius and neck of the children and the nonunion of the fracture of the radius and neck of the children. The complex anatomy of the elbow and forearms, the small head of the radius and the posterior interosseous nerve (posterior interosseous nerve, PIN) are closely related. So far, the fracture of the radius and neck of the children is a difficult problem to be dealt with. In this paper, the Metaizeau treatment of radial neck fracture in children was compared with the combination of percutaneous Kirschner 's wire leverage, PKWL and two minimally invasive methods. The operation time of the minimally invasive treatment, the items of attention and the effect of operation were analyzed. The minimally invasive treatment of the fracture of the radius and neck of children was made. Small trauma and good effect, but the posterior interosseous nerve and the radial neck are closely related, and the injury of the posterior interosseous nerve becomes a common complication in the operation of the radial neck fracture in children. Through the study of the radial neck of children, especially the study of the relationship between the posterior interosseous nerve, to reduce or even avoid the injury of the posterior interosseous nerve, to reach the radius neck bone of children. The first part of the posterior interosseous nerve at the proximal end of the radius: the posterior interosseous nerve has a very important role in the function of the upper limb. It nourishes and dominates the posterior muscles of the forearm. The radial nerve passes through the anterior part of the elbow capsule and divides into the superficial and deep branches of the radial nerve, and the superficial branch of the radial nerve travels in the deep face of the brachial and radial muscles. The deep branch of the radial nerve extends into the posterior interosseous nerve and passes through the posterior circumflex canal to reach the proximal end of the radius, reaching the extensor of the forearm and diverting the muscle.[1], although it is reported that the fracture of the radial head and the radial neck can lead to the injury of the posterior interosseous nerve, but the posterior interosseous nerve can also be a iatrogenic injury, especially through the anterior, lateral and posterolateral approaches. The proximal and even elbow arthroscopy can also damage the posterior interosseous nerve. It can avoid the injury by detailed study of the posterior interosseous nerve related anatomy. At least the incidence of.Diliberti, such as the incidence of injury, can be reduced to a safe area of the proximal end of the radius. However, the location of the posterior interosseous divine meridian has no reliable anatomical structure for reference. In this study, the changes in the position of the posterior interosseous nerve and the proximal radius of the bone were analyzed, and the posterior interosseous nerve was located. In the minimally invasive treatment of the fracture of the radius and neck of the children, especially in the process of prying reduction, the interosseous post was avoided. Methods: to dissect the upper limbs of 6 children's cadavers, the age of the upper limbs of 7-12 years old. For each specimen, open the superficial layer of the posterior pronation muscle, retain the deep posterior pronation muscles below the interosseous nerve and expose the posterior interosseous nerve. Distance from the distal joint of the humerus to the intersection of the interosseous posterior interosseous nerve across the medial axis of the lateral radius. The distance from the distal articular surface of the humerus to the interosseous axis of the radial diaphysis, measured from the distal joint of the humerus to the posterior interosseous God, measured the distance from the distal joint of the humerus to the posterior axis of the radial diaphysis. The distance between the interosseous points of the medial axis of the lateral bone of the radius was crossed. The posterior interosseous nerve was labeled with metal lines, and the specimens were examined and the three-dimensional CT examination. Results: the distance between the distal part of the humerus and the posterior interosseous nerve crossing the medial axis of the radial diaphysis (32 + 5.9) mm, the humerus The distance between the distal articular surface of the small head and the interosseous posterior nerve across the medial axis of the lateral radius of the radius is (19.5 + 3) mm. forearm at the complete pronation. The distance between the distal part of the humerus and the posterior interosseous nerve across the medial axis of the distal radius is (39 + 8.3) mm, and the distal joint of the humerus head to the posterior interosseous. The average distance (22 + 3.3) mm. elbow flexion and extension did not affect the distance between the nerve and the lateral cortical axis of the radial bone. When the length of the radius was (205.2 + 13.6) mm. forearm, the posterior axis of the cortical axis could be safely exposed at the proximal end, accounting for (15.5 + 2.1)% of the average radius and the axis of the lateral cortical bone. The near end was exposed to a safe range of radius (9.4 + 1)% of the average radius. The length of the forearm was increased to (18.8 + 3.1)% and (10.7 + 1)% when the forearm pronation was (10.7 + 1)%. Conclusion: the pronation effectively increases the safety area of the proximal interosseous nerve. Therefore, the forearm should be placed in the pronation position and the posterior interosseous nerve injury when the radial head is exposed. 9%. second part of the lateral needle point to the joint surface of the small head of the humerus is not more than the total length of the radius as far as possible for the treatment of the radial neck fracture in children: a minimally invasive treatment for the treatment of radial neck fracture: a minimally invasive treatment for the treatment of the radial neck fracture in children. In children with radial neck fracture, most of the fractures of the radius and neck in children were mainly treated with surgical open reduction and Kirschner fixation. After years of clinical follow-up observation, the treatment effect was poor, especially after the operation, the changes of the epiphysis ischemic necrosis, epiphyseal early closure, elbow valgus, elbow flexion extension and forearm were easy to occur in the children after the operation. .1980 year Metaizeau reported that the distal radius bone cortex was inserted into the intramedullary nail for the reduction and fixation of the fracture of the radius and neck in.1980 years. The results were analyzed in our hospital by using the Metaizeau method for the treatment of radial neck fracture in children with tilted displacement more than 30 degrees, and combined with the therapeutic effect and experience, the Metaizeau method was used to treat the tilted displacement of 30 degrees. Methods: a retrospective analysis of the clinical data of 12 cases of radial neck fracture in children with inclined displacement more than 30 degrees from August 2008 to February 2010 by Metaizeau method. The longitudinal incision of the radial lateral dorsal side of the distal growth plate above the radius and the long 1.5~ 2cm. to the distal metaphyseal bone skin of the distal radius were revealed. Quality, pay attention to avoiding the sensory branch of the opening vein and the dorsal radial nerve. The angle of the opening of the bone cortex is about 30 degrees, the opening of the perforated hole is not too large. The intramedullary nail is loosened and the intramedullary nail is inserted, and the intramedullary nail head is pointed to the radial side. The intramedullary nail is gradually pushed to the fracture end, and the intramedullary nail will encounter resistance at the fracture end. When the intramedullary nail reaches the broken end of the fracture, the intramedullary nail is retreated later, and the left hand squeezing the proximal end of the fracture in the upper part of the skin. It can properly rotate the forearm, assist the reduction, fix the small head of the radius, continue to push the intramedullary nail, make the head end of the intramedullary nail into the radial head, and reposition the radial head. If the radial neck fracture is still displaced horizontally or not, there is still horizontal displacement or insignificant fracture of the radial neck. Angle displacement and proper rotation of intramedullary nail to correct the angular deformity of the radial head and lateral displacement. After operation, the flexion of the elbow was 90 degrees, the forearm neutral or the supination plaster was fixed outside the chest. The trigonometric towel was suspended on the chest. After about 4 weeks, the external fixation was relieved and the intramedullary nails were removed about 3 months after the operation. Results: 10 cases of the successful reduction of Metaizeau method were 3. In the 10 cases of this group, 7 cases were good, 2 cases were good, 1 cases were good. After proper functional exercise, the limb appearance was no deformity and the range of elbow joint was basically normal. The postoperative follow-up was 3~12 months, averaging 9 months. According to the clinical functional criteria of the affected limbs of TiBone and Stoltz, 10 cases of Metaizeau method were successfully reset. The children were excellent in 8 cases, good in 2 cases of.2 cases with Metaizeau failure, 1 cases of good function recovery and 1 cases of elbow joint function recovery. X-ray examination showed that the broken end of radial neck fracture was delayed union. Conclusion: Metaizeau method is a minimally invasive, effective treatment for radial fracture of the neck of children, but for the severely displaced radius. The success rate of neck fracture is not high. For those with radial neck fracture more than 60 degrees, the failure rate of Metaizeau method is high and need open reduction, but open reduction and reduction of radial neck fracture, damage to the blood supply of the radial head and neck, cause the necrosis of the radial head and the nonunion of the fracture, with the growth of the children, the elbow eversion and aggravation. In addition, cut off. The interference of the open reduction on the surrounding tissue of the elbow can cause the function limitation of the elbow joint. Therefore, for the treatment of radial neck fractures in children, in addition to the Metaizeau method, another minimally invasive method is urgently needed to treat the displaced radial neck fracture in children. The third part is treated with a prying reduction combined with elastic intramedullary nail fixation. The blood supply of the radial neck is fragile. The blood supply of the radial neck is relatively fragile. The blood supply of the radial neck may be destroyed by the violence at that time. It may be affected by the manipulative reduction of violence. It may also be damaged by the surgical trauma of open reduction. The iatrogenic aggravation of the blood supply of the radius and neck causes the nonunion of the fracture of the radius and neck of the children. The treatment scheme mainly depends on the angle and horizontal displacement of the proximal end of the radius and neck fracture. The methods currently included include manipulation, closeintramedullarypinning, CIMP, percutaneouskirschner 'swireleverage, pkwl, and so on. Before the emergence of minimally invasive treatment of radial neck fractures in children, open reduction and / or Kirschner fixation are most important for the displaced radial neck fractures in children with obvious displacement. It is easy to have complications such as epiphyseal necrosis of the radial head, early closure of epiphyseal plate injury and intra-articular calcification. The effective rate is only between 20%-50%. Therefore, it is now advocated to avoid as much as possible. The treatment of radial and cervical fractures of type judetiii and IV children was treated with percutaneous reduction and elastic intramedullary nail fixation in our hospital. Combined with the results of treatment, the therapeutic effect of percutaneous Kirschner pin reduction and elastic intramedullary nail fixation for the treatment of judetiii and IV type children's radial neck fracture was evaluated. Methods: June 2010 to 201 In December 3 years, 50 cases of judetiii, IV type of radial neck fracture were treated with an average age of 8.4 years old, including 31 men, 19 women, 26 left cases and 24 right sides. The operation was closed reduction, such as closed reduction success or making angle less than 45 degrees, using radial bone marrow nail fixation and CIMP technique reduction and fixation. Closed reduction failure, pkwl technique Surgery, perspective displaced radial neck fracture has not been anatomic reduction, but the angle is less than 45 degrees, the elastic intramedullary nail CIMP technique can be used to help the reduction. After the operation, the long arm plaster is fixed to the functional position of the upper limb for 4-6 weeks. The result: 50 cases of judetiii, IV type radius neck fracture, 11 cases of radial neck fracture patients closed reduction Work, direct elastic intramedullary nail was fixed, 5 cases were assisted by CIMP technology to help the reduction and fixation, the average operation time was 58 minutes. 30 cases of radial neck fracture were treated with pkwl technique, and the average operation time was 50 minutes. 4 cases were treated by open reduction and elastic intramedullary nail fixation, and the average operation was performed. After 80 minutes, 2 cases of ulna proximal fracture were combined with open reduction and internal fixation, and 1 cases with radial nerve injury were treated by conservative treatment in March, and in March, the normal.Pkwl group was restored to the normal group and the closed reduction intramedullary nail and CIMP group. There was no significant difference between the operation time and the pkwl group. There was a greater degree of fracture displacement and the ratio of the angle degree of fracture to the degree of displacement. There was no significant difference between the open reduction group and the PKWL group, the closed reduction intramedullary nail, the CIMP group, the degree of angle of fracture, the degree of displacement and the ratio of the fracture, but the open reduction group was followed up for a longer operation time and the average follow-up time was 2 years. All cases were fractured. The average healing time was 4.1 months, and the average time for internal fixation was 4.3 months. According to the clinical evaluation criteria of Tibone and Stoltz, 3 cases were cut.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R726.8

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