课题背景：儿童肱骨髁上骨折的治疗方法选择越来越受到重视，目前国内外还没有达到一致的意见，甚至在手术指征方面都存在一些争议。手术治疗和非手术治疗各有优劣，如何把握好适应证，让患儿在肘关节功能恢复和外观均满意，是一个值得探讨的课题；骨折所致肘内翻机制不明确，导致临床缺乏足够的理论支持，这点也是学者们在积极探索的。

应用要点：试验结果显示，儿童肱骨髁上骨折治疗优良率与治疗方法有密切关系，而治疗方法应该根据患者骨折的分型及有无并发症作出相应的选择。Ⅱ型骨折尽可能选用手法复位加石膏外固定，因为手术毕竟本身也是一种创伤，带来的并发症也多；Ⅲ型有移位的骨折，无论向后内侧或后外侧移位，均无骨皮质接触，骨膜也可能已剥离，复位相当困难。所以Ⅲ型骨折的患者，具备了手术指征，应该选择手术治疗。

相关链接：儿童肱骨髁上骨折手术指征的进一步明确，可以更有效的预防患儿的术后并发症，对临床具有很大的指导性意义。现在外科朝着微创方向发展，是一个必然的趋势，不少国内外论文已经提出对儿童肱骨髁上骨折使用闭合复位+克氏针内固定，但疗效褒贬不一。

摘要
目的：肘内翻是肱骨髁上骨折晚期最常见的并发症，如何预防肘内翻的出现，近年出现了多种治疗方法，主要分为保守治疗和手术治疗两大类。探讨对儿童肱骨髁上骨折治疗方法的选择与预后康复的关系。
方法：①试验对象：选择2002-01/2006-12本科69例肱骨髁上骨折患者，纳入标准：年龄不大于14岁且经过X射线影像学表现确诊，所有病例均为伸直型，患者对治疗知情同意，并获得医院伦理委员会批准。按不同治疗方法分为手法复位加石膏外固定组（n =22）和手术复位内固定组（n =47）。按Gartland提出的肱骨髁上骨折分型将各组骨折分为Ⅰ、Ⅱ、Ⅲ型。②试验方法及评估：手法复位加石膏外固定组在复位时遵循桡侧嵌插，尺侧分离，尺偏型矫枉过正成轻度桡偏，桡偏型不矫枉过正的原则；同时长臂石膏托固定患肢。手术复位内固定组在手术过程中采用克氏针固定远端。所有病例经过9~36个月的随访，通过摄患侧标准肘关节正侧位X射线片，治疗前后测量Baumann角及参照Flynn对肱骨髁上骨折疗效的评定标准分析各组Ⅰ、Ⅱ、Ⅲ型骨折的疗效。
结果：纳入69例肱骨髁上骨折患者，均进入结果分析。①手法复位加石膏外固定组Ⅰ、Ⅱ型骨折治疗优良率无差别（P =0.455 > 0.05）；Ⅱ型骨折治疗的优良率高于Ⅲ型（P =0.036 < 0.05）；Ⅰ型骨折治疗的优良率亦高于Ⅲ型（P =0.002 < 0.05）；手术复位内固定组Ⅱ、Ⅲ型骨折疗效结果相比较，骨折治疗优良率没有差别(χ2=0.502，P =0.479 > 0.05)；手法复位加石膏外固定组和手术复位内固定组Ⅱ型骨折疗效相比较，优良率无差别（P =1.000 > 0.05）；Ⅲ型骨折疗效相比较，手术复位内固定组的优良率高于手法复位加石膏外固定组，差异显著（χ2=7.636，P =0.006 < 0.05）。
结论：儿童肱骨髁上骨折治疗优良率与治疗方法有密切关系，而治疗方法应该根据患者骨折的分型及有无并发症作出相应的选择。
关键词：肱骨髁上骨折；治疗方法；手法复位；骨折固定术；组织构建

乐国平，张明.儿童肱骨髁上骨折治疗方法与预后结构及功能重建的关系[J].中国组织工程研究与临床康复，2008，12(7):1209-1212 [www.zglckf.com/zglckf/ejournal/upfiles/08-7/7k-1209(ps).pdf]

Treatment, prognosis and functional construction in children with humeral supracondylar fracture

Abstract

AIM：Cubitus varus is a common complication of humeral supracondylar fracture at the advance stage. There are two therapies for preventing cubitus varus, including conservative therapy and surgery. This study discussed the correlation between the option and prognosis for humeral supracondylar fracture in children.
METHODS: ①Sixty-nine patients of humeral supracondylar fracture were selected from January 2002 to December 2006. Only patients aged less than 14 years and diagnosed as extension-type fracture according to X-ray imaging were enrolled. The informed consent was obtained from all subjects, and the experiment was approved by the Hospital Ethics Committee. According to the therapy, the patients were divided into manipulation plus plaster external fixation group (n =22) and operative reduction and internal fixation group (n =47). According to Gartland typing for humeral supracondylar fracture, the fracture was divided into type Ⅰ, Ⅱ, and Ⅲ. ②In manipulation plus plaster external fixation group, the radial side of the forearm was incarcerated in pronation, and the correction of the ulnar deviation was done so as to keep the normal axis of the fractured segment. The over correction of the ulnar deviation into radial deviation was preferred, and the affected limb was fixed by long-arm plaster slab. In operative reduction and internal fixation group, Kirschner wire was used to fix the distal end during the surgery. All the cases were followed for 9-36 months. The therapeutic effect of types Ⅰ,Ⅱ, and Ⅲ were evaluated according to Baumann angle of measurement in the X-ray and standard of clinical effects of Flynn.
RESULTS: Sixty-nine patients with humeral supracondylar fracture were included in the result analysis. ①In manipulation plus plaster external fixation group, there was no statistical difference in the therapeutic effect between type Ⅰand Ⅱ fracture (P =0.455 > 0.05); the effect of type Ⅱ was superior to type Ⅲ (P =0.036 < 0.05), and type Ⅰ superior to type Ⅲ (P =0.002 < 0.05). In operative reduction and internal fixation group, there was no statistical difference in fracture healing between type Ⅱand Ⅲ (χ2=0.502, P =0.479 > 0.05). There was no statistical difference in the treatment outcome of type Ⅱ fracture between two groups (P =1.000 > 0.05); but the treatment outcome of type Ⅲ fracture in operative reduction and internal fixation group was superior to that in there was statistical difference in manipulation plus plaster external fixation group (χ2=7.636, P =0.006 < 0.05).
CONCLUSION: The therapeutic effect of humeral supracondylar fracture in children is closely correlated with the choice of therapy based on the type of fracture and complications.

Yue GP, Zhang M. Treatment, prognosis and functional construction in children with humeral supracondylar fracture.Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu 2008;12(7):1209-1212(China)
[www.zglckf.com/zglckf/ejournal/upfiles/08-7/7k-1209(ps).pdf]