Çocuk suprakondiler humerus kırıklarında uygulanan açık ve kapalı cerrahi metodların değerlendirilmesi
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Date
2009
Authors
Aksakal, Ahmet Murat
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Publisher
Uludağ Üniversitesi
Abstract
Çalışmada tip III suprakondiler humerus kırığı bulunan çocuklarda anterior açık redüksiyon ve internal tespit yöntemi ile kapalı redüksiyon ve K teli ile tespit yöntemleri incelendi. Açık kırık, dolaşım sorunu, sinir etkilenme bulguları, yaygın ekimoz, ödem ve ciltte gamzelenme varlığı veya kapalı redüksiyonun yetersiz olması durumlarında tedavi yöntemi olarak açık redüksiyon seçildi. İki yöntemin karşılaştırılması amacıyla çocukların travmadan sonra ameliyata alınana kadar saptanan klinik bulguları, ameliyat sırasında kaydedilen bulguları ve tedavi sonunda dirseklerinde klinik ve radyolojik ölçütlere göre belirlenen fonksiyonel ve kozmetik değerlendirme bulguları kullanıldı.Çalışmaya dahil edilen 65 olgudan 40'ına anterior açık redüksiyon, 25'ine kapalı redüksiyon uygulandı. Ameliyat sonrası klinik değerlendirmelerinde iki yöntem arasında tedavi etkinliği veya komplikasyon oranları açısından her hangi bir fark gözlenmedi. Açık redüksiyon uygulanan çocuklar, kapalı redüksiyon uygulananlara göre travmadan sonra daha uzun sürede başvurmuşlardı ve yaş olarak daha büyüktüler. Açık redüksiyon uygulanan çocuklarda başvuru süresi 56.3±78.4 saat, ortalama yaş 7.7±2.79 yıl iken, bu değerler kapalı redüksiyon uygulananlarda 9.8±13.1 saat ve 5.96±2.50 yıldı (P<0.05). Son radyolojik kontrolde ölçülen Baumann ve lateral humerokapitellar açı farkı değerlerinin ortalaması açık redüksiyon uygulanan çocuklarda sırasıyla 3.42°±3.35° ve 8.32°±7.42°, kapalı redüksiyon uygulananlarda ise sırasıyla 3.48°±4.24° ve 7.04°±8.21° olarak ölçüldü (P>0,05).Başvuru sırasında 7 çocukta damar, 8 çocukta sinir, 2 çocukta ise aynı anda damar ve sinir hasarına ait klinik bulgular vardı. Ameliyat sırasında saptanan bulgular sonucunda bu hastaların 4 tanesinde brakial artere cerrahi girişim uygulandı. Ameliyat öncesinde her hangi bir sinir etkilenmesine ait bulgusu olmayan 4 çocukta ise ameliyat sırasında median sinirin kırık parçaları arasında sıkıştığı veya takıldığı belirlendi. Sinir lezyonu saptanan çocuklarda bu yapıların serbestleştirilmesi dışında cerrahi işlem uygulanmadı. Dolaşım sorunu veya nörolojik bulguları olan çocukların tümü son kontrollerinde damar ve sinir muayenesi açısından sorunsuzdu.Bu kırıklarda oldukça sık karşılaşılan damar ve sinir hasarına ait bulguların, veya kırık ekstremitede ileri derecede ödem gibi kapalı redüksiyon girişimlerini güçleştiren ve zaten hasarlı dokular üzerinde risk yaratan durumların varlığında anterior açık redüksiyonun belirgin üstünlükleri vardır. Bunlar özellikle damar incelemesi için ön tetkik ve zaman harcanmasına gerek kalmaması, anterior yaklaşım ile cilt dışında yumuşak dokuda ek hasar oluşturulmadan kırığa ve dirsek bölgesindeki önemli tüm yapılara doğrudan ulaşılabilmesi, hasar değerlendirmesinin ve gerektiğinde buna yönelik ek cerrahi girişimin yapılabilmesidir. Ayrıca kırık redüksiyonu ve K teli tespitinin kolaylıkla yapılabilmesi ve bu işlemler için floroskopi kullanımına ihtiyaç olmaması anterior yaklaşımın en önemli avantajlarındandır.
In this study, we have evaluated the management of type III supracondylar fractures of children with anterior open reduction-internal fixation technique or closed reduction-internal fixation with K-wires. Open reduction was the method of choice for cases with open fractures, vascular problems, symptoms of neurological involvement, excessive ecchymosis, edema and dimpling of the skin. In order to compare the two methods, clinical findings of the children prior to surgery, peroperative findings, and postoperative functional and cosmetic results based on clinical and radiological criteria.Of the 65 cases included in our study, 40 children underwent open anterior reduction while 25 patients underwent closed reduction. Efficiency and complication rates of these two techniques were clinically assessed postoperatively and the results did not reveal a difference. Children who had undergone open reduction were usually older and had longer time lap till hospital admission. while time lap till admission was 56.3+-78.4 hours and mean age was 7.7+-2.79 for the open reduction group, closed reduction group had time lap of 9.8+-13.1 and mean age of 5.96+-2.50 years(P<0.05). Baumann and lateral humerocapitellar angles were measured and the mean changes were found 3.42°±3.35° and 8.32°±7.42° degrees respectively for open reduction group, 3.48°±4.24° and 7.04°±8.21 degrees respectively for the closed reduction group(P>0,05).On admission, 7 children had vascular, 8 had neurologic and 2 had both vascular and neurologic symptoms. 4 of these patients underwent surgical intervention on the brachial artery. During the surgery of 4 other children who did not have symptoms of neurological compromise, median nerve was found to be trapped between the bone fragments. Children with neurological lesions did not receive any surgical intervention besides release of the damaged nerve. During their last visit, neurovascular examination of all of the children with previous vascular or neurological symptoms was normal.In the presence of factors such as marked edema which makes closed reduction difficult risking the already damaged tissues or in the presence of neurovascular symptoms which are quite common with these fractures, anterior open reduction has certain advantages. Among these are the fact that there is no need to spend time for clinical and radiological examination of the vascular structures, possibility of direct approach to the fracture line and vital structures in the vicinity of the elbow with a single skin incision without any extra soft tissue damage and the possibility of second look and any interventions if needed. Also, fracture reduction and fixation with K-wires is quite easy and fluoroscopy is not needed.
In this study, we have evaluated the management of type III supracondylar fractures of children with anterior open reduction-internal fixation technique or closed reduction-internal fixation with K-wires. Open reduction was the method of choice for cases with open fractures, vascular problems, symptoms of neurological involvement, excessive ecchymosis, edema and dimpling of the skin. In order to compare the two methods, clinical findings of the children prior to surgery, peroperative findings, and postoperative functional and cosmetic results based on clinical and radiological criteria.Of the 65 cases included in our study, 40 children underwent open anterior reduction while 25 patients underwent closed reduction. Efficiency and complication rates of these two techniques were clinically assessed postoperatively and the results did not reveal a difference. Children who had undergone open reduction were usually older and had longer time lap till hospital admission. while time lap till admission was 56.3+-78.4 hours and mean age was 7.7+-2.79 for the open reduction group, closed reduction group had time lap of 9.8+-13.1 and mean age of 5.96+-2.50 years(P<0.05). Baumann and lateral humerocapitellar angles were measured and the mean changes were found 3.42°±3.35° and 8.32°±7.42° degrees respectively for open reduction group, 3.48°±4.24° and 7.04°±8.21 degrees respectively for the closed reduction group(P>0,05).On admission, 7 children had vascular, 8 had neurologic and 2 had both vascular and neurologic symptoms. 4 of these patients underwent surgical intervention on the brachial artery. During the surgery of 4 other children who did not have symptoms of neurological compromise, median nerve was found to be trapped between the bone fragments. Children with neurological lesions did not receive any surgical intervention besides release of the damaged nerve. During their last visit, neurovascular examination of all of the children with previous vascular or neurological symptoms was normal.In the presence of factors such as marked edema which makes closed reduction difficult risking the already damaged tissues or in the presence of neurovascular symptoms which are quite common with these fractures, anterior open reduction has certain advantages. Among these are the fact that there is no need to spend time for clinical and radiological examination of the vascular structures, possibility of direct approach to the fracture line and vital structures in the vicinity of the elbow with a single skin incision without any extra soft tissue damage and the possibility of second look and any interventions if needed. Also, fracture reduction and fixation with K-wires is quite easy and fluoroscopy is not needed.
Description
Keywords
Çocuk suprakondiler humerus kırığı, Anterior açık redüksiyon, Cerrahi tedavi, Supracondylar humerus fractures of children, Anterior open reduction, Surgical treatment
Citation
Aksakal, A. M. (2009). Çocuk suprakondiler humerus kırıklarında uygulanan açık ve kapalı cerrahi metodların değerlendirilmesi. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.