术后早期综合康复对儿童青少年肱骨髁上骨折伴尺神经损伤的效果

doi:10.3969/j.issn.1006-9771.2024.01.014

摘要/Abstract

摘要：

目的观察术后早期综合康复对并发尺神经损伤的肱骨髁上骨折儿童青少年的肘关节功能障碍与尺神经损伤的效果。

方法 2016年1月至2021年12月在中国中医科学院望京医院治疗的并发尺神经损伤的肱骨髁上骨折术后的儿童青少年49例，随机分为对照组(n = 24)和治疗组(n = 25)。对照组采用蜡敷治疗和针灸治疗，治疗组采用药物熏蒸、关节松动术及肌电生物反馈治疗，治疗12周。治疗前后分别采用美国特种外科医院肘关节评定表(HSS)和英国医学研究院神经外伤学会报告(MCRR)进行评估。

结果治疗后，两组HSS评分均显著升高(|t| > 8.345, P < 0.001)，治疗组HSS评分显著高于对照组(t = 4.536, P < 0.001)，治疗组治疗前后HSS评分差值高于对照组(t = 3.717, P < 0.05)。治疗组尺神经恢复优良率高于对照组(χ² = 5.975, P < 0.05)。

结论术后早期综合康复可改善并发尺神经损伤的肱骨髁上骨折儿童青少年的肘关节功能，促进尺神经恢复。

关键词: 儿童, 青少年, 肱骨髁上骨折, 尺神经损伤, 肘关节功能障碍, 早期综合康复

Abstract:

Objective To observe the therapeutic effect of early postoperative comprehensive rehabilitation on elbow joint dysfunction and ulnar nerve injury in children and adolecents with supracondylar fracture of humerus complicated with ulnar nerve injury.

Methods A total of 49 children with supracondylar fracture of humerus complicated with ulnar nerve injury after operation were selected from January, 2016 to December, 2021 in Wangjing Hospital, which were randomly divided into control group (n = 24) and treatment group (n = 25). The control group accepted wax therapy and acupuncture, and the treatment group accepted medicine fumigation, joint mobilization and electromyographic biofeedback, for twelve weeks. They were assessed with The Hospital for Special Surgery Elbow score (HSS) and Medical Research Neurotrauma Society Report (MCRR) before and after treatment.

Results After treatent, the HSS scores increased in both groups (|t| > 8.345, P < 0.001). The HSS score was significantly higher in the treatment group than in the control group (t = 4.536, P < 0.001). The d-value of HSS scores before and after treatment was significantly higher in the treatment group than in the control group (t = 3.717, P < 0.05). The rate of excellent recovery of ulnar nerve function was significantly higher in the treatment group than in the control group (χ² = 5.975, P < 0.05).

Conclusion Early postoperative comprehensive rehabilitation could romote the recovery of elbow function and ulnar nerve injury in children and youth with supracondylar fracture of humerus complicated with ulnar nerve injury.

Key words: children, youth, supracondylar fracture, ulnar nerve injury, elbow joint dysfunction, early comprehensive rehabilitation

中图分类号:

R683.41

罗丽华, 王雨生, 李剑锋, 董继革. 术后早期综合康复对儿童青少年肱骨髁上骨折伴尺神经损伤的效果[J]. 《中国康复理论与实践》, 2024, 30(1): 105-110.

LUO Lihua, WANG Yusheng, LI Jianfeng, DONG Jige. Effect of early postoperative comprehensive rehabilitation on children and youth with supracondylar fracture of humerus complicated with ulnar nerve injury[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2024, 30(1): 105-110.

图/表 3

参考文献 36

[1]	KUMAR V, SINGH A. Fracture supracondylar humerus: a review[J]. J Clin Diagn Res, 2016, 10(12): re01-re06.
[2]	APARICIO MARTÍNEZ J L, PINO ALMERO L, CIBRIAN ORTIZ DE ANDA R M, et al. Epidemiological study on supracondylar fractures of distal humerus in pediatric patients[J]. Rev Esp Cir Ortop Traumatol (Engl Ed), 2019, 63(6): 394-399.
[3]	STRIANO B M, DE MATTOS C, RAMSKI D E, et al. Displaced supracondylar humerus fractures in toddlers[J]. Orthopedics, 2020, 43(5): e421-e424.
[4]	HOUSHIAN S, MEHDI B, LARSEN M S. The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures[J]. J Orthop Sci, 2001, 6(4): 312-315. doi: 10.1007/s007760100024 pmid: 11479758
[5]	RUPP M, SCHÄFER C, HEISS C, et al. Pinning of supracondylar fractures in children: strategies to avoid complications[J]. Injury, 2019, 50(Suppl 1): S2-S9.
[6]	JOYCE K M, DONY A, WHITEHOUSE H, et al. Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases[J]. J Hand Surg Eur Vol, 2023: 17531934231201925.
[7]	TOĞAÇ S, EKEN G, ERMUTLU C, et al. Forearm compartment pressure change in children operated for supracondylar humerus fracture[J]. J Pediatr Orthop, 2022, 42(9): 509-515. doi: 10.1097/BPO.0000000000002220 pmid: 35980756
[8]	CANALES-ZAMORA O A, MORA-RÍOS F G, MEJÍA-ROHENES L C, et al. [Complications of supracondylar humeral fractures in children][J]. [in Spanish]. Acta Ortop Mex, 2020, 34(2): 91-95.
[9]	CHEN R S, LIU C B, LIN X S, et al. Supracondylar extension fracture of the humerus in children. Manipulative reduction, immobilisation and fixation using a U-shaped plaster slab with the elbow in full extension[J]. J Bone Joint Surg Br, 2001, 83(6): 883-887. doi: 10.1302/0301-620X.83B6.0830883
[10]	HEYER J H, ANARI J B, BALDWIN K D, et al. Standardizing a postoperative protocol for supracondylar humerus fractures[J]. J Pediatr Orthop, 2022, 42(2): e103-e108. doi: 10.1097/BPO.0000000000002029
[11]	张殿英, 王艳华, 王天兵, 等. 肘关节术后6种不同功能评分标准的比较[J]. 中华手外科杂志, 2008, 24(4): 243-246.
	ZHANG D Y, WANG Y H, WANG T B, et al. Comparison of 6 different functional scoring criteria after elbow joint operation[J]. Chin J Hand Surg, 2008, 24(4): 243-246.
[12]	朱盛修. 现代显微外科学[M]. 长沙: 湖南科学技术出版社, 1994: 751-805.
	ZHU S X. Modern microsurgery[M]. Changsha: Hunan Science Technology Press, 1994: 751-805.
[13]	MANGWANI J, NADARAJAH R, PATERSON J M. Supracondylar humeral fractures in children: ten years' experience in a teaching hospital[J]. J Bone Joint Surg Br, 2006, 88(3): 362-365.
[14]	PAN T, WIDNER M R, CHAU M M, et al. Open supracondylar humerus fractures in children[J]. Cureus, 2021, 13(3): e13903.
[15]	POGGIALI P, NOGUEIRA F C S, NOGUEIRA M P M. Management of supracondylar humeral fracture in children[J]. Rev Bras Ortop (Sao Paulo), 2022, 57(1): 23-32. doi: 10.1055/s-0040-1709734
[16]	TOMASZEWSKI R, PETHE K, KLER J, et al. Supracondylar fractures of the humerus: association of neurovascular lesions with degree of fracture displacement in children: a retrospective study[J]. Children (Basel), 2022, 9(3) :308.
[17]	DUFFY S, FLANNERY O, GELFER Y, et al. Overview of the contemporary management of supracondylar humeral fractures in children[J]. Eur J Orthop Surg Traumatol, 2021, 31(5): 871-881. doi: 10.1007/s00590-021-02932-2 pmid: 33744996
[18]	GADGIL A, HAYHURST C, MAFFULLI N, et al. Elevated, straight-arm traction for supracondylar fractures of the humerus in children[J]. J Bone Joint Surg Br, 2005, 87(1): 82-87.
[19]	CHOONG J, BALDRIGHI C, OESTREITCH K, et al. Successful delayed neurolysis of the median nerve in a teenager 7 years after supracondylar fracture: a case report and review of the literature[J]. Ann Plast Surg, 2021, 87(4): e37-e39. doi: 10.1097/SAP.0000000000002916 pmid: 34559714
[20]	SHORE B J, GILLESPIE B T, MILLER P E, et al. Recovery of motor nerve injuries associated with displaced, extension-type pediatric supracondylar humerus fractures[J]. J Pediatr Orthop, 2019, 39(9): e652-e656. doi: 10.1097/BPO.0000000000001056
[21]	PANTA S, THAPA S, HAMAL B, et al. Prevalence of nerve injuries in supracondylar fracture of humerus in a tertiary care hospital[J]. J Nepal Health Res Counc, 2021, 19(2): 367-371. doi: 10.33314/jnhrc.v19i2.3637 pmid: 34601532
[22]	GRAFF C, DOUNAS G D, SUNG J, et al. Management of iatrogenic ulnar nerve palsies after cross pinning of pediatric supracondylar humerus fractures: a systematic review[J]. J Child Orthop, 2022, 16(5): 366-373. doi: 10.1177/18632521221124632 pmid: 36238145
[23]	SEGAL D, COBB L, LITTLE K J. Fracture obliquity is a predictor for loss of reduction in supracondylar humeral fractures in older children[J]. J Pediatr Orthop B, 2020, 29(2): 105-116. doi: 10.1097/BPB.0000000000000636 pmid: 31033871
[24]	刘扬, 刘勇, 张迪, 等. 学龄前期小儿肱骨髁上骨折肘关节功能障碍的综合康复治疗[J]. 中国康复理论与实践, 2013, 19(12): 1186-1188.
	LIU Y, LIU Y, ZHANG D, et al. Effect of comprehensive rehabilitation on elbow joint dysfunction in children with humeral supracondylar fracture[J]. Chin J Rehabil Theory Pract, 2013, 19(12): 1186-1188.
[25]	AKHTAR A, HUGHES B, WATTS A C. The post-traumatic stiff elbow: a review[J]. J Clin Orthop Trauma, 2021, 19: 125-131. doi: 10.1016/j.jcot.2021.05.006
[26]	O'DRISCOLL S W, GIORI N J. Continuous passive motion (CPM): theory and principles of clinical application[J]. J Rehabil Res Dev, 2000, 37(2): 179-188. pmid: 10850824
[27]	陈希文, 尹文喜, 曾起, 等. sEMG监测下动态关节松动术对骨折术后肘关节活动度受限的疗效[J]. 实用临床医学, 2020, 21(2): 1-4.
	CHEN X W, YIN W X, ZENG Q, et al. Mulligan's mobiliztion with movement technique under sEMG monitoring for elbow joint motion limitation after fracture operation[J]. Pract Clin Med, 2020, 21(2): 1-4.
[28]	王汝珊, 王洪玲, 罗婕, 等. 藏药五味甘露药浴方的临床应用规范化研究[J]. 中药与临床, 2021, 12(2): 59-64.
	WANG R S, WANG H L, LUO J, et al. Research progress on the clinical application of Tibetan medicine five-flavor Manna medicated bath prescription[J]. Pharm Clin Chin Materia Medica, 2021, 12(2): 59-64.
[29]	吴单. 中药熏蒸治疗四肢骨折后疼痛和关节僵硬的临床疗效观察[D]. 杭州: 浙江中医药大学, 2021.
	WU D. Clinical observation of Chinese medicine fumigation in treating pain and joint stiffness after limb fracture[D]. Hangzhou: Zhejiang Chin Med Univ, 2021.
[30]	侯旭东, 李景新, 郭迎喜. 中药薰洗治疗四肢关节僵硬的体会[J]. 中医药信息, 2000(2): 34-35.
	HOU X D, LI J X, GUO Y X. Experience in treating ankylosis of limbs by fumigating and washing with traditional Chinese medicine[J]. Inform Tradit Chin Med, 2000(2): 34-35.
[31]	DUARTE-MOREIRA R J, CASTRO K V, LUZ-SANTOS C, et al. Electromyographic biofeedback in motor function recovery after peripheral nerve injury: an integrative review of the literature[J]. Appl Psychophysiol Biofeedback, 2018, 43(4): 247-257. doi: 10.1007/s10484-018-9403-7
[32]	WASIELEWSKI N J, PARKER T M, KOTSKO K M. Evaluation of electromyographic biofeedback for the quadriceps femoris: a systematic review[J]. J Athl Train, 2011, 46(5): 543-554. doi: 10.4085/1062-6050-46.5.543
[33]	TAKAHASHI R, SANO K, KIMURA K, et al. Reproducibility and reliability of performance indicators to evaluate the therapeutic effectiveness of biofeedback therapy after elbow surgery: an observational case series[J]. Medicine (Baltimore), 2020, 99(34): e21889. doi: 10.1097/MD.0000000000021889
[34]	ORAVITAN M, AVRAM C. The effectiveness of electromyographic biofeedback as part of a meniscal repair rehabilitation programme[J]. J Sports Sci Med, 2013, 12(3): 526-532. doi: 10.1016/j.jsams.2008.09.012
[35]	周庆, 孔清泉, 高博. 儿童Gartland Ⅱ型及Ⅲ型肱骨髁上骨折的治疗[J]. 中国修复重建外科杂志, 2018, 32(6): 698-702.
	ZHOU Q, KONG Q Q, GAO B. Treatment of Gartland type Ⅱ and Ⅲ supracondylar fracture of humerus in children[J]. Chin J Reparat Reconstruct Surg, 2018, 32(6): 698-702.
[36]	REZAIE N, GUPTA S, SERVICE B C, et al. Elbow dislocation[J]. Clin Sports Med, 2020, 39(3): 637-655. doi: 10.1016/j.csm.2020.02.009

组别	n	性别(男/女)/n	年龄/岁	损伤侧别(左/右)/n
对照组	24	14/10	6.97±3.15	9/15
治疗组	25	16/9	7.21±3.66	12/13
χ²/t值		0.166	0.241	0.551
P值		0.684	0.811	0.458

组别	n	治疗前	治疗后	差值	t值	P值
对照组	24	27.23±10.92	52.95±11.44	25.72±15.24	-8.345	< 0.001
治疗组	25	26.62±10.63	67.31±10.25	40.69±12.27	-14.000	< 0.001
t值		0.194	4.536	3.717
P值		0.847	< 0.001	0.001