Murat AKSAKAL, Cenk ERMUTLU, Bartu SARİSOZEN, Burak AKESEN

Çocuklarda nörovasküler yaralanmalı suprakondiler humerus kırıklarına yaklaşım

Amaç: Bu çalışmanın amacı Gartland Tip 3 suprakondiler humerus kırıklarında (SHK) nörovasküler yaralanmaları incelemek, artmış açık redüksiyon gereksinimi ile ilişkili faktörleri ortaya koymak ve anterior açık redüksiyonun klinik sonuçlarını kapalı redüksiyonla kıyaslamaktı. Çalışma planı: Ocak 2002 – Haziran 2008 tarihleri arasında SHK nedeniyle cerrahi uygulanan 65 hasta (46 erkek, 19 kız; ortalama yaş: 7.03, dağılım: 1-14) çalışmaya dahil edildi. Kapalı redüksiyon ve perkütan pinleme öncelikli tedavi yöntemi olarak düşünüldü. Kapalı teknikle yeterli redüksiyon sağlanamaması veya dolaşım sorunu bulgularının olması açık redüksiyon endikasyonu olarak kabul edildi. Hasta demografikleri, fizik muayene bulguları, redüksiyon kalitesi, fonksiyonel ve kozmetik sonuçlar incelendi. Bulgular: Fizik muayenede dolaşım sorunu olan hastaların hepsinde antekubital yaklaşım esnasında damar patolojisine rastlandı. Bu hastaların yarısına vasküler girişim uygulandı. Ödem, ekimoz ve gamze bulgusu birlikteliği olan hastaların %93’ünde kapalı redüksiyon girişimi yeterli olmadı. Bu hastalardan nörolojik muayenesi normal olan dördünde median sinirin kırık fragmanları arasında sıkışmış olduğu görüldü. Açık redüksiyonun fonksiyonel, ve kozmetik sonuçları kapalı redüksiyon uygulananlar ile benzerdi (p>0.05). Çıkarımlar: Belirgin ödem, ekimoz ve gamze bulgusu olan ve radial nabzın alınamadığı olgularda kapalı redüksiyonda ısrar edilmemelidir. Anterior yaklaşım damar, sinir yapılarının doğrudan gözlenebilmesi ve aynı kesinin uzatılması ile gerekli ek girişimlerin yapılabilmesine olanak tanıması nedenleriyle tercih edilecek cerrahi yaklaşım olmalıdır.

Anahtar Kelimeler:

Antekubital; anterior yaklaşım; kapalı redüksiyon; nörovasküler yaralanma; suprakondiler humerus kırığı.

Approach to supracondylar humerus fractures with neurovascular compromise in children

Objective: The aim of this study was to evaluate neurovascular compromise in childhood Gartland Type 3 supracondylar humerus fractures (SHFs), identify the factors correlated with increased need of open reduction and compare the clinical outcome of anterior open reduction with that of closed reduction.Methods: The study included 65 patients (46 male, 19 female; mean age: 7.03 years, range: 1 to 14 years) treated surgically for SCH fracture between January 2002 and June 2008. Fractures underwent closed reduction with percutaneous pinning when possible. Open reduction was performed when adequate reduction via the closed technique failed or vascular compromise were indications for open reduction. Patient demographics, physical examination findings, adequacy of reduction, functional and cosmetic outcomes were assessed.Results: During the antecubital approach, vascular pathology was noted in all patients with signs of vascular compromise at physical examination. Half of these patients underwent vascular intervention. Closed reduction failed in 93% of patients with concomitant edema, ecchymosis and dimple sign. Of these, the median nerve was trapped between the bone fragments in 4 patients with normal neurological examinations. Functional and cosmetic results of open reduction were similar to closed reduction (p>0.05).Conclusion: Closed reduction should not be forced in cases with marked edema, ecchymosis, dimple sign, and absence of radial pulse. The anterior approach is the surgical approach of choice due to direct visualization of neurovascular bundle and availability of neurovascular intervention by extending the same approach.

Keywords:

Antecubital, anterior approach, closed reduction, neurovascular compromise supracondylar humerus fracture,

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