张立军 吉士俊

. 述评 Editorial .

与时俱进 开拓创新 造福儿童

张立军 吉士俊

创伤；骨折；髋关节发育不良；股骨头缺血性坏死；股骨头骨骺滑脱

近年来随着互联网的普及与发展，小儿骨科医生可在第一时间直接获取信息，不断更新专业知识，缩短了学习曲线，以指导临床与科研。我国小儿骨科取得了长足的进步。拉近了与发达国家的距离，为儿童服务的水平日渐提高。

儿童创伤已进入微创治疗时代。最为常见的儿童肱骨髁上骨折由开放、手术切开复位，已经逐步趋向微创、闭合复位，尽管有些单位仍在实施切开复位，但微创、闭合复位在国内已形成导向、指南。相信在不久的将来，会逐步达成统一的共识[1-3]。

对于肱骨外髁骨折的认知在 10 年中发生了根本性的转变。从误诊、漏诊及对大多数病例进行保守治疗而造成肘关节残疾，到目前共同的认知，应进行积极的外科干预[4]，改善了治疗效果，避免或降低致残风险。

应用钢板固定治疗股骨干骨折的观念在近 10 年发生了根本性的改变，市、县一级医院的医生已经达成共识，并将弹性髓内针治疗股骨干骨折作为首选治疗方法[5-8]，其创伤小、效果好且属于微创，符合目前治疗的理念。但也有其适应证，不可千篇一律。

采取肌肉下钢板治疗股骨干长斜行骨折逐渐为儿童骨科医生所接受，其特点是骨折两端小切口、骨折处不做切开、不剥离骨膜、钢板在骨膜外、肌肉下固定。由于骨折处不做切开，不做骨膜剥离，没有破坏骨折端的血液循环与供应，术后骨质愈合快，几乎很少发生骨延迟愈合或骨不连接。由于，骨折端上下小切口，创伤小，容易被患儿家属接受[9-11]。

采用带锁髓内针治疗大龄儿童股骨干骨折的优点是微创，骨折复位佳，术后不需要外固定，可让患儿早日回归学校。逐渐被儿童骨科医生所接受。但由于其方法有一定的限制：( 1 ) 儿童的生理解剖结构的限制如儿童时期股骨近端由股骨头，头下骺板，大转子软骨骨骺构成；( 2 ) 先期的带锁髓内针都是直向，需要从大转子梨状窝入针，而梨状窝又是供应股骨头血管的关键解剖所在，很容易造成滋养股骨头血管的损伤，导致术后股骨近端发育紊乱，股骨头缺血，甚而坏死。虽然临床上发生率不高，但这是灾难性的弊端；( 3 ) 我国缺乏适应于儿童骨科的带锁髓内针。目前国内可以应用的带锁髓内针，最佳的选择是直径 8.5 mm、分为左右侧。这种髓内针，需要从大转子顶点入针，理论上可以摒除梨状窝入针的弱点，但在临床中，由于入针点距离梨状窝很近，难以完全避免损伤，所以急需适应于儿童、从大转子外侧进针的新一代带锁髓内针。影响其在我国的应用与发展[12-15]。

股骨远端、胫骨近远端骨骺部损伤发生骨骺部分早闭的几率较高，并引起膝内外翻或踝内外翻畸形。目前尚缺乏有效的、可避免的方法。通过解剖复位，希望能够减少骨骺部的残余畸形。尤其对于生长潜力较大的患儿更应进行解剖复位。手术中往往会见到软组织镶嵌于骨折缝隙之中，这往往是保守治疗、手法整复不能满意复位的原因所在。青春期 Tillaux 骨折、三平面骨折也逐渐为儿童骨科医师熟知并采取有效的治疗方法[16-17]。

髋关节发育不良，奥地利医生 Graf[18]在 80 年代早期应用 B 超诊断新生儿和婴儿发育性髋脱位以来，超声检查在发达国家已经成为发育性髋关节发育不良 ( developmental dysplasia of the hip，DDH ) 新生儿普查的主要手段，是公认的早期诊断发育性髋脱位的首选方法，可以跟踪观察，重复操作，又可免受放射线损伤。超声比 X 线片测量髋臼形态变化更为精确。Pavlik 吊带的广泛应用，致使大龄 DDH 患儿明显减少。对于大龄儿童手术治疗，不同类型的三联截骨重新获得了认同[19-20]。髋关节发育不良早期治疗方法简单，疗效好，是解决先天性畸形治疗后、延迟发生骨关节炎的有效方法，也是避免发生骨性关节炎的重要途径[21-23]。Ponseti 石膏疗法治疗先天性马蹄内翻足已经普及并且取得良好的疗效，极大地降低了手术率，并消除了由手术导致的距、舟骨畸形。先天性胫骨假关节的治疗作为儿童骨科棘手的难题目前已有所突破，髓内针固定，周围植骨，同时外固定架胫骨近端牵开延长基本成为导向治疗。湖南儿童医院在此方面具有领先水平，已经治疗 300 余例，一期愈合率明显上升，再骨折发生率明显下降，并在 2016 年 POSNA 会议上报告，得到国际认同[24-27]。

股骨头缺血性坏死是否手术仍存在很大争议，但已形成初步共识：( 1 ) ＜ 5 岁：常不需要干预，股骨头外凸者除外；( 2 ) 5～8 岁：如果没有外凸，也不需要手术；( 3 ) 8～12 岁：应包容治疗，无论外凸与否。但非手术治疗、应用外展支具仍然可以取得较好的效果[28-30]。对于特发性股骨头骨骺滑脱的认识在近 10 年取得了飞跃的进展，尤其是对于中重度滑脱的病例，从原位固定到股骨头脱位、解剖复位固定，获得了较好的疗效。尤其是瑞士伯尔尼医院采取的改良 Dunn 手术即保护支配股骨头血管、脱出股骨头，刮除残余骺板、重新解剖复位股骨头，进行固定治疗使股骨头滑脱的治疗达到更高的水平，开创了治疗的先河，有了新的突破[31-33]。

目前我国小儿骨科专业分布极其不平衡。专业小儿骨科也多在省级单位建立。多数市一级和县一级单位没有小儿骨科专业。这一部分患者由成人骨科医生医治。但小儿骨科不是成人的缩影，有其特有的疾病及特殊的生理结构与特点，照搬成人的治疗方法会出现难以预料的医源性损伤。譬如骨骺部骨折钢板固定导致肢体成角畸形，可以导向微创治疗的肢体成角畸形，采取较大创伤的截骨治疗，病理骨折不问缘由的钢板固定等。这些均加大或导致患儿的医源性损伤。所以在市、县一级医院增设儿童骨科专业人员，普及儿童骨科专业知识，方能满足专业的需要，才能满足日益增长的儿童及家长的需求。

提倡科室学习制度、病例讨论制度，总结经验教训，发挥科室集体的智慧，这样不仅丰富了青年医生专业知识，资深医师也会受益，更是防范医疗风险的重要措施。

紧跟时代前进的步伐，与国际接轨，是对这一代有志医生的最基本的要求。在当今网络时代，不断学习，施展才华，必将迎来小儿骨科更加灿烂的明天。

[1]Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children[J]. J Bone Joint Surg Am, 2008, 90(5):1121-1132.

[2]Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts[J]. J Am Acad Orthop Surg, 2012, 20(2):69-77.

[3]Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence-based guideline[J]. J Pediatr Orthop, 2012, 32(Suppl 2):S143-152.

[4]Weiss JM, Graves S, Yang S, et al. A new classif i cation system predictive of complications in surgically treated pediatric humeral lateral condyle fractures[J]. J Pediatr Orthop, 2009, 29(6):602-605.

[5]Kocher MS, Sink EL, Blasier RD, et al. American academy of orthopaedic surgeons clinical practice guideline on treatment of pediatric diaphyseal femur fracture[J]. J Bone Joint Surg Am, 2010, 92(8):1790-1792.

[6]Luhmann SJ, Schootman M, Schoenecker PL, et al. Complications of titanium elastic nails for pediatric femoral shaft fractures[J]. J Pediatr Orthop, 2003, 23(4):443-447.

[7]Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome[J]. J Bone Joint Surg Br, 2006, 88(10):1361-1366.

[8]Ramseier LE, Janicki JA, Weir S, et al. Femoral fractures in adolescents: a comparison of four methods of fi xation[J]. J Bone Joint Surg Am, 2010, 92(5):1122-1129.

[9]Eidelman M, Ghrayeb N, Katzman A, et al. Submuscular plating of femoral fractures in children: the importance of anatomic plate precontouring[J]. J Pediatr Orthop B, 2010, 19(5):424-427.

[10]Sink EL, Hedequist D, Morgan SJ, et al. Results and technique of unstable pediatric femoral fractures treated with submuscular bridge plating[J]. J Pediatr Orthop, 2006, 26(2):177-181.

[11]Samora WP, Guerriero M, Willis L, et al. Submuscular bridge plating for length-unstable, pediatric femur fractures[J]. J Pediatr Orthop, 2013, 33(8):797-802.

[12]Garner MR, Bhat SB, Khujanazarov I, et al. Fixation of length-stable femoral shaft fractures in heavier children: fl exible nails vs rigid locked nails[J]. J Pediatr Orthop, 2011, 31(1):11-16.

[13]Park KC, Oh CW, Byun YS, et al. Intramedullary nailing versus submuscular plating in adolescent femoral fracture[J]. Injury, 2012, 43(6): 870-875.

[14]Keeler KA, Dart B, Luhmann SJ, et al. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point[J]. J Pediatr Orthop, 2009, 29(4):345-351.

[15]MacNeil JA, Francis A, El-Hawary R. A systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of the femoral head in the skeletally immature[J]. J Pediatr Orthop, 2011, 31(4):377-380.

[16]Brey JM, Conoley J, Canale ST, et al. Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications[J]? J Pediatr Orthop, 2012, 32(6):561-566.

[17]Leary JT, Handling M, Talerico M, et al. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest[J]. J Pediatr Orthop, 2009, 29(4):356-361.

[18]Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment[J]. Arch Orthop Trauma Surg, 1980, 97(2):117-133.

[19]Harcke HT, Grissom LE. Pediatric hip sonography. Diagnosis and differential diagnosis[J]. Radiol Clin North Am, 1999, 37(4):787-796.

[20]Tibrewal S, Gulati V, Ramachandran M. The Pavlik method: a systematic review of current concepts[J]. J Pediatr Orthop B, 2013, 22(6): 516-520.

[21]Kamath AF. Bernese periacetabular osteotomy for hip dysplasia: Surgical technique and indications[J]. World J Orthop, 2016, 7(5):280-286.

[22]Ganz R, Klaue K, Vinh TS, et al. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results[J]. Clin Orthop Relat Res, 1988, (232):26-36.

[23]Thawrani D, Sucato DJ, Podeszwa DA, et al. Complications associated with the Bernese periacetabular osteotomy for hip dysplasia in adolescents[J]. J Bone Joint Surg Am, 2010, 92(8):1707-1714.

[24]Liu YX, Mei HB, Zhu GH, et al. Relationship between postoperative complications and fi bular integrity in congenital pseudarthrosis of the tibia in children[J]. World J Pediatr, 2016.

[25]Zhu GH, Mei HB, He RG, et al. Combination of intramedullary rod, wrapping bone grafting and Ilizarov’s fixator for the treatment ofCrawford type IV congenital pseudarthrosis of the tibia: mid-term follow up of 56 cases[J]. BMC Musculoskelet Disord, 2016, 17(1):443.

[26]Horn J, Steen H, Terjesen T. Epidemiology and treatment outcome of congenital pseudarthrosis of the tibia[J]. J Child Orthop, 2013, 7(2):157-166.

[27]Agashe MV, Song SH, Refai MA, et al. Congenital pseudarthrosis of the tibia treated with a combination of Ilizarov’s technique and intramedullary rodding[J]. Acta Orthop, 2012, 83(5):515-522.

[28]Hosalkar HS, Mulpuri K. Legg-Calvé-Perthes disease: where do we stand after 100 years? Editorial comment[J]. Clin Orthop Relat Res, 2012, 470(9):2345-2346.

[29]Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part I: Classif i cation of radiographs with use of the modif i ed lateral pillar and Stulberg classif i cations[J]. J Bone Joint Surg Am, 2004, 86-A(10):2103-2120.

[30]Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome[J]. J Bone Joint Surg Am, 2004, 86-A(10):2121-2134.

[31]Dunn DM. The treatment of adolescent slipping of the upper femoral epiphysis[J]. J Bone Joint Surg Br, 1964, 46:621-629.

[32]Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis[J]. J Bone Joint Surg Br, 2001, 83(8):1119-1124.

[33]Ziebarth K, Zilkens C, Spencer S, et al. Capital realignment for moderate and severe SCFE using a modif i ed Dunn procedure[J]. Clin Orthop Relat Res, 2009, 467(3):704-716.

( 本文编辑：李慧文 )

. 作者须知 Instruction for authors .

本刊对稿件中统计学处理的要求

1. 统计研究设计：应交代统计研究设计的名称和主要做法。如调查设计 ( 分为前瞻性、回顾性或横断面调查研究 )；实验设计 ( 应交代具体的设计类型，如自身配对设计、成组设计、交叉设计、析因设计、正交设计等 )；临床试验设计 ( 应交代属于第几期临床试验，采用了何种盲法措施等 )。主要做法应围绕 4 个基本原则 ( 随机、对照、重复、均衡 ) 概要说明，尤其要交代如何控制重要非试验因素的干扰和影响。

3. 统计学分析方法的选择：对于定量资料，应根据所采用的设计类型、资料所具备的条件和分析目的，选用合适的统计学分析方法，不应盲目套用 t 检验和单因素方差分析；对于定性资料，应根据所采用的设计类型、定性变量的性质和频数所具备的条件以及分析目的，选用合适的统计学分析方法，不应盲目套用 χ2检验。对于回归分析，应结合专业知识和散布图，选用合适的回归类型，不应盲目套用简单直线回归分析，对具有重复实验数据的回归分析资料，不应简单化处理；对于多因素、多指标资料，要在一元分析的基础上，尽可能运用多元统计学分析方法，以便对因素之间的交互作用和多指标之间的内在联系进行全面、合理的解释和评价。

4．统计结果的解释和表达：当 P＜0.0 5 ( 或 P＜0.0 1 )时，应说明对比组之间的差异有统计学意义，而不应说对比组之间具有显著性 ( 或非常显著性 ) 的差别；应写明所用统计学分析方法的具体名称 ( 如：成组设计资料的 t 检验、两因素析因设计资料的方差分析、多个均数之间两两比较的 q 检验等 )，统计量的具体值（如 t 值，χ2值，F 值等 ) 应尽可能给出具体的 P 值；当涉及总体参数 ( 如总体均数、总体率等 ) 时，在给出显著性检验结果的同时，再给出 9 5% 可信区间。

Advancing with the times, exploring and innovating to benef i t children

ZHANG Li-jun, JI Shi-jun. Department of

Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China

There are huge and rapid developments in the fi eld of pediatric orthopedics in China particularly due to the internet-driven information age. We can obtain the latest medical information at the same time with other researchers all over the world and thereby narrow the distance with developed countries. The minimally invasive treatment has gradually become an essential method in the treatment of pediatric traumas. Closed reduction and percutaneous pinning versus open reduction techniques have taken over in the treatment of supracondylar fractures of the humerus and a guideline has been developed in China. Open reduction and plate fi xation for femoral shaft fractures has been abandoned and replaced by the elastic stable intramedullary nail, with the advantages of small trauma and satisfactory results. The interlocking intramedullary nail system has been adapted for older children. The triple osteotomy of the acetabulum has become a suitable technique for developmental dysplasia of the hip in older children. A breakthrough in the treatment of congenital tibial pseudarthrosis is on its way. The surgical versus nonsurgical treatment for Legg-Calvé-Perthes disease ( LCPD ) remains controversial, but as a preliminary fi nding it appears that the cases of the femoral head with poor covering require surgical intervention. Rapid developments in the treatment of moderate and severe slipped capital femoral epiphysis ( SCFE ) are occurring. The surgical dislocation and anatomical reduction with fi xation largely differing from in situ fi xation are huge innovations. However, the uneven distribution of the specialized pediatric orthopedists and the fewer professional pediatric orthopedists in China have unfortunately led to a lot of iatrogenic injuries resulting from the practice of similar treatment concepts and methods used for adult patients. Therefore, the young Chinese patients and their parents need to be more aware of the needs for specialized pediatric orthopedists and popularized knowledge in this fi eld, while the pediatric orthopedists need to continue to learn and update his or her professional knowledge and rapidly grasp the available international standards.

Injury; Fracture; Developmental dysplasia of the hip; Avascular necrosis of the femoral head; Slipped capital femoral epiphysis

10.3969/j.issn.2095-252X.2017.07.001

R683

2017-03-27 )

1 1 0 0 0 4 沈阳，中国医科大学附属盛京医院小儿骨科