張立軍 吉士俊

. 述評 Editorial .

與時(shí)俱進(jìn) 開拓創(chuàng)新 造福兒童

張立軍 吉士俊

創(chuàng)傷；骨折；髖關(guān)節(jié)發(fā)育不良；股骨頭缺血性壞死；股骨頭骨骺滑脫

近年來隨著互聯(lián)網(wǎng)的普及與發(fā)展，小兒骨科醫(yī)生可在第一時(shí)間直接獲取信息，不斷更新專業(yè)知識，縮短了學(xué)習(xí)曲線，以指導(dǎo)臨床與科研。我國小兒骨科取得了長足的進(jìn)步。拉近了與發(fā)達(dá)國家的距離，為兒童服務(wù)的水平日漸提高。

兒童創(chuàng)傷已進(jìn)入微創(chuàng)治療時(shí)代。最為常見的兒童肱骨髁上骨折由開放、手術(shù)切開復(fù)位，已經(jīng)逐步趨向微創(chuàng)、閉合復(fù)位，盡管有些單位仍在實(shí)施切開復(fù)位，但微創(chuàng)、閉合復(fù)位在國內(nèi)已形成導(dǎo)向、指南。相信在不久的將來，會逐步達(dá)成統(tǒng)一的共識[1-3]。

對于肱骨外髁骨折的認(rèn)知在 10 年中發(fā)生了根本性的轉(zhuǎn)變。從誤診、漏診及對大多數(shù)病例進(jìn)行保守治療而造成肘關(guān)節(jié)殘疾，到目前共同的認(rèn)知，應(yīng)進(jìn)行積極的外科干預(yù)[4]，改善了治療效果，避免或降低致殘風(fēng)險(xiǎn)。

應(yīng)用鋼板固定治療股骨干骨折的觀念在近 10 年發(fā)生了根本性的改變，市、縣一級醫(yī)院的醫(yī)生已經(jīng)達(dá)成共識，并將彈性髓內(nèi)針治療股骨干骨折作為首選治療方法[5-8]，其創(chuàng)傷小、效果好且屬于微創(chuàng)，符合目前治療的理念。但也有其適應(yīng)證，不可千篇一律。

采取肌肉下鋼板治療股骨干長斜行骨折逐漸為兒童骨科醫(yī)生所接受，其特點(diǎn)是骨折兩端小切口、骨折處不做切開、不剝離骨膜、鋼板在骨膜外、肌肉下固定。由于骨折處不做切開，不做骨膜剝離，沒有破壞骨折端的血液循環(huán)與供應(yīng)，術(shù)后骨質(zhì)愈合快，幾乎很少發(fā)生骨延遲愈合或骨不連接。由于，骨折端上下小切口，創(chuàng)傷小，容易被患兒家屬接受[9-11]。

采用帶鎖髓內(nèi)針治療大齡兒童股骨干骨折的優(yōu)點(diǎn)是微創(chuàng)，骨折復(fù)位佳，術(shù)后不需要外固定，可讓患兒早日回歸學(xué)校。逐漸被兒童骨科醫(yī)生所接受。但由于其方法有一定的限制：( 1 ) 兒童的生理解剖結(jié)構(gòu)的限制如兒童時(shí)期股骨近端由股骨頭，頭下骺板，大轉(zhuǎn)子軟骨骨骺構(gòu)成；( 2 ) 先期的帶鎖髓內(nèi)針都是直向，需要從大轉(zhuǎn)子梨狀窩入針，而梨狀窩又是供應(yīng)股骨頭血管的關(guān)鍵解剖所在，很容易造成滋養(yǎng)股骨頭血管的損傷，導(dǎo)致術(shù)后股骨近端發(fā)育紊亂，股骨頭缺血，甚而壞死。雖然臨床上發(fā)生率不高，但這是災(zāi)難性的弊端；( 3 ) 我國缺乏適應(yīng)于兒童骨科的帶鎖髓內(nèi)針。目前國內(nèi)可以應(yīng)用的帶鎖髓內(nèi)針，最佳的選擇是直徑 8.5 mm、分為左右側(cè)。這種髓內(nèi)針，需要從大轉(zhuǎn)子頂點(diǎn)入針，理論上可以摒除梨狀窩入針的弱點(diǎn)，但在臨床中，由于入針點(diǎn)距離梨狀窩很近，難以完全避免損傷，所以急需適應(yīng)于兒童、從大轉(zhuǎn)子外側(cè)進(jìn)針的新一代帶鎖髓內(nèi)針。影響其在我國的應(yīng)用與發(fā)展[12-15]。

股骨遠(yuǎn)端、脛骨近遠(yuǎn)端骨骺部損傷發(fā)生骨骺部分早閉的幾率較高，并引起膝內(nèi)外翻或踝內(nèi)外翻畸形。目前尚缺乏有效的、可避免的方法。通過解剖復(fù)位，希望能夠減少骨骺部的殘余畸形。尤其對于生長潛力較大的患兒更應(yīng)進(jìn)行解剖復(fù)位。手術(shù)中往往會見到軟組織鑲嵌于骨折縫隙之中，這往往是保守治療、手法整復(fù)不能滿意復(fù)位的原因所在。青春期 Tillaux 骨折、三平面骨折也逐漸為兒童骨科醫(yī)師熟知并采取有效的治療方法[16-17]。

髖關(guān)節(jié)發(fā)育不良，奧地利醫(yī)生 Graf[18]在 80 年代早期應(yīng)用 B 超診斷新生兒和嬰兒發(fā)育性髖脫位以來，超聲檢查在發(fā)達(dá)國家已經(jīng)成為發(fā)育性髖關(guān)節(jié)發(fā)育不良 ( developmental dysplasia of the hip，DDH ) 新生兒普查的主要手段，是公認(rèn)的早期診斷發(fā)育性髖脫位的首選方法，可以跟蹤觀察，重復(fù)操作，又可免受放射線損傷。超聲比 X 線片測量髖臼形態(tài)變化更為精確。Pavlik 吊帶的廣泛應(yīng)用，致使大齡 DDH 患兒明顯減少。對于大齡兒童手術(shù)治療，不同類型的三聯(lián)截骨重新獲得了認(rèn)同[19-20]。髖關(guān)節(jié)發(fā)育不良早期治療方法簡單，療效好，是解決先天性畸形治療后、延遲發(fā)生骨關(guān)節(jié)炎的有效方法，也是避免發(fā)生骨性關(guān)節(jié)炎的重要途徑[21-23]。Ponseti 石膏療法治療先天性馬蹄內(nèi)翻足已經(jīng)普及并且取得良好的療效，極大地降低了手術(shù)率，并消除了由手術(shù)導(dǎo)致的距、舟骨畸形。先天性脛骨假關(guān)節(jié)的治療作為兒童骨科棘手的難題目前已有所突破，髓內(nèi)針固定，周圍植骨，同時(shí)外固定架脛骨近端牽開延長基本成為導(dǎo)向治療。湖南兒童醫(yī)院在此方面具有領(lǐng)先水平，已經(jīng)治療 300 余例，一期愈合率明顯上升，再骨折發(fā)生率明顯下降，并在 2016 年 POSNA 會議上報(bào)告，得到國際認(rèn)同[24-27]。

股骨頭缺血性壞死是否手術(shù)仍存在很大爭議，但已形成初步共識：( 1 ) ＜ 5 歲：常不需要干預(yù)，股骨頭外凸者除外；( 2 ) 5～8 歲：如果沒有外凸，也不需要手術(shù)；( 3 ) 8～12 歲：應(yīng)包容治療，無論外凸與否。但非手術(shù)治療、應(yīng)用外展支具仍然可以取得較好的效果[28-30]。對于特發(fā)性股骨頭骨骺滑脫的認(rèn)識在近 10 年取得了飛躍的進(jìn)展，尤其是對于中重度滑脫的病例，從原位固定到股骨頭脫位、解剖復(fù)位固定，獲得了較好的療效。尤其是瑞士伯爾尼醫(yī)院采取的改良 Dunn 手術(shù)即保護(hù)支配股骨頭血管、脫出股骨頭，刮除殘余骺板、重新解剖復(fù)位股骨頭，進(jìn)行固定治療使股骨頭滑脫的治療達(dá)到更高的水平，開創(chuàng)了治療的先河，有了新的突破[31-33]。

目前我國小兒骨科專業(yè)分布極其不平衡。專業(yè)小兒骨科也多在省級單位建立。多數(shù)市一級和縣一級單位沒有小兒骨科專業(yè)。這一部分患者由成人骨科醫(yī)生醫(yī)治。但小兒骨科不是成人的縮影，有其特有的疾病及特殊的生理結(jié)構(gòu)與特點(diǎn)，照搬成人的治療方法會出現(xiàn)難以預(yù)料的醫(yī)源性損傷。譬如骨骺部骨折鋼板固定導(dǎo)致肢體成角畸形，可以導(dǎo)向微創(chuàng)治療的肢體成角畸形，采取較大創(chuàng)傷的截骨治療，病理骨折不問緣由的鋼板固定等。這些均加大或?qū)е禄純旱尼t(yī)源性損傷。所以在市、縣一級醫(yī)院增設(shè)兒童骨科專業(yè)人員，普及兒童骨科專業(yè)知識，方能滿足專業(yè)的需要，才能滿足日益增長的兒童及家長的需求。

提倡科室學(xué)習(xí)制度、病例討論制度，總結(jié)經(jīng)驗(yàn)教訓(xùn)，發(fā)揮科室集體的智慧，這樣不僅豐富了青年醫(yī)生專業(yè)知識，資深醫(yī)師也會受益，更是防范醫(yī)療風(fēng)險(xiǎn)的重要措施。

緊跟時(shí)代前進(jìn)的步伐，與國際接軌，是對這一代有志醫(yī)生的最基本的要求。在當(dāng)今網(wǎng)絡(luò)時(shí)代，不斷學(xué)習(xí)，施展才華，必將迎來小兒骨科更加燦爛的明天。

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( 本文編輯：李慧文 )

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1. 統(tǒng)計(jì)研究設(shè)計(jì)：應(yīng)交代統(tǒng)計(jì)研究設(shè)計(jì)的名稱和主要做法。如調(diào)查設(shè)計(jì) ( 分為前瞻性、回顧性或橫斷面調(diào)查研究 )；實(shí)驗(yàn)設(shè)計(jì) ( 應(yīng)交代具體的設(shè)計(jì)類型，如自身配對設(shè)計(jì)、成組設(shè)計(jì)、交叉設(shè)計(jì)、析因設(shè)計(jì)、正交設(shè)計(jì)等 )；臨床試驗(yàn)設(shè)計(jì) ( 應(yīng)交代屬于第幾期臨床試驗(yàn)，采用了何種盲法措施等 )。主要做法應(yīng)圍繞 4 個(gè)基本原則 ( 隨機(jī)、對照、重復(fù)、均衡 ) 概要說明，尤其要交代如何控制重要非試驗(yàn)因素的干擾和影響。

3. 統(tǒng)計(jì)學(xué)分析方法的選擇：對于定量資料，應(yīng)根據(jù)所采用的設(shè)計(jì)類型、資料所具備的條件和分析目的，選用合適的統(tǒng)計(jì)學(xué)分析方法，不應(yīng)盲目套用 t 檢驗(yàn)和單因素方差分析；對于定性資料，應(yīng)根據(jù)所采用的設(shè)計(jì)類型、定性變量的性質(zhì)和頻數(shù)所具備的條件以及分析目的，選用合適的統(tǒng)計(jì)學(xué)分析方法，不應(yīng)盲目套用 χ2檢驗(yàn)。對于回歸分析，應(yīng)結(jié)合專業(yè)知識和散布圖，選用合適的回歸類型，不應(yīng)盲目套用簡單直線回歸分析，對具有重復(fù)實(shí)驗(yàn)數(shù)據(jù)的回歸分析資料，不應(yīng)簡單化處理；對于多因素、多指標(biāo)資料，要在一元分析的基礎(chǔ)上，盡可能運(yùn)用多元統(tǒng)計(jì)學(xué)分析方法，以便對因素之間的交互作用和多指標(biāo)之間的內(nèi)在聯(lián)系進(jìn)行全面、合理的解釋和評價(jià)。

4．統(tǒng)計(jì)結(jié)果的解釋和表達(dá)：當(dāng) P＜0.0 5 ( 或 P＜0.0 1 )時(shí)，應(yīng)說明對比組之間的差異有統(tǒng)計(jì)學(xué)意義，而不應(yīng)說對比組之間具有顯著性 ( 或非常顯著性 ) 的差別；應(yīng)寫明所用統(tǒng)計(jì)學(xué)分析方法的具體名稱 ( 如：成組設(shè)計(jì)資料的 t 檢驗(yàn)、兩因素析因設(shè)計(jì)資料的方差分析、多個(gè)均數(shù)之間兩兩比較的 q 檢驗(yàn)等 )，統(tǒng)計(jì)量的具體值（如 t 值，χ2值，F(xiàn) 值等 ) 應(yīng)盡可能給出具體的 P 值；當(dāng)涉及總體參數(shù) ( 如總體均數(shù)、總體率等 ) 時(shí)，在給出顯著性檢驗(yàn)結(jié)果的同時(shí)，再給出 9 5% 可信區(qū)間。

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 沈陽，中國醫(yī)科大學(xué)附屬盛京醫(yī)院小兒骨科