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下面我们将为大家提供三期连载内容，回顾上期介绍了尺桡骨骨折的前臂功能解剖、损伤机制和骨折类型、检查及表现，本文为第二期，介绍尺桡骨骨折的治疗目标、骨折复位原理和手术治疗。
最重要的临床目标是能够长期恢复前臂运动的旋转度，同时最大限度地减少并发症。在实际治疗中，主要目标是确保骨折骨化时对位良好。长骨的自发重构可以作为治疗的一部分：但是不应高估重构的能力，因为角度变形在一年内将自发纠正不超过1°直到骨骼成熟。因此小儿前臂骨干骨折可接受的骨折对位程度与患儿的年龄相关。8岁以下的儿童可接受的成角不超过10°-15°，而8岁或以上的儿童可接受的成角为5°-10°。位移应不大于骨骼直径才会被接受，且9岁以下的儿童旋转畸形要小于45°，9岁以上的儿童旋转畸形应在30°以下。如果完全位移被接受，则应接受不超过10mm的缩短。骨干骨折越是在近端，越应尽量接近解剖复位。（表1）。
Table1 Acceptable alignment and displacement of forearm shaft fractures in children according to patients’ age. 表1 可接受的对位和前臂骨干骨折的移位取决于患儿的年龄。
对于儿童患者，通常在全身麻醉下进行骨折复位。不完全的青枝骨折和弓形骨折无需通过牵引进行闭合复位。在复位期间，医生必须了解损伤机制：沿着与损伤相反的方向“倒转”骨头至其解剖形态下进行复位。因此，旋后骨折通常需要将远端部分旋前，这样还能同时纠正背侧角畸形。旋前骨折需要将远端部分旋后从而进行复位。采用三点手法将骨头的成角畸形矫直。相对的，青枝骨折方面有不同意见：一部分人认为应避免内侧断裂，避免导致进一步畸形，而其他人则建议保持其完整以增加稳定性，作者也正是这么做的。完全骨折需要持续牵引，从而克服肌肉痉挛和纠正可能的缩短。在不稳定骨折中，牵引本身也会引起可能的旋转畸形自发复位。 实现良好复位之后，建议在肘关节屈曲状态下将长臂制动。肘关节处于伸直位可以得到良好的预后，但这无法实行。熟石膏是最普遍的材料，受到广泛的普及，但现代人工合成的石膏也可以使用。石膏应该是一个足够宽的夹板，能够同时覆盖前臂掌侧和背侧，并运用适当的纠正压力对抗对位不齐。石膏也应该控制尺桡骨分离，用来维持骨间膜的紧张，以及防止骨间隙塌陷。石膏制动旨在阻挡扭屈的肌力，尤其是骨折周围的旋后肌和旋前肌，直至骨折愈合。通常，近端三分之一处的骨折可以固定在旋后位，中间三分之一处的骨折固定在中位，远端三分之一处的骨折固定在旋前位。最后，采用围手术期透视检查来确定最佳的固定位置。
手术固定显著不稳定骨折，应遵循“最终彻底治疗”的原则。完全骨干骨折，尤其是那些在同一水平上发生倾斜或有巨大移位（>10mm）的骨折，以及角曲线大的（>45°）青枝骨折，可以最终通过手术治疗。由于骨折的稳定性只能在术中评估，因此骨骼不稳表明任何情况下都不能在治疗期前确定内固定。手术治疗适用于开放性骨折、部分（粉碎性）骨折、合并脱位、浮动肘和伴有严重软组织并发症的骨折。 患儿的年龄会影响治疗策略，学龄前儿童通常不采用任何接骨术治疗。学龄儿童最常见的手术是弹性髓内钉（ESIN）固定，这是该年龄组患儿前臂骨干骨折主要的固定方法。与年龄较小的儿童相比，ESIN的并发症更常见于10岁以上的患儿。现在至少有80％的前臂骨折需要由ESIN手术固定。细的髓内钉钉本身提供的稳定性不尽人意。然而，髓内钉产生令人满意的稳定性来自于其弯曲后产生的张力；弯曲的髓内钉在两个骨头间共同建立围绕整个前臂骨折的张力架（图3）。ESIN通常是由钛或不锈钢制成。BESIN（生物可降解-弹性稳定-髓内-钉）是一个创新技术，正在进行临床评估。
Fig.3 An unstable forearm shaft fracture in a school-age child (a, b) has been operatively treated and stabilized by ESIN. The diameter of thin nails (c,d) covers just 40% of the smallest diameter of the intramedullary canals, but the osteosynthesis still achieves satisfactory stability because of bending of the nails. ESIN, elastic stable intramedullary nailing. 图3 学龄儿童的不稳定前臂骨干骨折已接受手术治疗并由ESIN固定（a,b）。细髓内钉的直径只覆盖髓内骨道最小直径的40％（c,d），但由于髓内钉弯曲，接骨术的稳定性仍然令人满意。ESIN即弹性稳定髓内钉。
与治疗成人一样，骨骼即将发育成熟的青少年通常采用适当的手术入路并结合刚性钢板和螺钉内固定，以实现差别极小的复位。钢板固定与ESIN的功能预后相同。钢板固定的并发症风险与ESIN报道的类似。然而，钢板固定往往需要广泛的长切口，因此相比于微创技术其美学效果较差。过去的几年中只有5％的骨折由钢板和螺钉固定，而不考虑其令人满意的疗效。钢板是一种合适的方法，尤其适用于再骨折病例，因为髓内骨道可能阻塞，而且可能需要更多的刚性。部分骨折以及软组织损伤严重的骨折可能需要进行外固定。
Aims of treatment The most important clinical aim is to restore the rotational range of motion in the forearm in the long term, while minimizing complications. In practice, the primary aim is to secure ossification of the fractures in good alignment. Spontaneous remodelling of the long bones can be considered as a part of treatment: however, the capacity of remodelling should not be overestimated as the angular deformation will correct spontaneously not more than 1° in a year until skeletal maturity. Accepted alignment in children’s forearm shaft fractures is therefore related to the age of the patient. Not more than 10°–15° of angulation or 5°–10° of angulation should be accepted in children less than 8 years of age or of 8 years of age or more, respectively. Displacement should be accepted not more than that of bone diameter and rotational malformation under 45° and 30° in children less than 9 years and more than 9 years of age. If full displacement is accepted, no more than 10mm shortening should be accepted. The more proximal the shaft fracture, the closer the anatomic reduction required. (Table 1).
The principle of fracture reduction In children, fracture reduction is usually performed under general anaesthesia. Incomplete greenstick and bowing fractures will be reduced closed without traction. During reduction, the physician has to understand the injury mechanism: the reduction is performed by‘reversing’ the bones to their anatomic form following the opposite course than the previous injury. Therefore, for supination fractures, the distal part needs to be pronated, which usually also corrects dorsal angular deformity. In pronation fractures, the distal part is reduced by supinating it. A proper angular deformity of the bones is straightened using a three-point manoeuvre.There are opposite recommendations for the completion of a greenstick fracture:some suggest completion to avoid further deformation as a result of the inherent spring, whereas others advise maintaining it intact to increase stability, as do the authors, too. Complete fractures require sustained traction to overcome muscle spasm and to correct possible shortening. In the unstable fractures, traction itself may also result in spontaneous reduction of possible rotational malformation. After achieving good alignment, a long-arm cast over elbow-in-flexion is recommended. Elbow in extension can yield a good outcome, but it is impractical. Plaster of Paris is the most universal material widely available, but modern synthetic casts are also available. The cast should be a wide enough splint to cover both volar and dorsal sides of the forearm and applying appropriate corrective pressure against malalignment. The cast should also take control of separation of the radius and ulna to maintain tension on the interosseus membrane and to protect the interosseus space from collapse. Casting is aimed at neutralizing deforming muscle forces,in particular, supinator and pronation muscles around the fracture until it has healed. Usually, all the fractures in the proximal third can be immobilized in the supination position, those in the middle third in the neutral position and fractures in the distal third in pronation. Finally, the best position for immobilization is still recognized perioperatively using the fluoroscopy. Operative treatment Evidently unstable fractures should be fixed operatively according to the principle of ‘primarily definitive treatment’. Complete diaphyseal fractures, especially those that are oblique,occur on the same level or show huge displacement (>10mm), as well as greenstick fractures with a large (>45°)angular curve may justify primarily surgical osteosynthesis. Instability of the bones justifying internal fixation should be determined in every case not earlier than during the treatment because stability of fractures can only be assessed intraoperatively as radiographs are a poor guide for this. Evidently clear indications for operative treatment are open fractures, segmental(comminuted) fractures, concominant dislocation, floating elbow and fractures with severe soft-tissue complications. Patients’ age affects the treatment strategy; children of preschool age are not usually treated by any osteosynthesis. School-age children are most commonly operated by ESIN, which is the primary method for osteosynthesis in children’s forearm shaft fracturesin that age group. Complications of ESIN are more frequent in children older than 10 years of age compared with younger children. At least 80% of all forearm fractures requiring operative stabilization are treated by ESIN nowadays. Thin nails by themselves confer unsatisfactory stability for the fractured bone . However, satisfactory stability is based on bending of the nails; bent thin nails in both bones together establish a tension frame around the fracture in the entire forearm(Fig. 3). ESIN is usually made of titanium or stainless steel. There is a new innovative technique, BESIN (biodegradable-elastic stable- intramedullary- nailing), under on-going clinical evaluations. Adolescents nearing skeletal maturity will be treated like adults with a rigid plate and screw fixation to achieve a hairline reduction using a suitable surgical approach . The functional outcome of the plate fixation is as good as that of ESIN. The risk of complications after plating has been reported to be similar to that after ESIN. However, the aesthetic result used to be worse after plating as a result of generally longer incisions with plating compared with more mini-invasive techniques.Irrespective of satisfactory results, only 5% of the fractures have been stabilized by plate and screw fixation in the past few years. Plating is a suitable procedure in particular in refractures as the intramedullary canal may be obstructed and more rigidity may be required. External fixation may be needed in segmental fractures and in the fractures with severe soft-tissue damage.
由MediCool医库软件 赵婷 徐晶晶 编译 原文来自：The shaft fractures of the radius and ulna in children: current concepts Journal of Pediatric Orthopaedics B2015, 00:000–000
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