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上腕骨顆上骨折

著者: 都丸洋平 千葉こどもとおとなの整形外科

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/05/19
患者向け説明資料

概要・推奨   

  1. 骨折の診断には、単純X線検査、超音波検査が有用推奨度1)。 
  1. 転位が少ない症例は保存療法、転位の大きい・血流障害のある症例では手術加療が推奨される推奨度2)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
都丸洋平 : 未申告[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、診断・血行評価に関する超音波検査に関して追記した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 上腕骨顆上骨折は小児の肘関節周囲骨折のなかで60~80%と最も頻度が高く、5~6歳にピークがあり、男子に多い。
  1. 雲梯や鉄棒などの高所から転落し、手から地面について受傷する伸展型が多い。
  1. 骨の断面積が小さい上腕骨の顆上部にストレスが集中して骨折を生じる。
  1. 通常、末梢骨片は伸展位をとり、程度が強い場合には後内側へ転位し、回旋を伴う。
  1. 約10%に神経麻痺を合併する。多くの場合自然回復するが、尺骨神経麻痺は完全回復しないことが多いという報告もある[1]
  1. 急性期の腫脹により循環障害を生じ、重篤な機能障害を生じることがある。
  1. 骨折の整復とその保持が不十分な場合には合併症として高率に内反肘を生じる。
 
  1. 内反肘変形の計測(推奨度2)(参考文献:[2]
  1. 体前屈し肘関節を90°屈曲位で肩関節を内旋させる。最大内旋位にしたときの前腕と水平線とのなす角度を測定する。健側との角度差が肘関節の内旋角度となる。
  1. 内反肘の矯正手術の際の矯正角度の算定に有効である。
 
内旋角度の計測法

出典

img1:  澤泉卓哉先生ご提供
 
 
問診・診察のポイント  
問診:
  1. 受傷場所や受傷機転を確認する。通常、受傷時に現場にいて同行してきた大人に確認することが多い。

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文献 

著者: Maria Valencia, Luis Moraleda, Jesús Díez-Sebastián
雑誌名: J Pediatr Orthop. 2015 Sep;35(6):606-10. doi: 10.1097/BPO.0000000000000337.
Abstract/Text PURPOSE: It has been reported that most neurological injuries after sustaining a supracondylar fracture will usually resolve spontaneously in the first months; however, studies are lacking regarding the influence of these injuries in the upper limb functionality in the long-term follow-up. The aim of this study is to report the long-term functional outcome of neurological complications associated to pediatric supracondylar fractures.
METHODS: Medical records of 448 children who sustained a supracondylar humeral fracture were reviewed. Patients with a concomitant neurological injury were included. Clinical evaluation included grip and pinch strength and a thorough examination of sensibility. Clinical outcomes were described according to the Mayo Elbow Performance Score and Flynn criteria. Patients completed the quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) questionnaire.
RESULTS: There were 29 patients with a supracondylar humeral fracture and a neurological injury (6.5%). The median nerve was injured in 13 patients, the radial nerve in 14 patients and the ulnar nerve in 9 patients. Of them, 16 patients returned for clinical evaluation. The mean age at the time of fracture was 7.5±1.9 years and at revision 16±5.3 years. The average follow-up was 8.6±4.8 years (3.4 to 17.4 y). There were no differences in terms of grip or pinch strength. Seven patients referred paresthesias, 6 of them in the ulnar nerve's territory. The average score was 4±3 (median, 4) for the QuickDASH questionnaire and 96±7 for the Mayo Elbow Performance Score. According to Flynn criteria, results were satisfactory in 10 cases.
DISCUSSION: Functional results were excellent in the majority of patients. Almost half of the patients referred paresthesias, mostly in the ulnar nerve territory, that were not limiting normal daily activity. At final follow-up, although 100% of the radial nerve injuries and 87.5% of the median nerve injuries were fully recovered, only 25% of the ulnar nerve injuries were.
LEVEL OF EVIDENCE: Level IV-prognostic study.

PMID 25379825  J Pediatr Orthop. 2015 Sep;35(6):606-10. doi: 10.1097/B・・・
著者: I Yamamoto, S Ishii, M Usui, T Ogino, K Kaneda
雑誌名: Clin Orthop Relat Res. 1985 Dec;(201):179-85.
Abstract/Text Cubitus varus following supracondylar fracture of the humerus in children consists of varus, hyperextension, and internal rotation deformities of the distal bone fragment of the humerus. There has been no simple clinical method of measuring internal rotation deformity. The authors report here on a method of accurately measuring the internal rotation of the shoulder in a position with the elbow at 90 degrees flexion on the back and the shoulder held at the maximum extension. When a patient with developing cubitus varus attempts to rotate his shoulder internally, there is an apparent increase in the degree of internal rotation at the shoulder of the fractured side. The mean value of the angle formed between the horizontal plane of the back and the mid-line of the forearm was approximately 0 degrees in 217 normal children, whereas an increase of 35 degrees was seen in seven children with cubitus varus. When this angle was corrected successfully, the angle after surgical correction became approximately 0 degrees. In the treatment of cubitus varus deformity, it is necessary to simultaneously correct three-dimensional deformities.

PMID 4064403  Clin Orthop Relat Res. 1985 Dec;(201):179-85.
著者: A Y Tabak, L Celebi, H H Muratli, H H Murath, M F Yağmurlu, C N Aktekin, A Biçimoglu
雑誌名: J Bone Joint Surg Br. 2003 Nov;85(8):1169-72.
Abstract/Text We treated 22 children with a supracondylar fracture of the humerus and an ipsilateral fracture of the forearm by closed reduction and percutaneous fixation. There were four Gartland type-II and 18 Gartland type-III supracondylar fractures of the humerus. There were fractures of both bones of the forearm in 16 and of the radius in six. Both the supracondylar and the distal forearm fractures were treated by closed reduction and percutaneous fixation. The mean follow-up time was 38.6 months. At the latest follow-up there were 21 excellent or good results and one fair result. There were no cases of delayed union, nonunion or malunion. Five nerve injuries were diagnosed on admission and all recovered spontaneously within eight weeks. No patient developed a compartment syndrome.

PMID 14653602  J Bone Joint Surg Br. 2003 Nov;85(8):1169-72.
著者: M Benedetti Valentini, P Farsetti, O Martinelli, A Laurito, E Ippolito
雑誌名: Bone Joint J. 2013 May;95-B(5):694-8. doi: 10.1302/0301-620X.95B5.31042.
Abstract/Text Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

PMID 23632684  Bone Joint J. 2013 May;95-B(5):694-8. doi: 10.1302/0301・・・
著者: K Eckert, N Janssen, O Ackermann, B Schweiger, E Radeloff, P Liedgens
雑誌名: Eur J Trauma Emerg Surg. 2014 Apr;40(2):159-68. doi: 10.1007/s00068-013-0306-2. Epub 2013 Jun 11.
Abstract/Text PURPOSE: The objective of our study was to evaluate the safety and accuracy of ultrasound (US) compared to standard radiographs in diagnosing supracondylar fractures (SCFs) of the humerus in children.
PATIENTS AND METHODS: A total of 106 children (aged between 1 and 13 years) with clinically suspected SCF of the humerus were primarily examined by US followed by standard two-plane radiographs of the elbow. US was conducted with a linear scanner viewing the distal humerus from seven standardized sectional planes. US fracture diagnosis was established either by a cortical bulging or cortical gap, or by a positive dorsal fat pad (dFP) sign. X-ray diagnosis was stated by an independent pediatric radiologist and, afterwards, compared to our US findings. Sonographic and radiographic findings were collected in a contingency table. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for US fracture diagnosis were calculated according to the radiographs. In addition, by identifying significant angulation and/or disrupture, SCFs were classified as non-operative/stable and operative/instable SCFs according to the AO Pediatric Fracture Classification System.
RESULTS: By US, a SCF could be excluded in 43 patients and in 63 patients, a fracture was diagnosed. In contrast, by radiographs, an SCF could be excluded in 46 patients and in 60 patients, a fracture was diagnosed. For US fracture diagnosis in comparison to radiographs, we calculated a sensitivity of 100 %, a specificity of 93.5 %, an NPV of 100 %, and a PPV of 95.2 %. Thirty-nine SCFs were sonographically classified as stable grades 1/2 SCFs and confirmed in 37 patients by X-rays. All four operative/instable SCFs were correctly identified by US.
CONCLUSION: By identifying a positive dFP sign and/or cortical lesions of the distal humerus, SCFs can be detected very sensitively by US. Even the estimation of fracture displacement seems to be possible. We suggest US as an applicable alternative method in the primary evaluation of suspected SCF in children, guiding further diagnostics, where appropriate. After minor injuries, if clinical assessment for an elbow fracture is low and US examination is negative for fracture, additional radiographs are dispensable. Thereby, the amount of X-ray burden during childhood can be reduced, without loss of diagnostic safety.

PMID 26815896  Eur J Trauma Emerg Surg. 2014 Apr;40(2):159-68. doi: 10・・・
著者: Takuya Sawaizumi, Akinori Takayama, Hiromoto Ito
雑誌名: J Shoulder Elbow Surg. 2003 Nov-Dec;12(6):603-6. doi: 10.1016/S1058274603002052.
Abstract/Text Percutaneous pinning with a leverage technique for supracondylar fracture of the humerus was performed in 36 elbows in 35 children. The patient was placed in the lateral position with the forearm hanging. Under radiographic imaging, a Kirschner wire, as a reduction pin, was inserted into the fracture line from the dorsal side, passed through the posterior cortex of the proximal fragment, and turned distally. After reduction of the posterior displacement by the leverage technique, the reduction pin was driven into the anterior cortex of the proximal fragment. Subsequently, a Kirschner wire was inserted from the lateral condyle for fixation between the proximal and distal fragments. This percutaneous pinning technique was successfully performed in 32 of 36 elbows, with excellent functional results in 28 elbows and good results in 4, as well as excellent cosmetic results in 27 elbows and good results in 5, based on the evaluation criteria of Flynn et al.

PMID 14671527  J Shoulder Elbow Surg. 2003 Nov-Dec;12(6):603-6. doi: 1・・・
著者: Haleh Badkoobehi, Paul D Choi, Donald S Bae, David L Skaggs
雑誌名: J Bone Joint Surg Am. 2015 Jun 3;97(11):937-43. doi: 10.2106/JBJS.N.00983.
Abstract/Text A pediatric supracondylar humeral fracture with a pulseless, poorly perfused hand requires emergency operative reduction. If the limb remains pulseless and poorly perfused after fracture fixation, vascular exploration and possible reconstruction is necessary. A pediatric supracondylar humeral fracture with a pulseless, well-perfused hand should be treated urgently with operative fixation of the fracture and subsequent reassessment of the vascular status. Controversy exists regarding the optimal management of pediatric supracondylar humeral fractures with a pulseless, well-perfused hand following anatomic reduction and fixation. Options include immediate vascular exploration or twenty-four to forty-eight hours of inpatient observation. If perfusion is compromised during this period of observation, an emergency return to the operating room for vascular exploration and possible reconstruction is indicated.

Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
PMID 26041856  J Bone Joint Surg Am. 2015 Jun 3;97(11):937-43. doi: 10・・・

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