This study evaluated using ultrasonographic guidance with K-wires and elastic stable intramedullary nails to treat displaced radial neck fractures in children. 50 patients were divided into groups treated with or without US guidance. The group using US guidance had no injuries to the posterior interosseous nerve, compared to 5 injuries in the non-US group. US guidance also reduced radiation exposure and operation time. Both groups had similar postoperative outcomes according to the Mayo Elbow Performance Index. The study demonstrated that US guidance can help reduce risks of iatrogenic nerve injury during this type of fracture treatment in children.

1. Treatment of displaced radial neck fractures under
ultrasonographic guidance in children
超声引导下儿童桡骨颈移位骨折的治疗
Presenter: Dr. Anil KC
Guangxi medical university

2. Purpose of study/研究目的:
This study aimed to evaluate the feasibility of reduction under
ultrasonographic (US) guidance with Kirschner wires (K-wires) and
fixation with elastic stable intramedullary nails (ESINs) in the treatment
of radial neck fractures (RNFs).
本研究旨在探讨超声引导下克氏针复位及弹性稳定髓内钉固定治疗
桡颈骨折的可行性

3. Patient and method/病人和方法:
The inclusion criteria were as follows:
(1) closed reduction using the Métaizeau technique;
(2) displacement > 3 mm;
(3) angle > 30°; and
(4) Judet types III, IVA, and IVB, according to the Judet classification.
入选标准如下：（1） 采用Métaieau技术进行闭合还原；（2） 位移>3mm；（3） 角度>30°；以及（4）
Judet III型，IVA和IVB，根据Judet分类

4. Patient and method/病人和方法:
The exclusion criteria were as follows:
(1) conservative treatment,
(2) employment of a technique other than the Métaizeau technique,
(3) incomplete follow-up, and
(4) multiple fractures
排除标准如下：（1） 保守治疗，（2） 使用Métaieau技术以外的技术，（3）不完全随访，
以及（4） 多发性骨折

5. Patient and method/病人和方法:
• This retrospective study included 50 children treated for Judet types III and IV RNFs at our hospital
from September 2015 to November 2018. Patients were divided into two groups: group A (without
US) and group B (with US). Group A patients were treated using the Métaizeau technique; one K-
wire was used for reduction under the guidance of X-ray fluoroscopy. Group B patients were
treated using the same technique, but under the guidance of US. Post-operative radiographs, elbow
function, and complications were analyzed.
• 这项回顾性研究包括2015年9月至2018年11月在我院接受Judet III型和IV型RNFs治疗的50名儿
童。将患者分为两组：A组（无超声组）和B组（有超声组）。A组采用Métaieau技术治疗，X
线透视引导下用1根K线复位。B组采用同样的技术，但在我们的指导下。分析术后x线片、肘
关节功能及并发症。

6. Surgical procedure:
Patients were placed in the supine position, and US was used to locate the radial nerve, posterior
interosseous nerve (PIN), superficial branch of the radial nerve, interosseous dorsal nerve, and the
RNF. Nerves that projected on the skin were marked with a marking pen. Using US to locate the RNF,
a 2.0-mm K-wire needle was inserted laterally and upward to avoid injuring the radial nerve in the
fracture line. A K-wire was used as a lever to reduce the fracture.
患者仰卧位，超声定位桡神经、骨间后神经（PIN）、桡神经浅支、骨间背神经和RNF。投射
在皮肤上的神经用记号笔标记。利用超声定位RNF，在骨折线上用2.0mm的K线针横向向上插
入以避免损伤桡神经。采用K形钢丝作为杠杆，以减少骨折。

7. Surgical procedure:

10. Post operative evaluation/术后评估:
Postoperative radiological evaluations were performed according to the Métaizeau criteria , and
post-operative functional assessments were performed according to the Mayo Elbow Performance
Index (MEPI). The MEPI results were categorized as follows: > 90 points, excellent; 81–90 points,
good; 61–80 points, fair; and < 60 points, poor. Functional outcomes were also determined to be
excellent, good, fair, or poor according to the Métaizeau classification.
术后根据Métaieau标准进行放射学评估，并根据Mayo肘关节功能指数（MEPI）进行术后功能
评估。MEPI结果分为：>90分，优；81-90分，好；61-80分，一般；<60分，差。根据
Métaieau分类，功能结果也被确定为优秀、良好、一般或差。

11. Results/结果 :
All patients were followed up over a period of 12 months. Five patients in group A had posterior
interosseous nerve (PIN) injury, whereas no patient in group B had PIN injury (p = 0.016). The use of
US guidance resulted in lower radiation exposure and shorter operation time. According to the
Mayo Elbow Performance Index, there was no significant difference between the two groups (p =
0.814), including post-operative complications (radial head necrosis, fracture displacement, or
stiffness).
所有患者均随访12个月。A组5例有骨间后神经（PIN）损伤，B组无1例发生PIN损伤
（p=0.016）。使用美国的指导，减少了辐射暴露，缩短了操作时间。根据Mayo肘关节功能
指数，两组之间没有显著性差异（p=0.814），包括术后并发症（桡骨头坏死、骨折移位或僵
硬）.

12. Results :

13. Discussion/讨论 :
This study shows that US can help reduce RNFs with better preservation of the PIN and reduced
radiation and operation time. The main concern for surgeons is the risk of lesions in the PIN. The risk
of iatrogenic injury is a major concern for surgeons performing this surgery. The safe zone located
within 90° between the radial styloid and the Lister tubercle in the axial plane is also important to
stress the fixation. In this study, we used US for reduction guidance to avoid iatrogenic injury to the
PIN. While there were six patients with PIN injury in group A (without US), there were no patients
with PIN injury in group B (with US), demonstrating that the use of US can decrease the incidence of
iatrogenic PIN injury.
这项研究表明，超声有助于减少RNFs，更好地保存引脚，减少辐射和手术时间。外科医生最担
心的是针头有损伤的风险。医源性损伤的风险是外科医生进行这项手术的主要关注点。安全区
位于桡骨茎突与李斯特结节在轴面上的90°范围内，对加强固定也很重要。在这项研究中，我
们使用我们的复位指导，以避免医源性损伤的针。A组有6例发生针刺伤（无超声），B组无针
刺伤（有超声），说明使用超声可以降低医源性针刺伤的发生率

14. Discussion/讨论 :
A second advantage of US is that it allows monitoring of two vascular structures—the radial recurrent
artery on the ventral, lateral, and dorsal sides and the dorso-medial and medial branches of the ulnar
artery— which are critical for blood supply and future growth. No necrosis of the radial head was seen
in our study.
超声的第二个优点是它可以监测两个血管结构：腹侧、外侧和背侧的桡侧返动脉和尺动脉的背
内侧和内侧分支，这对血液供应和未来的生长至关重要。本研究未发现桡骨头坏死。

15. Discussion/讨论 :
Yet another advantage of US is that it allows fractures to be distinguished in younger children when
the radial proximal ossification centre cannot be located from radiographs, and surgeons had to use
contrast agents in arthrograms. Our study included two patients under the age of five years. The
ossification center did not appear in the radiographs; however, the US could easily detect the RNFs
and guide the reduction. The efficiency in the US group was much better than that in the radiograph
group, with the surgery time significantly lower in the US group (p = 0.001).
然而，我们的另一个优点是，当射线照片无法确定桡骨近端骨化中心时，它可以区分较年轻儿
童的骨折，外科医生必须在关节造影中使用造影剂[16]。我们的研究包括两名五岁以下的病人。
骨化中心在x线片上没有出现，但超声可以很容易地发现RNFs并指导复位。US组的效率明显好
于X线片组，手术时间明显少于X线组（p=0.001）。

16. Discussion/讨论 :
The ALARA (“as low as reasonably achievable”) radiation safety principle stresses that in all
procedures performed on children, the radiation should be minimized or avoided whenever
possible. In this study, authors agree with this principle and prevent the radiation exposure for both
the patient and the medical staff.
ALARA（“尽可能低的合理可行”）辐射安全原则强调，在对儿童进行的所有程序中，应尽可能
减少或避免辐射。在这项研究中，作者同意这一原则，并防止病人和医务人员的辐射暴露。

17. Limitation of study/学习的局限性:
There are some limitations to this study. First, it was a retrospective study, which may have led to
bias. Second, the sample size studied was small; thus, a future study is needed with more patients.
Moreover, a US machine is needed during the surgery and surgeons require special training;
therefore, further studies may be needed on the surgeons’ learning curve for fracture reduction
under US.
这项研究有一些局限性。首先，这是一项回顾性研究，这可能导致了偏见。第二，研究的样
本量很小；因此，需要对更多的患者进行未来的研究。此外，手术过程中需要一台美式机器，
外科医生需要特殊训练；因此，可能需要进一步研究外科医生在超声引导下骨折复位的学习
曲线。

18. Conclusion/ 结论:
US guidance during surgery is feasible to treat RNFs (Judet types III and IV). Moreover, it leads to
significantly less X-ray radiation exposure during the surgery. Furthermore, PIN injury is less common
with the US technique than the K-wire technique. Although the US technique requires time to be
mastered, we believe that paediatric orthopaedic surgeons will be encouraged by its advantages.
手术期间的超声引导对治疗RNFs是可行的（Judet III型和IV型）。此外，它还可以显著减少手
术期间的X射线照射。此外，与K-wire技术相比，US技术中的针刺伤不太常见。虽然美国的技
术需要时间来掌握，但我们相信儿科骨科医生将被它的优势所鼓舞。

19. Thank you