Behandlungsstrategien bei der suprakondylären Humerusfraktur im Kindesalter – Bewährtes und Kontroverses

 

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Zusammenfassung

Verletzungen im Bereich des Ellenbogengelenks stellen die zweithäufigste Frakturlokalisation im Kindesalter dar. Die Therapie erfordert hohe Kompetenz. Insbesondere müssen die ausreichende Analgesie und die effiziente, in Abhängigkeit des Frakturtyps differenzierte konservative und operative Therapie erfolgen. Folgeschäden, insbesondere durch Wachstumsstörungen, müssen unbedingt verhindert werden. Typ-I-Frakturen werden konservativ im Oberarmgips behandelt. Für die operative Versorgung stehen unterschiedliche Methoden zur Retention der Fraktur zur Verfügung. Wird durch geschlossene Reposition die anatomische Stellung erzielt, hat die Methode der antegraden elastisch-stabilen intramedullären Nagelung (ESIN) den Vorteil der Belastungsstabilität und ist somit allen anderen Methoden hierin – nach Meinung der Autoren – überlegen. Dennoch ist die Methode nicht unumstritten und findet derzeit keine weite Verbreitung. In Abhängigkeit vom Frakturtyp wird als probate Retentionstechnik die gekreuzte perkutane oder offen eingebrachte Kirschner-Draht-Osteosynthese durchgeführt. Diese ist aktuell noch die am weitesten verbreitete OP-Technik zur Behandlung der suprakondylären Humerusfraktur im Kindesalter. Besonders die neurovaskulären Begleitverletzungen erfordern eine differenzierte Behandlungsstrategie, um Langzeitfolgen zu verhindern, und sollten unbedingt in einem kindertraumatologischen Zentrum behandelt werden. Langzeitfolgen der suprakondylären Fraktur können Bewegungseinschränkungen, Nervenläsionen, Wachstumsstörungen sowie verbleibende Fehlstellungen wie der Cubitus varus (30 %) und valgus (3–7 %) sein. Letztere resultieren am häufigsten durch eine nicht ausreichende initiale anatomische Reposition. Spontankorrekturen finden lediglich bei (Klein-)Kindern bis zu einem Alter von 6–7 Jahren und hier lediglich in der Sagittalebene statt. Ziel der Behandlung sollte die patientengerechte Versorgung mit schnellstmöglicher Rekonvaleszenz und niedriger Langzeitschädigung sein. Hierfür bedarf es ausreichender Expertise in der konservativen und operativen Versorgung.

Abstract

Elbow fractures are the 2nd most frequent fractures in children. Their therapy needs high expertise. Particularly an adequate analgesic therapy as well as an efficient and differentiated non-surgical or surgical therapy depending on the fracture type needs to be chosen. Secondary damage, especially growth disturbances, has to be prevented. Type I fractures can be managed conservatively with a cast. The crossed percutaneous pin fixation after open or closed reduction is the typical and most frequent surgical treatment option in supracondylar humeral fractures in children. Another good treatment option for supracondylar fractures type II to IV after closed reduction is the elastic-stable intramedullar nailing (ESIN). It is a minimally invasive treatment away from the fracture zone, which allows immediate free movement of the extremity. An immobilisation in a cast is therefore not necessary. That are the most possible effects (opinion of the authors) of the ESIN method, but discussed controversial in the literature. Especially neurovascular concomitant injuries require a differentiated treatment strategy to prevent long-term damage and should only be carried out in a specialised paediatric surgery unit. Long-term complications of supracondylar fractures are limitations in range of motion, nerval palsies, disturbances of growth, as well as cubitus varus (30 %) and valgus (3–7 %). These last ones often result from an insufficient initial anatomic reduction. The aim of the therapy should in any case be a patient-orientated treatment with the expected quickest recovery time and lowest long-term complications. Therefore supracondylar fractures should be treated only by a specialised paediatric trauma team, which can provide all non-surgical and surgical treatments. The spontaneous correcture is only seen in the sagittal view in young children between 6–7 years of age.

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