We report on our treatment with percutaneous pinning in 40 cases of supracondylar fractures of the humerus in children, between 1989 and 1994. In our hospital, percutaneous pinning techniques have become the treatment of choice for displaced supracondylar fractures. There are no grave complications, and in most cases, there is adequate reduction and a good range of elbow motion. It is necessary to have primary adequate fixation and good alignment to prevent a cubitus varus deformity.

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【はじめに】当院では転位のある小児に対し，緊急経皮的ピンニングを第一選択としている．術後成績とともに，来院時間，来院から手術までの時間について検討した．【対象と方法】2007年2月～2013年12月の期間に当院で手術を行った31例を対象とした．術後成績評価にはFlynnの評価基準を用いた．【結果】Flynnの評価ではfunctional factor（excellent：30例，good：1例），cosmetic factor（excellent：29例，good：2例）であった．来院時間は18～20時の時間帯が最も多く，来院から手術までの時間は平均96.3分であった．【まとめ】緊急手術による対応は，患児の負担を軽減し，合併症のリスク軽減という観点からも有効であるが，そのためには時間外における麻酔科医や救急医との迅速な連携体制が重要である．

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Displaced supracondylar fracture of the humerus in children are common and predisposed to cubitus varus. We have employed the Kirschner-wire transfixation method for this fracture and obtained satisfactory results.
Over a period of five years, from 1997 to 2002, we treated 13 supracondylar fractures that were displaced and unstable when reduced. Of the 13, we treated 11 by blind pinning after closed reduction. The remaining two required open reduction.
Follow-up examinations were performed in all patients from nine months to five years after fracture. For grading we employed Flynn's criteria in which the loss of carrying angle (CA) and range of motion (ROM) were measured compared with that of opposite extremity. ROM as a functional factor provided satisfactory results in all patients (100%) , and CA as a cosmetic factor satisfactory results in 12 patients (92%) . Only one patient showed poor results, cubitus varus. This resulted from imperfect reduction and instability of pinning.
Pinning is an effective method for fixation of supracondylar fractures. But primary reduction and rigid stability are very important to avoid the commonest complication, cubitus varus.

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We commonly encounter the supracondylar fracture of the humerus in children and attempt many therapeutic methods. Since 1988 we have used percutaneous pinning. In this report we compare and investigate pinning and traction therapy. In the 16 cases of dislocation we investigated, there were 9 cases of pinning and 7 cases of traction. We used Flynn's criteria to measure the R. O. M. and carrying angle of the elbow joint. There was no difference in the prognosis of pinning and traction. The period of therapy was obviously shortened by using pinning. We found that if pinning was performed on the day of trauma, the prognosis was good. By using the pinning we also found that the management of the patient was much more convenient than using traction. We come to the conclusion that the percutaneous pinning is a better method compared with traction therapy in the treatment of the supracondylar fracture.

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Thirty-four cases with supracondylar fractures of the humerus in children were treated during five years period from 1982 to 1987.
Out of them twenty-three subjects were medically examined. Thirteen cases were treated surgically and ten by percutaneous pinning. These were compared to each other. We measured three factors, that is, coronal tilting (varus), anterior angulation (hyperextension) and horizontal rotation (internal rotation), which are thought to be connected with cubitus varus. We calculated coefficient of correlation between cubitus varus and three factors. There was a significant correlation between cubitus varus and coronal tilting (r=0.93, p<0.01), and a relatively high correlation between cubitus varus and anterior angulation (r=0.57, p<0.01). But the correlation between cubitus varus and horizontal rotation was not so significant (r=0.39, p<0.10).

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Over a 6 year period, 9 of 79 children's cases of supracondylar fractures of the humerus were treated by external fixation in our hospital. The average age at time of injury was 12 years (mean 6.6 years). We treated the patient with external fixation if the case had an open fracture or difficulty in bed rest, or in cases in which skeletal traction had failed to achieve an adequate reduction.
We inserted 2 Hoffman pins into each humerus and ulna, and fixed these with a Hoffmann external fixator. Using this method, it is not necessary to have a long period of hospitalization or bed rest. Moreover, it is possible to maintain the reduction position before bony union thereby achieving an excellent clinical result.

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　目的：正中神経が近位骨片の後方に転位して骨片間に陥入し，観血的整復を要した小児

の2例を経験したので報告する．

　症例：症例は7歳男児と7歳女児．2例とも鉄棒から転落し受傷した．来院時，橈骨動脈は触知不能で高位正中神経麻痺を認め，X-p像ではGartland分類type IIIの

を認めた．肘関節前方より展開したところ，正中神経は近位骨片の後内側を回り込むように走行し背側へ牽引されていた．上腕動脈は骨片により圧迫されていたが損傷はなかった．近位骨片と正中神経の引っ掛かりを解除し，骨折部を整復固定した．2例とも正中神経麻痺は改善した．

　考察：本例のように正中神経だけが近位骨片の後内側に回り込み，牽引・絞扼されていた報告は稀だが，このような症例に徒手整復を行うと正中神経の損傷を引き起こす可能性が高いため，徒手整復前に観血的に神経・動脈の確認を行うべきである．

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During the period from 1982 to 1987 sixty cases with supracondylar fracture of the humerus in children were treated by closed reduction and percutaneous pinning. Forty-eight cases out of them were examined with special reference to correlation between Baumann's angle, carrying angle and varus deformity.
The cubitus varus deformity appeared in 10 cases in which Baumann's angle calculated less than 12 degree. The causes of the deformity were resulted from the mal-reduction and -pinning. However, there were two cases with varus deformity without rotation and medial tilting of the distal fragment.

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We reviewed the clinical results of 34 children (21 males, 13 females) with supracondylar humeral fractures, treated by percutaneous pinning from 1983 to 2001. Their age ranged from 1 to 13 years (average age: 6.2 years) and follow-up ranged from 3 to 64 months (average: 16.9 months). They were classified as type 1 to type 4 (described by Abe). There were zero type 1, two type 2, 19 type 3, and 13 type 4. Pinning methods consisted of bilateral cross pinning (28 cases) and parallel pinning from the lateral side (6 cases). Perioperative complications were seen in 11 cases (5 nerve injury, 4 cubitus varus, 2 ROM limitation). Prevention of soft tissue swelling, pin insertion, method of reduction and Baumann’s angle should be taken into cousideration to prevent these complications.

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高位橈骨神経麻痺2症例の理学療法を経験し，臨床的に経過観察を行った。1例はに合併したneurapraxiaからaxonotmesisの状態を示す神経麻痺例であり，他の1例は，切創による神経完全断裂によるneurotmesisの状態であった。理学療法は骨折合併例で受傷後5週目，神経完全断裂例では，神経縫合術後5週より開始した。結果，骨折合併例では，関節可動域は14週でほぼ正常に回復したが，麻痺の回復はやや遅れ，橈骨神経末梢側の完全回復までは，18週を必要とした。一方，神経完全断裂例では，神経麻痺の回復は緩徐であり，橈骨神経末梢側支配の長母指伸筋，示指伸筋の筋収縮が認められるには，38週を必要とし，最終評価時においても軽度の麻痺が残存した。高位神経麻痺では，早期から拘縮予防，良肢位保持等を配慮しつつ，さらにTinel徴候などの評価を参考にし，麻痺の回復過程を念頭にいれ理学療法を行う事が重要であることが確認された。

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比較的稀な小児上腕骨遠位T-condylar fractureに対し手術を行った1例を報告する．患者は8歳男児．走っている際に転倒，右肘を打撲した．右肘外側に擦過創があり，神経血管損傷所見はなかった．単純X線は右

（Gertland 3A）に加え関節面へ骨折線があり，T-condylar fractureを呈していた．単純CTで遠位端の転位はわずかで内側皮質の多骨片化がみられた．手術は2本のKirschner鋼線（K-W）で顆間を固定し，3本のK-Wで遠位骨片と近位を固定した．術後は前腕回内位でギプス固定を行い，術後6週で抜線した．受傷後6ヶ月経過し，前腕回内・回外に健患差はないが，わずかな肘関節屈曲制限，生理的外反の減少があり，経過観察中である．本症例は内側皮質多骨片化と関節面へ骨折線があり，特に術後整復位損失が生じる可能性があった．小児上腕骨遠位T-condylar fractureは術中の固定力増加，過矯正，術後外固定の工夫等，術後内反肘変形のリスクを念頭に置き治療する必要がある．

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