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【摘要】 目的探讨尺桡骨近端粉碎骨折伴肘关节后脱位的治疗方法和疗效。方法 尺桡骨近端粉碎骨折伴肘关节后脱位患者30例,男23例,女7例;年龄18~52岁,平均年龄30岁。采用钢板螺钉内固定治疗,其中一期植骨20例。桡骨小头骨折部分,如骨折粉碎不严重,复位后用克氏针固定,并修补环状韧带;如骨折粉碎严重,则行人工桡骨头置换,同时取自体掌长肌腱重建环状韧带。尺骨冠突骨折部分,选用克氏针或拉力螺钉固定骨折块,同时探查尺侧副韧带前束,如损伤予以修复或重建;如合并尺骨鹰嘴骨折,采用钢板螺钉内固定治疗。结果 患者伤口均一期愈合,骨折愈合率为100%。术后随访10~48个月,平均29个月。5例有创伤性关节炎表现,2例发生轻度创伤性骨化。肘关节平均屈伸范围100°~110°,前臂平均旋转活动范围为90°~100°。按照Morrey等肘关节功能评分标准进行评价:优12例,良15例,可2例,差1例,总优良率为90%。结论 治疗尺桡骨近端粉碎骨折伴肘关节后脱位可采用钢板螺钉固定尺桡骨近端骨折,必要时行一期植骨,注意对桡骨,尺骨冠突骨折及肘关节侧副韧带损伤的治疗,以防止肘关节不稳定。
【关键词】尺骨近端骨折;桡骨头骨折;肘关节后脱位;骨折内固定
Treatment in the comminute fracture of proximal ulna and radial associated with the elbow posterior dislocation
Li Qiang, Zhou Zhi-Gang, Yan Zhao-Hua, et al. Department of orthopaedics, The First people’s hospital of jiujiang, Jiang Xi 332000, China
【Abstract】 Objective To investigate the surgical management of the proximal ulna and radial comminuted fractures associated with the elbow posterior dislocation and evaluate the clinical outcome. Methods From January 2000 to October 2007, 30 patients with proximal ulna and radial comminuted fractureds associated with the elbow posterior dislocation were treated,which involced 23 males ang 7 females with an average age of 30 years. All patients were treated with the plate and screw fixation.Bone graft had been done in 20 patients during the primary procedure. For radial head fractured, the internal fixation was performed or radial head replacement. For the ulna coronoid process fractures, internal fixation were performed and repaired the anterior bundle of the ulnar collateral ligaments. Results The mean time of the follow-up was 29 months.The union rate was 100%. No inflammation, neural injuries and elbow instability occurred. Traumatic osteoarthritis occurred 5 cases,and mild heterotopic ossification occurred in 2 cases. The mean range of motion of the afected elbow joint was 100°~110°,and the ROM of forearm rotation was 90°~100°. According to Morrey"s evaluation method, 12 patients was classified in excellent, 15 in good, 2 in fair and 1 in poor. The excellent a good rate was 90%. Conclusion Elbow stability must be restored by addressing the specific compinents in the injury. The proximal ulna must be anatomically reduced and internally fixed; the radial head and substantial coronoid fractures must be repaired or reconstructed. The repair of the ligaments of elbow is necessary.
【Key words】 Fracture of proximal ulna;Radial head fracture;Posterior dislocation of the elbow; Fracture internal fixation
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作者单位:332000江西省九江市第一人民医院骨科
肘关节损伤临床比较常见,多为轴向应力及继发的内、外翻应力引起,表现为不同结构的骨折和或脱位, 常伴有程度不同的软组织损伤。尤其对于复杂性肘关节骨折脱位, 肘关节脱位常伴有桡骨头骨折、尺骨鹰嘴、冠突骨折及内外侧韧带损伤,采用传统的治疗方法, 疗效及预后不够满意, 是临床治疗的难题。 本文通过回顾性分析2000年1月至2007年10九江市第一人民医院收治的30例尺桡骨近端粉碎骨折伴肘关节后脱位的临床资料,以探讨其治疗方法和疗效。
1 资料与方法
1.1 一般资料 本组30例,男23例,女7例,年龄18~52岁,平均年龄30岁;左侧13例,右侧17例。致伤原因:车祸伤21例,高处坠落伤9例。开放性损伤8例;闭合性损伤22例。开放性损伤均急诊行清创内固定等治疗,闭合性损伤者在伤后2周内进行手术。
1.2 骨折分类 桡骨头骨折按Mason法分类:桡骨头边缘无移位的小片骨折为Ⅰ型;桡骨头部分骨折伴移位为Ⅱ型本组23例;桡骨头完全粉碎骨折为Ⅲ型,本组7例。Johnston对 Mason法进行了改良,增加了桡骨头骨折伴肘关节后脱位为Ⅳ型。因此在本组病例中,所有的桡骨头骨折均为第Ⅳ型。尺骨冠突骨折根据其骨折线的位置、尺侧副韧带是否损伤、冠突受损程度及对肘关节稳定性的影响将尺骨冠突骨折分为四型[1]:尺骨冠突尖部不超过冠突高度1/2骨折为Ⅰ型,(冠突高度指尺骨冠突尖到滑车切迹最低点的垂直距离)本组2例;尺骨冠突高度处1/2骨折为Ⅱ型,本组12例。尺骨冠突基底部骨折为Ⅲ型,本组13例。常伴肱尺关节半脱位或后脱位,偶伴尺侧副韧带前束损伤;尺骨冠突严重粉碎性骨折伴肘关节不稳定,需行冠突和尺侧副韧带前束重建为Ⅳ型,本组3例。合并尺骨鹰嘴骨折按将鹰嘴骨折Schatzker改良的Colton分型[2],将横行骨折(发生在滑车切迹最深点)分为简单骨折两部分和复杂骨折(伴有关节面压缩),本组9例。斜行骨折分为近端骨折(鹰嘴顶点到半月切迹的中点)和远端骨折(半月切迹中点到冠突),本组10例。粉碎性骨折有多条骨折线,可合并肘关节脱位或桡骨头骨折,本组11例。该分型结合骨折的生物力学特征,有助于选择手术方式及放置内固定物的位置。
1.3 手术方法 臂丛或加硬膜外麻醉(需取髂骨植骨者),麻醉成功后,患者平卧位,患肢置于手术台旁清创车上,上臂近端上气囊止血带,压力为35～40Kpa。常规做后外侧切口,长约15 cm,切开皮肤,皮下组织及深筋膜,从肱三头肌与肱桡肌之间,再向下在肘后肌,尺侧腕伸肌与尺侧腕屈肌之间进入,此入路可显露尺骨近端及冠状突骨折,桡骨小头骨折和外侧副韧带损伤,本组9例,如图1。如经外侧入路操作尺骨冠突骨折困难,或经外侧入路固定之后,发现肘关节让仍然未达到中心复位,或术前有尺神经损伤症状,则再与肘关节内侧做内侧切口予暴露。保护好前臂内侧皮神经及贵要静脉,向两侧剥开深筋膜后,游离保护尺神经,切断�髁屈指肌总腱(保留至少8 mm以备术毕缝回)向前牵拉,即可完全暴露尺骨冠突。此入路可处理冠突骨折,桡骨小头骨折,内侧副韧带和尺神经损伤。本组21例,如图2。
重建肘关节:冲洗关节腔,清除凝血块和细小碎骨片(保留以备植骨用)、软骨片。辨认清楚损伤结构后,先重建骨性部分,首先复位尺骨冠状,以1.2导针暂时固定后,再旋入两枚3.0 mm空心螺钉固定,本组27例。合并桡骨小头骨折时,若桡骨小头粉碎不严重,行克氏针、3.0 mm空心螺钉固定并埋头,以免影响上尺桡关节活动,或指骨钢板固定,本组28例;若桡骨小头骨折粉碎,无法复位固定,则行人工桡骨小头置换,同时取自体掌长肌腱重建环状韧带,本组2例,作者不主张行单纯桡骨小头切除术。合并尺骨鹰嘴骨折,解剖复位尺骨滑车切迹,行尺骨鹰嘴支持钢板固定,本组29例。再修复软组织,经切口由深至浅依次修复破损关节囊、环状韧带、内外侧副韧带、屈指肌总腱等。30例患者切口内均常规放置负压引流管。
1.3 术后处理 本组患者均于术后口服消炎痛12.5 mg/d,以预防异位骨化的发生,进而影响肘关节功能。伤口引流量
图1 肘关节后外入路,显露尺骨近端及桡骨小头骨折端
图2 肘关节内侧入路,显露尺骨冠突骨折
图3 肘关节后外侧入路显露尺骨近端骨折术中复位
图4 男,30岁,车祸伤。术前肘关节正侧位片
图5 肘关节术后正侧位片
本组30例患者经上述手术治疗,并于术后早期行功能锻炼,末次随访时肘关节稳定性及活动度恢复均较好。作者认为对于尺桡骨近端粉碎性骨折伴肘关节后脱位的患者,手术准确重建关节面最为重要,同时重建柱的解剖关系并修复损伤软组织,才能最大限度的恢复肘关节这一高度适配关节的稳定性和活动度。
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