殷照陽(yáng) 殷建 孫曉 霍永峰 盛路新

肘關(guān)節(jié)內(nèi)翻—后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定的手術(shù)療效分析

殷照陽(yáng)1殷建2孫曉1霍永峰1盛路新1

目的探討創(chuàng)傷性肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定的術(shù)后療效。方法2011年6月至2015年12月連云港市第一人民醫(yī)院收治創(chuàng)傷性肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定患者10例（10個(gè)肘），其中男6例、女4例，平均年齡34.8歲（20～67歲）。術(shù)后早期功能鍛煉，采用Mayo肘關(guān)節(jié)功能評(píng)分系統(tǒng)（Mayo elbow performance score，MEPS）評(píng)價(jià)肘關(guān)節(jié)功能。定期復(fù)查X線片，采用Broberg和Morrey肘關(guān)節(jié)退行性關(guān)節(jié)炎X射線分級(jí)進(jìn)行評(píng)價(jià)。結(jié)果所有患者肘關(guān)節(jié)骨折3個(gè)月后獲得愈合，肘關(guān)節(jié)活動(dòng)穩(wěn)定，8例無(wú)疼痛癥狀，1例靜止時(shí)偶有疼痛，1例活動(dòng)時(shí)疼痛。肘關(guān)節(jié)活動(dòng)伸直平均角度（29.6±11.4）°，屈曲平均角度（113.6±10.2）°，旋前平均（55.2±13.6）°，旋后平均（40.2±9.2）°。1例術(shù)后2個(gè)月開(kāi)始出現(xiàn)骨化性肌炎，半年后予以手術(shù)松解，滿足日常生活需要。根據(jù)MEPS評(píng)分結(jié)果優(yōu)7例、良1例、中2例、差0例，優(yōu)良率80%。結(jié)論肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定一期手術(shù)治療至關(guān)重要，根據(jù)不同損傷類(lèi)型制定個(gè)性化治療方案有利于關(guān)節(jié)功能恢復(fù)。

肘關(guān)節(jié)； 外科手術(shù)； 骨折固定術(shù)

肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定是由于肘關(guān)節(jié)受到內(nèi)翻、后內(nèi)側(cè)旋轉(zhuǎn)及軸向的應(yīng)力導(dǎo)致外側(cè)副韌帶復(fù)合體從肱骨外髁止點(diǎn)撕脫，肱骨遠(yuǎn)端滑車(chē)撞擊尺骨冠狀突內(nèi)側(cè)面，引起以冠狀突內(nèi)側(cè)面骨折為基礎(chǔ)合并冠狀突、橈骨頭或尺骨近端骨折為特點(diǎn)的損傷類(lèi)型。此種類(lèi)型肘關(guān)節(jié)損傷臨床上少見(jiàn)，一期手術(shù)治療不當(dāng)而導(dǎo)致的肘關(guān)節(jié)功能障礙較為多見(jiàn)，而二期再次矯形手術(shù)的效果難以令人滿意，所以一期手術(shù)治療至關(guān)重要。自2011年6月至2015年12月連云港市第一人民醫(yī)院收治創(chuàng)傷性肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定患者10例，療效滿意，報(bào)道如下。

資料與方法

一、 一般資料

本組患者共10例（10個(gè)肘），其中男6例、女4例，平均年齡34.8歲（20～67歲）。均為優(yōu)勢(shì)肘，且無(wú)既往肘關(guān)節(jié)手術(shù)史。損傷原因：騎車(chē)摔傷4例、車(chē)禍4例、高處墜落傷1例、運(yùn)動(dòng)損傷1例。按O'Driscoll分型分為：ⅡA型3例、ⅡB型4例、ⅡC型3例。合并傷包括：合并橈骨小頭骨折1例（Mason Ⅲ型）、合并橈骨遠(yuǎn)端骨折3例。

二、納入及排除標(biāo)準(zhǔn)

納入標(biāo)準(zhǔn)：①放射線檢查證實(shí)存在冠狀突內(nèi)側(cè)面骨折基礎(chǔ)損傷，合并或不合并尺骨鷹嘴骨折、肘關(guān)節(jié)脫位，具有明確手術(shù)指征；②受傷至手術(shù)時(shí)間＜3周；③肘關(guān)節(jié)閉合性損傷；④無(wú)心、肺功能障礙等明顯手術(shù)禁忌證；⑤術(shù)前無(wú)認(rèn)知障礙，不影響術(shù)后隨訪。

排除標(biāo)準(zhǔn)：①陳舊性肘關(guān)節(jié)骨折脫位；②合并神經(jīng)、血管損傷的病例；③既往肘關(guān)節(jié)手術(shù)病史；④隨訪資料不完整或不配合治療的患者。

三、術(shù)前評(píng)估

術(shù)前應(yīng)著重注意軟組織腫脹情況，有無(wú)脫位和前臂骨筋膜室綜合癥，有無(wú)血管、神經(jīng)損傷。術(shù)前常規(guī)檢查肘關(guān)節(jié)前后位、側(cè)位及肘關(guān)節(jié)三維CT重建，重點(diǎn)觀察肱骨內(nèi)外側(cè)髁有無(wú)撕脫骨折片影，冠狀突骨折的部位及大小。肘關(guān)節(jié)MRI檢查提高了內(nèi)外側(cè)韌帶損傷程度診斷的正確率。術(shù)前如有脫位應(yīng)首先予以手法復(fù)位，然后屈肘90°位制動(dòng)，臥床患肢抬高以減輕軟組織的腫脹程度。

四、手術(shù)方法

手術(shù)修復(fù)的順序?yàn)橄葍?nèi)后外，即先固定冠狀突骨折塊。冠狀突內(nèi)側(cè)面骨折或涉及高聳結(jié)節(jié)的骨塊予以克氏針、螺釘或鋼板固定，冠狀突尖部骨折予以“套鎖”固定，然后探查內(nèi)側(cè)韌帶復(fù)合體，前束肱骨或尺骨止點(diǎn)撕脫或撕脫骨折予以錨釘縫線編織固定。前臂施加內(nèi)翻應(yīng)力，術(shù)中透視證實(shí)有無(wú)明顯的外側(cè)肱橈關(guān)節(jié)增寬，明顯增寬提示外側(cè)韌帶復(fù)合體斷裂，予以切開(kāi)骨縫合或帶線錨釘修復(fù)，再次透視下檢查外側(cè)肱橈關(guān)節(jié)間隙，然后施加前臂旋前、軸向應(yīng)力檢查有無(wú)肘關(guān)節(jié)半脫位。如果仍然存在外側(cè)肱橈間隙增寬或肘關(guān)節(jié)半脫位，予以肘關(guān)節(jié)同心圓支架固定，透視下確定肘關(guān)節(jié)旋轉(zhuǎn)中心，肱骨和尺骨擰入Schaze螺釘并組裝肘關(guān)節(jié)同心圓鉸鏈?zhǔn)酵夤潭ㄖЪ埽ㄍ膱A鉸鏈外固定支架的作用主要是保護(hù)修復(fù)的骨與軟組織結(jié)構(gòu)）。橈骨頭及橈骨遠(yuǎn)端骨折予以鋼板及螺釘固定。

五、術(shù)后處理

術(shù)后患肢肘關(guān)節(jié)支具固定3周，每天屈伸鍛煉2～3次。外固定支架固定術(shù)后第1天即可進(jìn)行肘關(guān)節(jié)屈伸活動(dòng)，但是術(shù)后3周內(nèi)肘關(guān)節(jié)伸直不宜超過(guò)30°，以后逐漸增加肘關(guān)節(jié)屈伸活動(dòng)度。術(shù)后6周拆除外固定支架，固定尺骨冠狀突尖部的克氏針待術(shù)后3個(gè)月骨折愈合后予以拔出。術(shù)后口服吲哚美辛共計(jì)6周以預(yù)防肘關(guān)節(jié)骨化性肌炎。

六、評(píng)價(jià)指標(biāo)

術(shù)后評(píng)估應(yīng)用Mayo肘關(guān)節(jié)功能評(píng)分系統(tǒng)（Mayo elbow performance score，MEPS）［1］對(duì)肘關(guān)節(jié)功能進(jìn)行評(píng)價(jià)，其主要內(nèi)容包括四個(gè)方面：肘關(guān)節(jié)疼痛程度、屈伸活動(dòng)度、穩(wěn)定性及日常功能。術(shù)后定期復(fù)查X線片，采用Broberg和Morrey肘關(guān)節(jié)退行性關(guān)節(jié)炎X射線分級(jí)［2］進(jìn)行評(píng)價(jià)。

結(jié) 果

10例患者均獲得隨訪，平均隨訪（13.8±3.6）個(gè)月（6～22個(gè)月）?；颊咝g(shù)前、術(shù)后及術(shù)后6個(gè)月影像學(xué)資料見(jiàn)圖1-6，10例肘關(guān)節(jié)骨折術(shù)后3個(gè)月后獲得骨性愈合，且肘關(guān)節(jié)活動(dòng)穩(wěn)定，1例偶有疼痛，1例活動(dòng)后疼痛。最后一次隨訪9例肘關(guān)節(jié)活動(dòng)伸直平均（29.6±11.4）°，屈曲平均（113.6±10.2）°，旋前平均（55.2±13.6）°，旋后平均（40.2±9.2）°，滿足日常生活需要。1例術(shù)后2個(gè)月開(kāi)始出現(xiàn)骨化性肌炎，半年后肘關(guān)節(jié)活動(dòng)受限明顯，予以手術(shù)松解，效果滿意，滿足日常生活需要。本組10例患者無(wú)骨與軟組織感染，無(wú)神經(jīng)、血管損傷癥狀。采用MEPS評(píng)價(jià)肘關(guān)節(jié)功能，平均82分（62～92分），優(yōu)7例、良1例、中2例、差0例，優(yōu)良率80%。Broberg和Morrey肘關(guān)節(jié)創(chuàng)傷性關(guān)節(jié)炎評(píng)估結(jié)果，8例無(wú)退行性改變，2例出現(xiàn)1級(jí)改變，未出現(xiàn)2級(jí)或3級(jí)創(chuàng)傷性關(guān)節(jié)炎改變。

圖1 肘關(guān)節(jié)骨折術(shù)前三維CT成像后面觀

圖2 肘關(guān)節(jié)骨折術(shù)前三維CT成像前面觀

圖3 肘關(guān)節(jié)骨折術(shù)后正位X線片

圖4 肘關(guān)節(jié)骨折術(shù)后側(cè)位X線片

圖5 肘關(guān)節(jié)骨折術(shù)后6個(gè)月正位X線片

圖6 肘關(guān)節(jié)骨折術(shù)后6個(gè)月側(cè)位X線片

討 論

肘關(guān)節(jié)不穩(wěn)定根據(jù)部位分為外翻不穩(wěn)定、內(nèi)翻不穩(wěn)定、前側(cè)不穩(wěn)定和后外側(cè)旋轉(zhuǎn)不穩(wěn)定，而在創(chuàng)傷引起的肘關(guān)節(jié)不穩(wěn)中，后外側(cè)旋轉(zhuǎn)不穩(wěn)定最為常見(jiàn)，內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定相對(duì)較為少見(jiàn)［3-6］，容易漏診或誤診，此類(lèi)骨折脫位治療不當(dāng)容易出現(xiàn)肘關(guān)節(jié)僵硬、創(chuàng)傷性骨性關(guān)節(jié)炎和肘內(nèi)翻。肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定的損傷機(jī)制是肘關(guān)節(jié)受到軸向、內(nèi)翻、后內(nèi)側(cè)旋轉(zhuǎn)應(yīng)力而發(fā)生肘關(guān)節(jié)內(nèi)翻、前臂旋前并向后內(nèi)側(cè)旋轉(zhuǎn)，導(dǎo)致外側(cè)韌帶復(fù)合體從肱骨外側(cè)髁撕脫或撕脫骨折，滑車(chē)撞擊冠狀突內(nèi)側(cè)面引起冠狀突內(nèi)側(cè)面骨折、合并或不合并內(nèi)側(cè)副韌帶前束損傷后的肘關(guān)節(jié)骨折脫位。此種類(lèi)型損傷后肘關(guān)節(jié)極度不穩(wěn)，如果采用保守治療或者冠狀突骨折不固定的手術(shù)方式，最終肘關(guān)節(jié)功能均不滿意［7-10］。也有學(xué)者認(rèn)為需在麻醉下進(jìn)行肘關(guān)節(jié)屈伸活動(dòng)，若發(fā)現(xiàn)肱尺關(guān)節(jié)半脫位，施加內(nèi)翻應(yīng)力時(shí)肱橈關(guān)節(jié)間隙增大，須進(jìn)行手術(shù)治療［11-12］。

肘關(guān)節(jié)周?chē)浗M織韌帶結(jié)構(gòu)包括內(nèi)側(cè)韌帶、外側(cè)韌帶復(fù)合體及前方的關(guān)節(jié)囊結(jié)構(gòu)。肘關(guān)節(jié)前方關(guān)節(jié)囊結(jié)構(gòu)對(duì)于肘關(guān)節(jié)穩(wěn)定性的影響相對(duì)較小。內(nèi)側(cè)韌帶包括前、后、橫束，其中后、橫束與關(guān)節(jié)囊融合在一起，起到加強(qiáng)關(guān)節(jié)囊的作用，而前束起于肱骨內(nèi)上髁，止于尺骨冠狀突基底部的高聳結(jié)節(jié)，是維持肘關(guān)節(jié)內(nèi)側(cè)穩(wěn)定、防止肘關(guān)節(jié)外翻最為重要的結(jié)構(gòu)。外側(cè)韌帶復(fù)合體包括外側(cè)韌帶結(jié)構(gòu)和伸肌、旋后肌等結(jié)構(gòu)，復(fù)合體對(duì)維持關(guān)節(jié)外側(cè)的穩(wěn)定約起50%的作用［13］，伸肌起協(xié)同作用。外側(cè)韌帶包括橈側(cè)副韌帶和環(huán)狀韌帶，橈側(cè)副韌帶起于肱骨外上髁的外下方，發(fā)出纖維組織一部分止于橈骨環(huán)狀韌帶，另一部分止于尺骨冠突的外下方為橈側(cè)尺副韌帶，后者對(duì)于維持肘關(guān)節(jié)后外側(cè)穩(wěn)定有重要作用［14-15］。肘關(guān)節(jié)后外側(cè)伸肌結(jié)構(gòu)在前臂旋后位時(shí)保持前臂穩(wěn)定并防止前臂外旋脫位，力學(xué)實(shí)驗(yàn)證實(shí)即使切斷肘關(guān)節(jié)后外側(cè)所有軟組織結(jié)構(gòu)，肘關(guān)節(jié)旋后位仍可以降低關(guān)節(jié)脫位趨勢(shì)，這為術(shù)后前臂旋后位固定提供了依據(jù)。

目前在處理肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定時(shí)，對(duì)于手術(shù)入路、骨折的固定方式、是否修復(fù)內(nèi)側(cè)和外側(cè)副韌帶、是否加用鉸鏈?zhǔn)酵夤潭ㄖЪ艿确矫嫒晕催_(dá)成共識(shí)。肘關(guān)節(jié)內(nèi)側(cè)手術(shù)入路最常用的是“過(guò)頂”入路，固定冠狀突骨折更加方便，冠狀突大的塊骨折可以選擇螺釘、3.0 mm空心螺釘或“T”型鋼板固定，小的骨折塊可予以“套索”、錨釘、克氏針連同附著的軟組織固定于原骨折處。如骨折塊太碎，則取出游離碎片，縫合前關(guān)節(jié)囊及肱肌腱。關(guān)于與前關(guān)節(jié)囊相連的尺骨冠狀突小骨折塊應(yīng)用螺釘或“套索”固定，哪種技術(shù)固定效果更佳尚無(wú)定論。肘關(guān)節(jié)結(jié)構(gòu)性穩(wěn)定系統(tǒng)分為四個(gè)柱，內(nèi)側(cè)柱由肱尺關(guān)節(jié)內(nèi)側(cè)和內(nèi)側(cè)副韌帶復(fù)合體組成，前側(cè)柱由冠狀突、橈骨頭前部及前方關(guān)節(jié)囊組成，肱肌提供輔助作用。冠狀突位于肱骨遠(yuǎn)端滑車(chē)的前方，其主要作用是對(duì)抗上臂肌肉牽拉尺骨向后的力量，同時(shí)也是對(duì)抗外傷導(dǎo)致肘關(guān)節(jié)內(nèi)翻的骨性結(jié)構(gòu)，而當(dāng)冠狀突骨折或缺失超過(guò)50%即可引起肘關(guān)節(jié)不穩(wěn)，出現(xiàn)肘關(guān)節(jié)復(fù)發(fā)性脫位或半脫位［16］。冠狀突基底部是內(nèi)側(cè)副韌帶前束的止點(diǎn)。王友華等［17］發(fā)現(xiàn)當(dāng)冠狀突骨折累及高度達(dá)到1/2時(shí)必然導(dǎo)致前束損傷，此時(shí)重建冠狀突對(duì)比修復(fù)和不修復(fù)前束韌帶的肘關(guān)節(jié)的穩(wěn)定性，發(fā)現(xiàn)肘關(guān)節(jié)在屈曲 0°、30°、60°、90°和120°時(shí)，外翻角度的顯著增加提示了肘關(guān)節(jié)的不穩(wěn)，證實(shí)內(nèi)側(cè)副韌帶前束在肘關(guān)節(jié)活動(dòng)過(guò)程中對(duì)抗外翻旋轉(zhuǎn)應(yīng)力起到非常重要的作用。O'Driscoll Ⅲ型冠狀突骨折多合并復(fù)雜肘關(guān)節(jié)損傷，冠狀突粉碎性骨折難以復(fù)位時(shí)，需取自體髂骨重建冠狀突，且重建冠狀突的高度至少達(dá)到原來(lái)高度1/2，從而獲得肘關(guān)節(jié)前方的骨性阻擋以維持肘關(guān)節(jié)的穩(wěn)定性，但如果同時(shí)合并橈骨頭骨折，無(wú)論尺骨冠狀突骨折塊多小均可能增加肘關(guān)節(jié)的不穩(wěn)［14］。因此，冠狀突同時(shí)參與組成肘關(guān)節(jié)前柱和內(nèi)側(cè)柱，其基底部是內(nèi)側(cè)副韌帶前束的止點(diǎn)，后者在肘關(guān)節(jié)活動(dòng)過(guò)程中對(duì)抗外翻旋轉(zhuǎn)應(yīng)力起到非常重要的作用，重建冠狀突的高度和修復(fù)內(nèi)側(cè)副韌帶，對(duì)于術(shù)后肘關(guān)節(jié)的穩(wěn)定性有決定性的作用。

關(guān)于內(nèi)側(cè)副韌帶是否需要一期修復(fù)存在爭(zhēng)議，有學(xué)者認(rèn)為復(fù)位固定冠狀突骨塊時(shí)應(yīng)一期探查內(nèi)側(cè)副韌帶前束，如果發(fā)現(xiàn)斷裂應(yīng)予以修復(fù)或重建，修復(fù)斷裂的內(nèi)側(cè)副韌帶明顯增加了肘關(guān)節(jié)的穩(wěn)定性。但有學(xué)者認(rèn)為內(nèi)側(cè)副韌帶并非必須修復(fù)［18］，外側(cè)韌帶復(fù)合體作用更為重要，只要固定冠狀突骨折塊和肘關(guān)節(jié)外側(cè)結(jié)構(gòu)（橈骨頭骨折塊和外側(cè)韌帶復(fù)合體），肘關(guān)節(jié)多數(shù)可獲得穩(wěn)定，無(wú)需一期修復(fù)內(nèi)側(cè)副韌帶。本組病例冠狀突內(nèi)側(cè)面骨折塊較大，多連帶內(nèi)側(cè)副韌帶前束一同移位，術(shù)中復(fù)位固定冠狀突骨折塊即可。肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定時(shí)常伴有外側(cè)副韌帶復(fù)合體損傷，肘關(guān)節(jié)外側(cè)副韌帶復(fù)合體損傷表現(xiàn)為肱骨止點(diǎn)處撕脫骨折或韌帶撕脫，也可能是韌帶體部的斷裂，以前者最為常見(jiàn)，韌帶止點(diǎn)處撕脫予以錨釘修復(fù)固定；若是韌帶體部斷裂，宜選擇韌帶重建，尺骨遠(yuǎn)、近端重建的骨道應(yīng)位于尺骨旋后肌嵴的橈骨頭近緣水平及遠(yuǎn)端15 mm的橈骨頭頸交界處水平，而肱骨外側(cè)髁骨道的位置可以通過(guò)尺骨骨道穿過(guò)一根縫線，在屈伸肘關(guān)節(jié)的過(guò)程中，確定其在外上髁周?chē)牡染帱c(diǎn)［19-21］，即肱骨外上髁前下方4點(diǎn)左右，也就是肱骨小頭外側(cè)面的圓心點(diǎn)。值得注意的是橈側(cè)尺副韌帶重建時(shí)尺骨骨道離肘關(guān)節(jié)越遠(yuǎn)，內(nèi)翻穩(wěn)定性越好，離肘關(guān)節(jié)越近，肘關(guān)節(jié)后外側(cè)穩(wěn)定性越好，術(shù)中應(yīng)根據(jù)具體情況酌情考慮。本組術(shù)中探查10例外側(cè)副韌帶均有損傷，均為橈側(cè)副韌帶肱骨止點(diǎn)撕脫或撕脫骨折，予以帶線錨釘編織韌帶后固定，透視下行肘關(guān)節(jié)內(nèi)翻應(yīng)力檢查，6例仍然出現(xiàn)肱橈間隙明顯增寬，加用同心圓外架固定。根據(jù)肘關(guān)節(jié)內(nèi)翻后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定的受傷機(jī)制，首先傷及肘關(guān)節(jié)后外側(cè)結(jié)構(gòu)導(dǎo)致后外側(cè)復(fù)合體的撕脫骨折或韌帶撕脫，術(shù)中是否需要常規(guī)探查修復(fù)尚無(wú)定論，有學(xué)者認(rèn)為內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)術(shù)中修復(fù)外側(cè)副韌帶難以牢固固定，需予以肘關(guān)節(jié)外固定支架固定以保護(hù)修復(fù)的軟組織，否則應(yīng)制動(dòng)患肢 1個(gè)月［22］。Ring［23］在術(shù)中不做切開(kāi)修復(fù)，固定冠狀突骨折后予以肘關(guān)節(jié)同心圓外固定支架固定，取得了良好效果。作者發(fā)現(xiàn)術(shù)中切開(kāi)修復(fù)后外側(cè)韌帶復(fù)合體且未使用同心圓外架的患者，術(shù)后每日主動(dòng)屈伸功能鍛煉2～3次防止肘關(guān)節(jié)僵硬，骨折愈合后肘關(guān)節(jié)功能滿意且無(wú)肘關(guān)節(jié)不穩(wěn)。雖然術(shù)中未使用同心圓支架固定可能會(huì)導(dǎo)致術(shù)后早期活動(dòng)時(shí)出現(xiàn)肘關(guān)節(jié)不穩(wěn)，但是通過(guò)術(shù)后肘關(guān)節(jié)的功能鍛煉可以明顯降低肘關(guān)節(jié)半脫位的發(fā)生率，有學(xué)者也作了相似報(bào)道［24］。因而，術(shù)中是否需要進(jìn)行內(nèi)側(cè)副韌帶修復(fù)，仍需要生物力學(xué)及臨床進(jìn)一步研究和大宗病例的對(duì)照和隨訪，而外側(cè)副韌帶損傷多主張予以探查修復(fù)。

對(duì)于是否使用肘關(guān)節(jié)同心圓外固定支架，作者的經(jīng)驗(yàn)是在肘關(guān)節(jié)內(nèi)側(cè)柱修復(fù)后，對(duì)外側(cè)韌帶復(fù)合體進(jìn)行加強(qiáng)縫合，如果仍然不穩(wěn)則加用鉸鏈?zhǔn)酵夤潭ㄖЪ?。外固定支架的作用在于保持肘關(guān)節(jié)的同心圓活動(dòng)，同時(shí)保護(hù)修復(fù)的骨與軟組織結(jié)構(gòu)［25］，也便于早期功能鍛煉［26］，但是旋轉(zhuǎn)中心的定位非常重要，輕度的偏移則會(huì)明顯增加肘關(guān)節(jié)活動(dòng)時(shí)的應(yīng)力。相對(duì)于外固定支架，更傾向于手術(shù)探查修復(fù)后外側(cè)韌帶復(fù)合體，大多數(shù)肘關(guān)節(jié)可獲得穩(wěn)定，而使用同心圓外固定支架可能出現(xiàn)更多的并發(fā)癥，如旋轉(zhuǎn)中心偏離過(guò)大致肘關(guān)節(jié)功能鍛煉時(shí)關(guān)節(jié)面磨損，橈神經(jīng)損傷、釘?shù)栏腥?、松?dòng)等。

肘關(guān)節(jié)內(nèi)翻-后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定較少發(fā)生橈骨頭骨折，偶爾伴有鷹嘴骨折。橈骨頭骨折的治療方法根據(jù)基于Mason分型，Ⅰ型骨折移位小予以保守治療；Ⅱ型骨折予以手術(shù)復(fù)位內(nèi)固定，固定骨折塊盡可能選擇螺釘固定，若涉及整個(gè)橈骨頭骨折可選擇鋼板固定，鋼板需放置于橈骨頭“安全區(qū)”內(nèi)，而當(dāng)橈骨頭骨折快較?。ㄐ∮跇锕穷^25%）且不累及乙狀切跡時(shí)可考慮橈骨頭骨塊切除；Ⅲ型骨折粉碎選擇橈骨頭置換。對(duì)于無(wú)法修復(fù)的橈骨頭骨折，決定進(jìn)行橈骨頭切除時(shí)應(yīng)充分評(píng)估肘關(guān)節(jié)的穩(wěn)定性，目前多數(shù)學(xué)者認(rèn)為橈骨頭粉碎骨折同時(shí)合并內(nèi)側(cè)副韌帶損傷，不宜進(jìn)行橈骨頭切除，否則易導(dǎo)致肘關(guān)節(jié)嚴(yán)重不穩(wěn)，如果行橈骨頭切除前提是內(nèi)側(cè)副韌帶完整。

肘關(guān)節(jié)功能的恢復(fù)情況與術(shù)后康復(fù)期的功能鍛煉密切相關(guān)。術(shù)后應(yīng)早期進(jìn)行功能鍛煉，否則會(huì)導(dǎo)致關(guān)節(jié)僵硬，但是如果在穩(wěn)定性和早期活動(dòng)這兩者之間作選擇，應(yīng)優(yōu)先考慮關(guān)節(jié)的穩(wěn)定性，矯正僵硬比慢性不穩(wěn)定的肘關(guān)節(jié)相對(duì)要簡(jiǎn)單?？傊?，術(shù)前應(yīng)對(duì)肘關(guān)節(jié)骨與軟組織的損傷程度做充分的評(píng)估，根據(jù)不同患者骨與軟組織損傷的不同情況制定個(gè)性化手術(shù)方案。骨性結(jié)構(gòu)的堅(jiān)強(qiáng)固定、軟組織結(jié)構(gòu)的修復(fù)以及術(shù)后正確的功能鍛煉是治療創(chuàng)傷性肘關(guān)節(jié)骨折脫位并取得滿意效果的必備條件。

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Yin Jian, Email:yinjian0511@163.com

Operative effect analysis of varus posteromedial rotatory instability of elbow joint

Yin Zhaoyang1, Yin Jian2,Sun Xiao1, Huo Yongfeng1, Sheng Luxin1.1Department of Orthopaedics, Lianyungang First People's Hospital,Lianyungang 222000, China;2Department of Orthopaedics, the Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 211100, China

BackgroundThe varus-posteromedial instability of elbow joint refers to the injury characterized by fractures of the medial surface of coronoid process combined with fractures of coronal process, radial head or proximal ulna. The fractures are caused by the avulsion of lateral collateral ligament from the insertion of external humeral condyle and the impingement of the medial surface of ulnar coronoid process by distal humeral trochlea due to varus, posteromedial and axial stresses on elbow joint. This type of elbow injury is rare in clinic. The elbow joint dysfunction is commonly seen if treated improperly at the first stage.Unfortunately, the effect of orthomorphia at the second stage is rarely satisfactory. Hence, the first stage operation is critical. From June 2011 to December 2015, 10 patients with traumatic varus-posteromedial rotatory instability were treated in the First People's Hospital of Lianyungang and obtained satisfactory results.Methods（1）General data. There were 10 patients （6 males and 4 females） in the group, and the average age was 34.8 years （20-67 years）. The dominate elbow joint was affected for all cases, and no patient had previous history of elbow surgery. The causes of injury included 4 cases of bicycle fall, 4 cases of traffic accident, 1 case of high fall and 1 case of athletic injury. According to the O' Driscoll classification, there were 3 cases of type IIA fractures, 4 cases of type IIB fractures and 3 cases of type IIC fractures. Thecombined injuries included 1 case of radial head fracture （Mason type III） and 3 cases of distal radial fracture.（2）Inclusive and exclusive criteria. Inclusive criteria: ① The presence of medial surface of coronoid process fracture with or without olecranon fracture or elbow joint dislocation confirmed by radiological examination suggested definite indication of operation; ②The time from injury to surgery ＜3 weeks ;③ Closed injuries of elbow joint；④ No obvious surgical contraindication such as cardio or pulmonary dysfunction;⑤ No preoperative cognitive impairment that affected postoperative follow ups. Exclusive criteria: ① Oboslete fracturedislocations of elbow joint; ② Combined neurovascular injuries; ③ Previous history of elbow joint surgery; ④ Incomplete follow-up data or patients who did not cooperate with treatment.（3）Preoperative evaluation. Special attentions should be paid preoperatively to the swelling of soft tissue and the presence of dislocation, compartment syndrome of forearm, or neurovascular injury. Preoperative routine examinations including anteroposterior and lateral views of elbow joint and three-dimensional CT reconstruction of elbow joint were conducted to mainly observe the presence of avulsion fractures at medial and lateral condyles of humerus and the location and size of coronoid fragment. Elbow MRI examination improved the diagnostic accuracy of the extent of medial and lateral ligament injury. If there was elbow joint dislocation before operation,manual reduction should be performed firstly. The elbow was then fixed in 90° of flexion, and the affected limb was raised in bed to reduce the swelling of soft tissue. （4）Operative method. The order of surgical repair was from inside to outside as described below. The fracture fragments of coronoid process were fixed firstly. The fractures of the medial surface of coronoid process or fracture fragments involving Sublime tubercle were fixed with Kirschner wires, screws or plates. Fractures of the apex of coronoid process were treated with “Lasso” fixation. Afterwards,the medial ligament complex was explored, and the anterior humeral or ulnar avulsion or the avulsion fracture was fixed with suture anchor. Varus stress was applied on the forearm to check whether the space of lateral radioulnar joint increased significantly under intraoperative fluoroscopy. The remarkable increment suggested the disruption of lateral ligament complex,which required open suture and/or suture anchor fixation. The gap of lateral radioulnar joint was checked again under fluoroscopy, and pronation and axial pressure was applied on the forearm to check whether there was elbow joint subluxation. If the increased lateral radioulnar joint space or elbow joint subluxation still exist, the elbow joint should be fixed by concentric circle bracket. As the rotating center of elbow joint was confirmed under fluoroscopy, the placement of Schaze screws on humerus and ulna and the assembly of hinged elbow external fixator （for protections of repaired bone and tissue structure） were executed subsequently. The fractures of radial head and distal radius were fixed with plates and screws. （5）Postoperative management.After operation, the affected limb was fixed with elbow brace for 3 weeks. Flexion and extension exercises were performed 2-3 times per day. The elbow flexion and extension activities were allowed on the 1st day after external fixation, but the range of elbow extension should not exceed 30° within 3 weeks after surgery. Later, the range of flexion and extension motions of elbow joint was gradually increased. The external fixator was removed 6 weeks after operation, and the Kirschner wire used for the fixation of ulnar coronoid process tip was removed when the fracture healed 3 months after operation. Oral indomethacin was given postoperatively for 6 weeks to prevent the myositis ossificans of elbow joint. （6）Evaluation index. Mayo elbow performance score （MEPS） was used for the postoperative evaluation of elbow function, which mainly included four aspects: level of pain, range of elbow flexion and extension, stability and daily function. The X-ray films were taken regularly for postoperative examinations, and the degenerative arthritis of elbow joint was evaluated by Morrey and Broberg classification. Results All patients were followed up for an average of （13.8±3.6） months （6-22 months）. Ten cases of fractures

bony union and achieved stable elbow joint movement 3 months after operation. There were one case of occasional pain and one case of pain after exercise. During the last follow up,9 cases of fracture had an average elbow extension angle of （29.6±11.4）°, an average elbow flexion angle of （113.6±10.2）°, an average pronation angle of （55.2±13.6）° and an average supination angle of （40.2±9.2）°. These results met the needs of daily life. Myositis ossificans occurred in 1 patient 2 months after operation. 6 months later, the elbow joint movement was remarkably limited. With arthrolysis, the operative effect was satisfactory, which met the needs of daily life. In this group of patients, no bone and soft tissue infection or neurovascular injury symptom was found. The elbow function was evaluated by MEPS, and the mean score was 82 points （62-92 points）. There were 7 excellent cases, 1 good case , 2 moderate cases and 0 poor case . The good and excellent rate was 80%. According to the elbow traumatic arthritis evaluation by Broberg and Morrey classification, there were 8 cases of no degenerative change, 2 cases of Grade 1 degenerative change and 0 case of Grade 2 or 3 degenerative change.ConclusionThe stage-one operative treatment is critical for the varus-posteromedial instability of elbow joint, and the individualized treatment based on injury types is beneficial to the recovery of joint function.The assessment of damage levels of elbow bone and soft tissue should be sufficiently made before operation. The individual operative plan is made based on the bone and soft tissue injury of patient. The rigid fixation of bone structure, the proper repair of soft tissue structure and the correct postoperative functional exercise are essential conditions for the successful treatment of traumatic elbow fracture-dislocation.

Elbow joint； Rotational instability； Facture fixation

10.3877/cma.j.issn.2095-5790.2017.03.004

連云港市衛(wèi)計(jì)委面上項(xiàng)目（201703）；南京醫(yī)科大學(xué)科技發(fā)展基金（2016NJMU156）

工作單位: 222000 連云港市第一人民醫(yī)院骨科1；211100 南京醫(yī)科大學(xué)附屬江寧醫(yī)院骨科2

殷建，Email:yinjian0511@163.com

2017-02-04）

（本文編輯：李靜；英文編輯：陳建海、張曉萌、張立佳）

殷照陽(yáng),殷建,孫曉,等. 肘關(guān)節(jié)內(nèi)翻—后內(nèi)側(cè)旋轉(zhuǎn)不穩(wěn)定的手術(shù)療效分析［J/CD］.中華肩肘外科電子雜志,2017,5（3）：173-179.