桡骨小头骨折与前臂骨间膜损伤的相关性研究

 目的 探讨桡骨小头骨折与前臂骨间膜损伤的相关性。方法 2007 年9 月至2010 年6月, 前瞻性观察26 例桡骨小头骨折患者, 男15 例, 女11 例;年龄21~53 岁, 平均(37.6±7.3)岁。桡骨小头骨折根据Mason 分型, I型7 例, II型9 例, III型10 例。所有患者均在1 周内行伤侧尺桡骨全长X线、CT及MR 检查(包括肘及腕关节), 以明确是否合并前臂骨间膜损伤及损伤程度、部位。桡骨小头骨折类型和骨间膜损伤程度的相关性采用Spearman 秩相关进行统计学分析。结果 Mason I~III型桡骨小头骨折均可伴前臂骨间膜损伤, 其中7 例Mason I型骨折中2 例、9 例Mason II型骨折中4 例、10 例MasonIII型骨折中7 例伴前臂骨间膜损伤。桡骨小头骨折与前臂骨间膜损伤呈正相关。桡骨小头骨折程度越严重, 前臂骨间膜损伤的发生率越高, 损伤程度也越重。Mason I型及 II型骨折中的6 例前臂骨间膜损伤均为膜部损伤, 而10 例MasonIII型骨折中的7 例前臂骨间膜损伤, 3 例为中央束断裂, 4 例为膜部损伤。结论 各类型桡骨小头骨折均可伴前臂骨间膜损伤, 桡骨小头骨折与前臂骨间膜损伤呈正相关。对于桡骨小头骨折, 尤其是MasonIII型骨折, 建议行前臂MR 检查, 以明确是否有骨间膜损伤。     

前臂骨间膜的磁共振成像及其动态变化

前臂骨间膜（interosseous membrane,IOM）损伤常作为前臂骨折的伴随损伤而出现（如Essex—Lopresti骨折、盖氏骨折和桡骨远端骨折等）。由于常规平片检查无法显示骨间膜,因而漏诊和误诊的病例较多,患者多出现长期腕部疼痛、握持力量减弱、前臂旋转功能受限及肘关节活动障碍等严重并发症。IOM对于维护前臂的纵向稳定和旋转功能至关重要。Hotchkiss等研究指出,桡骨头切除后前臂纵向稳定强度的71％由IOM中央区维持。目前运用磁共振成像（MRI）对骨间膜进行研究已有报道,但在临床应用方面尚无太多经验。     

前臂纵向不稳的诊断与治疗

桡-尺骨分离往往发生于高速暴力横贯前臂、腕部至肘部,造成桡骨头骨折、纤维三角软骨复合体(TFCC)损伤和骨间膜破裂三联征。桡骨是维持前臂稳定的主要结构,前臂骨间膜则可以使受力较均匀地分布于桡骨和尺骨之间,TFCC对维持前臂稳定也起一定作用。骨间膜的中央1/3段(腱性部分)要比两端膜性部分坚强3倍。急性前臂骨间膜损伤常有明确的上肢外伤史、腕尺侧疼痛和桡骨头骨折。查体可以发现腕尺侧压痛、前臂压痛和没有前     

前臂骨间膜损伤的核磁成像

前臂骨间膜对防止尺、桡骨远近端移位的重要作用已在伴有桡骨小头骨折的前臂损伤研究中得到证实。桡骨近端骨折合并骨间膜损伤的病人会出现远端尺桡关节的脱位或半脱位引起的腕部疼痛。确诊前臂骨间膜损伤对于制定外科治疗计划是很必要的 ,但是前臂骨间膜损伤的诊断困难。作者提出采用轴位、矢状位、冠状位核磁成像的快速自旋回波及脂肪抑制技术检查骨间膜损伤 ,取得了满意的效果。作者在 1998年 1月～ 5月对新鲜尸体的 8个前臂 ,未受伤志愿者的 4个前臂及 5名伤者前臂进行轴位矢状位、冠状位核磁Ｔ1、Ｔ2加权成像。摄片时前臂体位采用肘伸…     

Essex-Lopresti损伤诊断与治疗

高能量暴力作用于前臂引起的Essex-Lopresti损伤包括桡骨头骨折、三角纤维软骨复合体损伤及前臂骨间膜撕裂三联损伤,很容易漏诊.桡骨头骨折伴有下尺桡关节疼痛、前臂旋转受限时须考虑是否存在Essex-Lopresti损伤,详细体检、X线平片、超声、MRI及术中桡骨纵向牵拉试验可帮助诊断.治疗的关键在于维持前臂纵向稳定性,因此需要通过切开复位内固定或人工桡骨头置换来恢复桡骨的正常长度.近年研究提示前臂骨间膜和三角纤维软骨复合体对维持前臂纵向稳定性也相当重要.该文就该损伤的诊断与治疗研究进展作一综述.     

前臂骨间膜及其损伤的MRI表现

目的：研究正常和损伤的前臂骨间膜的MRI表现。方法：对2具前臂尸体标本进行回顾性MRI对比观察。结果：完整的骨间膜在MRI上呈现为从桡骨近端斜向尺骨远端的带状结构，在T1和T2加权像上表现为黑色低信号带，在T2脂肪抑制像上显示最清楚。断裂的骨间膜在MRI上显示出骨间膜的连续性中断，表现为波浪状、迂曲、移位的韧带纤维及前臂肌肉向骨间膜膨出。结论：MRI能清楚显示前臂骨间膜解剖结构，能准确诊断前臂骨间膜损伤。     

前臂纵向分离的研究进展

前臂纵向分离(longitudinal radioulnar dissociation,LRUD)是指腕部受到轴向暴力,造成桡骨头/颈骨折或脱位合并骨间膜撕裂和下尺桡关节分离的复杂联合损伤,引起前臂纵向不稳定。生物力学研究表明在切除桡骨小头情况下,单纯重建骨间膜仅能减轻桡骨向近侧移位,而恢复LRUD前臂的纵向稳定性需要骨间膜重建与桡骨头金属假体置换联合。LRUD误诊和漏诊率高,MRI和B超是早期检查骨间膜损伤的有效方法。目前治疗强调修复LRUD的所有损伤结构而恢复前臂稳定性,即修复或重建桡骨头、矫正下尺桡关节,同时重建骨间膜。治疗成功与否取决于能否早期诊断。     

Essex-Lopresti损伤治疗

EssexLopresti损伤包括桡骨头骨折、尺桡远侧关节分离和骨间膜撕裂,导致前臂活动障碍和纵向不稳定。Essex-Lopresti损伤发病率极低,容易漏诊而未予处置,使患肢功能受损;治疗不充分也会使前臂急性不稳定变成更为复杂的陈旧性纵向不稳定。及时诊断有赖于对此类损伤的充分了解和详尽的物理、超声及放射线检查。急性期损伤治疗旨在防止桡骨向近侧移位,需要正确处理桡骨头骨折,避免桡骨头切除,修复三角纤维软骨复合体,损伤的骨间膜重建与否尚有争议;陈旧性损伤处理的中心环节是重建完整的稳定结构,恢复尺桡远侧关节高度,最终恢复前臂尺桡骨之间的正常关系,消除纵向不稳定,方法包括人工桡骨头置换、尺骨截骨短缩、骨间膜中央束重建和三角纤维软骨复合体修复。     

前臂骨间膜解剖和生物力学研究进展

前臂纵向稳定的维持依赖于前臂骨间膜等解剖结构的相互作用。前臂骨间膜是从桡骨斜向至尺骨的腱性纤维组织,由中间1/3的腱性部分和两端的膜性部分构成,其中腱性部分是骨间膜的主要力学功能区,承担着大部分由桡骨传递至尺骨的应力。组织学和生化学研究显示,骨间膜由大量胶原纤维和少量弹性蛋白组成,这些成分使其既具有韧性又具有弹性,可承受很大的载荷,在前臂旋转运动时维持尺桡骨的稳定,并将应力由桡骨传导至尺骨。桡骨头切除后前臂的纵向稳定主要由前臂骨间膜维持,如果同时并发骨间膜损伤,将导致进行性桡骨向近端移位和下尺桡关节分离,其治疗的关键在于恢复前臂的正常长度及重建骨间膜的功能。该文就前臂骨间膜解剖结构、组织学、生化学及力学功能的研究进展作一综述,并讨论其在临床方面的实际意义。     

前臂骨间掌侧动脉腕背支尺骨骨(膜)瓣治疗桡骨骨不连

目的探讨前臂骨间掌侧动脉腕背支尺骨骨(膜)瓣治疗桡骨骨不连的临床效果。方法在前臂背侧设计S形偏尺侧切开,切除桡骨骨折不愈合之硬化骨,以钢板固定骨折端,用带骨间掌侧动脉腕背支血管蒂尺骨骨(膜)瓣移植治疗桡骨骨折不愈合5例,尺骨骨(膜)瓣最小为2·5cm×1·5cm,最大为3.0cm×2·0cm,血管蒂长4~5cm。结果全部病例均在术后3个月出现明显骨痂,术后8个月骨性愈合,上肢功能恢复满意。结论前臂骨间掌侧动脉腕背支尺骨骨(膜)瓣是治疗桡骨骨不连的一种较好的方法选择。     

MRI Detection of Forearm Soft Tissue Injuries with Radial Head Fractures

Background

This study aims to evaluate the incidence of forearm soft tissue abnormalities associated with radial head fracture severity based on the Mason classification system.

Methods

Eighteen patients (age 18–45 years) were prospectively evaluated with elbow radiographs and magnetic resonance imaging (MRI) following longitudinal forearm trauma. MRI was performed within 10 days of the initial injury. Radiographs and MR images were evaluated in a blinded fashion by two musculoskeletal radiologists.

Results

Thirteen of 18 patients presented with Mason type I radial head fractures. In all patients with Mason type I fractures, the interosseous membrane (IOM) was intact. Two patients had Mason type II fractures with associated partial and compete tearing of the IOM and three patients had Mason type III fractures with complete tearing of the IOM. Edema was noted in the pronator quadratus in six of 13 type I injuries and seen in all type II and III injuries. No structural forearm soft tissue abnormalities were present in patients with Mason type I injuries. The presence of edema within the pronator quadratus correlated with distal forearm pain.

Conclusions

The severity of radial head fracture correlates with longitudinal forearm injury evidenced by the presence of IOM tearing. The findings suggest patients with Mason type II or III fractures of the radial head should undergo further evaluation of the forearm for associated soft tissue injuries. Edema within the pronator quadratus was present following forearm trauma regardless of the severity of fracture and was related to symptomatic forearm pain.     

The sequelae of a missed Essex-Lopresti lesion

Radial head fractures are the most common type of elbow fracture in adults. Unrecognised disruption of the intraosseous membrane at the time of injury can lead to severe wrist pain from proximal radial migration especially if the radial head is excised. In this case, despite anatomical reduction and internal fixation of the radial head fracture, longitudinal forearm instability developed after delayed radial head resection was performed 7 months post-injury. A Suave-Kapandji procedure was performed due to ongoing wrist pain. Because of the previous radial head resection, this led to a floating forearm that could only be solved by creating a one-bone forearm, sacrificing all forearm rotation to achieve a stable lever arm between the elbow and wrist joint.     

Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Background and purpose Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture.

Patients and methods 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture.

Results Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury.

Interpretation The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.     

Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Background and purpose

Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture.

Patients and methods

44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture.

Results

Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury.

Interpretation

The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.     

Diagnosis and treatment of longitudinal instability of the forearm

Radio-ulnar dissociation can result from high-injury trauma that the compressive forces traverse the wrist forearm and elbow. This injury can be thought of as an "unhappy triad" of radial head fracture, triangular fibrocartilage complex failure, and a tear of the interosseous membrane. The radius is the primary stabilizer of the forearm with the forearm interosseous membrane enabling load sharing between the radius and the ulna. The central one-third of the interosseous membrane is 3 times stronger than the membranous portion and approaches the strength of the anterior cruciate ligament for determining interosseous membrane injury. Imaging studies with proven diagnostic efficacy include magnetic resonance imaging and ultrasound. Surgical treatment should be considered when circumstances imply longitudinal instability of the forearm. Surgical treatment includes open reduction/internal fixation or prosthetic replacement of the radial head as well as repair of the disrupted triangular fibrocartilage complex. Successful treatment of radioulnar dissociation is predicated on early diagnosis of the condition.     

Ultrasound diagnosis and surgical pathology of the torn interosseous membrane in forearm fractures/dislocations

Ultrasound was used to effectively diagnose and precisely locate a torn interosseous membrane in 2 forearm fracture/dislocations. The ultrasound appearance of the torn interosseous membrane in cadavers and in the fractures/dislocations shows disruption of the anterior and posterior layers in midsubstance or adjacent to the radius or ulna. The surgical pathology in 3 forearm fractures/dislocations (2 Galeazzi injuries and 1 Essex-Lopresti injury) shows a longitudinal oblique tear of the interosseous membrane, parallel to its major palmar fibers, oriented from proximal radial to the distal ulnar. After ultrasound diagnosis, we demonstrated the feasibility of direct primary repair of the torn interosseous membrane associated with the Essex-Lopresti injury in a clinical case.     

Ipsilateral fracture of distal and proximal ends of the radius: Does this injury pattern deserve special attention?

Background

Ipsilateral proximal and distal radial fractures represent an injury spectrum following trauma due to axial loading of forearm. This spectrum may vary from a minimal (undisplaced fractures at either ends) to a severe insult (associated proximal and distal ulnar fracture, comminution, displaced fragments and probable interosseous membrane damage).

Methods

Series of five cases on ipsilateral proximal and distal radial fractures and their results. Two of these cases occurred in paediatric age group.

Results

Both these injuries commonly result from a fall on outstretched hand. In older age group, especially osteoporotic elderly women, the fracture pattern can be a result of low energy trauma with minimal displacement of fractures. In younger age group, the injury complex mainly results from high-energy trauma with comminution, instability and significant soft tissue damage. The proximal fractures might be a part of a more severe elbow dislocation which may not be obvious at the time trauma radiographs are taken. The main sequellae in the series were related to involvement of radial head. In the paediatric group, the fracture pattern was complicated by avascular necrosis of radial epiphysis and premature physeal fusion.

Conclusions

Ipsilateral proximal and distal radial fracture is an uncommon injury pattern. The series illustrates a number of problems associated with this combination. Firstly, one should be aware of this rare injury pattern and there should be greater emphasis on clinical examination of elbow in cases of wrist injuries and vice versa. Once diagnosed, one faces the dilemma of appropriate management in these cases. The appropriate management will depend on the injury characteristics including the age of the patient and the fracture pattern. One should try to preserve the radial head to prevent a possible proximal radial migration especially in younger patients. In children, these injuries are extremely prone to complications and forewarning the parents of a possible poor result while treating these injuries is important.     

Herbert螺钉内固定治疗桡骨小头骨折15例

目的：观察随访用Herbert螺钉内固定治疗MasonⅡ、Ⅲ型桡骨小头骨折的临床近期疗效。方法：2008年3月至2010年7月,采用切开复位Herbert螺钉内固定治疗15例MasonⅡ、Ⅲ型桡骨小头骨折,男6例,女9例;年龄18～55岁,平均32岁;左侧7例,右侧8例。受伤到入院时间3～10h。患者入院时肘部肿胀疼痛,肘关节活动受限,肘关节可闻骨擦音,X线片示桡骨小头骨折。对患者术后肘关节功能恢复观察采用Mayo肘部评分系统。结果：术后患者伤口愈合Ⅰ/甲,术后未见肘关节骨化性肌炎,随访6～15个月,依据Mayo肘部评分,优8例,良5例,可2例。Mayo评分（86.67±1.26）分,其中疼痛（53.33±9.76）分,关节活动度（27.33±4.58）分,关节稳定性（6.00±2.07）分;肘关节活动度70°～130°,平均（105±10）°,前臂旋转度100°～130°,平均（120±16）°。结论：用Herbert螺钉对MasonⅡ型及部分MasonⅢ型桡骨小头骨折固定,复位满意、固定可靠、方法简单,利于早期进行功能锻炼。     

The role of biceps loading and muscle activation on radial head stability in anterior Monteggia injuries: An in vitro biomechanical study

IntroductionLittle evidence-based information is available to direct the optimal rehabilitation of patients with anterior Monteggia injuries.Purpose of the StudyThe aims of this biomechanical investigation were to (1) quantify the effect of biceps loading and (2) to compare the effect of simulated active and passive elbow flexion on radial head stability in anterior Monteggia injuries.Study DesignIn vitro biomechanical study.MethodsSix cadaveric arms were mounted in an elbow motion simulator. The effect of biceps loading, simulated active and passive elbow flexion motions was examined with application of 0N, 20N, 40N, 60N, 80N, and 100N of load. Simulated active and passive elbow flexion motions were then performed with the forearm supinated. Radial head translation relative to the capitellum was measured using an optical tracking system. After testing the intact elbows, the proximal ulna was osteotomized and realigned using a custom jig to simulate an anatomical reduction. We then sequentially sectioned the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane to simulate soft tissue injuries commonly associated with anterior Monteggia fractures.ResultsGreater magnitudes of biceps loading significantly increased anterior radial head translation. However, there was no significant difference in radial head translation between simulated active and passive elbow flexion except in the final stage of soft tissue sectioning. There was a significant increase in anterior radial head translation with progressive injury states with both isometric biceps loading and simulated active and passive motion.ConclusionsOur results demonstrate that anatomic reduction of the ulna may not be sufficient to restore radial head alignment in anterior Monteggia injuries with a greater magnitude of soft tissue injury. In cases with significant soft tissue injury, the elbow should be immobilized in a flexed and supinated position to allow relaxation of the biceps and avoid movement of the elbow in the early postoperative period.