冠突骨折行桡骨小头切除对肘关节稳定性的实验研究

[目的]桡骨小头粉碎骨折时往往行桡骨小头切除术。本研究目的是分析桡骨小头粉碎骨折伴尺骨冠突骨折时行桡骨小头切除前后肘关节的稳定性。[方法]选取骨密度值相近的上肢标本20对,经X线片证实无风湿、结核、肿瘤、骨折、畸形等。剥离上肢所有的皮肤、肌肉和筋膜,完整保留肘关节囊、内外侧副韧带、环状韧带及尺、桡骨骨间膜。调制好的牙托粉与标本两端固定后,将标本伸直侧位自由放置于生物力学机,关节轴与水平面垂直,肱骨外髁向上,于肱骨外髁处垂直向下载荷,记录肘外翻位移。将标本竖直固定于生物力学机,尺桡骨向下,肘关节伸直位,做肘外旋扭转,记录肘关节的转角。[结果]桡骨小头粉碎骨折伴冠突无骨折、Ⅰ型骨折、Ⅱ型骨折在桡骨小头切除后较切除前肘外翻位移及外旋角经统计学比较各组间并无显著性差异;伴冠突Ⅲ型骨折时在桡骨小头切除后较切除前肘外翻位移及外旋角显著增大。[结论]桡骨小头粉碎骨折伴冠突Ⅰ、Ⅱ型骨折行桡骨小头切除前后肘关节均稳定,可行桡骨小头切除术,Ⅲ型骨折不稳定,应修复桡骨小头或假体置换,并修复冠突及尺桡侧副韧带。     

桡骨小头骨折合并肘关节脱位的诊治进展

<正>桡骨小头骨折约占所有成人肘关节骨折的30%,Reit等[1]最近统计了333位桡骨小头骨折病例约有14%合并有肘关节脱位。Mason首先把桡骨小头骨折分为3型,Ⅰ型,桡骨头或颈骨折,无或微小移位(骨折关节内移位2mm);Ⅱ型,桡骨头或颈骨折,移位2mm;Ⅲ型,桡骨头和桡骨颈严重的粉碎性骨折,骨折多不可修复。     

尺骨冠状突骨折及合并桡骨小头粉碎骨折的治疗

尺骨冠状突骨折多合并桡骨小头粉碎骨折,常引起肘关节脱佗和功能障碍.我们曾对尺骨冠状突骨折及合并桡骨小头粉碎骨折时肘关节稳定性进行实验研究[1],结论是在单纯冠状突骨折情况下,Ⅰ、Ⅱ型骨折时肘关节在伸直外翻位及在伸直外旋位足稳定的,应以保守治疗为主;Ⅲ型骨折时不稳定,应该手术修复冠状突骨折.     

肘关节后脱位伴桡骨头和尺骨冠突骨折 (恐怖三联征)5例初步报告

[目的]介绍"肘关节恐怖三联征"的概念(肘关节后脱位同时伴有桡骨头和尺骨冠突骨折),并报告5例患者的临床治疗体会。[方法]自2004年4月～2007年3月,作者共收治肘关节三联征损伤5例。桡骨头骨折按Mason法分类:Ⅱ型4例,Ⅲ型1例;按Schatzker法分类:Ⅰ型1例,Ⅱ型3例,Ⅲ型1例。尺骨冠突骨折按Regan-Morrey法分类:Ⅰ型1例,Ⅱ型4例;按O′Driscoll法分类:5例均为Ⅰ型。4例采取了手术内固定治疗,以3 mm钛空心拉力螺钉或1 mm K针分别固定冠突和桡骨头,并缝合修复肘内外侧副韧带。术后屈肘90°前臂旋转中立位石膏外固定3周,开始屈伸和旋转康复训练。[结果]4例手术治疗的患者经3个月～3年随访,骨折愈合,肘关节稳定,无疼痛。肘关节屈伸幅度平均120°,前臂旋转幅度平均110°。3例随访1年以上,Mayo肘关节功能评分:优2例,良1例。未手术治疗的1例功能评定为差,有肘关节不稳定和疼痛。[结论]肘关节恐怖三联征的骨折片虽然很小,但伴有肘内外侧副韧带撕裂,肘关节严重不稳定。只有在重建了骨关节和软组织结构稳定的基础上,及早(3周内)进行康复锻炼,才能获得较好的功能恢复。     

肘关节恐怖三联征

[目的]介绍"肘关节恐怖三联征"的慨念、发生机制、损伤后肘关节稳定性变化以及诊疗中的注意事项.[方法]2008年2月～2009年7月共收治肘关节后脱位合并桡骨头和冠状突骨折患者13例.男8例,女5例,平均年龄35.7岁(17～54岁).桡骨小头骨折按照Mason分型:I型3例,Ⅱ型6例,Ⅲ型4例;尺骨冠状突骨折按照Regan-Morrey分型:I型5例,Ⅱ型6例,Ⅲ型2例.均行手术治疗,平均手术时间为伤后7.5 d(1～12 d).术后测量肘关节活动度,并对肘关节功能采用Mayo肘关节功能评分(MEPS)进行评分.[结果]本组13例患者均得到随访,平均随访19个月(14～31个月). 次随访肘关节平均屈伸范围117°;平均前臂旋转140°骨折均达到骨性愈合,2例出现异位骨化.5例患者术后1年肘关节活动时仍感疼痛.随访结束时平均MEPS评分81分(78～96分),其中优4例,良6例,可2例,差1例.[结论]上肢外展、前臂外翻及向后外侧旋转时的高能量损伤是发生肘关节在联损伤的主要原因,这种损伤导致了肘关节的严重小稳.早期手术恢复肘关节稳定、术后早期功能锻炼足预防肘关节三联损伤并发症的关键.     

组配式桡骨小头假体置换治疗合并韧带损伤的Mason Ⅲ型骨折

目的讨论组配式桡骨小头假体置换治疗合并韧带损伤的Masonll[型骨折的临床疗效和同期修复韧带的必要性。方法采用组配式桡骨小头假体对10例成人不稳定MasonllI型骨折进行手术治疗，并同期修复韧带。结果本组获随访11-36个月。按照Morrey等肘部功能评分标准进行评定：优6例，良2例，可2例。结论组配式桡骨小头假体置换可以提高肘关节的稳定性．对成人粉碎严重、不稳定的MasonⅢ型骨折的治疗非常适合，鉴于其不能完全恢复到正常水平，则需要靠修复韧带来弥补。     

老年性肘关节骨折脱位的手术治疗

目的:探讨手术联合外固定治疗老年性肘关节骨折脱位的方法及疗效。方法:回顾性分析2011年7月至2015年8月收治的老年性肘关节骨折脱位7例,其中三联征损伤5例。桡骨头骨折按Mason法分类:Ⅰ型1例,Ⅱ型3例,Ⅲ型1例。尺骨冠突骨折按Regan-Morrey法分类:Ⅰ型1例,Ⅱ型5例,Ⅲ型1例。7例均采取了手术内固定治疗,桡骨头骨折予钢板或Herbert钉固定,尺骨冠状突骨折根据骨折类型予缝线或克氏针或钢板螺钉内固定,并修复侧副韧带。术后屈肘90°前臂旋转中立位石膏外固定3周,3周后拆除石膏改用肘关节可活动铰链支具辅助锻炼。结果:7例均获随访,时间13~48个月,平均20个月,骨折愈合较满意,肘关节稳定,无疼痛。Mayo肘关节功能评分:优3例,良3例,可1例。结论:老年性肘关节骨折脱位骨质疏松,骨量低下,术中难以稳定内固定,经辅助外固定可获得较好的功能恢复。     

MasonⅢ型桡骨小头骨折

桡骨小头骨折是临床上较为常见的肘部骨折，约占17％～19％。粉碎桡骨小头骨折的治疗在临床上存在诸多争议，传统的桡骨小头切除术引发多种远期并发症，已经越来越成为共识。粉碎桡骨小头骨折治疗不当可导致肘关节疼痛、肘关节不稳、旋转功能障碍等症。我院自2005年7月至2007年11月采用切开复位“T”形或“L”形指骨钛板固定累及桡骨颈骨折的MasonⅢ型桡骨小头骨折28例，取得良好疗效，总结如下。     

组配式桡骨小头假体置换治疗合并韧带损伤的MasonⅢ型骨折

目的 讨论组配式桡骨小头假体置换治疗合并韧带损伤的MasonⅢ型骨折的临床疗效和同期修复韧带的必要性.方法 采用组配式桡骨小头假体对10例成人不稳定MasonⅢ型骨折进行手术治疗,并同期修复韧带.结果 本组获随访11～36个月.按照Morrey等肘部功能评分标准进行评定:优6例,良2例,可2例.结论 组配式桡骨小头假体置换可以提高肘关节的稳定性,对成人粉碎严重、不稳定的MasonⅢ型骨折的治疗非常适合,鉴于其不能完全恢复到正常水平,则需要靠修复韧带来弥补.     

肘关节三联征的诊断和治疗进展

肘关节三联征是一种复杂的肘关节骨折脱位,复位后肱尺关节和肱桡关节可达到同心圆复位、肘关节稳定,桡骨及冠突骨折块较小可保守治疗,但需定期复查。若需手术治疗,必须修复桡骨头骨折及外侧副韧带复合体。可以采用单一外侧入路也可以联合前内侧入路。MorryⅠ型和Ⅱ型冠状突骨折是否需固定,是否附加外固定支架固定及同时修复内侧副韧带损伤仍存在争议。     

The contribution of the coronoid and radial head to the stability of the elbow

We undertook this study to determine the minimum amount of coronoid necessary to stabilise an otherwise intact elbow joint. Regan-Morrey types II and III, plus medial and lateral oblique coronoid fractures, collectively termed type IV fractures, were simulated in nine fresh cadavers. An electromagnetic tracking system defined the three-dimensional stability of the ulna relative to the humerus. The coronoid surface area accounts for 59% of the anterior articulation. Alteration in valgus, internal and external rotation occurred only with a type III coronoid fracture, accounting for 68% of the coronoid and 40% of the entire articular surface. A type II fracture removed 42% of the coronoid articulation and 25% of the entire articular surface but was associated with valgus and external rotational changes only when the radial head was removed, thereby removing 67% of the articular surface. We conclude that all type III fractures, as defined here, are unstable, even with intact ligaments and a radial head. However, a type II deficiency is stable unless the radial head is removed. Our study suggests that isolated medial-oblique or lateral-oblique fractures, and even a type II fracture with intact ligaments and a functional radial head, can be clinically stable, which is consistent with clinical observation.     

尺骨近端粉碎性骨折伴肘关节不稳定的治疗

目的 探讨尺骨近端粉碎性骨折伴肘关节不稳定的治疗方法及疗效.方法 尺骨近端粉碎性骨折伴肘关节不稳定患者33例,男23例,女10例;年龄21～61岁,平均41.3岁.11例合并桡骨头骨折,15例合并尺骨冠突骨折,7例同时合并桡骨头及尺骨冠突骨折.采用钢板螺钉内固定治疗,其中一期植骨9例.合并桡骨头骨折患者,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.合并尺骨冠突骨折患者,12例Ⅱ、Ⅲ型骨折患者,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;4例Ⅳ型骨折患者,取自体骨重建冠突,取自体掌长肌腱重建尺侧副韧带前束.结果 患者伤口均一期愈合,骨折愈合率为100%.术后随访8～36个月,平均22个月.3例有创伤性关节炎表现,4例发生轻度创伤性骨化.肘关节平均屈伸范围为112°±24°,前臂平均旋转活动范围为108°±27°.按照Morrey等肘关节功能评定标准进行评价:优10例,良14例,可7例,差2例,总优良率为72.7%.结论 治疗尺骨近端粉碎性骨折伴肘关节不稳可采用钢板螺钉固定尺骨近端骨折,必要时行一期植骨,注意对桡骨头、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.     

Coronoid process fracture

The coronoid process is one of the main constraints providing ulnohumeral joint stability. The coronoid process and the radial head provide a buttress against posterior displacement of the elbow joint. Fracture of the coronoid process can be either an isolated finding following elbow dislocation or part of a more complex fracture-dislocation. Much attention has been focused on treatment of radial head fractures and lateral ligament reconstruction, although recently, attention has been directed at detection and treatment of coronoid fractures. Surgical approaches to coronoid fractures depend on the condition of the radial head. When an associated radial head fracture is present, a lateral approach to the coronoid fracture is often performed. An isolated coronal fracture is typically approached from the medial side. Intraoperative stress testing may be helpful in assessing the need for surgery and choosing the surgical approach.     

Treatment of fractures of the ulnar coronoid process

Objective: To discuss the classification, management and outcome of fractures of the ulnar coronoid process. Methods: Retrospective analysis was carried out in 31 patients (19 men and 12 women of average age 29.8 years [range, 18–52 years]) with fractures of the ulnar coronoid process. The fractures were classified into four major groups based on the extent of injury to the ulnar coronoid process, the state of the anterior bundle of the ulnar collateral ligaments (UCL) and elbow stability. A fracture of the coronoid process less than halfway up was defined as type I (eleven cases); of the middle of the coronoid process with injury of the UCL as type II (nine cases); of the base of coronoid process with dislocation of the elbow joint, sometimes with injury of the UCL, as type III (six cases); and severe comminuted fracture of the coronoid process with elbow instability as type IV (five cases). We chose treatment according to the type of injury. Results: Follow‐up was 18–72 months (average 28.6 months). All patients achieved fracture union without inflammation, neural injuries or elbow instability. One type III and two type IV patients had traumatic osteoarthritis, and two type III and two type IV developed heterotopic ossification. There was a statistically significant difference between the ranges of movement of the two‐side joints in type IV. Conclusion: We choose conservative treatment for type I fractures unless the bone fragment affected movement of the elbow joint, in which case we chose operative treatment so that elbow stability was not affected. Type II and type III fractures with elbow instability were reduced by internal fixation and the ligament repaired or reconstructed. In type IV cases, bone reconstruction was necessary to recover elbow stability. Proper post‐operative rehabilitation can decrease the occurrence of traumatic osteoarthritis.     

Surgical reconstruction of comminuted coronoid fracture in terrible triad injury of the elbow

The terrible triad injury of the elbow is the combination of an elbow dislocation, a radial head fracture and a coronoid process fracture. In this study, we explored the outcome of a modified protocol for terrible triad injury of the elbow in a consecutive series of 14 patients, with a focus on reconstruction of comminuted coronoid fractures. Fourteen patients with terrible triad injuries of the elbow were retrospectively reviewed at a mean follow-up of 23?months (range, 15–30?months) and were clinically and radiographically evaluated. For comminuted coronoid fractures, autografting with resected radial head fragment or ilium fragment with cartilage surface and transosseous suture with non-absorbable suture were performed. Internal fixation of the radial head was performed in six cases and arthroplasty in five. The collateral ligaments were repaired. Mean flexion at last follow-up was 125°, ranging from 100° to 135°. Mean extension loss was 13°, ranging from 0° to 38°. Mean pronation was 70° and mean supination was 66°. No patient experienced dislocation of the radial head prosthesis. The mean Mayo Elbow Performance Score (MEPS) was 87 (range, 75–100), with six excellent cases and eight good cases. According to our intraoperative examination, no patient demonstrated unacceptable residual instability in extension following restoration of all of the osseous and ligamentous lesions. In conclusion, our protocol can achieve stable reconstruction of the coronoid process, which promotes the functional outcome of surgical treatment on terrible triad injuries of the elbow.     

Monteggia''s骨折脱位的相关内容回顾

Monteggia’s骨折脱位是指任何部位的尺骨骨折合并桡骨头脱位。这种累及前臂和肘部的损伤并不常见，其发生率约占前臂骨折总数的5％。本文通过回顾Monteggia’s骨折脱位的历史发展，进一步明确了其定义分型、损伤机制和治疗原则，并对现有的治疗方法和预后评价标准进行了总结，并指出治疗的关键是及时诊断和及时治疗，使尺骨获得优良的解剖复位和稳定固定，另外必须重视对发生在肘关节水平的合并损伤的处理，包括冠状突骨折、桡骨头骨折、肱尺关节后外侧旋转不稳定等。而尺骨的粉碎骨折合并桡骨头骨折、冠状突骨折都将明显影响预后。     

Elbow dislocation with fracture of the coronoid process and comminuted fracture of the radius head

In fractures of the elbow with an associated fracture of the coronoid process, the size of the coronoid fragment determines the stability of the joint. A diminution of the arch of the incisura semilunaris by about 30 degrees causes instability of the elbow. We present an alternative way of treating the special case of a fracture of the coronoid process combined with comminuted fracture of the proximal end of the radius. A suitable fragment of the head of the radius is used to reconstruct the coronoid process. The stability achieved allows early functional postoperative treatment with a good range of movement at the elbow joint.     

Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation

PURPOSE: The purpose of this study was to evaluate the treatment of patients with Mason type III radial head fracture with and without elbow dislocation by open reduction with internal fixation, collateral ligament repair, and early mobilization. An additional purpose was to investigate whether there is any effect of elbow dislocation on the severity and functional outcome. METHODS: Twenty-five patients were treated with open reduction with internal fixation using low-profile miniplate and screws for comminuted fracture of the radial head. Eighteen fractures were Mason type III, and 7 fractures were Mason type III with elbow dislocation. There were 5 women and 20 men with a mean age of 34 years. The mean follow-up time was 27 months. Patients were reviewed for functional ability, physical examination, and radiographic assessment. RESULTS: The mean functional index in Mason type III fracture and Mason type III fracture with elbow dislocation was 87 for both groups. The mean range of motion at the elbow joint was calculated as 5 degrees extension to 136 degrees flexion for Mason type III and 7 degrees extension to 133 degrees flexion for Mason type III with elbow dislocation. The mean pronation and supination for all patients were 74 degrees and 67 degrees , respectively. CONCLUSIONS: Selected Mason III radial head fractures and fracture dislocations could be stabilized satisfactorily with internal fixation. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow after fixation of Mason type III radial head fractures with and without elbow dislocation and ligamentous injury. We believe there is still a role for prosthetic replacement in comminuted Mason III radial head fractures that cannot reliably be treated with open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.     

Newly defined fracture pattern specific to Mason III radial head fractures: fracture description, management and outcomes using screw fixation

Background: Radial head fractures are the most common type of elbow fracture and are universally classified under the Mason classification system. Mason type III fractures are comminuted and are the most difficult to treat, generally requiring plating if possible, or more commonly arthroplasty or excision, which gives a variable outcome. We hypothesized that a new and specific fracture pattern of the radial head (Mason III) can be treated successfully with screw fixation. Methods: Six patients presented to the senior surgeon's clinic with this unusual Mason III fracture pattern. In these patients, the fracture was acute, requiring an open reduction and internal fixation with the use of three headless compression screws. Average follow‐up time was 21 months. Using serial X‐rays and the Broberg–Morrey elbow score, the six acute fractures were evaluated radiologically and functionally. Results: All six patients had good to excellent results using the Broberg–Morrey scoring system. All patients showed radiological and clinical union within 3 months of injury. No patient required revision surgery or excision at a later date. Discussion: We have recognized a specific type of comminuted and displaced Mason III radial head fracture that has not previously been described in the literature. This type of fracture is amenable to open reduction internal fixation with buried compression screws giving a good to excellent outcome, while avoiding the common consequences seen with a radial head excision, arthroplasty or plate fixation.     

Fractures of the Coronoid Process of the Ulna: Which Ones to Fix and Which Ones to Leave Alone: A Review

Abstract The coronoid process of the ulna forms the anterior boundary of the trochlear notch and is crucial for elbow stability. Coronoid fractures are uncommon and they occur in aproximately 10% of elbow dislocations. They are mostly associated with ligamentous and capsular disruptions as well as concomitant fractures. Posterior elbow dislocations, combined with fractures of the coronoid and the radial head are known as the terrible-triad of the elbow. These injuries result in instability of the elbowjoint and, if not treated properly, lead to recurrent dislocations that can cause further damage. Depending on the pattern of the injury and the quality of the bone, the surgeon has to choose from a variety of treatment options. Large coronoid fragments and other associated fractures are ideally treated by ORIF (open reduction internal fixation); a prosthetic radial head replacement may be favorable if a comminuted radial head fracture is not reconstructable. Isolated small coronoid process fractures can be treated non-operatively with satisfactory results. Although rough guidelines can bemade, it is important to view each patient's elbow injury individually and then make a specific treatment plan. Data on treatment results are sparse. Improved understanding of coronoid fractures and their management will result in better outcomes and decrease possible complications including a certain degree of stiffness, neuropathy and arthrosis.