慢性肘关节不稳定的手术治疗

目的探讨慢性肘关节不稳定的原因和治疗方法。方法1998年8月～2002年8月,12例慢性肘关节不稳定患者完善体格检查及影像学检查,结合术中探查,分析其原因；采用内、外侧入路分别或同时修复与重建肘关节尺、桡侧副韧带,总结疗效。桡侧副韧带的修复方法是将指总伸肌腱的外侧半劈开向外侧转位,将外侧关节囊重叠缝合数针后,在尺骨冠突外侧尺侧副韧带前束的起止点处钻骨孔,将转位的肌腱穿过骨孔后缝合重建桡侧副韧带前束,然后将伸肌总腱缝合。尺侧副韧带的修复是将屈肌总腱劈为两半,取外侧半,保留其在肱骨髁的止点,从尺骨冠突内侧钻骨孔后将肌腱条穿过骨洞后反折缝合固定于尺侧副韧带前束的止点处,将后束增生瘢痕尽量切除,缝合关节囊及屈肌总腱。结果所有患者随访2～6年,平均3年。肘关节未发生复发性脱位,应力外翻试验阴性,肘关节外侧及后外侧轴移试验(PST)阴性,肘部无疼痛；活动范尉：平均屈伸0～135°,前臂旋转：平均旋前85°、旋后80°,患者均恢复正常生活及工作。根据中华医学会手外科学会(2000年,无锡)全国上肢功能评定标准进行肘关节功能评价,本组优8例,良4例,优良率为100%。结论慢性肘关节不稳定主要原因是肘关节侧副韧带损伤；采用手术重建肘关节侧副韧带治疗慢性肘关节不稳定效果可靠。     

前内侧入路结合外侧入路内固定治疗肘关节三联征

目的：探讨前内侧入路结合外侧入路治疗肘关节三联征的临床疗效。方法：2009年11月至2013年3月,采用前内侧入路结合外侧入路治疗肘关节三联征17例,男11例,女6例;年龄22~68岁,平均36.6岁;左侧10例,右侧7例。术中前内侧入路采用肘关节前内侧切口桡侧腕屈肌和掌长肌之间劈开指浅屈肌入路对冠状突骨折进行复位内固定,外侧入路采用肘关节外侧Kocher入路,沿肱骨外上髁在肱三头肌和肱桡肌间隙切开,向下在后侧的肘肌和尺侧腕伸肌间隙切开,显露外侧副韧带、关节囊和桡骨小头,采用微型钢板及螺钉固定桡骨小头,用带线锚钉修复外侧副韧带复合体。术后根据Mayo肘关节功能评分评价肘关节功能。结果：所有患者获得随访,时间13~24个月,平均12.4个月。所有患者术后末次随访时肘关节平均屈曲（134.0±8.8）°,平均伸直受限（6.4±2.3）°。末次随访时Mayo肘关节功能评分：疼痛42.4±5.9,屈伸活动17.6±2.6,关节稳定性9.7±1.2,日常生活功能22.1±2.5,总分91.8±7.9;优13例,良4例。术后2例出现一过性尺神经麻痹症状,异位骨化1例,无感染、骨折不愈合、肘关节不稳、脱位及僵硬等并发症发生。结论：前内侧入路结合外侧入路治疗肘关节三联征疗效可靠,术中能充分显露骨折部位,利于内固定植入,带线锚钉修复韧带可使关节获得充分稳定性,利于早期功能锻炼。     

肘关节副韧带的形态结构特点及功能分析

目的 搪塞肘关节副韧带的形态结构特点在不同屈曲角度时的形态变化规律。方法 在５４侧成人肘关节标本上解剖、观察肘关节副韧带的组成、形态特点及肘关节不同屈曲角度时副带的形态变化。结果 （１）尺侧副韧带前束起于肱骨内上髁的前下方,止于尺骨冠突内小结节;后束起于肱骨内上髁的内下方,止于尺骨鹰嘴内侧的骨面;（２）桡侧副韧带直于肱骨个上髁的外下方,其纤维部分止于环状韧带,部分止于尺骨冠突的外下方;桡侧副韧带     

肘关节侧副韧带的解剖及临床意义

肘关节是人体内对合最好的关节之一,在一个关节囊内,肱骨、尺骨和桡骨组成了三个关节。组成关节的骨性结构、侧副韧带及周围软组织为肘关节提供了稳定性。内侧副韧带(MCL)可对抗外翻应力,并对肱尺关节提供支撑,MCL功能不全时可出现肘内侧疼痛及外翻松驰。外侧副韧带(LCL)为肱骨、环状韧带(AL)及尺骨近端提供了稳定,以维持前臂近端与肱骨滑车和肱骨小头之间的正常关系。LCL功能不全相对少见,也没有特殊的运动方式容易发生LCL损伤,临床上可表现为后外侧旋转不稳定。     

急性肘关节尺侧副韧带损伤的诊断治疗

肘尺侧副韧带损伤是较常见的肘关节运动性损伤。一旦尺侧副韧带损伤将导致肘关节内侧疼痛和外翻不稳定,对于该韧带完全性撕裂,症状严重,被动肘外翻畸形明显的,要考虑手术治疗,通过手术恢复尺侧副韧带,恢复肘关节的稳定性。我院自2000年6月至2006年12月共手术治疗14例急性肘关节尺侧副韧带损伤病例,取得良好效果,现报告如下：     

肘外侧软组织压痛点的临床解剖学研究

目的 研究肘外侧软组织压痛点的解剖结构,为诊治肘外侧软组织痛提供解剖学依据.方法 解剖7具上肢标本,观测临床肘外侧常见压痛点(肱骨外上髁、肱桡关节间隙、环状关节面、Frohse弓和旋后肌)的解剖结构.结果 肱骨外上髁处附着的肌腱有前臂伸肌总腱、肱桡肌和旋后肌的部分起始腱;肱桡关节间隙前壁为肘关节囊纤维层,外侧壁为桡侧副切带;环状关节而表而被环状韧带覆盖,环状韧带两端附于尺骨桡切迹的前后缘,近端外侧通过桡侧副韧带附着于肱骨下端外上髁;旋后肌起点与尺侧腕伸肌起点愈着,肌腱与桡骨环状韧带和尺骨旋后肌嵴相连.肌纤维斜向下外走行,并向前包绕桡骨,止于桡骨上1/3的前面.结论 肘外侧各压痛点均有其各自对应的解剖结构,在诊治肘外侧软组织疼痛性疾病时应考虑到上述解剖学结构特征.     

胸背动脉—腹壁下动脉—旋股外侧动脉升支联合供应超长皮瓣移植一例报告

患者男,18岁。梳棉机致右上肢外伤5h入院。查体:右上肢从肩峰至手背桡侧纵长皮肤及软组织缺损,桡神经及肱三头肌桡侧半从肱骨中段至肘关节平面缺损,肱骨远段外侧皮质及外髁部分磨损,桡骨小头半脱位,桡动静脉、头静脉及桡侧腕长、短伸肌和肱桡肌从肘下3cm至腕关节平面全长缺损,前臂指浅屈肌桡侧半缺损。正中神经在前臂中段至腕部缺损约12cm,尺神经及尺动、静脉完好。前臂及手部血运良好,手指屈曲尚可,但掌指关节不能伸直,拇指不能对掌。创面污染严重,布满棉花碎絮,面积约85cm×10～14cm(图1)。     

肘关节后外侧旋转不稳定韧带损伤的载线影像学特点研究

目的 ：探讨肘关节外侧韧带复合体对肘关节后外侧旋转不稳定的作用及韧带损伤时肘关节侧位X线影像学中桡肱率变化特点。方法：取冷冻保存的新鲜成人肘关节标本20侧,将标本制成肘关节＂骨-韧带＂标本,随机分为两组。利用自行设计的维持肘关节后外侧旋转活动度的设备固定标本,A组按次序切断外侧结构：A1组,外侧韧带完整的标本组;A2组,切断桡侧尺副韧带组;A3组,增加切断环状韧带组;A4组,最后切断桡侧副韧带组。B组分为：B1组,外侧韧带完整的标本组;B2组,切断桡侧副韧带组;B3组,再切断环状韧带组;B4组,最后切断桡侧尺副韧带组。分别摄肘关节侧位X线片,在PACS系统中测量桡肱率,比较各组的差异,并统计分析。结果：A组,统计分析各组数据,各组间桡肱率增加差异有统计学意义。B组,统计分析前2次切断韧带,各组间桡肱率增加差异无统计学意义。切断桡侧尺副韧带（B4组）,与前3组比较差异有统计学意义。结论：桡侧尺副韧带是限制肘关节后外侧旋转脱位的主要结构,环状韧带、桡侧副韧带为次要结构;并根据肘关节后外侧旋转不稳定X线影像学特点将其分为4个等级。     

尺侧副韧带重建术治疗过顶投掷运动员尺侧副韧带损伤的研究进展

肘关节尺侧副韧带（UCL）是肘部外翻的主要稳定结构,其损伤常见于过顶投掷运动员,主要由反复受到外翻力所致,可导致肘部疼痛和影响运动员职业生涯。治疗过顶投掷运动员尺侧副韧带损伤的常用治疗手段是尺侧副韧带重建术（UCLR）。现已有多种UCLR不断被改良,主要体现在移植物构造、切口暴露、尺神经处理以及移植物在肱骨和尺骨隧道固...     

环状韧带重建术治疗陈旧性孟氏骨折桡骨头脱位

我院自 1985年开始对成人陈旧性孟氏骨折中的桡骨头脱位 ,行环状韧带重建术 ,治疗桡骨头脱位 36例 ,取得了满意的临床效果。1　临床资料　　本组 36例 ,男 2 0例 ,女 16例 ;左侧 2 3例 ,右侧 13例。桡骨头肘前脱位者 32例 ,肘后脱位者 4例。合并桡神经迟发损伤者 3例。2　治疗方法在臂丛神经阻滞和气囊止血带下 ,取肘后外侧切口。自肱骨外髁上方 2ｃｍ ,沿肱三头肌外缘至鹰嘴外侧 ,向远侧沿尺骨背侧直至尺骨骨折及畸形处 ,长约 8ｃｍ。剥离肘后肌及尺侧腕屈肌。在剥离肘后肌时 ,应从尺骨附着处开始 ,暴露桡骨头及桡骨近端和尺骨上段桡侧面 ,…     

肘关节尺侧副韧带屈曲角度与负荷关系的生物力学研究

[目的]研究肘关节尺侧副韧带(UCL)在不同的肘关节屈曲角度时生物力学特性的变化.[方法]选取8对新鲜冰冻肘关节尸体标本,测量每个标本在前臂旋前、旋后、中立位时,肘关节不同被动屈曲角度下UCL的张力变化;测量UCL在肘关节不同屈曲角度下(30°、50°、70°、90°)外翻应力试验时失效载荷与屈曲角度的关系.[结果]肘关节在被动屈曲0°～57°时,对UCL前束的前带和后带均没有产生超过3%的张力,屈曲导致的张力改变对后带的影响有显著性(P＜0.01),对前带的影响无显著性(P=0.128).在57°以后,后带上的张力随着屈曲角度的增大而增加,在100°～130°左右的范围达到最大.前臂的旋转对韧带张力的影响无显著性.在肘关节屈曲90°时UCL断裂失效所需载荷最大,在屈曲30°时最小.UCL断裂好发部位为其前束肱骨内侧髁止点处.[结论]UCL损伤或者重建术后的固定角度应为肘关节屈曲＜57°,早期的康复锻炼肘关节屈曲0°～57°为安全范围.肘关节在屈曲90°时具有最高的外翻稳定性,可以减少UCL损伤机率.     

Our operative approach to the elbow joint

Summary Several surgical approaches to the elbow joint have been described. The disadvantage of all is an insufficient view of a single incision to the anterior and posterior as well as the ulnar aspect of the joint. They require therefore an additional incision or the resection of the radial head with a detachment of the radial collateral ligament. Our single incision allows for an extensive view to the anterior and posterior aspect of the elbow joint without resection of the radial head and the sacrificing of the radial collateral ligaments. It makes in most instances an additional ulnar incision unnecessary. This incision has mainly been tested for subtotal elbow synovectomy in rheumatoid arthritis, for the mobilization of posttraumatic stiff elbows and the removal of loose bodies as in chondromatosis.     

The in vivo isometric point of the lateral ligament of the elbow

BACKGROUND: Many reports have discussed reconstruction of the lateral ulnar collateral ligament for the treatment of posterolateral rotatory instability of the elbow, but information regarding the isometric point of the lateral ligament of the elbow is limited. The purposes of the present study were to investigate the in vivo and three-dimensional length changes of the lateral ulnar collateral ligament and the radial collateral ligament during elbow flexion in order to clarify the role of these ligaments as well as to identify the isometric point for the reconstructed lateral ulnar collateral ligament on the humerus where the grafted tendon should be anchored. METHODS: We studied in vivo and three-dimensional kinematics of the normal elbow joint with use of a markerless bone-registration technique. Magnetic resonance images of the right elbows of seven healthy volunteers were acquired in six positions between 0 degrees and 135 degrees of flexion. We created three-dimensional models of the elbow bones, the lateral ulnar collateral ligament, and the radial collateral ligament. The ligament models were based on the shortest calculated paths between each origin and insertion in three-dimensional space with the bone as obstacles. We calculated two types of three-dimensional distances for the ligament paths with each flexion position: (1) between the center of the capitellum and the distal insertions of the ligaments (to investigate the physiological change in ligament length) and (2) between eight different humeral origins and the one typical insertion of the lateral ulnar collateral ligament (to identify the isometric point of the reconstructed lateral ulnar collateral ligament). RESULTS: The three-dimensional distance for the lateral ulnar collateral ligament was found to increase during elbow flexion, whereas that for the radial collateral ligament changed little. The path of the lateral ulnar collateral ligament gradually developed a detour because of the osseous protrusion of the lateral condyle with flexion. The most isometric point for the reconstructed lateral ulnar collateral ligament was calculated to be at a point 2 mm proximal to the center of the capitellum. CONCLUSIONS: The radial collateral ligament is essentially isometric, but the lateral ulnar collateral ligament is not. The lateral ulnar collateral ligament is loose in elbow extension and becomes tight with elbow flexion.     

尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤的手术治疗

目的探讨尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤的手术治疗方法及临床疗效。 方法回顾性分析2011年4月至2014年7月四川省骨科医院收治且获完整随访的9例尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤患者临床资料。其中男6例,女3例;年龄20~62岁,平均41岁。致伤原因：跌伤3例,自行车伤1例,电动自行车伤3例,交通事故伤2例。均为新鲜闭合骨折;无神经、血管损伤。受伤至手术时间4~12 d,平均7.2 d。均为O'Driscoll分型2型,其中1亚型1例,2亚型5例,3亚型3例。其中肘关节外侧副韧带肱骨外髁止点撕脱骨折4例,其余5例术中证实肘关节外侧副韧带肱骨外髁止点撕脱。伴有尺骨鹰嘴骨折或为肘关节恐怖三联征患者未纳入本组。经肘关节前侧或内侧入路复位,以支撑钢板、缝合锚、螺钉固定冠状突骨折及修复前侧关节囊。经后外侧入路,以缝合锚修复外侧副韧带。 结果术后切口均Ⅰ期愈合,无血管神经损伤。随访时间12~48个月,平均25.6个月,X线片示骨折均愈合。随访期间无内固定物失效、肘关节不稳定、创伤后骨关节炎等并发症发生。末次随访时患肘关节活动范围：伸肘0~10°,平均1.1°;屈肘110~135°,平均128.9°;前臂旋前40~70°,平均61.1°;旋后80~90°,平均88.9°。Broberg和Morrey肘关节功能评分为82~100分,平均95分;优6例,良3例,优良率100%。疼痛视觉模拟评分为0~2分,平均0.7分。 结论重视和识别尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤,对于存在肘关节内翻后内侧旋转不稳定者,根据冠状突骨折块的大小、部位及形态,经肘关节前侧或内侧入路复位,以支撑钢板、缝合锚及螺钉固定,修复前侧关节囊,经肘关节后外侧入路,以缝合锚修复外侧副韧带,术后早期活动锻炼,可获得满意疗效。     

Lateral collateral ligament deficiency of the elbow joint: A modeling approach

A computational model capable of predicting the effects of lateral collateral ligament deficiency of the elbow joint would be a valuable tool for surgical planning and prediction of the long‐term consequences of ligament deficiency. The purpose of this study was to simulate lateral collateral ligament deficiency during passive flexion using a computational multibody elbow joint model and investigate the effects of ligament insufficiency on the kinematics, ligament loads, and articular contact characteristics (area, pressure). The elbow was placed initially at approximately 20° of flexion and a 345 mm vertical downward motion profile was applied over 40 s to the humerus head. The vertical displacement induced flexion from the initial position to a maximum flexion angle of 135°. The study included simulations for intact, radial collateral ligament deficient, lateral ulnar collateral ligament deficient, and combined radial and lateral ulnar collateral ligament deficient elbow. For each condition, relative bone kinematics, contact pressure, contact area, and intact ligament forces were predicted. Intact and isolated radial collateral ligament deficient elbow simulations were almost identical for all observed outcomes. Minor differences in kinematics, contact area and pressure were observed for the isolated lateral ulnar collateral ligament deficient elbow compared to the intact elbow, but no elbow dislocation was detected. However, sectioning both ligaments together induced substantial differences in kinematics, contact area, and contact pressure, and caused complete dislocation of the elbow joint. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1645–1655, 2016.     

Arthroscopic release for the severely stiff elbow

Arthroscopic release for the stiff elbow has been widely used, but there are no reports limited to severe stiffness. The purpose of this study was to investigate the outcomes of severe cases. Ten patients with 10 severely stiff elbows defined by a limited arc of ≤ 60° underwent this arthroscopic release. Causes of stiffness were post-traumatic stiffness (one patient), osteoarthritis (three patients), and rheumatoid arthritis (six patients). Using arthroscopy, the capsule contracture and the intra-articular fibrosis were removed and the impinging osteophyte and part of the radial head were resected. For four patients with preoperative ulnar nerve symptoms or contracture of the posterior oblique ligament of the medial collateral ligament, mini-open ulnar nerve neurolysis and release of the posterior oblique ligament were performed. Patients were followed up for an average of 24 months. Arthroscopic release could be performed without any intraoperative complications. Range of motion for the elbow significantly improved from 95° of flexion and − 55° of extension to 109° of flexion and − 32° of extension. The Mayo Elbow Performance Score also improved from 56 points to 80 points. Two patients underwent a second arthroscopic surgery and gained further arc of motion. One patient showed osteophyte reformation and needed revision open surgery 1 year after the initial surgery. Arthroscopic release for the severely stiff elbow could improve range of motion. Careful attention should be given during surgery to avoid complications such as intramuscular bleeding or nerve damage.     

肘内侧副韧带损伤的病理发现及其临床意义

目的　探讨肘内侧副韧带损伤的病理发现及其临床意义。方法　肘内侧副韧带严重损伤的病例 6 4例 ,前臂屈肌起点前部、中部和后部撕裂。采用不同方法缝合。结果　随访 2年至 8年 ,疗效良好 ,肘关节侧向稳定 ,仅见肘伸直受限 5°和肘屈伸受限 10°各 1例。结论　肘内侧副韧带断裂宜及早手术 ,切除小撕脱骨片 ,恢复和保持肌起点和韧带断端的正常接触。     

Single-strand reconstruction of the lateral ulnar collateral ligament restores varus and posterolateral rotatory stability of the elbow

Because of a lack of biomechanical studies of lateral elbow ligament reconstruction in the literature, the initial stability afforded by 3 different techniques of lateral ulnar collateral ligament reconstruction was evaluated in 8 cadaveric elbows. The arm was mounted in a testing apparatus, and passive flexion was performed with the arm in varus and valgus orientations. A pivot shift test was performed with the arm in the vertical orientation. An electromagnetic tracking device was used to quantify motion pathways. After intact testing, each specimen underwent sectioning of the radial collateral and lateral ulnar collateral ligaments from the lateral epicondyle. Reconstruction of the lateral ulnar collateral ligament was performed in a randomized sequence, consisting of proximal single-strand, distal single-strand, and double-strand tendon grafts. Division of the radial collateral and lateral ulnar collateral ligaments from the lateral epicondyle caused a significant decrease in rotational stability when the pivot shift test was being performed (P <.0001). Varus-valgus stability also decreased after transection of the radial collateral and lateral ulnar collateral ligaments (P <.0001). Reconstruction of the lateral ulnar collateral ligament restored elbow stability to that of the intact state. There was no significant difference in stability between the single- and double-strand repair techniques (P >.05). This study demonstrates that both single- and double-strand reconstructions restore varus and posterolateral elbow stability and may be considered appropriate reconstructive procedures in patients with symptomatic insufficiency of the lateral ligaments of the elbow.     

Untreated intra-articular entrapment of the medial humeral epicondyle

Six children with entrapment of the medial epicondyle in the elbow after closed reduction of a posterior dislocation were seen an average of 14 weeks after injury. The elbows were painful and the average range of flexion was 22 degrees. Two children had ulnar nerve involvement which recovered after operation. The epicondyle was removed from the joint and either reattached to the humerus or excised, and the muscles reattached. Two children had anterior transposition of the ulnar nerve, one for pre-operative hyperaesthesia, and the other to relieve tension on the nerve. At follow-up, at an average of 15 months after operation, flexion had increased fivefold, none of the children had pain and all were leading normal lives.     

Understanding the medial ulnar collateral ligament of the elbow: Review of native ligament anatomy and function

The medial ulnar collateral ligament complex of the elbow, which is comprised of the anterior bundle [AB, more formally referred to as the medial ulnar collateral ligament (MUCL)], posterior (PB), and transverse ligament, is commonly injured in overhead throwing athletes. Attenuation or rupture of the ligament results in valgus instability with variable clinical presentations. The AB or MUCL is the strongest component of the ligamentous complex and the primary restraint to valgus stress. It is also composed of two separate bands (anterior and posterior) that provide reciprocal function with the anterior band tight in extension, and the posterior band tight in flexion. In individuals who fail comprehensive non-operative treatment, surgical repair or reconstruction of the MUCL is commonly required to restore elbow function and stability. A comprehensive understanding of the anatomy and biomechanical properties of the MUCL is imperative to optimize reconstructive efforts, and to enhance clinical and radiographic outcomes. Our understanding of the native anatomy and biomechanics of the MUCL has evolved over time. The precise locations of the origin and insertion footprint centers guide surgeons in proper graft placement with relation to bony anatomic landmarks. In recent studies, the ulnar insertion of the MUCL is described as larger than previously thought, with the center of the footprint at varying distances relative to the ulnar ridge, joint line, or sublime tubercle. The purpose of this review is to consolidate and summarize the existing literature regarding the native anatomy, biomechanical, and clinical significance of the entire medial ulnar collateral ligament complex, including the MUCL (AB), PB, and transverse ligament.