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。     

肘关节内翻-后内侧旋转不稳定的诊断与治疗

近年来,有学者[1-4]根据"后外侧旋转不稳定"提出了"肘关节后内侧旋转不稳定"的概念,即冠状突前内侧面骨折或缺损、外侧副韧带损伤、外侧肱桡关节间隙增宽,骨性损伤使冠状突相对于滑车内侧缘发生半脱位.不同的文献和专著均对其进行了简单的描述,但其名称尚不统一,在第6版的《格林手外科学》[3,5]和第6版的《Rockwood and Green,s fracture in adults》[6]中,即有"后内侧旋转不稳定"、"内翻-后内侧旋转不稳定"、"内翻-后内侧旋转损伤"等多种称呼,即使在同一专著的不同章节中,名称也并不统一.目前,我们根据其损伤机制,将其统一命名为"肘关节内翻-后内侧旋转不稳定".肘关节内翻-后内侧旋转不稳定很少见[4,7-8],此类损伤并不是真正的脱位,因为其关节面常对合正常[9].但有时会发生肘关节半脱位,偶尔还会伴有鹰嘴骨折,但一般不伴有桡骨头骨折[4,8].此类不稳定型骨折可仅表现为轻度的关节不匹配,易漏诊,很快会引起关节退变[10-13].与后外侧旋转不稳定相比,内翻-后内侧旋转机制引起的脱位更不稳定,需要手术治疗的可能性也更大[14].     

单人整复肘关节后脱位

单人整复肘关节后脱位河北医学院附属第三医院（０５００５１）邸军，张学东，周沛肘关节后脱位是人体大关节最常见的脱位之一，常伴有关节内，外骨折及神经损伤。偶亦有血管损伤，手法复位可取得满意疗效。但在病人就诊时往往由于值班人员较少，不能及时予以复位，延缓诊...     

肘关节内翻-后内侧旋转不稳定

肘关节内翻-后内侧旋转不稳定是指冠状突前内侧面骨折或缺损、外侧副韧带损伤和外侧肱桡关节间隙增宽,骨性损伤使冠状突相对于滑车内侧缘发生半脱位。文献报道由于冠状突相对于尺骨干其72%是突出于尺骨干的,因此一旦受到轴向外力撞击,容易发生骨折。肘关节内翻-后内侧旋转不稳定典型的影像学表现为肱桡关节面增宽,冠状突内侧面骨折。由于认识不足,易漏诊,治疗不当或不及时,会引起严重并发症;包括关节不稳定和陈旧性脱位、肘内翻、关节迅速退变出现创伤性关节炎、异位骨化、肘关节僵硬、尺神经炎等。在临床上我们需注意的是,这种损伤与肘关节恐怖三联征损伤机制是相反的。肘关节内翻-后内侧旋转不稳定病因包括骨折未获得解剖复位、骨折不愈合,继发性移位和冠状突骨折块缺血性坏死。因此需早期诊断并通过合理的治疗,能有效防止并发症的发生。多数学者认为此类患者需手术治疗,如冠状突前内侧面骨折块较小,且肘关节稳定性好的患者可以考虑保守治疗。在处理冠状突前内侧骨折时建议采用钢板结合克氏针进行固定。冠状突骨折固定完成后,如外侧不稳定,可切开修复,也可采用铰链式外固定架进行固定保护,外架固定术后第二天即可开始康复训练,效果更确切。对于外侧副韧带复合体是否必须修复有待进一步研究。     

肘关节恐怖三联征的诊治

肘关节脱位可以分为简单型和复杂型两种。简单型脱位仅有关节囊和韧带的损伤,而复杂型脱位常合并有肘关节周围的骨折。1996年Hotchkiss首先将肘关节后脱位合并尺骨冠状突和桡骨头骨折的这种复杂型脱位命名为“terribletriedinjuriesoftheelbow”,国内学者大多将其翻译为“肘关节恐怖三联征”。2005年Armstrong重新定义为肱尺关节后脱位合并尺骨冠状突骨折、桡骨头骨折及外侧副韧带损伤,伴或不伴有内侧副韧带、屈肌一旋前圆肌止点、伸肌总腱、肱骨头及尺骨滑车切迹等骨与软组织损伤。肘关节恐怖三联征可以引起肘关节僵硬、创伤性关节炎、异位骨化等各种并发症,因此,这种损伤越来越受到广大创伤学者的关注。本文将对肘关节恐怖三联征的诊治进行综述。     

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.     

肘关节“恐怖三联征”

肘关节恐怖三联征（Terrible triad of the elbow）指肘关节后脱位同时伴有桡骨头和尺骨冠状突骨折的损伤,属于复杂肘关节骨折脱位的一种,学界对该种损伤认识较晚,     

尺骨冠突前内侧关节面骨折合并肘关节脱位/半脱位(附2例报告)

[目的]介绍"尺骨冠突前内侧关节面骨折合并肘关节后脱位/内旋半脱位"的新概念.[方法]自2005年1月～2006年12月收治2例患者,其损伤特征包括:肘关节后脱位或内旋半脱位;冠突前内侧关节面劈裂骨折呈倒立三角形,连带内侧副韧带前束的附着点高耸结节,为O'Driscoll Ⅱ型;外侧副韧带从起点撕脱.治疗上采用肘关节内、外侧入路,分别固定骨折和修复韧带,并随访1年以上.[结果]肘关节无疼痛和不稳,屈伸和旋转幅度与健侧相同,恢复伤前体力工作.MEPS评分和DASH评分均为优.[结论]认识这一新的肘关节损伤类型,并手术固定骨折和修复韧带,能获得优良的功能效果.     

创伤性肘关节不稳的临床分析

目的：通过创伤性肘关节不稳的临床分析，提高该病的诊治水平。方法：对2001年1月—2002年12月收治的56例肘关节不稳病例进行回顾性分析，内容包括性别、年龄分布、受伤机制、伴发损伤、治疗方法和结果。结果：56例肘关节不稳中男22例，女34例；后外侧旋转脱位51例；50例的受伤机制是上肢过伸位的撑地伤；单纯性脱位40例，复合性脱位16例；伴发周围神经损伤4例；非手术治疗51例，手术治疗5例；随访中有3例关节功能位固定，22例有超过10。的关节伸直受限。结论：绝大多数的创伤性肘关节不稳为单纯性后外侧旋转脱位，肘过伸、旋后位的轴向应力是其主要的受伤机制，治疗以非手术外固定为主，部分复合性脱位需行骨折内固定和软组织修复与重建。     

肘关节不稳的诊断治疗

肘关节不稳是急性骨折脱位及慢性运动劳损中常见的肘部疾患,对于急性肘关节不稳的治疗至关重要,及时治疗避免形成慢性不稳.慢性不稳治疗较为困难.本文综述了肘关节不稳的表现、诊断及治疗.肘关节不稳的治疗原则为将复杂的骨折脱位变为简单的骨折脱位,恢复解剖结构,包括关节面和软组织.肱尺关节损伤时外侧组织的修复尤为重要.肘关节复发性不稳应以手术治疗为主.     

Total elbow arthroplasty for complete ankylosis of the elbow

Sixteen patients who received nineteen semiconstrained total elbow replacements for complete ankylosis of the elbow were followed for an average of five and three-quarters years (range, two to twelve years). The average preoperative elbow score was 23 points and the average postoperative score was 84 points. Postoperatively, the average flexion was 115 degrees; extension, 35 degrees; and pronation and supination, 95 degrees. There were fifteen excellent or good results. There was one failure due to a deep infection, but after removal of the prosthesis a satisfactory fascial arthroplasty was achieved in this elbow. Function was improved in all patients, and all patients had relief of the preoperative pain. For the arthroplasty to succeed, the patient must have a good understanding of the procedure and must be willing and able to comply with the postoperative rehabilitation program. The use of a semiconstrained, often custom-fit, implant is necessary. The Bryan-Morrey posteromedial approach to the elbow is recommended for the procedure, since this approach allows early institution of range-of-motion exercises.     

Total elbow arthroplasty in primary osteoarthritis of the elbow

Primary osteoarthritis of the elbow is an infrequent condition typically managed by some form of debridement. There is no comment in the literature regarding prosthetic replacement for this condition. We report 5 patients (mean age, 68), with a minimum assessment of 3 years (range, 37–125 years) after total elbow arthroplasty. Complications in 4 patients included subluxation, fracture of a humeral component with particulate synovitis, heterotopic ossification, recurrent osteophyte formation, and transient ulnar neuropathy. Although revision was required in 2 of the 5, currently all experience had satisfactory outcomes. While replacement has proven ultimately to be a successful option for this high-demand patient group because of the high complication rate, we do not recommend replacement unless alternate operative options are deemed unacceptable.     

Coonrad-Morrey半限制型假体全肘关节置换的临床应用

目的 探讨Coonrad-Morrey型半限制型假体全肘关节置换术的疗效.方法 2003年12月至2008年4月采用Coonrad-Morrey半限制型假体治疗肘部疾患30例(31肘),其中新鲜肱骨髁间骨折18例,髁间骨折内固定失效或骨折不愈合9例,类风湿性肘关节炎(RA)2例(3肘),骨性关节炎(OA)1例;其中男性8例,女性22例;年龄47～78岁,平均66岁.结果 20例(21肘)获得随访,均为骨折患者,平均随访35个月(12～52个月),术前因疼痛无法判断Mayo肘关节功能评分(MEPS评分),术后MEPS评分平均为84分;21肘中,6肘优(28%),11肘良(52%),2肘可(10%),2肘差(10%).优良率80%.并发症:1例术后发生"针-针系统"失效,1例术后切口迟延愈合,1例尺神经支配区域感觉减退,2例异位骨化.结论 全肘关节置换治疗肘关节损伤可解除疼痛、恢复稳定性及改善活动范围.对于老年肱骨髁间粉碎性骨折及骨折不愈合,严格选择病例,可获得较满意疗效.     

定制型人工肘关节重建肘部肿瘤切除后骨缺损

目的 探讨肘关节周围肿瘤切除术后行全肘关节成形术的疗效及并发症处理.方法 1998年6月至2007年6月,19例患者在北京大学人民医院接受了肿瘤切除后全肘关节置换术.其中男性13例,女性6例;转移癌6例,骨巨细胞瘤1例,恶性纤维组织细胞瘤(MFH)2例,骨肉瘤4例,尤文肉瘤3例,恶性淋巴瘤1例,滑膜肉瘤1例,骨的硬纤维瘤1例;年龄15～71岁,平均43岁;肱骨远端9例,尺骨近端5例,肱骨远端及尺骨近端均受累5例.结果 除1例失随访外,18例患者均至少随访1年或随访至死亡,平均随访时间37个月.根据Mayo评分标准,平均疼痛评分从3.6降至2.0.肘关节的平均屈伸范围由29°改善为73°(范围:55°～105°).14例患者手术效果优良(14/18,77.8%),4例患者手术效果可以接受(4/18,22.2%).尚无患者出现术后感染及伤口并发症.在随访期间,2例肺癌、1例直肠癌及1例卵巢癌骨转移患者均分别死于术后2年内.2例尤文肉瘤、1例MFH及1例骨肉瘤出现肺转移(4/18,22.2%),肿瘤局部复发2例(11.1%).3例患者术后随访中出现并发症(3/18,16.7%),1例患者术后5年出现肱骨假体柄穿出骨皮质,1例患者术后4年出现尺骨假体柄穿出骨皮质,2例均经设计较长假体柄行假体翻修术.1例患者术后4年出现肱骨假体柄松动,行假体翻修术后功能良好.结论 肿瘤切除后实施全肘关节成形术能够显著减轻疼痛,改善功能.转移瘤的患者,特别是其他方法 均不能缓解症状时,也可以采用这种手术方法.     

Total elbow arthroplasty in the treatment of posttraumatic conditions of the elbow

Posttraumatic arthritis, arthritis secondary to instability, and nonunion or malunion about the elbow may be treated by various methods. Recommended first-line treatment in the younger, more active patient population is nonprosthetic techniques. Total elbow arthroplasty should be considered primarily as a salvage procedure for these patients. Careful patient selection will determine whether total elbow arthroplasty is an acceptable choice, despite its inherent risks and complications. Prosthetic replacement is more applicable for patients with low physical demands who are older than 60 years of age with pain, stiffness, and/or instability of the elbow who will more likely be able to comply with postoperative rehabilitation and strict activity restrictions. Previous incisions, gross instability, periarticular fibrosis with ulnar nerve encasement, loss of bone and/or soft tissue, and previous infections represent obstacles for prosthetic reconstruction in these patients. The use of unlinked total elbow designs require good bone stock with little deformity and stable capsuloligamentous support, which uncommonly is found in elbows after trauma. Linked semiconstrained prostheses have been used most frequently with good short-term results reported in the literature. Reported failure rates after longer followup have led to a search for improvements in prosthetic design, cementing techniques, and better patient selection.     

Stabilizers of the elbow

The elbow joint is stabilized by the conforming shape of its articular surfaces, by the joint capsule and collateral ligaments, and by muscles that pass across the joint. Each of these static and dynamic stabilizers serve to keep the joint surfaces in apposition. The relative contribution of these structures to stability varies as a function of joint orientation and the extent of muscle activation. In this article our present understanding of the stabilizers of the elbow is reviewed. Important implications regarding the management of osseous and ligamentous injuries about the elbow are highlighted.     

Fracture-dislocation of the elbow

Recognition of the pattern of an elbow fracture-dislocation allows immediate knowledge of the treatment principles, pitfalls, and prognosis of the injury. Specific techniques for each injury component increase the surgeon's ability to restore stability to the elbow. When complications are anticipated and avoided or addressed expediently, it is possible to restore elbow function in spite of the complexity of these injuries.     

Osteochondromatosis of the elbow

A case of osteochondromatosis of the elbow is reported with clinical, operative and pathologic findings. Postoperative observation over a period of five months showed practically complete return of function, the principal feature of disability being a 10-degree restriction of extension of the elbow.     

Arthroplasty of the elbow

Elbow arthroplasty is still one of the less frequently performed joint replacement procedures. It is technically demanding, and numerous complications are possible. It is therefore indicated mainly in severely handicapped patients in whom all other alternatives have been attempted. A review of the literature relating to arthroplasties monitored over follow-up periods of more than 5 years shows that the results are now quite acceptable. They are far better than those seen following most resection arthroplasties. The results achieved with our GSB III prosthesis are compared with those obtained with other prosthetic devices in current use. It appears that in a large proportion of cases our prosthesis allows a good range of painfree motion, which we attribute in part to the operative approach used. The complication rate appears to be relatively low.