儿童陈旧性桡骨头脱位合并桡神经损伤的治疗分析(附26例报告)

[目的]评价儿童陈旧性桡骨头脱位合并桡神经深支损伤（Monteggia骨折）手术治疗的中、远期效果。[方法]8例单纯性桡骨头脱位合并桡神经损伤采用切开整复桡骨头脱位重建环状韧带术治疗（5例患者同时施行神经松解术）。18例Monteggia骨折合并桡神经深支损伤采用切开尺骨矫形、桡骨头复位并重建环状韧带术治疗（9例同时施行神经松解术）。[结果]26例患者随访6个月～2a，根据肘功能评价标准（美国特种外科医院，HSS），评定结果：术前优良率88．4％；术后优良率84．6％。桡神经深支功能恢复优良率：松解组71．4％；非松解组91．6％。[结论]手术切开整复桡骨小头脱位重建环状韧带治疗儿童陈旧性桡骨头脱位效果良好；桡神经深支损伤在桡骨头脱位整复后大多能自行恢复，神经松解效果欠佳。     

同侧上肢多处骨折脱位的处理

同侧上肢多处骨折脱位是较少见的严重创伤,治疗较困难。1980～1989年泸州市三个医院共治疗28例,现报告如下。 1 临床资料 1.1 一般资料 本组28例,男21例,女7例。年龄6～33岁,平均18.5岁。致伤原因:高处坠落伤25例,车创伤3例。随访时间:1～9年,平均2年3个月。 28例共83处骨折伴42个关节脱位。其中一肢4处骨折伴2个关节脱位8例(肱骨干或肱骨髁上、尺骨鹰嘴、尺桡双骨折伴肘和上或下尺桡关节脱位5例;肱骨内或外髁、桡骨和尺骨多段骨折伴肘和上或下尺桡关节脱位3例);3处骨折伴1～2个关节脱位11例(肱骨外科颈或肱骨下l/3和尺桡双骨折伴肩或肘和上或下尺桡关节脱位3例;肱骨内或外髁及尺桡双骨折伴上下及上或下尺桡关节脱位6例;肱骨干及肱骨内或外髁及桡骨骨折伴肘关节脱位2例);2处骨折伴1个关节脱位9例(肱骨髁间粉碎骨折和桡骨骨折伴肘关节脱位3例;尺桡双骨折伴上或下尺桡关节脱位6例)。28例中9例(处)为开放性骨折,3例并桡神经损伤,肱动脉和尺神经损伤各1例。     

儿童上肢晚期神经损伤的治疗

报告并评价儿童上肢晚期神经损伤的治疗效果。方法：报道１３岁以下儿童平均７岁上肢晚期神经损伤１５例２１条（正中神经８条，尺神经７条，桡神经５条，肌皮神经１条）。完全断裂９条，粘连、压迫１２条。损伤神经的处理时间为伤后１年至１４年（平均４年４个月）。采用神经外膜对端缝合术７条，神经松解术１２条，自体神经移植术１条，神经瘤对端缝合术１条。结果：１３例１８条神经随访１年至２３年６个月（平均４年９个月），优良率为６６．７％，尚有２７．８％病人恢复了保护性感觉。结论：本研究证实晚期神经损伤有修复价值，儿童病人能取得更满意疗效。     

中西医结合治疗开放性复杂关节内骨折

自１９８９年始应用中西医结合的方法治疗开放性复杂关节内骨折３２例，取得较满意的效果，现报道如下。临床资料３２例中男２４例，女８例；年龄１２～６１岁；肱骨髁间骨折８例，股骨髁间骨折５例，胫骨平台骨折６例，三踝骨折１３例；全部为粉碎性，程度严重，移位明显；１３例合并关节脱位（其中肘关节脱位３例，踝关节脱位１０例），神经损伤６例（桡神经４例，腓总神经１例，尺神经１例），１１例合并休克，１８例合并其它部位的骨折和损伤；车祸１２例，高处坠落１５例，重物压砸３例，棍棒击打２例；伤后就诊时间从２０分钟至８小时…     

肱骨干骨折合并桡神经损伤不同治疗方法的临床分析

目的探讨不同疗法治疗肱骨干骨折合并桡神经损伤的临床效果。方法选取2012-01—2014-01间收治的60例肱骨干骨折合并桡神经损伤患者,依据不同治疗方法分为2组。A组35例实施早期桡神经探查治疗,B组25例实施保守治疗。观察2组的治疗效果。结果 A组优良率为88.6%,B组优良率为80.0%。A组术后随访时间为(12.2±2.3)个月,骨折愈合时间为(4.1±0.3)个月。B组术后随访时间为(12.1±2.4)个月,骨折愈合时间为(4.0±0.2)个月。2组患者术后无1例发生延迟愈合或者骨不连。2组差异均无统计学意义(P0.05)。结论对肱骨干骨折合并桡神经损伤患者给予早期桡神经探查或采取保守治疗均能够提高整体治疗效果,促进神经功能的恢复。     

桡骨远端骨折合并腕部尺神经损伤的诊断与治疗

目的总结桡骨远端骨折合并腕部尺神经损伤的发病机制、临床表现和治疗方法。方法对桡骨远端骨折合并尺神经支配区单纯掌侧感觉、运动或感觉和运动同时改变的7例患者，进行腕尺管探查尺神经松解术。结果术后随访时间为6～12个月，按中华医学会手外科学会上肢部分功能评定试用标准评定：优5例，良1例，可1例。结论部分伸直型桡骨远端骨折可合并腕部尺神经卡压，一经明确诊断即应早期行尺神经松解手术。     

儿童闭合性Gartland Ⅲ型肱骨髁上骨折合并血管神经损伤的治疗

目的 探讨治疗儿童闭合性GartlandⅢ型肱骨髁上骨折合并血管神经损伤的手术方法及疗效.方法 回顾性分析2000年7月至2003年6月治疗的398例儿童闭合性GartlandⅢ型肱骨髁上骨折患者资料,男207例,女191例;年龄1.3～14.0岁,平均7.5岁;伸直尺偏型372例,伸直桡偏型10例,屈曲型16例.桡动脉搏动缺失25例,较对侧减弱40例;正中神经损伤27例,桡神经损伤18例,正中神经和桡神经同时受累12例.所有患者均在伤后24 h内在臂丛神经阻滞麻醉和C型臂X线机监测下闭合复位满意后,分别在内、外髁部位穿入克氏针交叉固定,术后屈肘60°～ 90°位石膏托固定2周,主动功能锻炼,3周去除内固定,开始主动和被动功能锻炼.按照Flynn临床功能评定标准评定肘关节功能.结果 360例患者术后达解剖复位,38例复位后有轻度桡偏,肱骨前倾角略减小.桡动脉搏动恢复,术后3～24周(平均6周)神经损伤恢复.286例患者术后获6～ 27个月(平均18个月)随访,肘关节功能恢复正常,4例出现轻度肘内翻,但无需手术矫形.按照Flynn临床评定标准评定疗效:优280例,良6例,优良率为100％. 结论 充分麻醉下闭合复位、经皮穿针内固定可有效治疗儿童闭合性GartlandⅢ型肱骨髁上骨折合并血管神经损伤,可作为首选治疗方法之一.     

Monteggia骨折150例报告（附文献复习）

小儿高位Ｍｏｎｔｅｇｇｉａ骨折亦称Ｈｕｍｅ骨折。１９８６～１９９１作者采用手法复位、纸塑瓦楞夹板固定法治疗１５０例，平均临床愈合时间４５ｄ。８７例获得随访，平均随访时间４１５月。结果优良率９３８％。作者提出扩大Ｈｕｍｅ骨折的概念范围为：小儿尺骨近段或鹰嘴骨折，合并桡骨头各方向的脱位或半脱位。作者对临床资料分析认为：（１）先整复尺骨骨折，再整复桡骨头，可使变异了的近尺桡间隙得到纠正，为桡骨头的复位创造条件。（２）Ｘ线检查采用前臂中立位投照法和“划点法”，可排除前臂旋转及伤后畸形的干扰，避免漏诊和误诊。（３）前臂中立位固定、置肘关节极度屈曲位，是维持桡骨头稳定的关键。同时还可以预防继发性桡神经损伤     

前臂严重辗轧撕脱伤的早期治疗

目的 探讨早期治疗前臂严重辗轧撕脱伤的方法及疗效.方法 2003年4月至2010年7月收治23例前臂严重辗轧撕脱伤患者,男16例,女7例;年龄17 ～43岁,平均27.5岁.骨折情况:尺、桡骨双骨折11例,尺、桡骨单发骨折6例,桡骨中远段骨折并下尺桡关节脱位4例,尺骨近段骨折并桡骨头脱位2例.血管损伤情况:尺、桡动脉均断裂4例,尺、桡动脉单发断裂14例,肱动、静脉断裂2例.神经损伤情况:正中、尺神经单发断裂8例,正中、尺神经均断裂2例,桡神经深支断裂1例.按Gustilo分型:Ⅱ型3例,ⅢA型6例,ⅢB型8例,ⅢC型6例.采用急诊彻底清创、骨折可靠内固定,一期组织功能重建肌腱、神经,利用全层皮植皮、游离皮瓣或带蒂皮瓣移植等方法延期闭合创面,积极康复治疗.按中华医学会手外科学会上肢断肢再植功能评定试用标准评定疗效. 结果 所有患者术后获15 ～29个月(平均18个月)随访,肢体及移植皮瓣均顺利存活.所有骨折均于伤后3～8个月(平均4.1个月)获骨性愈合,无一例发生骨性感染.按中华医学会手外科学会上肢断肢再植功能评定试用标准评定疗效:优12例,良8例,差3例,优良率达87.0％. 结论 采用急诊彻底清创、骨折可靠固定、早期组织功能重建、延期闭合创面、积极康复等方法治疗前臂严重辗轧撕脱伤,可取得满意疗效.     

儿童Monteggia＇s骨折的治疗选择

摘要：[目的]探讨儿童Monteggia＇s骨折的治疗方法及效果。[方法]本组患儿66例，男47例，女19例，其中新鲜骨折61例，陈旧性骨折5例。按Bado分型：Ⅰ型46例，Ⅱ型4例，Ⅲ型15例，Ⅳ型1例。采用非手术和手术治疗方法，对患儿进行针对性的个体化治疗。非手术治疗行手法复位、石膏固定，手术治疗则是在手法复位成功后，分别采用单针固定尺骨或肱桡关节、双针固定尺骨和肱桡关节，再行石膏固定，手术中均未修复或重建环状韧带。[结果]66例患儿在门诊获得6个月～5年的随访，参照李汉民等制定的评定标准，非手术组的优良率为95．7％，手术组的优良率为84．2％。未发生骨化性肌炎、骨间背侧神经损伤、尺桡骨骨性连接、尺骨骨不连、迟发性桡骨小头脱位等并发症，合并神经损伤的患儿术后2～4个月均完全恢复。[结论]儿童Monteggia＇s骨折的治疗效果优良，治疗的关键在于应争取在急诊下复位，并根据骨折类型及肱桡关节的复位情况，采用针对性的内固定措施以防止骨折移位及再脱位的发生，防止漏诊。     

Ipsilaterale Begleitverletzungen an der oberen Extremit?t und des Schultergürtels nach proximalen Humerusfrakturen

Question.

The aim of this study was to elucidate associated injuries of the upper extremities and shoulder girdle in proximal humeral fractures and to evaluate their impact on clinical outcome.

Methodology.

Between January 2001 and March 2008 a total of 641 patients where operated due to proximal humeral fractures. All patients were retrospectively analyzed in terms of associated injuries and 58 patients (9?%) with associated injuries on the ipsilateral upper extremity were identified, of whom 36 (mean age 67 years, 24 women, 12 men) could be clinical examined (DASH and Constant scores) after a mean follow-up of 38 months.

Results.

The 58 patients with associated injuries where treated with plate osteosynthesis (38 patients), nail osteosynthesis (7?patients) and primary shoulder prosthesis in 12 patients. One patient received a screw osteosynthesis. Most associated injuries were distal radial fractures and nerve injuries. Appearance of distal radial fractures was linked to low-energy trauma, whereas high-energy trauma was related to elbow injuries, especially elbow dislocation. Proximal humeral fractures with glenohumeral dislocation were associated with a higher risk of nerve injury. Associated injuries occurred more often in women and mostly in patients aged 60 years and older. Men with associated injuries were distributed over the whole life span. Evaluation of 36 patients in follow-up revealed a mean DASH score of 35 points and a mean Constant score of 56 points. Osteosynthesis of proximal humeral fractures led to better results than primary arthroplasty.

Conclusion.

The combination of proximal humeral fracture and ipsilateral associated injury is common and related to osteoporotic bone. Treatment includes osteosynthesis of all fracture sites to allow fast mobilization. Functional results are dependent on type of treatment of proximal humeral fractures. This trial might help clinicians to identify a risk population for those injuries in respect to patient age, sex and energy of trauma.     

Upper limb nerve injuries in developmental age

Our series includes 105 children with peripheral nerve injuries of the upper limb due to trauma. The aim of this study is to validate our therapeutic approach to peripheral nerve injuries of the upper limb in children and to identify the suitable waiting time before surgical exploration. Case series examination included evaluation of (1) type of lesion; (2) topographical site of nerve injury; (3) motor and sensory outcome; (4) recovery time; (5) results after surgery. Open injuries (Sunderland V) received immediate treatment with direct suturing or nerve grafts or biological tubules in case of loss of nerve substance. After closed nerve injury, a waiting period of variable duration should precede surgery. Most of the cases had peripheral nerve injuries associated to fracture and cutting lesions followed by injuries due to other causes. Open or closed injuries of the median and radial nerves had a generally favorable prognosis, whereas ulnar nerve injuries (both isolated and associated) had a poor prognosis. Stable skeletal fixation is essential in fractures at risk of nerve involvement. During nerve exploration, secondary surgery interventions were never associated. In the absence of adequate clinical and instrumental response, the authors suggest to resort to nerve surgery at 6 months from injury to accelerate recovery time. Secondary surgery should be delayed as patient's recovery time can be very long. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes

BACKGROUND: Comminuted fractures of the radial head are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is an alternative treatment with results that compare favorably with those reported after open reduction and internal fixation of similar fractures. The purpose of this study was to evaluate the two-year outcomes and the rate of recovery of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with a modular metallic prosthesis. METHODS: Twenty-six patients (seventeen female and nine male; mean age, fifty-four years) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a modular metallic radial head arthroplasty. Patients who had presented more than four weeks following the injury or had had the radial head arthroplasty as a second-stage or salvage procedure were excluded. Of the twenty-six patients, twenty-two had an associated elbow dislocation, and thirteen of them also had an associated fracture of the coronoid process. Patients were prospectively followed at three, six, twelve, and twenty-four months. Self-reported limb function, general health, range of motion, and isometric strength were assessed by an independent observer. RESULTS: Following treatment of the injury, significant decreases in self-reported and measured impairments were noted over time, with the majority of the recovery occurring by six months and little further recovery noted between six and twenty-four months. There were slight-to-moderate deficits in the range of motion and strength compared with the values on the contralateral, unaffected side. Patient satisfaction was high at three months and remained high at two years. All elbow joints remained stable, no implant required revision, and there was no evidence of overstuffing of the joint. Mild osteoarthritis was seen in five (19%) of the twenty-six patients. CONCLUSIONS: An arthroplasty with a modular metallic radial head is a safe and effective option for the treatment of unreconstructible radial head fractures associated with other elbow injuries. Recovery primarily occurs by six months, with minimal additional improvements over the next eighteen months.     

Childhood fractures requiring inpatient management

INTRODUCTION: Fractures account for significant morbidity during childhood. Children requiring inpatient management for their fractures represent the most serious injuries. The aim of this study was to identify injury patterns in childhood fractures requiring inpatient management at a regional trauma centre. METHODS: Three thousand and forty two consecutive injured children were admitted to our orthopaedic centre over a 4-year period. Data was prospectively collected by independent audit clerks and entered onto a database. Data recorded included type of injury, mechanism of injury and place of injury. This was then used to assess injury patterns and trends. RESULTS: Upper limb and lower limb fractures accounted for 51% (n=1,565) and 21% (n=637) of all emergency admissions, respectively. Other causes included soft tissue injury, Infections, Polytrauma and Dislocations. Twice as many males were admitted with upper or lower limb fractures compared to females (67% versus 33%) (P<0.001). Males were more likely to be older (P<0.001) compared to females. Distal radial fractures accounted for 60% of upper limb fractures. Distal and midshaft tibial fractures accounted for 52% of lower limb fractures. Sports injuries were responsible for the majority of lower limb fractures with falls accounting for the majority of upper limb fractures. Fracture incidence peaked during summer months. CONCLUSION: Males are twice as likely to require inpatient management for fractures as females. Male adolescents are particularly at risk. Distal radial fractures following falls and distal tibial fractures following sports injuries are the most common fractures requiring admission. Identifying ways of minimising risk of these injuries would reduce childhood morbidity.     

Surgical management of nerve injuries of the upper extremity in children: a 15-year survey

In a 15-year retrospective study, the results of 37 surgically treated nerve lesions of the upper extremity in 33 children were reviewed after a mean follow-up of 2 years. Children ranged in age from 4 to 15 years. There were 19 ulnar, 12 median, and 6 radial nerve injuries. Discontinuity of the nerve trunk was found in 23 patients operated by interfascicular grafting (18 patients) or epineural suture (5 patients). The other 14 lesions were treated by decompressive external neurolysis. Useful sensory function (S4-S3) assessed at the autonomous zone was restored in 31 patients (84%). Satisfactory motor recovery was achieved in 25 patients (67%). Independent of the type of lesion, the median nerve showed the best ability to regain complete motor and sensory function. In lesions with continuity of the nerve trunk, those affecting the radial nerve had a worse prognosis regarding motor function recovery. Unfavorable prognosis was mainly related to a time interval of more than 1 year between nerve damage and surgery.     

Does coexistant fractures impair the results of treatment of elbow dislocations in children?]

We present 33 children with 34 elbow dislocations. In 22 cases concomittant fractures around the elbowe were noted: 13 displaced medial epicondyle fractures, 5 radial neck fractures, 2 radial head fractures, 2 coronoid process fractures, 1 olecranon fracture, 1 lateral condyle fracture, 1 medial condyle fracture. In 5 children more than one concomittant fracture were noted. The mean age during dislocation was 11 years (from 4 to 15), the mean follow up period was 3.5 years (from 2 to 5). On follow up a clinical examination of the elbow was performed including axis assesment and elbow ROM. X-ray were taken in all children in AP and lateral view. All children had a satisfying function of the extremity and no pain was noted. No difference in ROM was noted in children with isolated elbow dislocation or with concomittant medial epicondyle fractures however in 3 of those children a persistent flexion contracture was observed. Among children with other fractures poorer results occured in 3 patients, specially after displaced radial neck fractures. In one of them there was slight supination and pronation restriction, in second a complete ankylosis of proximal radioulnar joint occured in neutral forearm position. In one child after elbow dislocation and medial condyle fracture a late radial dislocation occured. We think that concomitant medial epicondyle fracture does not impare good results of elbow dislocation treatment if well recognised and treated. Other fractures, specially radial neck fractures, increase the risk of complications.     

Upper limb fractures in children

This article provides an overview of upper limb fractures in children from clavicle fractures to fractures of the wrist. We will focus more on common injuries including fractures around the elbow and those of the forearm. We will review the aetiology and classifications of common fractures and discuss appropriate considerations for management to provide a general overview of treatment options. This article will cover injuries that are managed differently from those seen in adults.     

The incidence of associated fractures of the upper limb in fractures of the radial head

Radial head fractures are common injuries. In American publications, one-third of the patients with these fractures have been shown to have associated injuries. The aim of this retrospective study is to describe the epidemiology of radial head fractures and associated fractures of the ipsilateral upper extremity in a European population. This study describes the epidemiology of radial head and associated fractures of the upper extremity in a Dutch population by a retrospective radiographic review of all patients with a radial head fracture between 1 January 2006 and 1 July 2007. A total of 147 radial head fractures were diagnosed in 145 patients. The incidence in the general population was 2.5 per 10.000 per year. The average age was 45.9 (SD 17.3) years and male–female ratio was 2:3. The mean age of males was significantly lower (37.1, SD 14.2 years) than of women (53.9, SD 16.4 years). Associated fracture of the upper extremity was found in 10.2%. Coronoid fractures were most common (4.1%). Associated upper limb fractures in patients with a radial head fracture are common in the European population. It is of clinical importance to suspect associated lesions and to perform a thorough physical examination and additional radiological examination on demand.     

MasonⅠ型及Ⅱ型桡骨头骨折保守治疗失败病例分析

目的分析经过保守治疗的Mason Ⅰ型及Ⅱ型桡骨头骨折病例失败的主要因素,同时探讨手术对保守治疗失败病例的疗效。 方法回顾性研究2010年2月至2015年6月在本中心行保守治疗的16~65岁急性Mason Ⅰ型及Ⅱ型的桡骨头骨折病例,排除合并同侧上肢其他损伤、颅脑外伤等影响桡骨头骨折预后的患者。收录信息包括患者一般情况、诊断、制动方式及时间,随访内容包括转为手术率、视觉模拟评分（visual analogue scale, VAS）、肘关节活动度、Mayo肘关节功能评分系统（Mayo elbow performance score, MEPS）等。 结果共612例患者符合纳入标准,其中成功随访患者345例,包括男205例、女140例,平均年龄37.5岁（17~65岁）,平均随访时间13.4个月（5~23个月）。345例患者中有27例（7.8%）患者因疼痛、活动障碍等原因转为手术治疗,转为手术治疗的患者平均制动时间要显著高于保守治疗成功组的患者,其中Mason Ⅱ型19例（70.4%）,3例（11.1%）术中证实存在骨软骨游离体,1例（3.7%）存在环状韧带关节囊嵌顿,4例（14.8%）存在外侧韧带复合体损伤,25例（92.6%）有明确的关节僵硬而行松解术,另有5例（18.5%）因康复过程中出现尺神经损伤而行神经探查松解术。27例转为手术的患者,平均VAS评分从术前（5.6±1.4）分降到术后（1.2±0.8）分,MEPS评分从（55.6±8.6）分提高到（89.6±4.9）分,平均上肢功能评分表（disability of arm shoulder and hand, DASH）从术前（44.4±9.8）分降至术后（15.4±5.9）分。 结论骨折类型、制动时间过长以及遗漏合并损伤是Mason Ⅰ型及部分Mason Ⅱ型桡骨头骨折保守治疗失败的主要原因,手术治疗可以满意解决相应的关节僵硬、疼痛、韧带和游离体嵌顿等并发症。     

Die Fraktur der Oberarmkondylen im Kindesalter

Apart from supracondylar fractures of the humerus those of the lateral and the medial humeral condyle are the most common injuries of the elbow in children. 5 to 15 years after the accident we followed up conservatively treated fractures of the radial humeral condyle (n=24) and the ulnar humeral condyle (n=17). In both injuries a strict correlation was found between the degree of dislocation of the fracture and the outcome of treatment. In 30 to 50% of the fractures the fragments were dislocated, similarly in 40 to 50% of all cases the results of treatment were unsatisfying or poor. We feel that the only way to achieve better results is a surgical treatment: exact anatomic reduction and internal fixation.