关节镜下桡骨头切除治疗成人MasonⅢ型桡骨头骨折的疗效分析

目的观察关节镜下桡骨头切除治疗MasonⅢ型桡骨头骨折的临床疗效。方法采用关节镜下桡骨头切除治疗成人桡骨头骨折患者12例。结果12例患者均获随访,随访时间6～18个月,平均10个月。肘关节轻度异位骨化1例,未发生肘关节不稳和桡神经损伤。按照Broberg和Morrey的肘关节评分标准,优10例,良2例。结论关节镜下桡骨头切除治疗成人MasonⅢ型桡骨头骨折,避免了传统切开桡骨小头切除术并发症较多的缺点,可早期进行功能锻炼,是治疗成人桡骨头骨折的有效方法。     

Delayed anterolateral radial head dislocation secondary to radial shaft fracture malunion: A case report

Rationale:Traumatic radial head dislocation (RHD) can occur due to hyperpronation injury with sequential disruption of the annular ligament, quadrate ligament, and the interosseous membrane. Although studies have shown that traumatic RHD is generally associated with Monteggia fracture-dislocation, traumatic RHD occurring with ipsilateral radial shaft fractures has rarely been reported. Delayed RHD secondary to the malunion of isolated radial shaft fractures is extremely rare.Patient concerns:We report the case of a 12-year-old right-handed boy with progressive pain and limited range of motion in the right elbow.Diagnosis:The patient was diagnosed with delayed RHD associated with radial shaft fracture malunion.Interventions and outcomes:A corrective osteotomy was performed at the site of malunion with open reduction of the radial head using an extensile lateral approach. The annular ligament was disrupted. Forearm rotation causes radial head subluxation Therefore, the Bell Tawse procedure was additionally performed to reconstruct the annular ligament by turning down a strip of triceps tendon and anchoring it around the radial neck.Lessons:Malunion of the radial shaft can cause delayed RHD with a limited elbow range of motion. Annular reconstruction using a strip of the triceps tendon and corrective osteotomy of the radial shaft with an extensile lateral approach may be useful for treating this rare entity or situation.     

肘关节三维有限元模型的建立及意义

目的建立肘关节三维有限元模型,并验证其在分析肘关节应力分布中的价值。方法选取1名正常成年男性为研究对象,使其左肘关节处于旋前伸直位,行螺旋CT断层扫描,得到CT数据二维图像,采用Mimics10.0软件系统处理,利用Abaqus6.7建立肘关节三维有限元模型,模拟施加1000N冲击载荷,分析冠状突及桡骨小头内应力分布情况。结果所构建的肘关节三维有限元模型共129341单元。在腕部冲击载荷作用下,肘关节矢状面显示尺桡骨出现纵向移位及以关节间隙为轴心的旋转（即尺骨冠状突中上部应力集中）,并随肘关节屈曲逐渐增强;冠状面显示桡骨小头处出现较明显的应力集中、强于冠状突,但此现象随肘关节屈曲及旋后逐渐减弱。结论本研究建立的肘关节三位有限元模型与人体解剖实际相符,此为临床肘关节疾病的诊治提供了新的思路;肘关节的稳定还涉及到周围侧副韧带维持及肌肉的牵拉,模型有待进一步完善。     

Treatment of Monteggia-like-lesion in a young patient: A case report

Introduction:A Monteggia fracture was described initially as a fracture of the proximal third ulna and anterior dislocation of the proximal epiphysis radius.^[1] In 1967, Bado discovered “true Monteggia lesions” and classified them into 4 groups.^[2] He also used the term “equivalents” or “Monteggia-like-lesions” to describe specific injuries with similar radiographic patterns.^[3] This type of fracture is rare and frequently associated with complications, poor functional results, and further operations.^[4]Patient concerns:A 16-year-old girl was admitted to our emergency department after a single motorcycle accident. Her main complaint was the pain and swollen of her left elbow. She was reluctant to move her arm due to pain.Diagnosis:Radiograph examination showed a displaced fracture of the left proximal third ulna accompanied by displacement of the left proximal radius. This fracture was similar to the Monteggia type III fracture except for proximal radial disruption that occurred laterally through a Salter-Harris type II fracture.Interventions:The patient underwent surgical debridement, and the forearm was immobilized using a backslap in a supine position and elbow flexion 90^o. Open reduction and internal fixation were performed 5 days later. The ulna was reduced and stabilized first using a 3.5 mm one-third tubular plate (ORMED), and internal fixation of the radial epiphysis was done using a 1.6 mm miniplate (Prohealth).Outcomes:After 3 months, the patient showed improvement with the Mayo Elbow Performance Score (MEPS) of 85. She did not complain of any pain and decreased strength. The patient regained 0 to 125^o of elbow flexion and 0 to 165^o of supination and pronation.Conclusion:Monteggia-like-lesion has many variations in physical and radiograph appearance. Careful evaluation of fracture pattern, identification of injury mechanism, and appropriate treatment planning based on Monteggia fracture treatment principles are mandatory to achieve the patient''s best outcome.     

Carcinomatous arthritis of the elbow caused by metastatic breast carcinoma

We report a case of persisting chronic monoarthritis of the elbow in a 54-year-old woman with previous breast surgery for carcinoma. An open biopsy of the elbow showed a chronic nonspecific synovitis and a poorly differentiated metastatic adenocarcinoma on the radial head. This is the first report of elbow arthritis due to metastatic breast carcinoma.     

Survival analysis and longterm results of elbow synovectomy in rheumatoid arthritis

OBJECTIVE: To evaluate longterm results and survival rate of open synovectomy of the elbow joint in patients with rheumatoid arthritis (RA). METHODS: Between 1986 and 2000, synovectomy of the elbow was performed on 103 joints in 92 patients with RA. Eighty-five joints were included in this study. Mean age at time of surgery was 52 years (range 13 to 62 yrs). On 13 elbows with Larsen stage I and II disease, early synovectomy preserving the radial head was performed; in 72 cases with Larsen stage III and IV, late synovectomy with radial head resection was necessary. RESULTS: In early synovectomy, one joint received prosthetic joint replacement and 2 joints underwent resynovectomy a mean of 9 years after primary surgery. The survival rate (no further operations) was 91% after 5 years and 78% after 10 years. In late synovectomy, 16 elbow joints were operated again a mean of 4.6 years after primary surgery (10 prosthetic joint replacements, 2 resection interposition arthroplasties, 4 resynovectomies). Survival rate was 82% after 5 years and 66% after 10 years. Sixty-one elbows were examined clinically at a mean followup period of 8.7 years (range 2.8-17.3 yrs). There was a significant improvement of the Morrey score at followup, especially due to effective relief of pain. Improvement of joint motion was seen in late synovectomy for pronation and supination. The mean preoperative Larsen stage was 3.11, which decreased significantly to 3.66 at followup. CONCLUSION: Our findings suggest that synovectomy is a safe and effective procedure in differential treatment of RA of the elbow.     

Iatrogenic pseudoaneurysm in a hemodialysis patient: the hidden hazard of a high radial artery origin

High origin of the radial artery is the most common variation in the arterial network of the upper extremities in humans. A 36-year-old Japanese woman undergoing chronic hemodialysis presented with a pseudoaneurysm originating from the brachial portion of the radial artery and associated with a high radial artery origin. Recognition of variants of the arterial network in the upper extremities is crucial for clinicians because their superficial position at the elbow joint may make these vessels vulnerable to injury.This paper was presented at the 48th Congress of the Japanese Society for Dialysis Therapy, in Osaka, Japan, in June 2003     

Two-stage strategy for neglected Monteggia fracture in children: A retrospective study of 51 patients

A neglected Monteggia fracture is defined as the fracture of the proximal ulna associated with radial head dislocation (RHD) without undergoing any treatment for 4 weeks or more after injury. One-stage operation of ulnar corrective osteotomy and open reduction of RHD might result in many complications. Therefore, a two-stage strategy, including ulnar osteotomy (UO) with or without annular ligament reconstruction (ALR), was adopted at our institute since 2010.We performed a retrospective review of 51 patients with neglected Monteggia fracture between January 2010 and January 2018. Patients with bilateral problems or concomitant injuries in the ipsilateral extremity were excluded. Radiological and clinical data were collected from Hospital Database and clinical visits. All patients were divided into 2 groups based on the status of the ALR: the UO alone (UO) group and the ALR group.There were 15 patients in the UO group and 36 patients in the ALR group. The age in the UO group (6.1 ± 2.3, year) was significantly younger than the ALR group (9.8 ± 2.8, year) (P < .001). Concerning the duration from initial injury to surgery, there was a significant difference between the UO group (8.6 ± 3.2 months) and the ALR group (23.3 ± 12.6 months, P < .001). Concerning the preoperative elbow function, there was no significant difference between the UO group (67.6 ± 5.0) and the ALR group (66.6 ± 4.4) according to the Mayo elbow performance score (MEPS) (P = .51). Concerning the postoperative parameters, including postoperative ROM of the joint, removal of external fixator (6.7 ± 0.8, 6.9 ± 0.9 weeks) (P = .55), lengthening (8.9 ± 2.5, 10.3 ± 2.5 mm) (P = .10) and MEPS (92.7 ± 2.1, 91.6 ± 2.1) (P = .08), there was no significant difference between the UO group and ALR group.Two-stage strategy is a reasonable choice for selected patients with long-lasting RHD with ulnar deformity.     

Rheumatoid arthritis of the elbow. Pattern of joint involvement, and results of synovectomy with excision of the radial head.

Thirty-two rheumatoid elbow joints in 25 patients which had undergone synovectomy and excision of the radial head have been studied from the point of view of pattern of joint involvement and the efficacy of surgery. In this group of patients there was a significant trend towards affection of proximal joints occurring earlier in the course of the disease than distal joints. There was a high incidence of involvement of wrist and knee. There was a positive relationship between dominance and the elbow affected. Pain diminished in all cases after surgery, and there was a significant improvement in hinge movement but no significant improvement in range of forearm rotation though it was less painful. Single lateral approach gave satisfactory exposure and is favoured. Complciations of the procedure were few.     

Comparative responsiveness of four elbow scoring instruments in patients with rheumatoid arthritis.

OBJECTIVE: This prospective study investigated the comparative responsiveness to change of 4 different elbow scoring instruments: 2 Hospital for Special Surgery elbow assessment scales, the Mayo Clinic Elbow Performance Index, and the Elbow Functional Assessment (EFA) Scale. METHODS: A group of patients with rheumatoid arthritis (RA) (median age 60 yrs) undergoing either elbow arthroplasty (22 elbows) or synovectomy with radial head excision (3 elbows) were evaluated both before and after surgery (median 7 mo postoperatively). Changes in the scores obtained using the scales under study were calculated and analyzed. The patient's opinion of global perceived effect of the intervention was used as an external criterion to classify them as "improved" or "non-changed." Responsiveness was evaluated with 3 different statistical approaches: using paired t statistics (pre and postsurgery scores), effect size statistics (standardized response mean, effect size, and responsiveness ratios), and receiver operator characteristic curves. Minimal clinically important difference was estimated using patient satisfaction as the external criterion. RESULTS: Each of the elbow rating measures under study proved to be responsive to change when evaluating patients with RA undergoing elbow arthroplasty or synovectomy. The EFA scale had the highest power to detect a clinically meaningful difference and had the best discriminative ability to distinguish improved from no-change patients, as shown by all responsiveness statistics applied. CONCLUSION: Using the EFA scale requires smaller sample sizes to achieve a fixed level of statistical power than the other scales we studied.     

Elbow synovectomy and excision of the radial head in rheumatoid arthritis: a short term palliative procedure

We present the results of synovectomy and excision of the radial head in 65 elbows affected by rheumatoid arthritis. Eighty-four percent of elbows had good pain relief 6 months after operation but after an average of 5 years only 54% remained relatively pain-free. Range of motion remained the same or improved in the majority of patients. Synovitis occurred in 39% of elbows during the followup period and intraarticular steroid injections were frequently given. This undoubtedly modified results of pain relief that might have been attributed to the operation. Destructive changes in the humeroulnar joint were considered the main cause of elbow pain at the time of review.     

尿毒症患者桡动脉病变影响因素及临床意义

目的：观察尿毒症患者血管病变的临床与病理联系，探讨导致血管病变的各种危险因素。方法：对27例尿毒症患者的临床检测指标以及桡动脉病理改变（按病变程度分为轻、中、重组）进行了观察和分析。结果：尿毒症患者与正常对照组（n=50)比较，存在血浆胰岛素（INS）、C肽、甲状旁腺激素（PTH）、皮质醇、血清脂蛋白（a)[Lp(a)]、三酰甘油和平均动脉压（MAP）增高（P＜0．01），同时存在血清高密度脂蛋白胆固醇（HDL－C）、胰岛素敏感指数（IAI）等降低（P＜0．01），其中，重度血管病变组的INS、PTH显著增高（与另两组比较P＜0．01），血浆皮质醇增高也较明显（与中度组比较P＜0．05）。Lp(a)水平有随血管病变程度加重而逐渐升高的趋势。此外，血管病变程度与临床心血管检查指标异常的发生率之间呈正相关（P＜0．05），其中超声心动图（UCG）与血管病变程度关系最为密切（P＜0．01）。结论：高胰岛素血症、胰岛素抵抗（IR）和LP（a),PTH，皮质醇增高是导致尿毒症患者血管病变的危险因素。对上述因素及时干预可能延缓尿毒症血管病变的发生和发展。     

The Ultrastructure of Spontaneous Radial Segmentation of the Nuclei in Bone Marrow Cells from 3 Patients with Acute Myeloid Leukaemia

Bone marrow cells with spontaneous radial segmentation of the nuclei from three patients with acute myeloid leukaemia were analysed by means of electron microscopy. The centriole was found in the centre of the cluster of nuclear segments. Cytoplasmic microtubules were found in the intersegmental clefts and in the pericentriolar area. The present observations support the hypothesis that spontaneous radial segmentation of the nuclei in tumour cells is due to a microtubule-associated contractile process, by which the nucleus is folded into segments.     

Elbow injuries

The elbow is a commonly injured joint, yet physicians may be less comfortable treating injuries to the elbow compared with knee and shoulder injuries. Common injuries involving the elbow are tendinosis, instability, tendon ruptures, osteochondritis dissecans, and fractures. Tendinosis is a common overuse injury and may occur on the lateral, medial, or infrequently, the posterior side of the elbow. Injury to the medial or lateral ulnar collateral ligaments may result in instability. Repetitive trauma from overuse is the most common etiologic factor in athletes. Distal biceps and triceps tendon injuries may result in elbow disability in active individuals. Partial tears are more difficult to diagnose than complete ruptures. Osteochondritis dissecans of capitellum affects adolescents involved in overhead throwing athletics. Fractures about the elbow most commonly involve the radial head in adults, and the distal humerus in children. Athletes are prone to elbow injuries resulting from both overuse and acute trauma. Our purpose is to describe the diagnosis and treatment of these common elbow injuries in athletes of all ages.     

New device for compression of the radial artery after diagnostic and interventional cardiac procedures

Recently the transradial route has emerged as a valuable alternative to the femoral approach for coronary angiography and angioplasty. However, sheath and catheter size and their immediate removal after the procedure, combined with aggressive antiplatelet and anticoagulant therapies, have favored mechanical compression of the radial artery to achieve satisfactory hemostasis. We report on our initial clinical experience with a new device specially designed for prolonged controlled mechanical compression of the radial artery (the RadiStop™ radial compression system, RADI Medical Systems AB, Uppsala, Sweden). A total of 159 consecutive patients (mean age 60 ± 11 yr, 130 males) who required either coronary angiography (group 1, 103 patients) or ad hoc or elective coronary angioplasty (group 2, 56 patients) via the right radial route had local hemostasis with the RadiStop™ system. In group 1, 4F and 5F sheaths and catheters were used, whereas in group 2, 6F systems were inserted in the radial artery. Hemostasis was achieved with the device in all patients but was considered difficult to obtain in 4 patients (2.5%). Twenty-eight patients (18%) considered the device uncomfortable or painful, but no release of pressure was necessary. The mean compression time was 151 ± 82 min (114 ± 64 min in group 1, and 223 ± 64 min in group 2; P = 0.0001). There were 23 local complications (15%). In 7 patients (4.4%), the radial pulse was absent after compression and at discharge, without major clinical consequences. In one patient, recurrent bleeding occurred 2 hr after compression, requiring a new compression session. In 15 patients, a small local hematoma was observed. Neither heparin dosage nor the use of a 6F sheath affected the rate of radial artery patency in this survey. We conclude that the use of this device for mechanical compression of the radial artery after coronary angiography and angioplasty is efficient, and that its use is related to an acceptable rate of local complications. Cathet. Cardiovasc. Diagn. 40:297–300, 1997. © 1997 Wiley-Liss. Inc.     

急诊经桡动脉与股动脉入路介入治疗ST段抬高急性心肌梗死对比研究

目的观察经桡动脉入路行急诊ST段抬高急性心肌梗死直接经皮冠状动脉介入(PCI)治疗的有效性和安全性。方法选择沈阳军区总医院2005年1月至2006年10月连续607例ST段抬高性急性心肌梗死(STEMI)住院患者,分别接受经桡动脉入路(273例)或经股动脉入路(334例)途径行PCI治疗,观察两组手术成功率和并发症发生率。结果两组患者PCI成功率差异无统计学意义(97.07%对95.81%,P>0.05)。经桡动脉入路组局部血肿、假性动脉瘤、迷走反射发生率显著低于经股动脉入路组。结论行PCI治疗的STEMI患者经桡动脉入路途径是安全、有效和可行的方法,与经股动脉比较,经桡动脉途径可减少并发症的发生。     

Feasibility and safety of the successive use of distal transradial access for coronary angiography and intervention in the same arm

Distal transradial access (dTRA) is a novel alternative to conventional radial artery access for coronary catheterization. However, the feasibility and safety of repeated use of dTRA have not been fully elucidated. This study aimed to evaluate the feasibility and safety of the repeated use of dTRA for coronary angiography and intervention in the same arm. A total of 1717 patients underwent angiography or angioplasty via dTRA. We retrospectively analyzed the catheterization records of patients who underwent repeated puncture of the distal radial artery in the same arm. The incidence of successive applications of dTRA and the reasons for dropout were retrospectively investigated. A total of 416 patients, including three who underwent coronary catheterization with the bilateral dTRA in the initial attempt were analyzed. A 3-, 4-, 5-, or 6-French sheath or sheathless guide catheter was used in the initial procedure. A maximum of four successive coronary catheterization procedures were performed. The second procedure with dTRA on the same arm was successfully performed in 395 cases (94.3%), with a successive rate of 89.6% for both the third and fourth dTRA procedures. Conversion to another approach site (n = 30) was attributed to radial artery occlusion (n = 9), narrowing of the distal radial artery (n = 19), and puncture failure (n = 2). The current data indicate that the repeated use of dTRA is safe and feasible, and this approach may become a standard approach site in the future.     

Management of fixed flexion contracture of the elbow in haemophilia

The authors stress that prevention of flexion contractures and artropathy by early factor replacement and physical therapy for every haemophiliac is the standard of care. Physical therapy, serial casting, and Quengel cast correction have not proven successful in correction of fixed flexion contractures at the elbow. In the patient who has a flexion contracture that interfered with function, an attempt at physical therapy combined with the use of either the Dynasplint or Flowtron will be tried. If there is no response, a surgical synovectomy combined with a possible radial head resection and anterior capsular relase would be the authors’ procedure of choice. In the face of advanced arthropathy, the authors would consider a distraction arthroplasty.     

A comparison of the radial and the femoral approach in vein graft PCI. A retrospective study

BACKGROUND: Transradial PCI is a safe and effective method of percutaneous revascularization. However, there is limited data on the efficacy of the transradial approach for saphenous vein graft (SVG) PCI. METHODS: We studied 334 patients who underwent SVG PCI between January 2000 and December 2003, and compared the radial (132 patients) and the femoral (202 patients) approach. RESULTS: Mean EF (55.6±18.6% radial versus 58.1±16.8% femoral), lesion location (proximal, mid, distal: 22.6/50.6/26.7% versus 22.6/44.5/32.9% respectively) and lesion type (B1/B2/C: 3.4/4.1/92.5% versus 0.4/3.1/96.5%) were similar in both groups (P>0.05). Five patients had a failed radial attempt (3.8%) and were switched to the femoral approach. Mean fluoroscopy time (20.4±12.2 versus 18.4±10.2min), procedural time (60.0±27.2 versus 61.6±24.9?min) and the use of contrast (223±91 versus 234±91ml) IIB/IIIA inhibitors (27.2 versus 33.2%), and stenting (81.5 versus 81.3%) were similar in both groups, whereas 5 or 6 French sheaths were used more often in the radial group (83.4 versus 64.9%, P<0.01). Angiographic success (93.9 versus 92.9%), in hospital MACE (radial:5 MI (3.8%) versus femoral: 1 death (0.5%) and 7 MI (3.5%) and major vascular complications (0.7 versus 0.5%) were also similar. CONCLUSIONS: The radial approach in SVG PCI is as fast and successful as the femoral.     

Effects of subcutaneously infiltrated nitroglycerin on diameter,palpability, ease-of-puncture and pre-cannulation spasm of radial artery during transradial coronary angiography

Background

The success of transradial catheterization depends on meticulous access of radial artery which in turn depends on palpating a good radial pulse.

Objectives

Our objectives were to analyze the effects of subcutaneously infiltrated nitroglycerin on diameter of radial artery, palpability of radial pulse, ease-of-puncture and pre-cannulation spasm of radial artery during transradial coronary angiography.

Methods

Patients undergoing transradial coronary angiography were randomized to Group NL or Group SL. In Group NL, 3 ml of solution containing nitroglycerin and lignocaine was infiltrated subcutaneously at the site intended for puncture of radial artery. Similarly, saline and lignocaine were infiltrated in Group SL. Diameter of radial artery was objectively assessed by ultrasonography. Measurements were performed at baseline and repeated at 1 min after injecting the solutions. The ease-of-puncture was evaluated by the number of punctures and the time needed for successful access of radial artery.

Results

Both groups had 100 patients each. Baseline diameter of radial artery was similar between two groups. The post-injection diameter of radial artery increased by 26.3% in Group NL and 11.4% in Group SL. Nitroglycerin significantly improved the palpability of radial pulse, reduced the number of punctures and shortened the time needed for successful access of radial artery. Pre-cannulation spasm of radial artery occurred in 1% of Group NL and 8% of Group SL.

Conclusions

Subcutaneously infiltrated nitroglycerin leads to significant vasodilation of radial artery. This avoids pre-cannulation spasm of radial artery, enhances palpability of the radial pulse and thus makes the puncture of radial artery easier.