肘部损伤"三联征"的手术治疗及入路选择

目的 探讨肘部损伤"三联征"(肘关节后脱位复合桡骨头骨折、尺骨冠状突骨折)的手术方法,分析各种手术入路的优缺点和适应证,以期优化肘部损伤"三联征"的治疗.方法 2003年6月至2008年8月共收治17例肘部损伤"三联征"患者,男11例,女6例;年龄22～48岁,平均34.5岁;受伤至手术时间3～7d,平均5.4 d.桡骨头骨折按照Mason分型:Ⅰ型2例,Ⅱ型10例,Ⅲ型5例;尺骨冠状突骨折按照ReganMorrey分型:Ⅰ型3例,Ⅱ型12例,Ⅲ型2例.采用外侧入路9例,外侧入路联合内侧入路2例,前侧入路6例.尺骨冠状突骨折行摘除1例,内固定16例;桡骨头骨折行内固定14例,单纯桡骨头切除1例,桡骨头置换2例.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)进行评估.结果 所有患者获得12～48个月(平均21个月)随访.所有切口均一期愈合,无骨不连、骨不愈合及前臂缺血性肌挛缩发生.出现迟发性尺神经麻痹1例,异位骨化2例.末次随访肘关节平均活动度:屈伸128.3°±6.8°,旋转74.6°±4.2°.MEPS评分:优6例,良8例,可2例,差1例,优良率82.4%.除1例桡骨头切除患者外,其余患者术后肘关节稳定性好,影响评分的主要因素为运动受限和日常生活功能部分丧失.结论 肘部损伤"三联征"为复杂类型的肘关节损伤,应根据骨折和损伤类型选择合适的手术入路.

Selection of operative approaches for "terrible triad" of the elbow

Objective To discuss selection of operative approaches for treatment of"terrible triad" of the elbow(backward dislocation of the elbow combined with fractures of the radial head and ulnar coronoid process). Methods From June 2003 to August 2008,we treated 17 patients with"terrible triad"of the elbow.11 males and 6 fomales,with an average age of 34.5 years(22 to 48 years).The average interval between injury and surgery was 5.4 days,ranging from 3 to 7 days.Lateral approach was applied in 9 cages,lateral plus medial approaches in 2 cases,and elbow anterior approach in 6 cases.For fractures of the ulnar coronoid process.resection was performed in one case and internal fixation in 16 ca8esI For radial head fractures,internal fixation was performed in 14 cases,excision in one case,and replacement in 2 cases.According to the stability of fracture and internal fixation,continuous passive motion(CPM)or active functional exercises was conducted postoperation.Mayo elbow performance score(MEPS)was used to evaluate the elbow funotions.Remrs The patients were followed up from 12 to 48 months,with an average of 21 months.All incisions healed without bone nonunion or isehemic forearm muscle contracture.Delayed ulnar nerve palsy occurred in one case and heterotopic ossification in 2 cases.MEPS was excellent in 6 cases,good in 8,fair in 2 and poor in one,with an excellent to good rate of 82.4%.All patients but one undergoing radial head resection maintained good elbow stability.The main factors affecting the Mayo score were limitation of movement and partial loss of everyday kinetic capability. Conclusions For "terrible triad"of the elbow,the complex elbow injuries,selection of the operative approaches should be based on the type of fractures and injuries.Reasonable surgical treatment and active functional exercise may lead to an excellent prognosis.