应用双球关节外固定架治疗儿童陈旧孟氏骨折的初步报告

Treatment of missed Monteggia fractures in children with dual-socket external fixators

目的探讨尺骨截骨后、应用双球关节外固定架治疗儿童陈旧孟氏骨折的临床疗效。方法2004年6月至2006年6月，采用双球关节外固定架治疗儿童陈旧孟氏骨折7例，平均年龄7．9岁，伤后至手术时间1～30个月（平均11．7个月）。患者X线片示桡骨均存在过度增长、尺骨向掌侧甚至桡侧成角畸形。经肘前Henry入路肱桡关节切开、瘢痕清理，尺骨嵴近端矢状面30。斜形截骨、Orthofix双球关节外固定架延长并同时过度矫正尺骨畸形，透视下实时调整尺骨截骨端、于桡骨头稳定复位后紧固夹钳螺钉，拍片确认复位效果。术中可游离解剖出环状韧带残端，则予以修补；否则行彻底瘢痕切除，不重建环状韧带，完全依赖尺骨畸形的矫正及其长度的恢复来维持肱桡复位关系。术后2-3周长臂后托石膏固定；尺骨截骨端骨胜愈合后，去除外固定架。结果随访3～26个月，尺骨端全部愈合，肱桡关系好，肘内外翻稳定性佳、无疼痛。按照Morrey标准：好6例，中1例。结论双球关节外固定架可有效维持尺骨截骨后的矫正性成角和延长长度，并于安置之后（甚至术后）仍可进行调整，以妥善稳定并维持手术获得的肱桡对应关系，还可早期进行功能训练，具有可操作和可调整优势。

Objective To discuss the treatment of missed Monteggia fractures in children with dual-socket external fixators. Methods Seven patients, 6 boys and 1 girl, with missed Monteggia fracture were treated by dual-socket external fixators （Device of the wrist joint, s/n 37000, Orthofix Co., England）. Their average age was 7.9 （3.5 to 11） years. Intervals between injury to operation averaged 11.7 （1 to 30） months. X-ray showed excessive growth of the radius and volar or even radial angulation of the ulna besides dislocation of the radial head. The radiohumeral joint was reached through Henry approach and any interposed tissues were cleaned. Then, oblique osteotomy at 30 degrees was performed in the proximal ulna. Once the Orthofix dual-socket fixator set properly, lengthening and then corrective angulating as well as real-time ad- justing of the osteotomy site of the ulna, according to the radiocapitellar congruity at pronation, neutral posi- tion, and supination of the forearm, were managed under a fluoroscope. When concentric reduction was achieved, the radiocapitellar relation was secured by the repair of the annular ligament if its remnant could be debrided from the interposed scar in the radiohumeral space. A long-arm plaster splint was applied after operation and was maintained for 2 to 3 weeks. Removal of the fixator was done only when the osteotomy site of the ulna had already got bony healing. Results All 7 patients were followed up between 3 to 26 months, with bony healing of the ulna, good radioeapitellar relationship and painless elbow joint. According to Morrey criteria, there were 6 good and 1 fair results. Conclusions Orthofix dual-socket fixators can effectively maintain the required location of the ulna after osteotomy and stabilize the proper correlation of the radiohumeral joint. Their advantages include easy adjustment during operation or even postoperatively, and early exercise of the elbow and forearm due to their firm fixation.