肘关节“恐怖三联征”的手术治疗

OPERATIVE TREATMENT OF TERRIBLE TRIAD OF THE ELBOW

目的回顾分析手术治疗"恐怖三联征"的临床疗效。方法2003年10月-2007年9月,收治10例"恐怖三联征"患者。其中男3例,女7例;年龄18～66岁。损伤原因:车祸伤4例,高处坠落伤4例,摔伤2例。冠突骨折按Regan-Morrey分型:Ⅰ型5例,Ⅱ型3例,Ⅲ型2例;桡骨头骨折按Mason分型:Ⅰ型1例,Ⅱ型6例,Ⅲ型1例,余2例曾行桡骨头切除术。术中按从深层至浅层依次修复冠突骨折、前方关节囊、桡骨头骨折、外侧副韧带及伸肌总腱起点,酌情修复内侧副韧带,并以铰链外固定支架固定。采用HSS2肘关节评分标准进行疗效评价。结果1例术后7d伤口感染,行脐胸带蒂皮瓣移位修复伤口愈合;其余伤口均Ⅰ期愈合。患者均获随访,随访时间6～51个月,平均24.9个月。术后6～20周骨折达临床愈合,平均9.6周。术后6个月,肘关节屈伸度85～130°,平均106.5°;旋转度100～160°,平均138°。按HSS2肘关节评分标准:优4例,良4例,一般2例。无关节僵硬、肱尺关节炎等并发症发生。1例术后1d出现桡神经损伤症状,行松解术后4～6个月症状消失;6例术后6个月出现异位骨化,1例术后36个月X线片示肘关节半脱位,均未作特殊处理。结论"恐怖三联征"造成肘关节严重不稳定,应采取手术治疗,尽可能恢复骨性解剖结构、修复关节囊及侧副韧带,并辅以外固定支架;术后早期功能锻炼,可最大限度避免关节僵硬,恢复关节功能。

elbow. Methods From bjective To retrospectively reviewed the operative therapy of the terrible triad of the October 2003 to September 2007, 10 cases of terrible triad were treated, with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. There were 3 males and 7 females with the age of 18-66 years. The injury was caused by traffic accidents in 4 cases, falling from a height in 4 cases, and tumbling in 2 cases. The coronoid process fractures of the patients were 5 cases of type I, 3 cases of type II and 2 cases of type III according to Regan- Morrey classification. The radial head fractures of the patients were 1 case of type I, 6 cases of type II and 1 case of type III according to Mason classification, and their radial heads of the other 2 patiants were resected before they were in hospital. The general approach was to repair the damaged structures sequentially from deep to superficial, from coronoid to anterior capsule to radial head to lateral ligament complex to common extensor origin. And selected cases were repaired of the medial collateral ligaments and assisted mobile hinged external fixation to keep the forearm fixed in functional rotation position. The function of the elbows were evaluated with the criteria of the HSS2 score system. Results The other wounds healed by first intention except 1 case which had infection 7 days after operation and whose soft tissue defect in posterior elbow were repaired with the pedicle thoracoumbilical flap. The patients were followed up 6 to 51 mouths （mean 24.9 mouths）. The fracture healing time was 6 to 20 weeks （mean 9.6 weeks）. Six mouths postoperatively, the mean flexion-extension arc of the elbow was 106.5° （85-130°）, and the mean pronation-supination arc of the forearm was 138°（ 100-160°） respectively. According to the criteria of the HSS2 score, the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases. No complications such as stiffness and ulnohumeral arthrosis occurred. The radial nerve injury was found in 1 patient 1 day after operation who was treated with neurolysis, and the nerve function was recovered after 4-6 months. And beterotopic ossification occurred in 6 patients 6 months after operation and radiographic subluxation developed in 1 patient 36 months after operation, and conservative treatment were given. Conclusion The terrible triad of the elbow can lead to serious elbow instability and should be treated with operation to restore the anatomic structures, to repair the articular capsule and the collateral ligament, using the adjuvant hinged external fixation and early exercise to avoid immobilization and recover the articular function.