肘前内侧切口入路手术治疗尺骨冠状突前内侧面骨折

Treatment of anteromedial coronoid facet fractures with open reduction and internal fixation through anteromedial approach

目的:探讨尺骨冠状突前内侧面骨折手术治疗入路和合并损伤的处理。方法:自2009年7月至2011年8月,共收治尺骨冠状突前内侧面骨折6例,男4例,女2例;年龄19～49岁,平均32.6岁;左侧3例,右侧3例;优势侧4例,非优势侧2例;均为闭合性骨折。根据O'Driscoll尺骨冠状突骨折分型均为冠状突前内侧面骨折2亚型或3亚型,均采用肘前内侧切口桡侧腕屈肌和掌长肌之间劈开指浅屈肌入路行微型接骨板固定,其中3例行冠状突固定后肘关节内翻应力位X线检查可见肱桡间隙增宽,表现出肘关节内翻后内侧旋转不稳定,桡侧副韧带未进行探查修复。术后石膏固定2周行肘关节功能锻炼,表现出内翻后内侧旋转不稳定者石膏固定4周。术后随访记录患者肘关节活动范围、疼痛和稳定情况,肘关节力量和手部握力,根据改良An和Morrey肘关节功能评分评价肘关节总体功能。结果:6例术后均获随访,时间7.5～13个月,平均9.3个月。患侧肘部和手部力量均同健侧,肘关节平均屈曲(129.0±6.5)°(120°～135°),平均伸直(4.0±4.2)°(0°～10°),前臂旋转活动度平均旋前(84.0±6.5)°(75°～90°),平均旋后(89.0±7.1)°(80°～100°),1例术后出现尺神经感觉症状并于半年后恢复,所有患者未出现肘关节疼痛、不稳定,改良An和Morrey肘关节功能评分均为优。结论:尺骨冠状突前内侧面骨折可采用桡侧腕屈肌和掌长肌间入路进行切开复位内固定治疗,伴肘关节内翻-后内侧旋转不稳定者可适度延长制动时间。

Objective ：To investigate the approach of open reduction and internal fixation for the treatment of anteromedial eoronoid facet fractures and associated injury. Methods：From July 2009 to August 2011,6 coronoid anteromedial facet frac- tures were treated （4 males and 2 females ,the average age was 32.6 years old ,ranged from 19 to 49 years old） in our hospital. Three patients had fractures in the left side and 3 in the right （4 dominant sides and 2 non dominant sides）. All the patients had close fractures. All the fractures were subtype 2 or subtype 3 of coronoid anteromedial facet fracture according to O＇Driscoll classification. The anteromedial incision of elbow and the approach of splitting flexor digitorum superficialis between flexor carpi radialis and palmaris longus were used to apply internal fixation with mini-plate. After fixation of coronoid fracture, widening of radiohumeral joint interspace under varus stress occurred in 3 cases, elbow varus posteromedial rotational instabil- ity was showed, and the exploration and repair of radial collateral ligament was not carried out. Plaster was applied for 2 weeks before rehabilitation and the time of plaster application extended to 4 weeks in the patients showed varus posteromedial rota- tional instability. The motion degree, pain and stability, strength of elbow and hand were recorded, the elbows were evaluated with modified An and Morrey functional rating index. Results ： All the patients were followed up, and the average duration was 9.3 months （ranged from 7.5 to 13 months）. The strength of elbow and hand were equal to that in the contralateral side. The average flexion was （129.0±6.5） degree （ranged from 120 to 135 degree）; the average extention was （4.0±4.2） degree （ranged from 0 to 10 degree ） ;the average forearm pronation was （84.0±6.5） degree （ranged from 75 to 90 degree） ; average supination was （89.0±7.1） degree （ranged from 80 to 100 degree）. One patient had ulnar sensory neuropathy after operation and healed in half-year, no postoperative complications as pain and instability accured. All the patients obtained excellent re- sults according to modified An and Morrey functional rating index. Conclusion ： The approach of splitting flexor digitorum su- perficialis between flexor carpi radialis and palmaris longus could be used in open reduction and internal fixation of anterome- dial eoronoid facet farcture, rehabilitation should be postponed in the patient showed elbow varus posteromedial rotational in- stability.