儿童陈旧性孟氏骨折:需要重建环状韧带吗?

Children’s old Monteggia fracture: Annular ligament reconstruction or not?

背景:桡骨头的再次脱位一直是陈旧性孟氏骨折令人担忧的并发症之一,许多治疗方法已描述治疗中骨折和环状韧带重建的需要,但并不明确。目的:通过两组儿童治疗上的对比,从而强调探讨环状韧带重建的实用性。方法:纳入12例陈旧性孟氏骨折儿童并进行前瞻性研究,所有儿童均接受桡骨头切开复位内固定。其中5例儿童接受尺骨延长矫形截骨和环状韧带重建治疗;7例患儿仅行尺骨延长矫形截骨而没有韧带重建治疗;病程从损伤至临床表现为3-18个月(平均9个月)。10例患儿为Bado用Ⅰ型,另外2例分别是BadoⅡ、Ⅲ型。治疗前后采用Kim标准评价韧带重建对于治疗的可靠性。结果与结论:12例均获得随访,平均随访22个月(8-26个月)。愈后按照Kim标准进行评估:优10例,无畸形,无疼痛,关节活动度>250°,无肘关节受限,日常生活活动能力25分);良2例,轻度畸形,轻度或间歇性疼痛,关节活动度200°-250°,肘关节受限,日常生活活动能力15分;差0例,严重畸形,疼痛,关节活动度<200°,肘关节严重受限,日常生活活动能力0分。随访22个月,所有患儿尺骨截骨平均愈合时间为8周(6-14周)。伤口均一期愈合,无感染及骨不连发生。说明尺骨延长截骨矫形在桡骨头稳定性中具有重要意义,是否行环状韧带重建基于受伤时间、手术方式及术中桡骨头稳定性而定。

BACKGROUND： Radial head re-dislocation is one of the alarming complications of old Monteggia fracture. Many treatment methods have described the necessary of fracture and annual ligament reconstruction during treatment, but still unclear. OBJECTIVE： To emphasize the practicality of annular ligament reconstruction through comparing the children＇s treatment in two groups. METHODS： Twelve patients with children＇s old Monteggia fracture were included for retrospective analysis. All the patients were treated with radial head open reduction and internal fixation. Among them, five cases received ulna extending osteotomy and annual ligament reconstruction, and seven cases received ulna extending osteotomy without annual ligament reconstruction. The course was 3-18 months from damage to the clinical manifestations （an average of 9 months）. Ten cases with Bado type I and two cases were Bado type Ⅱ and Ⅲ. The reliability of ligament reconstruction was evaluated before and after treatment with Kim standard. RESULTS AND CONCLUSION： All the 12 cases were followed-up for 22 months （8-26 months）. Evaluation according to the Kim standard after treatment showed excellent in 10 cases without abnormalities and pain, the range of motion 〉 250°, and no elbow was limited, the activities of daily living was 25 points; good in two cases with mild deformity and mild or intermittent pain, the range of motion was 200°-250° with elbow limited, activities of daily living was 15 points; no poor （serious deformity, Pain, range of motion 〈 200°, elbow severely limited, activities of daily living was 0 points）. Followed-up lasted for 22 months and found that the average healing time of ulnar osteotomy was 8 weeks （6-14 weeks）. The wounds were healed primarily without infection and nonunion. The results indicate that ulna extending osteotomy has great significance in keeping stability of radial head, and annular ligament reconstruction is determined by the time of injury, surgical procedures and intraoperative radial head stability.