肘关节“恐怖三联征”的诊断和治疗

Diagnosis and treatment of “terrible triad”of elbow joint

目的：通过对13例患者临床资料进行系统性回顾分析，探讨肘关节“恐怖三联征”的诊断、治疗策略以及术后康复。方法我科2010年3月～2013年9月，共收治这类损伤13例，均采取手术内外固定治疗。其中桡骨头骨折按Mason和Hotchkiss分类法：Ⅰ型7例，Ⅱ型4例，Ⅲ型2例。尺骨冠状突骨折按Regan和Morry分类法：Ⅰ型4例，Ⅱ型6例，Ⅲ型3例。本组病例中均合并有肘内外侧副韧带的损伤。13例均采取了手术内外固定治疗，以2.0、2.7、3.0mm螺钉分别固定冠状突骨折和桡骨头骨折，其中2例因桡骨头粉碎骨折无法修复，行桡骨小头置换术，内外侧副韧带损伤均采用带线锚钉固定，13例病例均使用带铰链的外支架屈肘90°前臂旋转中立位固定，术后即在外固定支架保护下行肘关节屈伸功能锻炼，4周后拆除外固定支架主动行肘关节屈伸和旋转功能锻炼。结果经3个月～3年随访，骨折愈合，肘关节稳定，无疼痛，肘关节屈伸幅度平均120°，前臂旋转幅度平均110°。 Mayo肘关节功能评分（MEPS）显示，优10例，良2例，差1例。结论肘关节“恐怖三联征”不仅有桡骨头及冠状突骨折，同时伴有肘内外侧副韧带损伤，肘关节稳定性差。只有通过对骨及韧带稳定结构的重建，配合及早正规的功能锻炼，肘关节功能才能获得满意的效果。

Objective We retrospectively analyzed the clinical features of 13 patients with “terrible triad”injury of elbow,so as to investigate its diagnosis ,treatment and postoperative rehabilitation .Methods From Mar. 2010 to Sep.2013,13 patients with “terrible triad” injury of elbow were treated with internal and external fixation . The Mason and Hotchkiss classification for radial head fractures indicated 7 cases of type Ⅰ,4 cases of type Ⅱ,and 2 cases of type Ⅲ.The Regan and Morry classification for fractures of ulna coronoid process indicated 4 cases of type Ⅰ,6 cases of type Ⅱand 3 cases of type Ⅲ.In addition ,all cases were associated with elbow medial collater-al ligament sprain .2.0-mm,2.7-mm and 3.0-mm screws were used to fix the coronoid process fracture and radial head fractures ,respectively .Two patients with comminuted fracture of radial head were taken radial head replace-ment.Medial and lateral collateral ligament injury was treated with suture anchors fixation .The 13 cases were ex-ternally fixed at 90°of elbow flexion with the forearm in neutral rotation .Postoperative flexion exercises were taken with external fixation to protect the downstream of elbow joint ,and active flexion and rotation function exercises were taken 4 weeks after operation .Results The 3 months to 3 years follow-up showed fracture healed ,elbow joint sta-ble and no pain in all the 13 cases,the average elbow flexion and forearm rotation was 120 °,and the average forearm rotation was 110 °.According to the Mayo score system ,there were 10 cases of excellent,2 cases of good,and 1 case of poor .Conclusion “Terrible triad” injury of the elbow is a type of injury combining with radial head and coronoid process fracture ,and medial and lateral collateral ligament injury of the elbow ,in which the elbow stability is poor .The elbow function can obtain satisfactory results only through stable structure reconstruction of bone and ligament and early functional exercise .