前后联合入路治疗儿童陈旧性孟氏骨折

Combined anterior and posterior approach for treatment of chronic Monteggia fracture in children

[目的]探讨前后联合入路行关节切开复位、尺骨截骨术治疗儿童陈旧性孟氏骨折的方法及疗效。[方法]回顾性分析2010年11月~2015年1月收治的22例陈旧性孟氏骨折患儿资料。男15例,女7例,平均年龄7.5岁。伤后至手术时间除2例分别为3年、5年外,其余20例为1~12个月。患者X线片示桡骨头脱位,尺骨桡侧或掌侧弓形弯曲,伤后时间长者见桡骨过度生长。2例伴有桡神经深支损伤症状。所有患儿均采用经肘前Henry入路行肱桡关节切开、瘢痕彻底清除,有桡神经损伤者同时行神经探查松解;肘后沿尺骨嵴做纵切口,在尺骨鹰嘴下4~5 cm横行截骨,矫正尺骨畸形并反向成角、截骨端延长后予钢板固定。所有患儿均不行环状韧带重建。[结果]本组患儿随访12~59个月,平均15.4个月。根据Mackay功能评定标准,优19例,良2例,差1例。X线片示1例再脱位、2例半脱位,余复位稳定。术后肘关节屈伸功能较术前改善,差异具有统计学意义(P<0.05);手术前后前臂旋转功能的差别无统计学意义(P>0.05)。未出现血管神经损伤、异位骨化、尺桡骨骨性连接等并发症。2例桡神经深支损伤患儿3个月内恢复正常。[结论]前后联合入路治疗儿童陈旧性孟氏骨折具有术野显露好、术中操作简便、术后并发症少等优势。前入路允许直视下处理关节内病理改变,同时便于行桡神经探查松解,后入路有利于尺骨截骨矫形术。

[Objective] To investigate the clinical outcome of combined anterior and posterior approach for the treatment of chronic Monteggia fractures in children. [Methods] Twenty-two patients with chronic Monteggia fracture were treated sur- gically in our department from November 2010 to January 2015. The patients included 15 males and 7 females, with a mean age of 7.5 years old. The interval from injury to surgery ranged from 1 to 12 months, except 3 and 5 years in another 2 cases. X-ray examination showed dislocation of head of radius, excessive growth of radius, and even a bending ulna towards the ra- dial or palmar side. Radial nerve injury was also found in 2 cases. In the surgical procedure, open reduction and excision of fi- brous scar was performed using Henry approach, at the same time, ulnar osteotomy was carried out using a posterior ap- proach. Reconstruction of the annular ligament was not given to any patient. [Results] All patients were followed up for an av- erage of 15.4 months （range, 12-59 months） . According to Mackay＇s criteria, excellent outcomes were achieved in 19, good in 2 and poor in 1 child. Redislocation occurred in a patient while subluxation in other 2 cases. At the last follow-up, flex- ion and extension showed significant improvement compared to pre-operation （P〈0.05） . No severe complications, such as vascular injuries, heterotopic ossification or radioulnar synostosis, were noted in any patient. However, deep branch of radial nerve palsy was found in 2 patients, which recovered spontaneously to normal in 3 months. [Conclusion] The anterior ap- proach facilitates the radial nerve exploration and directly deal with intra-articular pathological change, whereas the posterior approach is convenient for ulna osteotomy. Combined approach has advantages of better exposure, easy intraoperative manage- ment, and fewer postoperative complications.