肘关节恐怖三联征损伤的手术治疗研究

Operative treatment of terrible triad of the elbow

背景:肘关节是人体最容易发生骨折的部位之一,其中以肘关节恐怖三联征最严重,包含了肘关节脱位、桡骨头骨折及尺骨冠突骨折,外科手术治疗的目的是重建肘关节,恢复其稳定性,术中注意骨折与韧带的固定与修复,达到早期功能锻炼的目的。目的:探讨肘关节后外侧、前内侧联合入路治疗肘关节恐怖三联征损伤的方法和临床疗效。方法:选取2011年1月至2016年1月于我院就诊的肘关节恐怖三联征患者18例,其中,男10例,女8例;年龄23~56岁,平均(36.89±9.40)岁。尺骨冠突骨折按O'Driscoll分型标准:Ⅰ型17例,Ⅱ型1例。桡骨头骨折按Mason分型标准:Ⅰ型3例,Ⅱ型9例,Ⅲ型6例。均采用肘关节后外侧、前内侧联合入路行骨折复位内固定和韧带修复。结果:所有患者均获随访,随访时间13~29个月,平均(16.50±3.57)个月,其中,16例没有疼痛,2例轻微疼痛,没有严重疼痛。最后随访时,屈曲90°~140°,平均125.06°±18.12°,伸直丢失0°~70°,平均21.83°±16.93°,旋前20°~85°,平均64.69°±15.25°,旋后30°~85°,平均59.50°±12.73°。所有冠状突和桡骨头骨折显示骨愈合,骨折愈合时间8~14周,平均(10.72±1.87)周。所有患者肘关节在伸屈位和内翻位稳定,维持肱尺关节和肱桡关节的同心圆复位。3例术后6个月出现肘关节轻度异位骨化(Brooker 1级),未作特殊处理;1例术后18个月出现肘关节轻度退行性改变,经康复锻炼后未见进一步进展;没有桡骨头假体的下沉或明显的肱骨小头骨磨损。根据Broberg和Morrey功能评分标准,本研究58~98分,平均(81.89±9.39)分,优10例,良5例,可2例,差1例,优良率83.3%。结论:肘关节后外侧、前内侧联合入路有利于恐怖三联征损伤的复位和固定;修复桡骨头、冠状突和内外侧副韧带能有效恢复肘关节稳定,便于术后早期活动,促进关节功能恢复。

Background： Elbow is one of the most vulnerable parts of the human body and it is liable to fracture. Terrible triad of the elbow is the most severe fracture of the elbow, which contains elbow dislocation, radial head fracture and ulna coronoid fracture. The purpose of surgical treatment is to rebuild the elbow and restore its stability. Attention should be paid to fracture and ligament fixation and repair during the operation. Early functional exercise is thereafter achieved. Objective：To explore the operative procedures and clinical result of posterolateral and anteromedial elbow approaches in the treatment of terrible triad of the elbow. Methods： Between January 2011 and January 2016, 18 patients with closed terrible triad of the elbow were selected including 10 males and 8 females with an average age of（36.89±9.40） years（range, 23 56 years）. According to O＇Driscoll classification for fractures of the ulnar coronoid, there were 17 patients of type I and 1 patient of type II; according to Mason classification for fractures of the radial head, there were 3 patients of type I, 9 patients of type II, and6 patients of type III. All patients underwent fracture fixation and ligament repair by posterolateral and anteromedial elbow approaches. Results： All patients were followed up for 13 29 months with the mean as（16.50±3.57）months. 16 patients had no pain, 2 patients had mild pain, and none of the patients suffered from severe pain. Mean flexion was 125.06° ± 18.12°（range, 90° 140°）, mean extension loss was（21.83° ± 16.93°）（range, 0° 70°）, mean pronation was 64.69° ± 15.25°（range,20° 85°） and mean supination was 59.50°±12.73°（range, 30° 85°） at last follow up. The bony union time was 8 14 weeks with an average of（10.72±1.87）weeks. Elbows were stable in flexion extension and varus valgus in all patients. Elbows maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation. Mild ectopic ossification of the elbow occurred in 3 patients at 6 months after operation（Brooker, Grade 1）, and no special treatment was applied. Mild degenerative change in 1 patient at 18 months after operation was observed and the degeneration did not progress after rehabilitation exercises. There was no subsidence of the radial head implants or evidence of significant capitellar bone loss. According to Broberg and Morrey elbow performance score the mean score of all patients was（81.89±9.39）（range, 58 98）, the results were excellent in 10 patients, good in 5 patients, fair in 2 patients and poor in 1 patient, and the excellent and good rate was 83.3%. Conclusions： Posterolateral and anteromedial elbow approaches can facilitate the reduction and fixation of terrible triad of the elbow;repair of radius head, coronoid process and medial and lateral collateral ligament can restore suffi ciently elbow stability, allow early motion postoperatively, and enhance the functional outcome.