Mason Ⅰ型及Ⅱ型橈骨头骨折保守治疗失败病例分析

Analysis of failure case of conservative treatment of Mason type Ⅰ and Ⅱ radial head fractures

目的分析经过保守治疗的MasonⅠ型及Ⅱ型桡骨头骨折病例失败的主要因素,同时探讨手术对保守治疗失败病例的疗效。方法回顾性研究2010年2月至2015年6月在本中心行保守治疗的16~65岁急性MasonⅠ型及Ⅱ型的桡骨头骨折病例,排除合并同侧上肢其他损伤、颅脑外伤等影响桡骨头骨折预后的患者。收录信息包括患者一般情况、诊断、制动方式及时间,随访内容包括转为手术率、视觉模拟评分(visual analogue scale,VAS)、肘关节活动度、Mayo肘关节功能评分系统(Mayo elbow performance score,MEPS)等。结果共612例患者符合纳入标准,其中成功随访患者345例,包括男205例、女140例,平均年龄37.5岁(17~65岁),平均随访时间13.4个月(5~23个月)。345例患者中有27例(7.8%)患者因疼痛、活动障碍等原因转为手术治疗,转为手术治疗的患者平均制动时间要显著高于保守治疗成功组的患者,其中MasonⅡ型19例(70.4%),3例(11.1%)术中证实存在骨软骨游离体,1例(3.7%)存在环状韧带关节囊嵌顿,4例(14.8%)存在外侧韧带复合体损伤,25例(92.6%)有明确的关节僵硬而行松解术,另有5例(18.5%)因康复过程中出现尺神经损伤而行神经探查松解术。27例转为手术的患者,平均VAS评分从术前(5.6±1.4)分降到术后(1.2±0.8)分,MEPS评分从(55.6±8.6)分提高到(89.6±4.9)分,平均上肢功能评分表(disability of arm shoulder and hand,DASH)从术前(44.4±9.8)分降至术后(15.4±5.9)分。结论骨折类型、制动时间过长以及遗漏合并损伤是MasonⅠ型及部分MasonⅡ型桡骨头骨折保守治疗失败的主要原因,手术治疗可以满意解决相应的关节僵硬、疼痛、韧带和游离体嵌顿等并发症。

Background The treatment of isolated radial head fractures has been a subject of debate for many years.Conservative treatment has been used for nondisplaced and mild shift of the radial head fractures(Mason typeⅠandⅡ).However,there are few reports on the risk factors and types of complications that influence the prognosis of conservative treatment.Therefore,for radial head fractures,fracture type may not be a single factor in determining the treatment,and other reasons for failure of conservative treatment are worth further exploring.Objective To investigate the major factors of failure of conservative treatment and the effect of operation on the failure cases.Methods Retrospective studies were performed on patients aged 16 to 65 years who were acute Mason typeⅠand II radial head fractures and treated conservatively in our trauma center from February 2010 to June 2015.Patients who were treated with additional ipsateral upper limb injuries,as well as craniocerebral trauma affected the prognosis of radial head fractures were excluded.Information were included on the patient's general condition,diagnosis,method and duration of immobilization.Follow-ups included complications,re-operation,pain(VAS score),elbow motion,and Mayo elbow performance score(MEPS).Results A total of 612 patients met the inclusive criteria,among which 345 patients were successfully followed up,including 205 males and 140 females,with a mean age of 37.5 years(17-65 years)and a mean follow-up time of 13.4 months(5.4-23 months).Of the 345 patients,27(7.8%)turned to surgical treatment due to pain and mobility disorders.The mean immobilization duration of patients converted to surgical treatment was significantly higher than that of patients who were successfully treated in the conservative treatment group,including 19 Mason type II cases(70.4%),3 cases with osteochondral free bodies(11.1%),1 case with annular ligament capsule entrapment(3.7%),and 4 cases with lateral ligament complex injury(14.8%)There were 25 patients(92.6%)with definite joint stiffness who underwent release surgery and 5 patients(18.5%)with ulnar nerve injury during rehabilitation who underwent nerve exploration and release.Among the 27 patients who switched to surgery,the mean VAS scores decreased from(5.6±1.4)points to(1.2±0.8)points,the mean MEPS increased from(55.6±8.6)points preoperatively to(89.6±4.9)points postoperatively,and the mean DASH scores decreased from(44.4±9.8)points to(15.4±5.9)points.Conclusion Fracture type,prolonged immobilization duration and associated injuries are the main reasons for the failure of conservative treatment in Mason typeⅠand II radial head fractures.Surgical treatment can solve the corresponding complications such as joint stiffness,pain,ligament and free body cartilage incarceration.