经鹰嘴骨折肘关节前脱位的诊疗策略

The clinical strategy of anterior elbow joint dislocation via olecranon fracture

目的探讨经鹰嘴骨折肘关节前脱位损伤的病理特征和治疗策略。方法筛选自2013年7月至2021年7月期间就诊治疗的23例经鹰嘴骨折肘关节前脱位患者,并回顾性分析患者的病历和影像资料。其中男17例、女6例,平均年龄39岁(21~65岁)。左侧肘关节受累10例,右侧肘关节受累13例。10例患者为简单横行、斜行的鹰嘴滑车切迹骨折(Mayo分型ⅢA型),13例患者为复杂粉碎性鹰嘴滑车切迹骨折(Mayo分型ⅢB型),其中4例骨折碎片向尺骨近端延伸。合并冠突骨折12例,均为Regan-Morrey分型Ⅱ型。经肘关节后正中手术入路,解剖恢复其鹰嘴的解剖长度、尺骨近端背侧的解剖曲度,所有患者均使用尺骨近端3.5 mm解剖钢板坚强内固定鹰嘴骨折。对于4例尺骨近端骨折粉碎严重患者,另于尺骨前方内侧或外侧予以1~2块2.7 mm小型钢板固定粉碎骨折块。冠突骨折复位后采用经尺骨近端钢板的螺钉固定。或使用埋头加压空心螺钉、锚钉等固定,并修复前方肘关节囊。结果23例患者获1~8年随访,平均2.55年。所有患者的骨折均在3~6个月(平均4.5个月)后获得骨性愈合;所有患者肘部的解剖关系良好,并发症创伤性关节炎3例,异位骨化3例,神经损伤1例,经相应处理后恢复良好;所有患者均未发生内固定失效、感染等;肘关节的长期功能随访均好,末次随访时的平均屈伸活动范围为107.8°、平均肘关节旋转活动范围为102.5°。术后末次随访的视觉模拟评分(visual analogu scale,VAS)平均为0.8分;上肢功能评定表(disabilities of the arm,shoulder and hand,DASH)平均分为37.6分;Mayo肘关节功能(Mayo elbow performance score,MEPS)评分为91.7分。结论经鹰嘴骨折肘关节脱位作为肘关节复杂骨折脱位的一种,临床较少见。笔者强调重视解剖修复鹰嘴及滑车切迹、钢板坚强内固定、早期功能锻炼的诊疗策略,可基本恢复肘关节旋转屈伸功能,降低经鹰嘴骨折脱位术后的肘关节不稳定发生率,提高患者肘关节的临床疗效。

Background The elbow dislocation of trans-olecranon fracture is a rare type of injury.It is often caused by high-energy violence or low-energy injury in elderly patients with osteoporosis.In the semi-flexion of the elbow,the violent axial impact of the distal humerus on the trochlear notch of the proximal ulna leads to olecranon fractures or complex concomitant fractures of the proximal ulna,including the trochlear notch of the olecranon.After the injury,the alignment relationship between the humeroulnar and humeroradial joint was destroyed,the anterior joint capsule was torn,and the elbow joint and forearm were dislocated.Coronary fractures often accompany it.However,it always maintains stability of the upper radioulnar joint and is less associated with ligament injury,and the annular ligament is usually left intact.The change of humeroulnar joint position was mainly due to the destruction of bone structure at the trochlear notch of the olecranon rather than ligament injury.The fracture of bone structure has many forms,such as simple non-comminuted transverse fracture,oblique fracture,complex comminuted fracture of trochlear notch,etc.Objective The elbow dislocation of trans-olecranon fracture is not common in clinical practice.The purpose of this retrospective study is to investigate the pathological characteristics and treatment strategies of this injury.Methods The author selected 23 patients with elbow dislocations of trans-olecranon fractures from July 2013 to July 2021 and retrospectively analyzed their medical records and imaging data.Among them are 17 males and 6 females with an average age of 39(21-65).There were 10 cases of left elbow joint involvement and 13 cases of right.Ten patients had simple transverse or oblique olecranon trochlear notch fractures(Mayo type IIIA),13 patients had complex comminuted olecranon trochlear notch fractures(Mayo type IIIB),of which 4 had fracture fragments extending towards the proximal end of the ulna.Twelve combined coronal process fractures were classified according to Regan Morrey type II.We restored the olecranon's anatomical length and the proximal ulna's anatomical curvature through the posterior median surgical approach of the elbow joint.All patients were treated with 3.5 mm proximal ulna anatomical plates for rigid internal fixation of olecranon fractures.For 4 patients with severe comminuted proximal ulnar fractures,1 or 2 small plates with a diameter of 2.7 mm were used to fix the comminuted fracture on the medial or lateral front of the ulna.After reducing the coronal process fracture,we set it with screws of a proximal ulnar plate or used countersunk compression hollow screws and anchor nails and repaired the anterior elbow joint capsule.Results 23 patients were followed up for 1-8 years,with a mean follow-up period of 2.55 years.All patients’fractures achieved bone healing after 3 to 6 months,with an average time of 4.5 months.All patients had good anatomical relationships at the elbow,with complications such as traumatic arthritis in 3 cases,ectopic ossification in 3 cases,and nerve injury in 1 case.After the corresponding treatment,they recovered well.All patients did not experience internal fixation failure,infection,etc.The long-term functional follow-up of the elbow joint was good,with an average range of flexion and extension motion of 107.8 degrees and an average range of elbow rotation motion of 102.5 degrees at the last follow-up.The average VAS score at the final postoperative follow-up was 0.8 points.The average DASH score is 37.6 points.The MEPS score is 91.7 points.Conclusions The elbow dislocation of trans-olecranon fracture is a common type of complex fracture dislocation of the elbow in clinical practice.The author emphasizes the importance of anatomical repair of the olecranon and trochlear notch,rigid internal fixation with plates,and early functional exercise as diagnostic and treatment strategies,which can restore the rotation,flexion,and extension function of the elbow,reduce the incidence of elbow instability after olecranon fracture and dislocation surgery,and improve the clinical efficacy of patients'elbow joints.