肱骨小头软骨损伤碎片扦插桡骨头骨折缝隙的诊治误区分析

Analysis of misdiagnosis in the diagnosis and treatment of capitulum cartilage injury fragments interposed into the gap of the radial head fractures

目的探讨肱骨小头软骨损伤(CCI)碎片扦插桡骨头骨折(RHF)缝隙临床特点和诊治误区。方法回顾性分析2011年1月至2022年12月RHF术中探查证实伴CCI,且CCI碎片扦插RHF缝隙9例患者临床资料。男6例,女3例;年龄17~69岁,平均为36.1岁。分析其临床特点。RHF按Mason分型,CCI按王健方法分型。随访13~30个月,平均随访14.2个月。患肢功能按Mayo肘关节功能评分标准(MEPS)评价。结果该骨折占RHF的6.8%,占RHF伴CCI的25%。跌伤6例,坠落伤3例。均有明显肘关节屈伸和前臂旋转活动受限,4例局部有骨擦音。6例因RHF较重、3例RHF较轻但局麻后体检试验阳性行手术。Mason Ⅰ、Ⅱ和Ⅲ型各1、7和1例。CCI分型Ⅰ、Ⅱ、Ⅲ型各3、4和2例。CCI仅1例Ⅲ型术前获MRI诊断,其余8例影像学检查均阴性。CCI位于肱骨小头外侧、后外侧和前外侧各4、3和2例;范围12~100 mm^(2),平均19.8 mm^(2)。RHF均内固定;CCI摘除8例,缝合固定1例,Ⅱ型行微骨折处理2例。RHF均愈合。末次随访,MEPS评价优良率88.9%。结论CCI碎片扦插RHF缝隙临床少见,易漏诊,但患者活动明显受限、局部骨擦音和局麻后体检试验阳性常提示该骨折可能;手术探查仍是诊断金标准,值得重视;CCI应按类型选择不同处理方法。

Objective To investigate the clinical characteristics and misconceptions in the diagnosis and treatment of capitulum cartilage injury(CCI)fragments interposed into the gap of the radial head fractures(RHFs).Methods A retrospective study was conducted on 9 patients with concomitant CCI fragments interposed into the gap of the RHFs,which were confirmed by intraoperative exploration from January 2011 to December 2022.There were 6 males and 3 females.The age ranged from 17 to 69 years old,with an average of 36.1 years.The clinical characteristics were analyzed.RHF was classified according to Mason's classification and CCI was classified according to Wang Jian's method.The follow-up time ranged from 13 to 30 months,with an average follow-up of 14.2 months.The function of the affected limb was evaluated by Mayo Elbow Score(MEPS).Results This fracture accounted for 6.8%of RHF,and accounted for 25%of RHS with CCI.6 cases caused by falls and 3 cases by falls from height.All had significantly limited range of movement(ROM)of flexion-extension and rotation of the forearm,and 4 cases had local crepitus.6 cases underwent surgery because of severe RHS and 3 cases because of positive physical examination test after local anesthesia with light RHF.RHF included 1 case of Mason type Ⅰ,7 type Ⅱ and 1 type Ⅲ.CCI included 3 cases of type Ⅰ,4 type Ⅱ and 2 type III.CCI was diagnosed by preoperative MRI in 1 case with type Ⅲ,and the remaining 8 cases were negative by radiology examinations.CCI was located on the lateral side of the humeral head in 4 cases,posterolateral in 3 cases,and anterolateral in 2 cases,its size ranged from 12 mm^(2) to 100 mm^(2),with an average of 19.8 mm2.All RHFs were internally fixed.CCI was removed in 8 cases,sutured in 1 case,and microfracture performed for type Ⅱ in 2 cases.All fractures healed.At the last follow-up,the excellent and good rate was 88.9%according to MEPS.Conclusions CCI fragments interposed into the gap of RHFs is rare and easy to be missed,but obviously limited ROM,local crepitus and a positive physical examination after local anesthesia suggest possibility of this fracture.Surgical exploration remains the gold standard for diagnosis and deserves attention.CCI should choose different treatment methods according to its type.