成人孟氏骨折治疗的临床探讨

Clinical study for the treatment of monteggia fracture in adult

目的探讨成人孟氏骨折临床特点及其治疗方法。方法对30例成人孟氏骨折患者进行回顾性总结。BadoⅠ型8例、Ⅱ型15例、Ⅲ型3例、Ⅳ型4例,均为新鲜骨折,开放性骨折4例、伴桡神经损伤5例、桡骨头骨折5例。所有骨折均采用切开复位内固定治疗,尺骨骨折均采用切开复位钛板螺钉内固定,其中16例桡骨小头脱位采用闭合复位,14例桡骨小头脱位采用切开复位(分外侧副韧带修复术和环状韧带重建术)。男性21例、女性9例,年龄18~72岁,平均36.7岁。左侧患肢18例,右侧患肢12例。结果 30例患者均获随访,随访时间10~60个月,平均18.5个月。骨折愈合时间2~5个月,平均150.7d,桡神经损伤患者术后0.75~4个月内均完全恢复。30例患者无1例出现不愈合或畸形愈合,所有结果均按Broberg和Morrey评分系统进行评定,本研究按优和良为满意,可和差为不满意进行统计。根据桡骨小头的手术情况,分为桡骨小头闭合复位组和桡骨小头切开复位组。桡骨小头闭合复位组中,平均93.8分,优10例、良4例、可2例,满意率87.5%;切开复位组中,平均92.5分,优8例、良4例、可2例,满意率85.7%。30例患者总满意率为86.7%。结论根据本组实验结果,成人孟氏骨折应内固定治疗;尺骨骨折的解剖复位和钛板坚强内固定是取得较好疗效的主要原因,恢复尺骨正常长度,在孟氏骨折的治疗中非常的关键;在闭合复位桡骨失败时,应积极行切开复位手术,以维持桡骨稳定性及避免对肘关节造成进一步的损伤,闭合复位减少了局部创伤有利于局部软组织复原;伴随桡神经损伤者应结合患者临床症状、相关检查结果和术中患者的实际情况,在一定程度上放宽桡神经手术探查的指征。

Background Monteggia fracture is uncommon,accounting for about 1%-2% of the forearm fractures.The Monteggia fracture in adults is different from that in children and there are obvious differences in the aspects of mechanism of injury,type,prognosis and treatment method. However,compared to the clinical reports about Monteggia fracture in children,the number is relatively smaller in adults.Improperly treated adult Monteggia fracture may have more complications and need to draw enough attention from doctors.Thirty patients of fresh adult Monteggia fracture were treated with operation.Their clinical data was retrospectively analyzed by the author to explore its clinical features and treatment methods.Methods (1 )Clinical data:From December 2005 to April 2013,30 patients were admitted into our hospital,including 21 males and 9 females.Eighteen cases were on the left extremity and 12 cases were on the right side.Their ages ranged from 18 to 72 with an average of 36.7 years.According to Bado classification,there were 8 cases of Bado I (extension type),&nbsp;15 cases of Bado Ⅱ (flexion type),3 cases of Bado Ⅲ (adduction type)and 4 cases of Bado IV (special type).All the cases were fresh fractures with 4 cases of open fracture,5 cases of radial nerve damage and 5 cases of radial head fracture.All the patients were treated by open reduction and internal fixation of the ulnar fractures with titanium plate and screw.Sixteen cases of radial head dislocation were performed close reduction,and 14 cases were performed by open reduction.The lateral collateral ligament repair was done in 9 cases.Lateral collateral ligament repair with reconstruction of the annular ligament was done in 5 cases.Among 5 cases of radial nerve injury,2 cases were performed radial nerve exploration.(2)Operation methods:The operation was performed under brachial plexus block with tourniquet control.As to the open fracture,debridement was performed first to expose the ulnar fracture site.After reduction,the ulna was internally fixed with titanium plate.Closed ulnar fracture was performed open reduction and titanium plate and screw fixation.Both the ulna and the radius needed to be fixed for Bado type IV fractures.The pronation and supination of forearm were examined with C-arm.The radial head was observed under fluoroscopy and some of the dislocations could be reduced automatically in some cases (12 cases in this group).For the unreduced radial head, their upper edges were observed reducing to the level of lateral humeral condylar articular surface under fluoroscopy.Reduction was obtained through proper forearm pronation and compression on the radial head.The stability after reduction was checked with forearm in supination.If instability was still present,the humeroradial joint was fixed with one 2.5 mm Kirschner wire (4 cases in this group). Open reduction was indicated when"piano key"sign was positive,or there was radial head fracture,or failure of close reduction (14 cases in the open reduction group).At this point,lateral incision of radial head was made through the interval of anconeus muscle and extensor carpi ulnaris muscle to explore the annular ligament.With the forearm pronated,the joint capsule and the periosteum were released from the ulna side.The deep branch of radial nerve should be carefully protected.The humeral capitellum and dislocated radial head were explored.The radial head fracture was reduced and fixed with screws.The ruptured anular ligment was repaired at the same procedure (9 cases in this group);if repair of the anular ligment was not possible,reconstruction was performed with a deep fascia strip of 8-10 cm in length and 1 cm in width,and the pedicle was in the dorsal lateral of olecranon.A bone tunnel was drilled below the lesser sigmoid fossa of ulna.The fascia strip was enlaced around the radial neck,pulled through the bone tunnel below the radial side of the ulna,and finally sutured with its pedicle tissue.(5 cases in this group).Of the 5 cases with radial nerve injury,2 patients showed severe symptoms of nerve damage and had difficulty in reducing their radial heads,1 case was found that the deep branch of radial nerve was entrapped in the humeroradial joint.The entrapped radial nerve was carefully explored and released to its anatomic position.The elbows were immobilized in long arm plaster cast for 6 weeks after operation.For fractures of Bado Ⅰ,Ⅲ,Ⅳ,forearm was immobilized in neutral position and elbow in 1 10°of flexion;For Bado type Ⅱ fracture,the elbow was immobilized in 70° of flexion.All the patients received outpatient rehabilitation guidance.Results All the postoperative radiographs revealed good alignment and complete reduction of radial head.Thirty patients were followed up for 10 to 60 months with an average of 18.5 months.Fracture healing time was 2-5 months with an average of 1 50.7 days.It takes 3 - 4 months for the patients with radial nerve injury to obtain complete recovery.No nonunion or malunion occurred.All the results were assessed according to Broberg and Morrey systems and divided into 4 categories of excellent (95 -100),good (80-94),normal (60 - 79)and bad (< 60).According to the operation methods of the radial head,the patients were divided into close reduction group and open reduction group.10 excellent cases,4 good cases,and 2 normal cases were in the close reduction group with the mean score of 93.8 and the satisfaction rate of 87.5%.8 excellent cases,4 good cases,and 2 normal cases were in the open reduction group with the satisfaction rate of 85.7%.The total satisfaction rate of 30 patients is 86.7%.Discussion According to the results of this study,adult Monteggia fracture should be treated with internal fixation.The main reasons of achieving good outcome are anatomical reduction and titanium plate fixation of ulnar fracture.Restoration of normal ulnar length is critical in the treatment&nbsp;of Monteggia fracture.Close reduction reduces local trauma,which is beneficial to the healing of soft tissue.Once the closed reduction of the radius fails,open reduction should be actively conducted to maintain radial stability and avoid further damage to the elbow.Radial nerve palsy should be explored in primary procedure when complete entrapment is suspected.