创伤性肘关节僵硬的围手术期护理及康复治疗

Perioperative nursing care and rehabilitation for patients with traumatic elbow joint stiffness

目的探讨创伤性肘关节僵硬患者围手术期护理及康复治疗要点。方法 2010年1月至2014年12月,北京大学人民医院创伤骨科采用开放式肘关节松解结合铰链式外固定架治疗创伤性肘关节僵硬患者8例。非常严重僵硬(活动范围≤30°)2例,严重僵硬(活动范围30°~60°)6例。Mayo肘关节功能评分45~75分,平均53.8分。其中3例患者术前合并尺神经卡压症状。术前开始给予心理护理;术后给予患肢伤口护理、疼痛护理、外固定架针道护理及针对性功能锻炼治疗。结果8例患者均得到11~61个月随访,平均随访时间35.4个月。患者肘关节活动度平均105°。Mayo评分70~95分,平均85.0分。3例患者合并尺神经卡压中的2例尺神经损伤症状完全缓解,1例残留部分手内在肌萎缩。所有8例患者均无肘关节不稳定现象,术后未出现其他并发症。结论采用开放式肘关节松解结合铰链式外固定架治疗创伤性肘关节僵硬,要严格辅助围手术期各项护理及康复治疗,可以有效改善肘关节活动范围,可促进肘关节功能恢复。

Background The elbow joint is a composite joint consisted of the humeroulnar joint , humeroradial joint ,and proximal radioulnar joint .The causes for elbow joint stiffness include joint capsule scar contracture ,ectopic ossification around the joint and long‐term immobilization .The conservative treatment can be applied to early elbow joint stiffness .The open elbow release surgery is applicable for patients who do not respond to conservative therapy .Although satisfactory range of motion is obtained after complete release ,the loss of range of motion may occur again if the patients don′t exercise due to pain .The assistance of hinged external fixator helps to prevent joint capsule scar contracture ,promote early function exercise ,and effectively prevent relapse of elbow joint stiffness .In this study ,we reported the perioperative nursing care and rehabilitation in 8 cases who presented good outcomes after open release surgery combined with hinged external fixator for traumatic elbow joint stiffness in the department of traumatic orthopedics in the Peking University‐affiliated People′s Hospital from January 2010 to March 2014 .Methods General data:8 cases including 3 males and 5 females with a mean age of 38 .3 years ranged from 17‐61 years were included in the group .4 cases had primary injury caused by dislocation of elbow joint .1 case had radial head fracture .1 had supracondylar fracture of humerus .2 had intercondylar fracture .The time from the initial injury to the surgery ranged from 10‐36 months ,with a mean of 18 .2 months .According to Morrey classification of elbow joint stiffness ,2 cases had very severe stiffness (range of motion ≤30°);6 cases had severe stiffness (range of motion 30°‐60°) .According to Mayo scale for elbow function ,the score ranged from 45‐75 ,with a mean of 53 .8 .Three cases of them had complicated entrapment of the ulnar nerve .Surgery method:All patients of the group were subject to general anesthesia .The surgery with medial and lateral approaches were performed to release the capsular ligament and tendon ,and remove the ectopic ossification .Normal release was performed for the prepositioned ulnar nerve .The center of rotation of the elbow joint was positioned under fluoroscopy .2‐mm Kirschner wire was inserted in the center of rotation .Stryker Dynamic Joint Distractor (DJD II) was used for external fixation .2 screws for external fixation were inserted from the humerus and ulna ,respectively .The screws should be in parallel with the Kirschner wire in the same plane .The screws were connected with the external fixator using clamp .The elbow joint gap was open by rotating the retractor .Key points for nursing :(1) Psychological nursing before surgery :The patients were subject to health education based on the assessment of patients′understanding of the condition .Patients were informed of the surgery objective and outcome ,possible discomforts after surgery and relative measures and the importance of function exercise .Rehabilitation plan was made for patients .They are also motivated to cooperate during surgery ,postoperative nursing care and rehabilitation so that good results could be obtained .(2 ) Postoperative nursing for affected extremity :During stay in bed ,the patients were on the horizontal position with soft pillow elevating the affected extremity .The affected extremity was gently massaged from the distal to the proximal end to promote vein reflux .When the patients are able to get out of the bed ,the forearm was supported by strap .The temperature ,blood supply ,feelings and mobility were assessed to determine whether symptoms of nerve injury developed .(3 ) Pain management after surgery :Long‐term physical therapy and drugs were used to relieve pain .The cold pack was applied to the affected extremity three times per day ,20 min once .The patients in the group had no history of gastrointestinal ulcer before surgery .The patients were intravenously administered with flurbiprofen axetil twice at a dose of 50 mg during stay after surgery .In case of flare of pain ,people with pain score≥4 were intramuscularly administered with 50 mg pethidine hydrochloride .After discharge ,the patients were orally administered with celecoxib ,200 mg once ,twice per day .(4 ) Nursing of approaches after surgery :The dressings were immediately changed if exudate was observed after function exercise at early period .75% alcohol was used to sterilize skin around the approaches ,twice per day .The patients were told to keep the affected extremity and external fixator clean .The approaches and external fixator should not be touched at will .If purulent exudate on the approach or red swelling around the approach skin was observed ,it was suspected as approach infection .This should be immediately reported to the physician to avoid loosening of external fixator .(5) Function exercise after surgery :1 day after surgery ,the fixing pole was removed from the external fixator to help patients to do passive isometric exercise at elbow joint flexion and extension ,3 to 5 sets a day ,5‐10 repeats per set .The patients were motivated to do active forearm rotation exercise .The pain killers and cold packs were combined to ease pain before and after exercise .The psychological nursing was strengthened for patients .Adequate encouragement and positive assessment were provided to patients to increase their confidence in rehabilitation ,thereby increasing rehabilitation benefits .Furthermore , based on the types of elbow joint stiffness such as flexion stiffness and extension stiffness ,the elbow jont was immobilized at maximum extension or flexion position at night .Adequate attention should be attached to the active motion of the shoulder joint ,wrist joint and other joints of the hand .4 weeks after the surgery ,patients were motivated to do active elbow joint flexion activities .6‐8 weeks after surgery,theexternalfixatorwasremoved.Results 8caseswerefollowedupfor11‐61months(witha mean of 35 .4 months) .The mean range of joint was 105° .The score for Mayo was 70‐95 ,with a mean of 85 .0 .Two of 3 cases with complicated ulnar neuritis had complete response ,and the other one had contraction in the residual intrinsic muscle of hand .Instable characteristics were not observed in all 8 cases .There were no other complications after surgery .Conclusion The elbow joint is one of the joints that are most likely to develop post‐traumatic stiffness .10%‐15% patients develop joint stiffness after trauma .The aim of treatment for elbow joint stiffness is to recover the function of elbow joint and relive mobility‐induced pain .The open release surgery is a common option for elbow joint stiffness .It can obviously imporve the range of motion of the elbow joint .The key for nursing is associated with psychological nursing and nursing of the affected extremity .Another important thing is pain management and nursing for approaches for the external fixator .Also ,the patients should have exercise ,regular follow‐up during stay in the hospital or after discharge ,thereby improving the outcome of surgery .