肘關節鏡輔助下復位固定治療尺骨冠狀突骨折

楊順 向明 楊國勇 陳杭 胡小川 唐浩琛

·論著·

肘關節鏡輔助下復位固定治療尺骨冠狀突骨折

楊順 向明 楊國勇 陳杭 胡小川 唐浩琛

目的介紹在肘關節鏡輔助下復位固定治療尺骨冠狀突骨折的手術方法，并通過臨床病例隨訪分析其療效。方法自2009年11月至2012年1月共收治16例尺骨冠狀突骨折（Morry－Regan分型Ⅱ～Ⅲ）患者，其中14例得到隨訪。終末隨訪時應用X線片評估骨折愈合情況，應用改良肘關節HSS評分評價肘關節功能，根據VAS進行疼痛評分。結果術后平均隨訪12．6個月（8～24個月）。所有患者術中均達到解剖復位。終末隨訪時改良肘關節HSS平均33分（28～35分），平均VAS疼痛評分（1．2±0．5）分，平均肘關節屈曲132．4°，平均伸直10．6°，總體優良率為100% （14／14）。結論在肘關節鏡輔助下，復位固定治療尺骨冠狀突骨折的手術方式，手術創傷小，復位固定可靠，術后肘關節恢復時間短，是治療尺骨冠狀突骨折的一種有效方法。

關節鏡；尺骨骨折；外科手術，最小侵入性

尺骨冠狀突骨折反映了肘部創傷的嚴重程度［1］。主要是由于肘關節伸直位跌倒，冠狀突與肱骨滑車碰撞所致，常導致肘關節不穩定［2］。暴力大時常合并肘關節脫位，骨折塊較大時由于肌腱牽拉，復位不容易維持，使肘關節穩定性受到嚴重影響，常需手術治療，恢復關節的穩定性。本院自2009年11月至2012年1月在肘關節鏡輔助下復位固定治療16例尺骨冠狀突骨折，報道如下：

資料與方法

自2009年11月至2012年1月應用肘關節鏡輔助下復位固定治療16例尺骨冠狀突骨折患者，其中男性10例，女性6例；年齡24～51歲，平均39歲；摔傷11例，車禍傷5例；左側6例，右側10例；合并肱骨小頭骨折1例，合并后外側旋轉不穩定3例；骨折按Regan－Morrey分型：Ⅱ型10例，Ⅲ型6例。

術前經肘關節X線、CT及三維成像檢查（圖1～4）后確診，精確了解骨折部位、骨折塊大小、移位程度［3］。手術在全麻下進行，采用側臥位，患肢置于肘托上（如圖5～10）。術中應用充氣式止血帶，充氣壓力240mmHg，止血帶時間40～90min，平均（63．3±25．0）min。肘關節鏡手術采用屈肘位近端前外側入路及近端前內側入路，因為：（1）近端前內側入路距離尺神經、正中神經最遠，為內側入路中最安全的入路（尺神經的距離為15．5mm，正中神經的距離為13．8mm）；（2）近端前外側入路距離橈神經（距橈神經10mm）最遠，鏡子操作靈活，鏡下視野良好，為外側入路中最安全、有效的入路；（3）肘關節屈曲90°位與伸直位比較，神經更遠離入路穿刺點，因此選擇在肘關節屈曲90°位時穿刺更安全［4］。通常采用中外側入路注水，充盈肘關節，建立關節鏡通道，刨削清理關節內瘀血及滑膜，暴露冠狀突骨折塊，關節鏡輔助下以探鉤復位，復位滿意后行克氏針或螺釘固定，螺釘或克氏針自尺骨后側至冠狀突方向固定，螺釘選擇合適長度的直徑3．0mm中空螺釘，尖端穿過冠狀突前方均不超過2mm（如圖11～12）。如應用克氏針，針尾折彎后留于皮下。存在伴隨損傷（如肱骨小頭骨折）需同時固定及行切開操作，包括（如后外側旋轉不穩定）內、外側副韌帶的修補或重建等。術后屈肘固定1周后，在醫生指導下行早期功能鍛煉。

圖1～4 傷后X線片及CT片。肘關節正位（圖1）和側位（圖2）X線片提示尺骨冠狀突骨折；肘關節矢狀位CT平掃片（圖3）和CT重建片（圖4）提示尺骨冠狀突骨折Regan－MorreyⅡ型

圖5～10 術中體位及復位固定照片。圖5術中體位；圖6關節鏡下探查復位冠狀突；圖7第1枚克氏針固定；圖8第2枚克氏針固定；圖9螺釘固定后；圖10固定后骨折端穩定

圖11～12 術后X線片。術后肘關節正位（圖11）和側位（圖12）X線片提示尺骨冠狀突骨折術后對位對線良好，二枚空心釘固定有效在位

結 果

其中14例得到隨訪，平均隨訪12．6（8～24）個月。術后切口均Ⅰ期愈合，無切口滲液、神經損傷及骨折再移位發生，1例發生異位骨化。終末隨訪時應用X線片評估骨折愈合情況，X線片顯示骨折均臨床愈合，愈合時間為10～14周，平均12周。所有患者術中均達到解剖復位。終末隨訪時改良肘關節HSS平均33（28～35）分，視覺模擬評分法平均（visual analog scale，VAS）疼痛評分（1．2±0．5）分，平均肘關節屈曲132．4°，平均伸直10．6°，平均旋前68．5°，平均旋后78．6°（如圖13～18），總體優良率為100%（14／14）。

討 論

圖13～18 術后18個月X線片及功能圖像。肘關節正位（圖13）和側位（圖14）X線片提示尺骨冠狀突骨折術后對位對線良好，二枚空心釘固定有效在位，骨折已愈合；肘關節伸直0°（圖15），屈曲130°（圖16），旋后80°（圖17），旋前60°（圖18）

尺骨冠狀突與尺骨鷹嘴構成尺骨半月切跡，與肱骨滑車構成屈戌關節。尺骨冠狀突是肘關節前方最主要的骨性阻擋結構，與內側副韌帶并列為防止肘關節后脫位及后內側旋轉不穩定的重要組成部分，尺骨冠狀突也是肘關節前方重要軟組織的附著點，包括前方關節囊、內側副韌帶前束、肱肌等，起抵抗肱二頭肌、肱肌和肱三頭肌牽拉尺骨向肘后移位的作用，是維持肘關節穩定的主要結構。冠狀突是前柱和內側柱的重要組成部分，構成肘關節前方穩定環［5］，當其損傷時，將導致肘關節前方和內側不穩定。如處理不當或不及時，很容易引起習慣性脫位。因此，在治療尺骨冠狀突骨折時，恢復或重建冠狀突的高度和形狀以及修補或重建內側副韌帶前束顯得非常重要。隨著對肘關節研究的深入，尺骨冠狀突在肘關節穩定性中的重要作用目前已得到公認，其骨折通常會造成復雜的創傷性肘關節不穩定，因此尺骨冠狀突骨折的治療也越來越受到臨床醫生的重視［6］。骨折塊較大（Regan－MorreyⅡ型、Ⅲ型）時，由于屈肌牽拉、骨折塊移位，易伴隨肘關節不穩定，手法復位骨折塊位置維持困難。由于骨折位于肘窩內，暴露、固定困難，特別是冠狀突小塊或粉碎性骨折尤為明顯。治療方法不得當，易引起關節失穩，并發創傷性關節炎、骨化性肌炎和關節僵硬等。

冠狀突骨折屬于關節內骨折，解剖復位和堅強內固定治療關節內骨折是恢復關節功能的基礎。解剖復位有利于關節的活動，減輕關節疼痛，防止創傷性關節炎的發生；堅強內固定利于早期功能鍛煉，防止肘關節的僵硬，減少肌肉萎縮，阻止動力性不穩和創傷性關節退變的發生，獲得較好的功能。尺骨冠狀突骨折常合并肘關節不穩定，國外學者相關系列病例報道中探討了治療方案與相關預后，同時也提出了診斷標準及手術治療方案［7－9］；國內學者也有類似報道和文獻綜述，介紹治療經驗，討論新手術入路及方案等［8］。

目前主要的固定方法有鋼絲固定、克氏針固定、微型螺釘內固定、微型鋼板內固定和可吸收螺釘內固定［10－13］等。目前對尺骨冠狀突骨折切開復位內固定常規從前路手術，但直視下將骨折的冠狀突復位內固定非常困難，因為：（1）肘關節前方血管、神經排列緊密，必須經血管神經間隙或肌間隙進入，可能增加副損傷；（2）冠狀突位置較深，觸及骨折線難度非常大，因為尺骨冠狀突上有很多軟組織與之相連并牽拉之，在此情況下很難從前方摸清骨折線并復位；如果將冠狀突上的軟組織徹底切除，包括前內側面高聳結節內側副韌帶前束止點、肱肌止點及關節囊，復位雖容易了許多，但在某種程度失去了復位的意義；（3）冠狀突骨折塊往往比較小，從前方壓緊后手指又占據了打孔固定的位置；（4）開放復位手術創傷大，易形成異位骨化，同時遺留較大手術疤痕，影響美觀。

隨著對肘關節功能解剖的深入了解及患者對肘關節功能要求的提高，微創手術越來越成為關節內骨折安全、有效的治療方法。因關節鏡下手術具有創傷小和恢復快的優點，近年來其應用在肘關節內骨折取得了較快的進展。在急性肘關節創傷中，肘關節鏡技術不僅可以進行小骨折塊或脫落軟骨的清理，還可行復位內固定術。如橈骨頭骨折、鷹嘴骨折、冠突骨折、肱骨髁骨折等復位內固定術均有報道［14］。Adams等［15］應用肘關節鏡對7例尺骨冠狀突骨折進行復位固定，終末隨訪療效滿意，無異位骨化及肘關節炎發生。

肘關節鏡入路采用屈肘位近端前外側入路及近端前內側入路，因為：（1）近端前內側入路距離尺神經、正中神經最遠，為內側入路中最安全的入路（尺神經的距離為15．5mm，正中神經的距離為13．8mm）；（2）近端前外側入路距離橈神經（距橈神經10mm）最遠，鏡子操作靈活，鏡下視野滿意，為外側入路中最安全、有效的入路；（3）肘關節屈曲90°位與伸直位比較，神經更遠離入路穿刺點，因此選擇在肘關節屈曲90°位時穿刺更安全［4］。對于Regan－MorreyⅡ型且伴粉碎性骨折，術前CT充分估計骨折塊大小，因骨折塊較小，行空心螺釘固定可能造成骨折塊破裂，而且固定效果不確切。為防止這種情況發生，我們對Regan－MorreyⅡ型且伴粉碎性骨折行自尺骨后側至冠狀突方向克氏針固定；對Regan－MorreyⅡ型單純骨折及Regan－MorreyⅢ型骨折塊較大者，行自尺骨后側至冠狀突方向空心螺釘固定。

與其他關節相比，肘關節鏡技術要求更高，術者必須非常熟悉肘關節周圍的解剖［16］。因為肘關節周圍解剖復雜，有很多重要的神經血管，肘關節鏡手術雖然作為一種有效微創的治療手段，并發癥的發生率比膝、肩等關節鏡手術高，但是絕大多數都是輕微可逆的，并且經過一定的措施這些并發癥也是可以避免的，故肘關節鏡是一種安全有效的技術［17］。此外，關節鏡技術可提供更好的關節內視野，更少的手術創傷，更短的術后康復時間。

應用肘關節鏡輔助下復位固定治療尺骨冠狀突骨折的手術方式，肘關節具有手術切口小、創傷小、效果好和恢復快等優點。關節鏡能直接觀察關節面，使關節內骨折解剖復位，減少創傷性關節炎，并且可使神經、血管損傷等并發癥減至最少，還可減少手術創傷，降低肘關節損傷的并發癥，但要求術者有豐富的鏡下操作經驗及局部解剖知識，嚴格手術適應證的選擇，才能最大限度地避免并發癥的發生［18］。

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Elbow arthroscope assisted reduction and fixation treatment for coronoid fracture

Yang Shun，Xiang Ming，Yang Guoyong，Chen Hang，Hu Xiaochuan，Tang Haochen．Department of Upper Extremity，Sichuan Province Orthopaedic Hospital，Chengdu 610041，China

BackgroundCoronoid fracture of ulna reflects the severity of the elbow trauma．It is mainly due to the fall with the elbow in a straight position，which caused by collision with trochlea of humerus，leading to elbow instability．Violent trauma often causes elbow dislocation．If the fracture block is large，because of the pulling force of tendon，it is not easy to maintain reduction，and the stability of the elbow is badly affected，often requiring surgery treatment to restore the stability of the joints．In our hospital，From November 2009to January 2012，we treated 16cases with fracture of coronary fracture with elbow arthroscopy assisting reduction and fixation．MethodsFrom November 2009to January 2012，we treated 16cases with fracture of coronary fracture with elbow arthroscopy assisting reduction and fixation，including 10males and 6females，with an average age of 39（24－51）．There are 11cases caused by fall and 5cases caused by traffic accidents；6cases were the left side，and 10cases were on the right side；There were one case combined with fracture of the humeral capitellum and 3cases combined with posterolateral rotation instability；According to Regan－ Morrey classification：Ⅱ type 10cases，Ⅲ type 6cases．Diagnosis by preoperative elbow CT and threedimensional imaging，we accurately knew of fracture position，size of fracture block，the degree of displacement of fracture．With general anesthesia and lateral position，the patients were positioned with limb in the elbow ancon．To applly pneumatic tourniquet inflation pressure band，with the pressure of 240mmHg，tourniquet time 40－90min，average（63．3±25．0）min．Anterolateral approach in the elbow－flexion position and proximal medial approach from the proximal part were used，because：（1）there is safest distance of ulnar nerve and median nerve in anterolateral approach in the elbow－flexion position，it is the safest approach in the medial approach into the road （the distance to the ulnar nerve is 15．5mm，the distance to the median nerve is 13．8mm）．（2）there is safest distance（10mm）to radialnerve in the anterolateral approach to，With the advantage of flexible operation and good microscopic field of vision，it is the most safe and effective one of the lateral approachs into the way；（3）We choose the position of 90°elbow flexion position to puncture operation since nerve is away from point of puncture．Usually water injection were operated from the lateral approach establishing arthroscopy channel，cleaning blood stasis and synovial joints of joint，exposing fracture block of coronary，and completing the reduction with arthroscopy．After the satisfied reduction，to fix the fracture from the back to coronary direction with screws or wires．Usually，the appropriate length of hollow screw is 3．0 mm，and the cutting－edge through coronary is not more than 2mm．Also，the needle tail should be placed subcutaneously after bending．To combined fractures，such as capitellum fractures，open reduction and fixation is needed at the same time，including the repair or reconstruction of the lateral collateral ligament when posterolateral rotation unstability occurrs．Elbow should be fixed in a flexion position no less than 1week，then early functional exercise was operated under the guidance of doctor．Results14cases were followed－up，with an average time of 12．6months（8－24months）．All the postoperative incision healed good（typeⅠhealing），no incisional drainage，nerve damage and fracture displacement occurs，with 1case of heterotopic ossification．X ray film was applied at the time of terminal follow－up to assess fracture healing，showing fracture clinical healing of all the cases，and the healing time was 10－14weeks，12weeks on average．All patients reached anatomical reduction in the operation．The improved elbow HSS score was an average of 33 （28－35），average score of Visual Analog Scale is 1．2±0．5，with an average of 132．4°of elbow flexion，and 10．6°of elbow straighten，68．5°of pronation，78．6°of supination．the total good and excellent rate was 100%（14／14）．Discussion Discuss Elbow joint is is composed of trochlea of humerus and half－month notch of ulna，composed of coronary and olecranon．Ulna coronary is the most important humeral blocking structure in front of elbow，which is an important part preventing elbow dislocation and posteriormedial rotation unstability．There are many important soft tissue attachment points important structures in front of the elbow including the joint capsule，the medial collateral ligament，brachialis，and so on，．It is the main stable structure of elbow，resisting biceps，brachialis and triceps pulling ulna to elbow．Coronary processes is an important part of the anterior column and the medial column，forming a stable ring in front of the elbow．When it damages，elbow medial and front instability may occurs．Improper handling may lead to habitual dislocation．Therefore，in the treatment of ulna coronary fracture，restore or rebuild the height and shape of the coronary and repair or reconstruction the anterior beam of medial collateral ligament is very important．With development of further research of elbow joint，the important role of elbow has been recognized，the fractures usually lead to complex traumatic elbow instability，so the treatment of ulna coronary fracture also attract more and more attention of surgons．When the fracture fragment is large（Regan－MorreyⅡ，Ⅲ），because of the flexor pull leading fracture displacement，elbow instability easily occurs and it is difficult．to manually reduce and maintain the position of fracture．And because the fracture is hard to expose，and fix，especially for small pieces or comminuted fracture of the coronary．Improper treatment may easily causes joint instability，myositis ossificans，traumatic arthritis，stiff joints，etc．Coronary fracture belongs to intra－articular fracture，anatomical reduction and strong internal fixation is the basis of the joint function recovery in the treatment of intra－articular fractures．Anatomical reduction is beneficial to the activities of the joint，relieve joint pain，and prevent the occurrence of traumatic arthritis；Strong internal fixation is beneficial to early functional exercise and prevent the stiffness of the elbow joint，reduce muscle atrophy，and dynamic instability and prevent the occurrence of traumatic arthritis，achieving good function．Ulna coronary fractures often combined with elbow instability，foreign scholars not only reported and discussed the treatment and prognosis，but also put forward the diagnostic criteria and surgical treatment scheme．Domestic scholars have similar report and literature review，introduces the treatment experience，and discuss new approaches and solutions，etc．The main method of fixation are steel wire fixation，kirschnerwire fixation，mini screw internal fixation，mini plate internal fixation and absorbable screw fixation，etc．Open reduction and internal fixation of coronary fracture was operated through theconventional anterior approach，but it is very difficult to coronary reduction and internal fixation，because：（1）the neurovascular structure in front of the elbow closely packed，operation through blood vessels or nerve gap is safe，and the vice injury occures easily；（2）the position of coronary is deep，it is very difficulty to touch the fracture line，because there is a lot of soft tissue，in this case it is difficult to touch the front clear fracture line and clean．If the soft tissue on the coronary was cleaned radically，including the attachment point of the medial collateral ligament，the brachial muscle，and the joint capsule，the meaning of reduction will lose；（3）fragment of coronal fractures tend to be small，the compaction fingers from the anterior part may occupy the fixing position again；（4）surgery of open reduction is a kind of great trauma，easily lead to heterotopic ossification and larger scars left，affecting beautiful appearance．With the deep understanding of the anatomy of elbow function and the improvement of elbow function requirements of patients，and minimally invasive surgery is more and more become a safe and effective treatment of intra－articular fractures．Because arthroscopy surgery has the advantages of little trauma and quick recovery in recent years，the application in the elbow fracture has made rapid progress．In acute elbow trauma，elbow arthroscopy technology can not only clean up small pieces fragment including cartilage ones，but also compete reduction and internal fixation of fracture feasiblly．And radial head fractures，olecranon fractures，coronoid process fractures，humerus condyle fracture reduction and internal fixation were reported．Adams reported 7cases of ulna coronary condyle fracture appling elbow arthroscopy technology for reduction and fixation，final follow－up showed the curative effect is satisfied，with no heterotopic ossification and elbow arthritis．Operation approach of elbow arthroscopy are anterolateral approach and anteromedial approach in the position of elbow flexion．Because：（1）there is safest distance of ulnar nerve and median nerve in anterolateral approach in the elbow－flexion position，it is the safest approach in the medial approach into the road（the distance to the ulnar nerve is 15．5mm，the distance to the median nerve is 13．8mm）．（2）there is safest distance（10mm）to radial nerve in the anterolateral approach to，With the advantage of flexible operation and good microscopic field of vision，it is the most safe and effective one of the lateral approachs into the way；（3）We choose the position of 90°elbow flexion position to puncture operation since nerve is away from point of puncture．For Regan－ Morrey Ⅱ type comminuted fracture，preoperative CT fully estimated size of fracture block，due to the small fracture fragment，cannulated screws may break down the fracture fragment and the fixing effect is not exact．To prevent this occurs，for Regan－MorreyⅡtype frature．we fix with kirschner wire from the back of the elbow to coronary direction；For Regan－MorreyⅡtype simple fracture and Regan－MorreyⅢtype fracture，if the fragment is large，hollow screws should be used from the back of the ulna to the coronary direction．Compared with other joints，arthroscopy technical of elbow joint requires higher technique．performer must be very familiar with anatomy around the elbow．Because the structure is complex around the elbow joint with a lot of important nerve and blood vessels，although elbow surgery is a kind of effective and minimally invasive treatment，the incidence of complications than knee and shoulder arthroscopy surgery is higher，but the majority are mild reversible disease，and after some measures，these complications can be avoided，so the elbow arthroscopy surgery is a safe and effective technique．In addition，arthroscopic technique can provide better joint vision，less surgical trauma，less postoperative recovery time．Application of elbow arthroscopic technique assisted reduction and fixation in the treatment of ulna coronary fracture has the advantage of small incision，small trauma，good effect，fast recovery，etc．articular surface can be observed directly under arthroscopy，leading anatomicalintra－articular reduction，reducing traumatic arthritis，and can make the complications such as nerve，blood vessel damage to a minimum extent，still can reduce surgical trauma and reduce the complications of elbow injury．But the performer should has rich experience in the microscopic operation and local anatomical knowledge，strictly control the choice of operation indication，in order to avoid the happening of the complications to the maximum extent．

Arthroscopes；Ulna fractures；Surgical procedures，minimally invasive

Xiang Ming，Email：josceph＿xm＠sina．com

2013－07－19）

（本文編輯：胡桂英）

10．3877／cma．j．issn．2095－5790．2014．03．003

610041 成都，四川省骨科醫院上肢科

向明，Email：josceph＿xm＠sina．com

楊順，向明，楊國勇，等．肘關節鏡輔助下復位固定治療尺骨冠狀突骨折［J／CD］．中華肩肘外科電子雜志，2014，2（3）：144－150．