吳加?xùn)| 卞化 沈孝天 王超 孫煥建 王友華 劉璠

肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折的手術(shù)治療

吳加?xùn)|1卞化1沈孝天1王超1孫煥建1王友華2劉璠2

目的探討手術(shù)治療肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折的臨床療效。方法選擇東南大學(xué)醫(yī)學(xué)院附屬鹽城醫(yī)院2005年1月至2014年6月收治的13例肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折患者，男8例，女5例，年齡24～56歲，平均（31.4±2.1）歲，肱骨遠(yuǎn)端骨折AO分型：B1型3例，C1型7例，C2型3例。肱骨遠(yuǎn)端骨折行鋼板固定，橈骨頭骨折行鋼板、螺釘固定或置換，冠突骨折行鋼板、螺釘或克氏針固定，修復(fù)內(nèi)外側(cè)副韌帶。術(shù)后按照Broberg-Morrey評(píng)估系統(tǒng)對(duì)肘關(guān)節(jié)功能進(jìn)行評(píng)分。結(jié)果11例患者獲得隨訪，隨訪時(shí)間12～22個(gè)月，平均（16.2±2.1）個(gè)月。骨折愈合時(shí)間19～23周，平均（20.2±3.2）周。Broberg-Morrey評(píng)分：優(yōu)2例（18.2%）、良6例（54.5%）、可2例（18.2%）、差1例（9.1%），優(yōu)良率72.7%。肘關(guān)節(jié)屈伸范圍75～116°,平均（101.2±10.9）°；前臂旋轉(zhuǎn)范圍為90～120°，平均（107.7±8.4）°。結(jié)論 肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折為高能量損傷，關(guān)節(jié)嚴(yán)重不穩(wěn)定，需重建骨關(guān)節(jié)及軟組織的解剖結(jié)構(gòu)，肘關(guān)節(jié)功能可得到良好恢復(fù)。

肘關(guān)節(jié)； 恐怖三聯(lián)征； 肱骨遠(yuǎn)端骨折

隨著工業(yè)及交通業(yè)的迅猛發(fā)展，復(fù)雜肘關(guān)節(jié)骨折脫位其發(fā)生率在臨床上逐年增加，人們對(duì)此已倍加關(guān)注。Hotchkiss［1］于1996年首次將肘關(guān)節(jié)后脫位伴橈骨頭和冠狀突骨折命名為“恐怖三聯(lián)征”。其合并肱骨遠(yuǎn)端骨折，繼發(fā)于肘關(guān)節(jié)伸直位遭受垂直軸向的巨大暴力，肱骨遠(yuǎn)端與尺橈骨近端直接撞擊所致，因內(nèi)外側(cè)副韌帶起止點(diǎn)的解剖特性，其常常連帶著肱骨遠(yuǎn)端骨塊一起牽扯移位，故此類損傷較單純性“恐怖三聯(lián)征”相比，往往骨性結(jié)構(gòu)破壞更重。本文采用重建損傷的骨性結(jié)構(gòu)、關(guān)節(jié)囊及韌帶的方法治療13例患者，其中11例獲得隨訪，療效滿意，報(bào)道如下。

資料與方法

一、一般資料

2005年1月至2014年6月收治的13例肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折患者，男8例、女5例，均為閉合性損傷，其中合并尺神經(jīng)損傷2例。年齡24～56歲，平均（31.4±2.1）歲，致傷原因：交通傷7例（53.8%）、墜落傷4例（30.8%）、其他傷2例（15.4%）。肱骨遠(yuǎn)端骨折AO分型：B1型3例，C1型7例，C2型3例。橈骨頭骨折分型按Mason分型［2］：Ⅱ型8例，Ⅲ型5例。因合并肘關(guān)節(jié)脫位，按照J(rèn)ohnston-Mason分型［3］均為Ⅳ型。尺骨冠突骨折按照Regan-Morrey分型［4］：Ⅰ型2例，Ⅱ型4例，Ⅲ型7例。急診閉合復(fù)位，長(zhǎng)臂石膏托臨時(shí)固定。受傷至手術(shù)時(shí)間3～10 d，平均5.2 d。

二、術(shù)前準(zhǔn)備與手術(shù)方法

術(shù)前常規(guī)行X線、CT檢查以明確骨折分型。使用甘露醇、七葉皂苷等消腫，待局部軟組織條件允許后行手術(shù)治療，術(shù)中預(yù)防使用抗生素。

臂叢麻醉或全麻下，取側(cè)臥位，患肢置于側(cè)胸壁，取肘后“S”型切口，潛行分離皮下，解剖保護(hù)尺神經(jīng)，先用2枚克氏針或電鉆自尺骨鷹嘴尖向尺骨遠(yuǎn)端鉆通骨隧道備用，距尺骨近端約2cm處做“V”形截骨，向近端翻轉(zhuǎn)附帶肱三頭肌肌腱的鷹嘴骨塊，將髁間骨折轉(zhuǎn)變?yōu)轺辽瞎钦? 解剖型鋼板固定于肱骨遠(yuǎn)端后外側(cè)及（或）內(nèi)上髁嵴上，將鷹嘴截骨塊復(fù)位, 行張力帶內(nèi)固定。從肘肌和尺側(cè)腕伸肌間隙進(jìn)入顯露橈骨頭骨折，安全區(qū)內(nèi)置放鋼板螺釘或橈骨頭置換。取肘前內(nèi)側(cè)切口，自尺側(cè)腕屈肌的兩頭之間進(jìn)入，自前向后或自后向前雙頭加壓螺釘固定冠突骨塊，若骨塊較小，自前向后克氏針固定，從鷹嘴背側(cè)引出，折彎剪短預(yù)置于尺骨背面。肘關(guān)節(jié)后脫位常伴有不同程度內(nèi)外側(cè)副韌帶損傷，若起止點(diǎn)撕脫，用錨釘固定骨面，若體部斷裂，用不可吸收縫線編織縫合，對(duì)尺神經(jīng)有原發(fā)性損傷或術(shù)中發(fā)現(xiàn)內(nèi)固定物與尺神經(jīng)毗鄰時(shí)，需將尺神經(jīng)前置于皮下筋膜。檢查肘關(guān)節(jié)在屈伸30～130°范圍內(nèi)未發(fā)生脫位，提示關(guān)節(jié)相對(duì)穩(wěn)定，C型臂X線機(jī)透視再次確認(rèn)關(guān)節(jié)在位，骨折復(fù)位良好，內(nèi)固定位置滿意。所有患者具體骨折類型和治療方式見(jiàn)表1。

三、術(shù)后處理及評(píng)估

常規(guī)口服吲哚美辛12.5 mg/d，1次/d，預(yù)防骨化性肌炎的發(fā)生。術(shù)后以可屈性支具固定，3 d后即指導(dǎo)肘關(guān)節(jié)康復(fù)鍛煉，包括肘關(guān)節(jié)屈伸及前臂旋轉(zhuǎn)功能，逐步加大主動(dòng)訓(xùn)練?；颊呔谛g(shù)后第1、3、6及12個(gè)月定期隨訪。評(píng)估項(xiàng)目包括：肘關(guān)節(jié)屈伸和前臂旋轉(zhuǎn)范圍。功能評(píng)估采用Broberg和Morrey評(píng)估系統(tǒng)［5］：滿分100分，包括運(yùn)動(dòng)40分、力量20分、疼痛35分、穩(wěn)定性5分等4方面。

結(jié) 果

13例患者中11例獲得隨訪，隨訪時(shí)間12～22個(gè)月，平均（16.2±2.1）個(gè)月。骨折愈合時(shí)間19～23周，平均（20.2±3.2）周。肘關(guān)節(jié)屈伸范圍 75～116°,平均（101.2±10.9）°；前臂旋轉(zhuǎn)范圍為 90～120°，平均（107.7±8.4）°。術(shù)后 3例出現(xiàn)肘關(guān)節(jié)僵硬,骨化性肌炎1例,創(chuàng)傷性關(guān)節(jié)炎1例,無(wú)深部感染、內(nèi)固定物松動(dòng)斷裂的發(fā)生，2例合并尺神經(jīng)損傷患者術(shù)后經(jīng)神經(jīng)營(yíng)養(yǎng)等治療后逐步好轉(zhuǎn)。Broberg-Morrey評(píng)分：優(yōu)2例（18.2%）、良6例（54.5%）、可 2例（18.2%）、差1例（9.1%），優(yōu)良率72.7%。典型病例見(jiàn)圖1～3。

圖1 肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折術(shù)前正（A）、側(cè)（B）位X線片

圖2 肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折術(shù)前正（A）、側(cè)（B）位CT片

圖3 肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折術(shù)后正（A）、側(cè)（B）位X線片

討 論

肘關(guān)節(jié)穩(wěn)定環(huán)分為內(nèi)、外、前、后4柱。前柱包括冠狀突、肱肌、前關(guān)節(jié)囊,后柱包括鷹嘴突、三頭肌、后關(guān)節(jié)囊,內(nèi)側(cè)柱由尺側(cè)副韌帶、冠狀突、內(nèi)髁或內(nèi)上髁組成,外側(cè)柱由橈骨頭、肱骨小頭和橈側(cè)副韌帶組成。在成年橈骨頭的生理作用包括兩部分,即維持肘關(guān)節(jié)外側(cè)的穩(wěn)定性和傳導(dǎo)應(yīng)力。冠突系內(nèi)側(cè)副韌帶前束附著部，和鷹嘴形成半月（滑車）切跡，與肱骨滑車構(gòu)成肱尺關(guān)節(jié)。冠突骨折將致半月弧形關(guān)系不連續(xù)，肱尺關(guān)節(jié)紊亂。Hammacher等［6］把肘關(guān)節(jié)比喻成“希臘的廟宇”,橈骨和尺骨是兩個(gè)“柱子”,支撐著“屋頂”—肱骨遠(yuǎn)端,屋頂與柱子間的連接在尺側(cè)由韌帶構(gòu)成,在橈側(cè)由肌肉的張力及韌帶維系。肘關(guān)節(jié)“恐怖三聯(lián)征”表現(xiàn)為橈骨頭骨折、冠突骨折及肘關(guān)節(jié)脫位，其穩(wěn)定環(huán)中的一柱或多柱受累，或“希臘”柱子中的任一支撐柱破壞，肘關(guān)節(jié)必將失穩(wěn)。若前臂軸向暴力過(guò)大，同時(shí)合并肱骨遠(yuǎn)端骨折，骨性結(jié)構(gòu)損傷較單純“恐怖三聯(lián)征”更為嚴(yán)重，肘關(guān)節(jié)穩(wěn)定性徹底喪失,治療相當(dāng)棘手。

復(fù)雜肘關(guān)節(jié)骨折脫位，累及多柱，很難在單一切口內(nèi)完成。肘后“S”形入路，可兼顧肱骨遠(yuǎn)端骨折及橈骨頭骨折，筋膜皮瓣掀起后，鷹嘴“V”形截骨，可充分顯露肱骨遠(yuǎn)端，單鋼板或雙鋼板固定［7］。沿Kocher間隙（肘后肌及尺側(cè)腕伸肌間隙）顯露橈骨頭，安全區(qū)內(nèi)置放螺釘或鋼板［8］，通常橈骨頭粉碎，內(nèi)固定困難或無(wú)法實(shí)現(xiàn)堅(jiān)強(qiáng)固定，推薦橈骨頭置換，以利外側(cè)柱可靠支撐。自肘關(guān)節(jié)尺側(cè)腕屈肌的兩頭之間進(jìn)入顯露冠突，自前向后或自后向前雙頭加壓螺釘固定冠突骨塊，若骨塊較小，自前向后克氏針固定，從鷹嘴背側(cè)引出，折彎剪短預(yù)置于尺骨背面，操作簡(jiǎn)便可行，有報(bào)道用“套索”縫合固定或錨釘固定，其可行性及穩(wěn)定性有待進(jìn)一步驗(yàn)證。內(nèi)側(cè)副韌帶損傷常見(jiàn)于體部或冠突附著部，外側(cè)副韌帶損傷常見(jiàn)于肱骨外髁附著部，若起止點(diǎn)撕脫，用錨釘固定骨面，若體部斷裂，用不可吸收縫線編織縫合。

術(shù)后以可屈性支具固定，3 d后即指導(dǎo)肘關(guān)節(jié)康復(fù)鍛煉，包括肘關(guān)節(jié)屈伸及前臂旋轉(zhuǎn)功能，逐步加大主動(dòng)訓(xùn)練。肘關(guān)節(jié)僵硬是復(fù)雜肘關(guān)節(jié)骨折脫位術(shù)后常見(jiàn)并發(fā)癥，大部分患者伴有不同程度活動(dòng)范圍喪失。一般不推薦術(shù)后石膏固定，強(qiáng)調(diào)鎮(zhèn)痛狀態(tài)下（圍手術(shù)期服用吲哚美辛、塞來(lái)昔布等）或配用鉸鏈?zhǔn)酵夤潭ㄖЪ芟略缙诠δ苠憻挘?-10］，防止關(guān)節(jié)粘連。

作者發(fā)現(xiàn)，肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折為高能量損傷，但內(nèi)外側(cè)副韌帶常因關(guān)節(jié)上下附著骨結(jié)構(gòu)同時(shí)骨折而分散受力，其損傷往往較單純“恐怖三聯(lián)征”脫位時(shí)的強(qiáng)行拽扯較輕，因此重建骨結(jié)構(gòu)是關(guān)鍵，修復(fù)軟組織損傷可最大程度的恢復(fù)其原有解剖形態(tài)及生理功能，臨床隨訪，效果滿意。

表1 13例患者的骨折類型和治療方式

本文的局限性：（1）該類損傷是一個(gè)涉及多個(gè)骨折、多發(fā)韌帶損傷的模型，其受傷機(jī)制復(fù)雜，因樣本量小，未能將其軟組織損傷情況與單純“恐怖三聯(lián)征”詳細(xì)對(duì)比研究，這在今后的研究中值得進(jìn)一步深入。（2）臨床療效隨訪仍需大樣本、大數(shù)據(jù)支持。

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Shen Xiaotian, Email: sxt20101@163.com

Surgical treatment of terrible triad of the elbow combined with distal humeral fracture

Wu Jiadong1,Bian Hua1, Shen Xiaotian1, Wang Chao1, Sun Huanjian1, Wang Youhua2, Liu Pan2.1Department of Orthopaedics, The Affiliated Yancheng Hospital of Southeast University Medical College, Yancheng 224005, China;2Department of Orthopaedics, The Affiliated Hospital of Nantong University,Nantong 226001, China

BackgroundWith the rapid development of industry and transportation, the occurrence of complex elbow fractures and dislocations is increasing by years, to which people have paid more attention on. In 1996, the posterior elbow dislocation combined with radial head and coronoid process fractures was named as “terrible triad of elbow” by Hotchkiss. It is combined with distal humeral fractures, secondary to the great violence perpendicular to the long axis in elbow extension and the direct impact of distal humerus and proximal ulna. Due to the anatomical features of medial and lateral collateral ligaments attach points, it is often associated with distal humeral fragment. Therefore, compared with simple“terrible triad”, bone structure damage is often more severe in this type of injury.Methord（1）General information.From January 2005 to June 2014, 13 cases （8 males and 5 females） with terror triad of elbow combined with distal humerus fractures were treated, all of which were closed injuries, including 2 cases of ulnar nerve injuries. The ages were 24-56 years with an average of （31.4 ±2.1） years. Causes of injuries included 7 cases of traffic injuries （53.8%）, 4 cases of falling injuries （30.8%） and 2 cases of other injuries （15.4%）. AO classification of distal humeral fractures: 3 cases of type B1, 7 cases of type C1 and 3 cases of type C2. Radial head fractures were classified according to Mason classification, including 8 cases of type Ⅱ and 5 cases of type Ⅲ . According to Johnston-Mason classification, all the cases were type IV fractures because of the combined elbow dislocations. Coronoid process fractures of ulna were classified according to Regan-Morrey classification, including 2 cases of type I, 4 cases of type Ⅱ and 7 cases of type Ⅲ. Closed reduction was conducted in the emergency department with long arm plaster for temporary immobilization. The time from injury to surgery was 3-10 days with an average of 5.2 days. （2）Preoperative preparation and operative methods.X-ray and CT examinations were performed routinely to define the fracture patterns. Mannitol and aescinate were used to reduce swelling. Operation was conducted as the local soft tissue condition permitted, and antibiotics were given to prevent infection intraoperatively.Under brachial plexus block or general anesthesia, the patient was in lateral position with the affected limb on the ipsilateral chest. An “S” shape incision was made to separate subcutaneous tissue and then anatomize and protect ulnar nerve. Firstly, a bone tunnel was prepared with two Kirschner wires or electric drill from the tip of olecranon to the distal ulna. A "V" shaped osteotomy was conducted approximately 2 cm from the proximal ulna. The olecranon fragment with triceps tendon was inverted proximally, and the intercondylar fracture was transformed to supracondylar fracture. The anatomical plates were fixed on the posterolateral site of distal humerus and （or） the epicondylic ridge, and the olecranon fragment was fixed by using tension band after reduction. The radial head fracture was exposed through the gap between anconeus and cubitalis posterior. Then the plate and screws were placed in the safe area or the radial head replacement was performed instead. Through the anteromedial incision of elbow and the gap between two heads of cubitalis anterior, the coronoid process fragment was fixed with double-head compression screw from anterior to posterior or from posterior to anterior. If the fragment was small, it could be fixed from anterior to posterior with Kirschner wire that came out from the back of olecranon, bended and clipped and placed on the back of ulna. Posterior dislocation of elbow joint was often combined with various degrees of medial and lateral collateral ligaments. The bone surface should be fixed with anchor if the attachment point was avulsed, and the ligament body, if ruptured, should be knitted with non-absorbable sutures. The ulnar nerve should be placed in the subcutaneous fascia if it had primary injury or was adjacent to internal fixators. If the elbow joint was not dislocated with in 30-130° of flexion and extension during examination, it was relatively stable.With the further confirmation under fluoroscopy, the fracture was well restored and the location of internal fixation was satisfactory. （3）Postoperative management and evaluation.Oral indomethacin was taken routinely with 12.5 mg one day at a time to prevent the occurrence of heterotopic ossificans. The flexible brace could be used for fixation after operation, and the elbow rehabilitation exercises were guided 3 days later, including elbow flexion and extension and forearm rotation with gradual increase of active training. All patients were followed up regularly in the 1st, 3rd, 6th and 12th month after operation. Assessment projects included the range of elbow flexion and extension and forearm rotation. Broberg and Morrey evaluation system was used for functional evaluation. The total score was 100 points in 4 aspects, including 40 points of motion, 20 points of strength, 35 points of pain and 5 points of stability.ResultsOf the 13 patients, 11 cases were followed up for 12-22 months with an average of （16.2±2.1） months. The fracture healing time was 19-23 weeks with an average of （20.2±3.2） weeks. The range of elbow flexion and extension was 75-116° with an average of （101.2±10.9）°; the range of forearm rotation was 90-120° with an average of （107.7±8.4）°. After operation, 3 cases had elbow stiffness, 1 case had heterotopic ossificans and 1 case had traumatic arthritis. No deep infection, internal fixator loosening or breakage occurred. Two cases combined with ulnar nerve injuries had gradually improved after neurotrophic therapy. Broberg-Morrey score: 2 excellent cases （18.2%）, 6 good cases （54.5%）, 2 moderate cases （18.2%） and 1 poor case（9.1%）. The good and excellent rate was 72.7%.ConclusionThe terrorist triad of elbow combined with distal humeral fracture is an high energy injury. However, as fractures occur at both proximal and distal bone structures attached by elbow joint, the injuries to medial and lateral collateral ligaments are less severe compared to that of forced pulling during joint dislocations in the terrible triad. Therefore, the reconstruction of bone structures is the key. Soft tissue repair can maximize the restoration of its original anatomy and physiological function, and the outcomes of clinical follow ups are satisfactory.

Elbow joint; Terrible triad of the elbow; Distal humeral fracture

10.3877/cma.j.issn.2095-5790.2017.03.007

鹽城市醫(yī)學(xué)科技發(fā)展計(jì)劃項(xiàng)目（YK2013068）

224005 東南大學(xué)醫(yī)學(xué)院附屬鹽城醫(yī)院(鹽城市第三人民醫(yī)院)骨科1；226001 南通大學(xué)附屬醫(yī)院骨科2

沈孝天，Email: sxt20101@163.com

2017-02-08）

（本文編輯：李靜；英文編輯：陳建海、張曉萌、張立佳）

吳加?xùn)|, 卞化,沈孝天,等. 肘關(guān)節(jié)“恐怖三聯(lián)征”合并肱骨遠(yuǎn)端骨折的手術(shù)治療［J/CD］.中華肩肘外科電子雜志,2017,5（3）：194-198.