彈性髓內(nèi)針治療兒童橈骨頸骨折的臨床應(yīng)用研究

李兵 張軍 張亞軍

彈性髓內(nèi)針治療兒童橈骨頸骨折的臨床應(yīng)用研究

李兵 張軍 張亞軍

目的探討彈性髓內(nèi)針治療橈骨頸骨折療效。方法我院于2006年5月至2009年9月應(yīng)用彈性髓內(nèi)針治療23例橈骨頸骨折患者，其中男性17例，女性6例，年齡6～13歲，平均9．3歲。摔傷21例，絞傷2例。按Judet分型，其中Ⅱ型3例、Ⅲ型16例、Ⅳ型4例。合并肘關(guān)節(jié)其他部位損傷3例，其中肘關(guān)節(jié)內(nèi)側(cè)副韌帶損傷2例，肱骨內(nèi)上髁骨折1例。結(jié)果術(shù)后隨訪6～38個月，平均17．5個月。根據(jù)Métaizeau術(shù)后X線片評價標(biāo)準(zhǔn)，優(yōu)18例、良3例、中2例，優(yōu)良率達91%。功能評價采用Métaizeau功能評價標(biāo)準(zhǔn)，優(yōu)16例、良6例、一般1例，優(yōu)良率達96%。其中2例橈骨頭骺變形膨大，1例出現(xiàn)關(guān)節(jié)周圍異常鈣化。結(jié)論彈性髓內(nèi)針治療橈骨頸骨折操作簡便，效果滿意。

彈性髓內(nèi)針；骨折，橈骨頸

橈骨頸骨折在肘關(guān)節(jié)骨折中約占5%～10%［1－2］，多數(shù)為無移位或輕微移位骨折，保守治療效果滿意，而對于嚴重移位的橈骨頸骨折，臨床上對于其治療方法的選擇及療效存在爭議。目前文獻報道的治療方法及療效不一，而諸如橈骨頭壞死、肘關(guān)節(jié)功能障礙等并發(fā)癥也困擾著臨床醫(yī)生。為探討橈骨頸骨折的治療方法，為臨床診治積累經(jīng)驗，我院于2006年5月至2009年9月應(yīng)用彈性髓內(nèi)針治療23例橈骨頸骨折患者，療效滿意，現(xiàn)總結(jié)報道如下。

材料和方法

一、一般資料

自2006年5月至2009年9月，我院共收治橈骨頸骨折患者23例。其中男性17例，女性6例，年齡6～13歲，平均9．3歲。致傷原因：摔傷21例、機器絞傷2例；右側(cè)20例、左側(cè)3例；手術(shù)距受傷時間1～5d，平均2．3d。合并肘關(guān)節(jié)其他部位損傷3例，其中肘關(guān)節(jié)內(nèi)側(cè)副韌帶損傷2例、肱骨內(nèi)上髁骨折1例。所有患者入院后給予X線和CT檢查，并根據(jù)橈骨頸成角移位的嚴重程度，按Judet分型：其中Ⅱ型3例、Ⅲ型16例、Ⅳ型4例。

二、治療方法

1．閉合復(fù)位彈性髓內(nèi)針內(nèi)固定：患者取仰臥位，麻醉滿意后，患肢外展，放于側(cè)臺上，C臂X線透視下，在橈骨遠端橈側(cè)骺板近端1～2cm處切口，保護橈神經(jīng)淺支及周圍肌腱，以尖錐在橈骨遠端橈側(cè)垂直骨皮質(zhì)開髓，待尖椎頭進入髓腔后，改變尖椎角度，使之與橈骨干交角約為45°，繼續(xù)向橈骨近端刺入，將尖端預(yù)彎好AO彈性髓內(nèi)針插入髓腔內(nèi)，針的直徑以橈骨干最小橫徑的1／2～2／3為宜［3］，將針體向近端旋轉(zhuǎn)推進直至橈骨頭，牽引前臂，并將肘關(guān)節(jié)內(nèi)翻以擴大肱橈關(guān)節(jié)間隙，按壓移位的橈骨頭，矯正成角移位，同時將彈性髓內(nèi)針尖端推至并頂住橈骨頭，進一步矯正成角畸形，使用T柄旋轉(zhuǎn)髓內(nèi)針糾正橈骨頭側(cè)方移位。C臂X線透視復(fù)位滿意后，輕輕擊打彈性髓內(nèi)針尾端，使其進一步穩(wěn)定固定折端，剪斷髓內(nèi)針尾，使之有0．5cm長度留置于橈骨遠端骨皮質(zhì)外，方便取出。術(shù)后患肢屈肘90°中立位石膏固定。

2．克氏針經(jīng)皮撬撥彈性髓內(nèi)針內(nèi)固定：對于橈骨頭傾斜角度較大的患者，由于橈骨頸外側(cè)緣常有不同程度嵌插和壓縮，關(guān)節(jié)周圍的關(guān)節(jié)囊被撕裂破壞，閉合復(fù)位橈骨頭可能較為困難，此時需要經(jīng)皮輔助克氏針復(fù)位骨折端。一位助手牽引患者上臂，另一位助手牽引前臂做對抗，將肘關(guān)節(jié)內(nèi)翻以擴大肱橈關(guān)節(jié)間隙，維持肘關(guān)節(jié)半屈曲位。術(shù)者右手持1枚克氏針，于肘外下方視橈骨頭移位情況選擇進針點，在C臂X線透視下，將克氏針進至骨折端，利用遠折面作支點，橈骨小頭外側(cè)皮質(zhì)為受力點，抬高針尾，通過克氏針尖端撬撥橈骨小頭，同時左手拇指逆骨折移位方向推擠橈骨小頭使其復(fù)位。之后打入彈性髓內(nèi)針，進一步輔助骨折端復(fù)位和固定。

3．切開復(fù)位彈性髓內(nèi)針內(nèi)固定：對于骨折端移位較大，閉合復(fù)位及輔助克氏針復(fù)位后仍不能復(fù)位的患者，為防止進一步閉合復(fù)位導(dǎo)致的軟組織損傷，可行切開復(fù)位。術(shù)中要注意防止損傷橈神經(jīng)深支，顯露橈骨頭后將其復(fù)位，在C臂X線透視下，打入彈性髓內(nèi)針，維持骨折端復(fù)位。

三、合并損傷治療

本組合并肘關(guān)節(jié)其他部位損傷3例，其中肘關(guān)節(jié)內(nèi)側(cè)副韌帶損傷2例，肱骨內(nèi)上髁骨折1例。對于2例肘關(guān)節(jié)內(nèi)側(cè)副韌帶損傷的患者未行特殊治療。1例肱骨內(nèi)上髁骨折患者，在治療橈骨頸骨折同時，肘關(guān)節(jié)內(nèi)側(cè)切口，行肱骨內(nèi)上髁切開復(fù)位內(nèi)固定。

四、術(shù)后處理

術(shù)后所有患者給予常規(guī)抗炎治療3d，患肢屈肘90°，中立位，石膏固定3～4周，拆除石膏，指導(dǎo)患者以健側(cè)肢體輔助患側(cè)肘關(guān)節(jié)自行進行主動屈伸及前臂旋前、旋后功能鍛煉，盡可能減少被動功能鍛煉，以防止出現(xiàn)過度疼痛及異位骨化。分別于術(shù)后6周、12周、6、12、24、36個月進行隨訪，隨訪內(nèi)容包括：攝X線片，了解骨折愈合情況和橈骨頭變化，了解肘關(guān)節(jié)功能恢復(fù)情況及是否存在并發(fā)癥。

結(jié) 果

一、療效評定標(biāo)準(zhǔn)

按照Métaizeau術(shù)后X線片評定標(biāo)準(zhǔn)評定［4］：解剖復(fù)位為優(yōu)；傾斜成角＜20°為良；20°～40°為中等；＞40°為差。后期則按照Métaizeau功能評定標(biāo)準(zhǔn)［4］：肘關(guān)節(jié)及前臂活動無受限為優(yōu)；肘關(guān)節(jié)屈伸或前臂旋前、旋后受限活動度之和＜20°為良；肘關(guān)節(jié)屈伸或前臂旋前、旋后受限活動度之和介于20°～40°為一般；＞40°為差。

本組全部患者中，有2例切開復(fù)位，6例克氏針經(jīng)皮撬撥輔助復(fù)位，其余15例均為單純閉合復(fù)位，彈性髓內(nèi)針固定。手術(shù)時間20～50min，平均36．4min。術(shù)中出血5～20ml，平均8．3ml。術(shù)后石膏固定3～4周，平均3．7周。術(shù)后骨折愈合時間3～4周，平均3．7周。去除內(nèi)固定時間為術(shù)后3～12個月，平均4．7個月。術(shù)后隨訪6～38個月，平均17．5個月。術(shù)后X線片評定：優(yōu)18例、良3例、中2例，優(yōu)良率達91%。功能評價：優(yōu)16例、良6例、一般1例，優(yōu)良率達96%。無感染、骨折不愈合、遲延愈合病例。2例橈骨頭骺變形膨大，1例出現(xiàn)關(guān)節(jié)周圍異常鈣化（表1）。

表1 橈骨頸骨折患者分型、復(fù)位方式與術(shù)后X線片評定、功能評定結(jié)果統(tǒng)計

二、典型病例

患者肖某，男性，10歲，因摔傷致肘部腫痛、活動受限，于傷后1d就診于我院，攝X線片，診斷為橈骨頸骨折（圖1）。完善化驗后，于傷后2d在臂叢麻醉下，行左橈骨頸骨折閉合復(fù)位，彈性髓內(nèi)針內(nèi)固定術(shù)，術(shù)后骨折復(fù)位及內(nèi)固定物位置良好（圖2），常規(guī)抗炎換藥，屈肘90°中立位石膏固定3周，去除石膏，指導(dǎo)患肘關(guān)節(jié)進行主動屈伸及前臂旋前、旋后功能鍛煉，術(shù)后4周骨折愈合。術(shù)后9個月攝X線片顯示骨折愈合良好，未見明顯骨骺膨大及橈骨頭壞死征象（圖3）。查體顯示，患側(cè)旋轉(zhuǎn)功能較健側(cè)完全恢復(fù)（圖4，5）。

圖1 術(shù)前X線片示橈骨頸骨折 圖2 術(shù)后X線片示骨折復(fù)位、內(nèi)固定物位置良好 圖3 術(shù)后9個月X線片示骨折愈合良好，未見明顯骨骺膨大及橈骨頭壞死征象

討 論

一、橈骨頸骨折的特點

橈骨頸骨折多發(fā)于兒童，主要原因是兒童跌倒時，前臂旋前肘關(guān)節(jié)伸直位，應(yīng)力延前臂橈側(cè)向上傳遞，肘關(guān)節(jié)易受到垂直及外翻應(yīng)力作用，而兒童在骨發(fā)育成熟前，韌帶連接強度是骨與軟骨連接強度的2～5倍，骺板及干骺端成為生物力上的薄弱區(qū)，同時由于橈骨頸的生理結(jié)構(gòu)的特點，即橈骨頸與骨干約呈平均12．5°外傾和3．5°前傾，從而導(dǎo)致橈骨頸骨折，并出現(xiàn)成角移位，如應(yīng)力進一步傳遞，還可以導(dǎo)致肘關(guān)節(jié)內(nèi)側(cè)附韌帶、肱骨內(nèi)上髁、尺骨鷹嘴等合并損傷。損傷應(yīng)力越大，橈骨頸移位越嚴重，合并的損傷越多。

圖4 術(shù)后9個月外旋功能恢復(fù)情況

圖5 術(shù)后9個月內(nèi)旋功能恢復(fù)情況

二、診斷要點

通過查體和標(biāo)準(zhǔn)的肘關(guān)節(jié)正側(cè)位X線片，橈骨頸骨折的診斷并不困難。但對無明顯移位的青枝骨折或嵌插骨折，應(yīng)該引起注意，故對于癥狀重、體征明顯而X線片無明顯骨折的患者，應(yīng)詳細查體，拍健側(cè)X線片對照，必要時行CT檢查。對于骨折移位嚴重的患者，應(yīng)該重點檢查肘關(guān)節(jié)的穩(wěn)定性，防止漏診肘關(guān)節(jié)合并損傷。本組合并肘關(guān)節(jié)其他部位損傷3例，其中肘關(guān)節(jié)內(nèi)側(cè)副韌帶損傷2例、肱骨內(nèi)上髁骨折1例，均為JudetⅣ型患者。近年來有雙側(cè)橈骨頸骨折的報道［5－6］，故對于雙手同時著地的患者，要詳細詢問受傷史，對雙上肢傷情進行物理和影像學(xué)檢查，防止漏診。

三、治療

由于橈骨頸骨折多為SalterHarrisⅠ、Ⅱ型損傷或干骺端骨折，因此盡可能要求解剖復(fù)位。對于JudetⅠ型和多數(shù)Ⅱ型骨折通過保守治療即可。但是對于移位較大的不穩(wěn)定骨折或?qū)χ怅P(guān)節(jié)功能要求高，難以配合長時間肘關(guān)節(jié)制動Ⅱ型患者需通過手術(shù)來治療。本組3例Ⅱ型骨折患者，均難以配合長時間石膏固定，故均采用手術(shù)治療。對于橈骨頸骨折手術(shù)的方法選擇，臨床上一直存在爭議。一些學(xué)者認為單純閉合復(fù)位或經(jīng)皮克氏針撬撥復(fù)位及石膏外固定［3，7－8］，復(fù)位效果及骨折端的穩(wěn)定性均無法確切維持，可能發(fā)生繼發(fā)性移位。切開復(fù)位曾是一些學(xué)者的選擇，但是由于切開復(fù)位可能使受損的橈骨頭血運進一步損傷，有可能導(dǎo)致橈骨頭壞死、異位骨化等并發(fā)癥，有學(xué)者報道［9］切開復(fù)位并發(fā)癥的發(fā)生率超過50%。對于內(nèi)固定物的選擇，有學(xué)者認為可以在骨折復(fù)位后，通過橈骨頭外側(cè)斜行向橈骨遠段內(nèi)側(cè)固定克氏針，但是該方法操作較為困難，有損傷橈神經(jīng)的可能，在患者功能鍛煉時，由于克氏針影響肌肉滑動，可能引起不適感。另外，有學(xué)者建議通過肱骨小頭與橈骨頭貫穿克氏針固定［6］，但是進一步損傷了肱橈關(guān)節(jié)，可能引起肘關(guān)節(jié)后期的功能障礙。此外，較細的克氏針通過橈骨頭、橈骨頸后進入橈骨髓腔，無法確切穩(wěn)定骨折端，而較粗的克氏針，又會導(dǎo)致骨骺的損傷，因此該方法并非首選。

1980年，法國Métaizeau報道通過髓內(nèi)針治療橈骨頸骨折取得良好療效，之后在此基礎(chǔ)上，眾多學(xué)者進行了臨床研究［10－12］。對于移位較大的橈骨頸骨折，保護骨折端的血運的同時盡可能穩(wěn)定骨折端。近來有文章報道，對于復(fù)位困難的骨折，可以采用將克氏針打入橈骨頭，通過控制克氏針尾復(fù)位成功的技術(shù)［13］，但本組患者除2例患者閉合復(fù)位不成功后改用切開復(fù)位，其余均采用閉合復(fù)位或經(jīng)皮撬撥復(fù)位成功，而彈性髓內(nèi)針的使用，兼有復(fù)位和固定骨折端的作用。術(shù)中入髓內(nèi)針前，一定要通過C臂X線透視，避開橈骨遠端骨骺。插入彈性髓內(nèi)針后，爭取一次復(fù)位成功，不要反復(fù)通過髓內(nèi)針復(fù)位，否則會引起骨折端骨道擴大，導(dǎo)致復(fù)位困難及固定效果差。留置于橈骨遠端的針尾不宜過長，以0．5cm為宜，防止出現(xiàn)局部假性囊腫，引起不適。術(shù)后盡早去除石膏外固定，指導(dǎo)患者進行功能鍛煉。本文中多數(shù)患者取得良好療效，1例切開復(fù)位的患者，術(shù)后關(guān)節(jié)外可見異位骨化，關(guān)節(jié)功能受限，因患者無進一步功能要求，未做處理。另外2例患者橈骨頭骺變形膨大，考慮與骨折及治療中的進一步骨骺損傷有關(guān)，但是對于肘關(guān)節(jié)功能影響不大，故未做處理。該結(jié)果與文獻的報道一致［3，8，14－15］。

本組患者治療效果滿意，并發(fā)癥較少，分析可能有以下原因：（1）本組患者多數(shù)為JudetⅢ型患者，損傷相對較輕，肘關(guān)節(jié)合并損傷較少；（2）本組患者年齡均較小，肘關(guān)節(jié)代償塑形能力較強［16］；（3）手術(shù)損傷較小，術(shù)后早期功能鍛煉。不過本組患者隨訪時間較短，平均17．5個月，對于遠期效果還不明確。總之，彈性髓內(nèi)針是一種具有微創(chuàng)、出血少、不干擾骨折端愈合、并發(fā)癥低，并兼有復(fù)位和固定作用的一種治療橈骨頸骨折的方法，值得在臨床上推廣。

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Clinical application of elastic stable intramedullary nail in treatment of radial neck fractures

LiBing，ZhangJun，ZhangYajun．DepartmentofTraumaandOrthopaedic，TheSecondWujingHospital，Beijing100037，China

：ZhangYajun，Email：zhangyajun＠vip．sina．com

BackgroundRadial neck fractures account for 5%－10%in elbow joint fractures and most of them are slightly displaced or non－displaced types．Satisfactory therapeutic results can be achieved by conservative treatment．As to severe displaced radial neck fractures，it is controversial in selection of therapeutic methods and curative effect clinically．To explore clinical therapeutic effect of radial neck fractures with elastic intramedullary nail and accumulate experience for diagnosis and treatment，23cases of radial neck fracture were treated with elastic intramedullary nail from May 2006 to September 2009in our hospital．MethodsFrom May 2006to September 2009，23cases of radial neck fracture were admitted into our hospital and treated with elastic intramedullary nail，including 17 male and 6female，aged from 6to 13，and the average age was 9．3years．Traumatic mechanisms were classified as fallen injuries with 21cases and wringer injuries with 2cases．Twenty cases were in right elbow and 3cases were in left elbow．Operation time from injury ranged from 1to 5days，and averaged in 2．3days．There were 3cases of associated injuries on other parts of the elbow joint，including 2cases of medial collateral ligament injury and 1case of fracture of medial epicondyle of humerus．All patients were given X－ray and CT examinations after hospitalization．According to the severity of radial neck angular displacement and Judet classification system，3patients were classified into type II，16patients into typeⅢ，and 4patients into type IV．Close reduction and elastic intramedullary nail fixation：After successful anesthesia，the patient was in spine position with the affected limb abducted．The nail would be inserted from distal to proximal．The insertion site was just 1to 2cm proximal to the distal radial epiphyseal plate level．A small incision was made．The underlying tendons and superficial branch of radial nerve were well protected．An awl was used perpendicular to the lateral radius to open the cortex．And then proceeded the awl 45°to radial shaft into bone canal．An AO elastic intramedullary nail was pre－bended on its tip and inserted into radius retrorward．The optimal diameter of the nail was 1／2－2／3of the minimum transverse diameter of the radial shaft．Proximally rotated，the nail body is pushedto the radial head with traction of the forearm，and the space of humeroradial joint is broadened by varus of the elbow．The displaced radial head was pressed from outside by doctor’s finger to correct angular deformity．Then the elastic intramedullary nail was further introduced into the radial head to achieve further angular correction．The nail was then rotated by its T handle to correct lateral displacement of the radial head．After successful reduction under Carm fluoroscopy，gently hammer at the nail tail for further stability of fracture end．Cut off the nail tail with 0．5cm left out of cortical bone in the distal radius，which will make it convenient for extraction．After the operation，the elbow joint is fixed with plaster in 90°flexion of neutral position．Percutaneous poking reduction by Kirschner wire and elastic intramedullary nail fixation：For patient with large tilted angle of radial head，the lateral borders of the radial neck have impacted or compression fracture of various levels and the periarticular joint capsule is lacerated or interrupted，resulting in difficulties of closed reduction for radial head，hence，percutaneous reduction of fracture end with Kirschner wire assisted is essential．With the traction of forearm by one assistant and the countertraction of upper limb by the other，the space of humeroradial joint is enlarged by the varus of elbow maintained in semiflexion．The selection of entry point depends on the situation of fracture displacement in the lower outer bottom of the elbow．Kirschner wire in the right hand，the operator put it into the fracture end under the C arm fluoroscopy．Through the use of distal fracture end as fulcrum and lateral bone cortex of radial head as pressure point，the reduction is gained by elevating the nail tail，poking the radial head with the tip of Kirschner wire，and in the meanwhile pushing it in the reverse direction of fracture shift via the left thumb．After that，the intramedullary nail is inserted to further assist the reduction and fixation of fracture end．Open reduction and elastic stable intramedullary nail fixation：For patient with large fracture displacement and inefficiency of closed or Kirschner wire assisted reduction，it is feasible to perform open reduction in order to prevent soft tissue damage caused by further closed reduction．Intraoperative attention should be paid to prevent damage to the deep branch of radial nerve，then expose and reduce the radial head under the fluoroscopy of C arm，and insert the elastic intramedullary nail to maintain the reduction of fracture ends．Treatment of combined injury：There are 3patients with injuries on other parts of the elbow joint in this group，including 2cases of medial collateral ligament injury and 1case of humeral medial epicondyle fracture．No special treatment was given to the 2patients with medial collateral ligament injury．Open reduction and internal fixation via medial incision of elbow joint as well as treatment of radial neck fracture were conducted at the same time in treatment of humeral medial epicondyle fracture．Postoperative management：All patients were given regular anti－inflammation therapy within 3days after operation．The affected limb was externally fixed with plaster in 90°flexion of the elbow joint for 3or 4weeks．After removal of the plaster，the patients were instructed to take functional exercises of forearm pronation and supination as well as elbow flexion and extension．Follow－ ups were conducted in the 6thweek，12thweek 6thmonth，1styear，2ndyear，and the 3rdyear，including taking X－ray films，understanding the state of fracture healing and change of radial head，and as well understanding the state of functional recovery of elbow joint and whether complications did exist．ResultsEvaluative criteria of curative effect：In accordance with Métaizeau postoperative X－ray assessment standards：Anatomic reduction is excellent；tilted angle＜20°is good；tilted angle ranging from 20°to 40°is medium；tilted angle＞40°is poor．In accordance with Métaizeau functional evaluative standards in the later stage：No limitation of elbow and forearm activity is excellent；The sum of the limited elbow flexion and extension activity，or the limited forearm pronation and supination activity＜20°is good；The sum of the limited elbow flexion and extension activity，or the limited forearm pronation and supination activity ranging from 20°to 40°is good，and＞40°is poor．2All patients of this group include 2cases of open reduction，6cases of percutaneous poking assisted reduction by Kirschner wire，and the remaining 15cases of simple closed reduction and elastic intramedullary nail fixation．The operative time ranged from 20to 50minutes，and the mean time is 36．4minutes．Intraoperative bleeding was from 5to 20ml with the average of 8．3ml．The duration of external fixation with plaster was 3to 12months and the average period was 3．7months．Fracture healing time after operationranged from 3to 4months，and the mean time was 3．7months．The time of removing internal fixator was 3to 12months with an average of 4．7months．Postoperative follow－ups last 6to 38months and the average is 17．5months．Postoperative X－ray assessment：18cases were excellent，3cases were good，1case was normal，and the assessment was good and excellent in 91%．Functional assessment was conducted by on the basis of Métaizeau functional evaluative standards：16cases were excellent，6 cases were good，1case was normal，and the assessment was good and excellent in 96%．Among the patients were 2cases of enlargement deformation of the radial head epiphysis and 1case of periarticular abnormal calcification．No case of infection，nonunion and delayed union was detected．ConclusionsElastic intramedullary nailing for radial neck fracture is a treatment method with minimal invasiveness，less bleeding，less interference with fracture healing，low complication rate，and the act of both reduction and fixation．It is simply operated in treatment of radial neck fracture with satisfactory effects，and worth of promoting in clinical practice．

Elastic stable intramedullary nail；Fractures，radial neck

2014－03－10）

（本文編輯：李靜）

10．3877／cma．j．issn．2095－5790．2014．02．006

100037 武警北京總隊第二醫(yī)院骨科

張亞軍，Email：zhangyajun＠vip．sina．com

李兵，張軍，張亞軍．彈性髓內(nèi)針治療兒童橈骨頸骨折的臨床應(yīng)用研究［J／CD］．中華肩肘外科電子雜志，2014，2（2）：97－102．