成人孟氏骨折治療的臨床探討

武云鶴 陳賓 關(guān)舒丹 王桂平 崔成喜 張宇軒 楊佳寧楊帥 龔平 張寶琦 趙龍 尚瑞松 王竹君 宋有鑫

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·論著·

成人孟氏骨折治療的臨床探討

武云鶴 陳賓 關(guān)舒丹 王桂平 崔成喜 張宇軒 楊佳寧楊帥 龔平 張寶琦 趙龍 尚瑞松 王竹君 宋有鑫

目的 探討成人孟氏骨折臨床特點(diǎn)及其治療方法。方法 對(duì)30例成人孟氏骨折患者進(jìn)行回顧性總結(jié)。BadoⅠ型8例、Ⅱ型15例、Ⅲ型3例、Ⅳ型4例，均為新鮮骨折，開放性骨折4例、伴橈神經(jīng)損傷5例、橈骨頭骨折5例。所有骨折均采用切開復(fù)位內(nèi)固定治療，尺骨骨折均采用切開復(fù)位鈦板螺釘內(nèi)固定，其中16例橈骨小頭脫位采用閉合復(fù)位，14例橈骨小頭脫位采用切開復(fù)位(分外側(cè)副韌帶修復(fù)術(shù)和環(huán)狀韌帶重建術(shù))。男性21例、女性9例，年齡18～72歲，平均36.7歲。左側(cè)患肢18例，右側(cè)患肢12例。結(jié)果 30例患者均獲隨訪，隨訪時(shí)間10～60個(gè)月，平均18.5個(gè)月。骨折愈合時(shí)間2～5個(gè)月，平均150.7 d，橈神經(jīng)損傷患者術(shù)后0.75～4個(gè)月內(nèi)均完全恢復(fù)。30例患者無1例出現(xiàn)不愈合或畸形愈合，所有結(jié)果均按Broberg和Morrey評(píng)分系統(tǒng)進(jìn)行評(píng)定，本研究按優(yōu)和良為滿意，可和差為不滿意進(jìn)行統(tǒng)計(jì)。根據(jù)橈骨小頭的手術(shù)情況，分為橈骨小頭閉合復(fù)位組和橈骨小頭切開復(fù)位組。橈骨小頭閉合復(fù)位組中，平均93.8分，優(yōu)10例、良4例、可2例，滿意率87.5%；切開復(fù)位組中，平均92.5分，優(yōu)8例、良4例、可2例，滿意率85.7%。30例患者總滿意率為86.7%。結(jié)論 根據(jù)本組實(shí)驗(yàn)結(jié)果，成人孟氏骨折應(yīng)內(nèi)固定治療；尺骨骨折的解剖復(fù)位和鈦板堅(jiān)強(qiáng)內(nèi)固定是取得較好療效的主要原因，恢復(fù)尺骨正常長(zhǎng)度，在孟氏骨折的治療中非常的關(guān)鍵;在閉合復(fù)位橈骨失敗時(shí)，應(yīng)積極行切開復(fù)位手術(shù)，以維持橈骨穩(wěn)定性及避免對(duì)肘關(guān)節(jié)造成進(jìn)一步的損傷，閉合復(fù)位減少了局部創(chuàng)傷有利于局部軟組織復(fù)原;伴隨橈神經(jīng)損傷者應(yīng)結(jié)合患者臨床癥狀、相關(guān)檢查結(jié)果和術(shù)中患者的實(shí)際情況，在一定程度上放寬橈神經(jīng)手術(shù)探查的指征。

孟氏骨折；成人；橈神經(jīng)；閉合復(fù)位

孟氏骨折并不多見，約占前臂骨折的1%～2%。成人孟氏骨折和兒童孟氏骨折是不同的，其損傷機(jī)制、損傷類型、預(yù)后和治療方法方面有明顯的區(qū)別，但相對(duì)于兒童孟氏骨折，成人孟氏骨折的臨床報(bào)道卻相對(duì)較少。成人孟氏骨折如處理不當(dāng)，并發(fā)癥較多，有必要引起醫(yī)務(wù)工作者足夠的重視。筆者回顧性分析30例手術(shù)治療的成人新鮮孟氏骨折患者的臨床資料，旨在探討該骨折的損傷特點(diǎn)、手術(shù)方法、治療方案及預(yù)后等問題，現(xiàn)報(bào)道如下。

對(duì) 象 與 方 法

一、臨床資料

2005年12月至2013年4月我院共收治成人孟氏骨折30例，男性21例、女性9例，年齡18～72歲，平均36.7歲。Bado Ⅰ型(伸直型)8例、Ⅱ型(屈曲型)15例、Ⅲ型(內(nèi)收型)3例、Ⅳ型(特殊型)4例。所有骨折均為新鮮骨折，其中閉合骨折26例、開放骨折4例，合并橈神經(jīng)損傷5例、橈骨頭骨折5例，所有骨折均采用手術(shù)切開復(fù)位內(nèi)固定治療，尺骨均采用鈦板螺釘固定。橈骨小頭閉合復(fù)位16例、橈骨小頭切開復(fù)位14例，其中切開復(fù)位后行外側(cè)副韌帶修復(fù)術(shù)9例，切開復(fù)位外側(cè)副韌帶修復(fù)加環(huán)狀韌帶修復(fù)重建術(shù)5例，伴橈神經(jīng)損傷者5例，行橈神經(jīng)探查2例。

二、手術(shù)方法

手術(shù)在臂叢麻醉、氣囊止血帶下進(jìn)行。開放性骨折先清創(chuàng)，暴露尺骨骨折處，復(fù)位后采用鈦板堅(jiān)強(qiáng)內(nèi)固定。非開放性骨折行尺骨切開復(fù)位鈦板螺釘堅(jiān)強(qiáng)內(nèi)固定，對(duì)于Bado Ⅳ型骨折則需固定尺橈骨骨折。此后C型臂下活動(dòng)前臂旋前和旋后檢查，透視下觀察橈骨小頭情況，部分病例可自行復(fù)位(本組12例)。對(duì)于未復(fù)位者，透視下觀察，橈骨小頭上緣一般已降到肱骨外髁關(guān)節(jié)面水平，適當(dāng)旋轉(zhuǎn)前臂，并向后外方按壓橈骨頭(屈曲型則相反)，即可達(dá)到完全復(fù)位，將前臂置于旋后位觀察橈骨小頭復(fù)位穩(wěn)定情況，若發(fā)現(xiàn)存在脫位的傾向，可用1枚2.5 mm克氏針固定肱橈關(guān)節(jié)(本組4例)。以上橈骨小頭已復(fù)位且穩(wěn)定者縫合切口(閉合復(fù)位組共16例)。若強(qiáng)行手法復(fù)位時(shí)肘關(guān)節(jié)存在明顯的琴鍵感、橈骨小頭存在骨折、閉合復(fù)位失敗或不能明確已復(fù)位者切開探查(本組為切開復(fù)位組共14例)。此時(shí)，另取橈骨小頭外側(cè)切口，探查環(huán)狀韌帶，前臂旋前，靠近尺骨從肘后肌與尺側(cè)伸腕肌間隙進(jìn)入，切開關(guān)節(jié)囊和骨膜。為防止損傷橈神經(jīng)深支，應(yīng)在關(guān)節(jié)內(nèi)或骨膜下剝離，顯露肱骨小頭和脫位之橈骨小頭，探查橈骨小頭、環(huán)狀韌帶情況。存在橈骨小頭骨折的，應(yīng)予以螺釘固定；對(duì)于韌帶，若環(huán)狀韌帶擠向一側(cè)，應(yīng)認(rèn)清其移位方向，以使橈骨小頭復(fù)位，若環(huán)狀韌帶破裂，提起橈骨小頭使之復(fù)位，復(fù)位后修復(fù)環(huán)狀韌帶(本組9例)，若環(huán)狀韌帶破裂嚴(yán)重?zé)o法修復(fù)或無法找到，可在切口內(nèi)適當(dāng)部位制備一深筋膜條，長(zhǎng)8～10 cm，寬約1 cm，其蒂部應(yīng)在尺骨鷹嘴的背外側(cè)。在尺骨橈切跡下方鉆孔，將筋膜條圍繞橈骨頸穿過尺骨橈側(cè)下方的切跡孔，并與蒂部做重疊縫合固定，即形成一個(gè)新的環(huán)狀韌帶(本組5例)。重建的環(huán)狀韌帶松緊度應(yīng)以不妨礙橈骨頭旋轉(zhuǎn)，又不能滑出為宜，光滑面應(yīng)對(duì)橈骨頸。橈神經(jīng)損傷5例中，有2例患者橈神經(jīng)損傷癥狀嚴(yán)重，且橈骨頭閉合復(fù)位困難，切開復(fù)位時(shí)行橈神經(jīng)探查，其中1例于術(shù)中發(fā)現(xiàn)橈神經(jīng)深支卡在肱橈關(guān)節(jié)間，遂對(duì)橈神經(jīng)進(jìn)行游離、解壓，修補(bǔ)環(huán)狀韌帶。術(shù)后應(yīng)用長(zhǎng)臂石膏托制動(dòng)6周。Bado Ⅰ、Ⅲ、Ⅳ型骨折固定于前臂旋轉(zhuǎn)中立位，屈肘110°位；Ⅱ型骨折固定于屈肘70°(半伸直位)作漸進(jìn)性肘關(guān)節(jié)旋轉(zhuǎn)功能鍛煉，患者均接受門診康復(fù)指導(dǎo)。

結(jié) 果

術(shù)后X線片顯示骨折處均對(duì)位對(duì)線良好，橈骨小頭完全復(fù)位。所有病例均獲隨訪，隨訪時(shí)間10～60個(gè)月，平均18個(gè)月。骨折愈合時(shí)間2～5個(gè)月，平均150.7 d，橈神經(jīng)損傷患者術(shù)后0.75～4個(gè)月內(nèi)均完全恢復(fù)。所有病例均無1例出現(xiàn)不愈合或畸形愈合，所有結(jié)果均按Broberg和Morrey評(píng)分系統(tǒng)進(jìn)行評(píng)定，95～100分為優(yōu)，80～94分為良，60～79分為可，少于60分為差。本研究按優(yōu)和良為滿意，可和差為不滿意進(jìn)行統(tǒng)計(jì)。橈骨小頭閉合復(fù)位組中，平均93.8分，優(yōu)10例、良4例、可2例，滿意率87.5%。切開復(fù)位組中，平均92.5分，優(yōu)8例、良4例、可2例，滿意率85.7%。30例患者總滿意率為86.7% (表1)。

表1 橈骨頭閉合復(fù)位組與切開復(fù)位組比較

討 論

一、成人孟氏骨折的特點(diǎn)

本組資料顯示，成人孟氏骨折以Bado Ⅱ型骨折(15例占50%)多見，這與Hotchkiss[1-2]報(bào)道的比較一致。Bado Ⅱ型骨折橈骨小頭較易損傷形成三角形骨片(肱骨小頭的剪切損傷所致)。成人孟氏骨折與兒童孟氏骨折在治療方法上也存在一定的區(qū)別：成人孟氏骨折目前趨向于切開復(fù)位內(nèi)固定，凡是閉合復(fù)位不能達(dá)到要求時(shí)尺骨即應(yīng)切開復(fù)位，加強(qiáng)內(nèi)固定，尺骨骨折的解剖復(fù)位和穩(wěn)定固定是保證橈骨頭復(fù)位及保持穩(wěn)定性的關(guān)鍵。目前內(nèi)固定以鈦板加螺釘內(nèi)固定為首選，因成人與兒童生理結(jié)構(gòu)不盡相同，成人尺骨髓腔較寬，應(yīng)力較大，克氏針固定尺骨可能使骨折端固定不夠穩(wěn)定，容易引起骨延遲愈合或不愈合，因此已較少用于成人固定。本研究證實(shí)鈦板加螺釘內(nèi)固定可以完成尺骨的解剖復(fù)位，維持尺骨術(shù)后穩(wěn)定性。

二、尺骨骨折的解剖復(fù)位和堅(jiān)強(qiáng)內(nèi)固定是取得較好療效的主要原因

在未受損傷時(shí)，尺、橈骨通過關(guān)節(jié)囊、纖維軟骨盤、旋前方肌，兩骨干間的骨間膜、環(huán)狀韌帶及旋后肌相互連接，形成一個(gè)相互協(xié)調(diào)的運(yùn)動(dòng)整體。在成人孟氏骨折形成過程中，尺骨骨折兩端成角或錯(cuò)位，前臂長(zhǎng)度失去尺骨的支撐作用。當(dāng)暴力繼續(xù)作用于橈骨，使橈骨頭與尺骨近端間的環(huán)狀韌帶受到破壞，或使橈骨頭脫出環(huán)狀韌帶，并應(yīng)其受力方向而脫出，橈骨也失去了對(duì)前臂的支撐作用。致使橈骨、尺骨一同相對(duì)短縮。而尺骨骨折遠(yuǎn)折段與橈骨的連結(jié)組織，如骨間膜的遠(yuǎn)折段部分、旋前方肌、三角形纖維盤及遠(yuǎn)端關(guān)節(jié)囊均未受到明顯破壞，依然能使尺骨骨折遠(yuǎn)端與橈骨保持著縱軸方向上的正常穩(wěn)定狀態(tài)，因此可視為一個(gè)整體。當(dāng)尺骨復(fù)位堅(jiān)強(qiáng)固定后，可起到支撐作用[3]。進(jìn)而通過手法復(fù)位而使橈骨小頭得到部分或完全復(fù)位。并將前臂置于旋后位獲得相對(duì)穩(wěn)定。對(duì)于部分復(fù)位后穩(wěn)定性較差的病例(本組4例)，可通過旋轉(zhuǎn)前臂，并按壓橈骨頭使之完全復(fù)位，并用1枚克氏針固定肱橈關(guān)節(jié)。部分病例環(huán)狀韌帶或軟骨嵌入關(guān)節(jié)內(nèi)以及橈骨小頭移位較遠(yuǎn)，關(guān)節(jié)囊彈性回縮嵌占肱橈關(guān)節(jié)位置造成閉合復(fù)位失敗時(shí)需切開復(fù)位，此種類型患者切忌強(qiáng)行復(fù)位，否則可對(duì)肘關(guān)節(jié)造成進(jìn)一步的損傷。

本院30例患者均取得了較好的療效，根據(jù)手術(shù)效果，筆者認(rèn)為尺骨的解剖復(fù)位及堅(jiān)強(qiáng)內(nèi)固定對(duì)于維持橈骨小頭復(fù)位后的穩(wěn)定性起到了主要的作用，是治療時(shí)取得較好療效的主要原因，同意孫志剛提出的“恢復(fù)尺骨正常長(zhǎng)度，在孟氏骨折的治療中非常的關(guān)鍵”的理論[4]。

三、橈骨閉合失敗者切開復(fù)位的重要性及注意事項(xiàng)

大部分患者可以通過橈骨閉合復(fù)位取得成功，但還有部分患者由于復(fù)位時(shí)存在琴鍵感、橈骨頭存在骨折碎片、不能明確已復(fù)位等原因?qū)е麻]合復(fù)位失敗。馬松立等[5]提出骨折發(fā)生時(shí)橈骨頭在外力作用下向前上方?jīng)_擊，造成脫位，然后繼續(xù)沖擊關(guān)節(jié)囊，使其被撕裂成“鈕扣眼樣”畸形，關(guān)節(jié)囊被撕裂后，外力減緩，將脫位在關(guān)節(jié)囊外的橈骨頭、頸緊緊卡在扣眼外，使之不能還納于關(guān)節(jié)囊內(nèi)，越牽拉越緊，夾擠越嚴(yán)重，閉合復(fù)位已難以成功。張國(guó)柱等[6]認(rèn)為導(dǎo)致BadoⅡ型復(fù)位結(jié)果不滿意的另一個(gè)因素是合并橈骨頭損傷。對(duì)于Bado Ⅱ型骨折，橈骨小頭較易損傷形成三角形骨片(肱骨小頭的剪切損傷所致)，小骨片對(duì)橈骨的卡壓作用有可能導(dǎo)致閉合復(fù)位無法順利完成。此外，部分患者橈骨呈粉碎性骨折，單純手法復(fù)位已無法維持其穩(wěn)定性，需要切開進(jìn)行內(nèi)固定。本院涉及到的14例患者中，積極行手術(shù)治療，取得了較好的手術(shù)效果。筆者認(rèn)為在閉合復(fù)位橈骨失敗時(shí)，應(yīng)積極行切開復(fù)位手術(shù)，以維持橈骨穩(wěn)定性及避免對(duì)肘關(guān)節(jié)造成進(jìn)一步的損傷，且手術(shù)過程中，橈骨復(fù)位切口應(yīng)行選擇，以避免尺橈骨融合的形成。

四、修補(bǔ)或重建環(huán)狀韌帶對(duì)于術(shù)后前臂功能的預(yù)后無太大影響

對(duì)于維持橈骨小頭復(fù)位后的穩(wěn)定性，筆者同意尺骨的解剖復(fù)位起到了決定性作用這一觀點(diǎn)。雖然，環(huán)狀韌帶對(duì)于維持橈骨小頭的穩(wěn)定性也起著關(guān)鍵作用[7]，環(huán)狀韌帶的重新修復(fù)對(duì)于維持橈骨小頭的穩(wěn)定性是有幫助的，但實(shí)際情況中，有些病例因環(huán)狀韌帶損傷嚴(yán)重?zé)o法修復(fù)，即使能修復(fù)，由于修復(fù)后的韌帶松緊度把握不好，仍可能影響前臂的旋轉(zhuǎn)功能。至于用筋膜條重建環(huán)狀韌帶，其強(qiáng)度及張力更加難以與正常環(huán)狀韌帶相比，而且易引起肘部組織粘連，另外增加了橈神經(jīng)以及上尺橈關(guān)節(jié)損傷的機(jī)會(huì)，可引起異位骨化、骨橋等并發(fā)癥的可能[8]。術(shù)后功能恢復(fù)滿意度閉合復(fù)位組與切開復(fù)位環(huán)狀韌帶修補(bǔ)或重建組差異無統(tǒng)計(jì)學(xué)意義。

所以筆者支持部分學(xué)者[8-10]提出的對(duì)于橈骨小頭脫位的處理應(yīng)本著能閉合復(fù)位不切開復(fù)位，環(huán)狀韌帶能自行修復(fù)不修補(bǔ)，能修補(bǔ)不重建的原則。閉合復(fù)位讓環(huán)狀韌帶、關(guān)節(jié)囊及周圍血腫機(jī)化時(shí)粘連自行修復(fù)，而不行手術(shù)修復(fù)環(huán)狀韌帶，減少了局部創(chuàng)傷，符合微創(chuàng)理念，有利于局部軟組織復(fù)原。

五、伴隨橈神經(jīng)損傷者應(yīng)根據(jù)情況決定是否行探查手術(shù)

對(duì)于術(shù)前懷疑橈神經(jīng)損傷的患者，目前多數(shù)學(xué)者并不主張?jiān)谑中g(shù)的同時(shí)進(jìn)行神經(jīng)探查術(shù)。認(rèn)為這種神經(jīng)損傷的癥狀一般是由于神經(jīng)受牽拉所致的神經(jīng)麻痹，可在6～12周內(nèi)恢復(fù)功能。受傷后3個(gè)月時(shí)仍未恢復(fù)神經(jīng)功能，方考慮進(jìn)行手術(shù)探查[11]。另有部分學(xué)者[12]通過臨床研究認(rèn)為應(yīng)及時(shí)對(duì)橈神經(jīng)進(jìn)行探查，在對(duì)5例伴橈神經(jīng)深支損傷患者診療過程中，其中2例患者神經(jīng)損傷表現(xiàn)嚴(yán)重，且橈骨頭閉合復(fù)位困難。切開復(fù)位時(shí)行橈神經(jīng)探查，其中1例術(shù)中發(fā)現(xiàn)橈神經(jīng)深支卡在肱橈關(guān)節(jié)間，遂對(duì)橈神經(jīng)進(jìn)行游離、解壓、復(fù)位。此類患者若不行神經(jīng)探查，橈神經(jīng)深支功能將難以恢復(fù)，可能最終只能選擇功能重建，延誤患者治療。所以筆者認(rèn)為應(yīng)結(jié)合患者臨床癥狀、相關(guān)檢查結(jié)果和術(shù)中患者的實(shí)際情況，在一定程度上放寬橈神經(jīng)手術(shù)探查的指征。

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[5] 馬松立，曲家富，左玉明，等.小兒孟氏骨折脫位扣眼畸形的病理認(rèn)識(shí)以及環(huán)狀韌帶重建術(shù)的探討[J].中華小兒外科雜志，2001，22(2)：79-81.

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(本文編輯：李靜)

武云鶴，陳賓，關(guān)舒丹，等.成人孟氏骨折治療的臨床探討[J/CD].中華肩肘外科電子雜志,2015,3(1):9-13.

Clinical study for the treatment of monteggia fracture in adult

WuYunhe，ChenBin，GuanShudan,WangGuiping，CuiChengxi，ZhangYuxuan，YangJianing，YangShuai，GongPing，ZhangBaoqi，ZhaoLong，ShangRuisong，WangZhujun,SongYouxin.

SixthDepartmentofOrthopaedics,AffiliatedHospitalofChengdeMedicalCollege,Chengde067000,China

SongYouxin,Email:songyouxx@sohu.com

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),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 110° of flexion; For Bado type Ⅱ fracture,the elbow was immobilized in 70° of flexion.All the patients

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 150.7 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%.Conclusion 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 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.

Monteggia fracture;Adult;Radial nerve;Closed reduction

10.3877/cma.j.issn.2095-5790.2015.01.003

2015年河北省科技廳指令性項(xiàng)目(15277767D)

067000承德醫(yī)學(xué)院附屬醫(yī)院骨外六科

宋有鑫，Email：songyouxx@sohu.com

2014-04-01)