肘關(guān)節(jié)“恐怖三聯(lián)征”的手術(shù)治療：附14例報(bào)告

孟亞軻 劉巖 葉添文 歐陽躍平 陳愛民 郭永飛

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肘關(guān)節(jié)“恐怖三聯(lián)征”的手術(shù)治療：附14例報(bào)告

孟亞軻 劉巖 葉添文 歐陽躍平 陳愛民 郭永飛

目的 回顧分析手術(shù)治療肘關(guān)節(jié)“恐怖三聯(lián)征”的療效及策略。方法 我院骨科從2010年7月至2013年10月手術(shù)治療并完整隨訪的14例肘關(guān)節(jié)“恐怖三聯(lián)征”患者，其中尺骨冠突骨折按照Regan-Morrey分型：Ⅰ型2例，Ⅱ型10例，Ⅲ型2例；橈骨頭骨折按照Mason 分型：Ⅰ型4例，Ⅱ型7例，Ⅲ型3例；本組病例中均合并有肘關(guān)節(jié)內(nèi)、外側(cè)副韌帶的損傷。采取常規(guī)肘關(guān)節(jié)內(nèi)、外側(cè)聯(lián)合入路，給予患肘關(guān)節(jié)復(fù)位，然后由深至淺依次固定冠狀突骨折和橈骨頭骨折，修復(fù)外側(cè)副韌帶。冠狀突骨折采用微型鋼板、拉力螺釘、縫合錨釘及套索縫合技術(shù)固定；橈骨頭骨折采用克氏針、微型螺釘或微型鋼板固定；所有患者給予編織非吸收性縫線縫合或錨釘修復(fù)外側(cè)副韌帶(lateral collateral ligaments,LCL)，2例使用非吸收性編織縫線縫合、錨釘修復(fù)內(nèi)側(cè)副韌帶(medical collateral ligaments,MCL)，1例放置外側(cè)鉸鏈?zhǔn)酵夤潭ㄖЪ?，?3例患者術(shù)后給予肘關(guān)節(jié)屈曲90°、前臂中立位石膏固定，術(shù)后積極進(jìn)行康復(fù)功能鍛煉。結(jié)果 平均隨訪18個(gè)月(10～37個(gè)月)。所有病例實(shí)現(xiàn)骨折愈合，平均愈合時(shí)間為12.4周。術(shù)后6個(gè)月，肘關(guān)節(jié)屈位(0°～20°)，伸位(130°～145°)，平均活動范圍為116.5°；旋前(60°～85°)，旋后(45°～75°)，平均旋轉(zhuǎn)范圍為126°。1例患者出現(xiàn)肘關(guān)節(jié)僵硬；2例患者術(shù)后6個(gè)月在影像學(xué)上出現(xiàn)異位骨化，但不影響肘關(guān)節(jié)功能。結(jié)論 肘關(guān)節(jié)“恐怖三聯(lián)征”通過積極有效的手術(shù)治療，大多患者能夠得到滿意的結(jié)果。對于該類損傷，我們應(yīng)盡可能通過有效的內(nèi)固定重建骨及韌帶的穩(wěn)定結(jié)構(gòu)，恢復(fù)肘關(guān)節(jié)的穩(wěn)定性，及早配合正規(guī)的功能鍛煉，最大程度恢復(fù)肘關(guān)節(jié)的功能。

肘關(guān)節(jié)；恐怖三聯(lián)征；骨折；脫位；固定

肘關(guān)節(jié)“恐怖三聯(lián)征”是指肘關(guān)節(jié)后脫位合并尺骨冠狀突骨折和橈骨頭骨折，常伴有肘關(guān)節(jié)內(nèi)、外側(cè)副韌帶的損傷。軸向應(yīng)力作用于前臂旋后、肘關(guān)節(jié)外展產(chǎn)生的壓縮剪切力是主要的損傷機(jī)制[1]。我科自2010年7月至2013年10月手術(shù)治療并完整隨訪了14例肘關(guān)節(jié)“恐怖三聯(lián)征”患者，治療效果較好，現(xiàn)報(bào)道如下。

資 料 與 方 法

一、一般資料

本組患者14例，男性11例，女性3例，年齡23～48歲，平均35.4歲。左側(cè)5例，右側(cè)9例,均為閉合性損傷。無相關(guān)神經(jīng)血管損傷。致傷原因：高處墜落5例，交通事故3例，跌倒損傷4例，運(yùn)動損傷2例。入院后常規(guī)行肘關(guān)節(jié)X線正側(cè)位片、肘關(guān)節(jié)CT掃描及三維重建以判斷骨折的類型及移位情況(圖1、2)。尺骨冠突骨折Regan-Morrey分型[2],Ⅰ型2例，Ⅱ型10例，Ⅲ型2例；橈骨頭骨折按照Mason 分型[3]，Ⅰ型4例，Ⅱ型7例，Ⅲ型3例；其中1例合并有同側(cè)橈骨遠(yuǎn)端骨折，1 例合并有同側(cè)尺骨干骨折；本組病例均合并有肘內(nèi)、外側(cè)副韌帶的損傷。

圖2 肘關(guān)節(jié)CT平掃

二、手術(shù)方法

患者平臥于手術(shù)臺上，患肢近端上充氣性止血帶。在臂叢神經(jīng)阻滯麻醉下，常規(guī)使用肘關(guān)節(jié)內(nèi)、外側(cè)聯(lián)合入路，給予患肘關(guān)節(jié)復(fù)位，然后由深至淺依次修復(fù)冠狀突骨折，前關(guān)節(jié)囊，橈骨頭骨折，外側(cè)副韌帶，伸肌總腱起點(diǎn)。冠狀突骨折采用微型鋼板、拉力螺釘、縫合錨釘或套索縫合技術(shù)固定；橈骨小頭骨折采用克氏針、微型螺釘、微型鋼板固定；所有患者使用非吸收性編織縫線縫合或錨釘給予修復(fù)外側(cè)副韌帶(lateral collateral ligaments,LCL)。閉合切口前行肘關(guān)節(jié)伸直位內(nèi)外翻試驗(yàn)及外翻過載試驗(yàn)判斷肘關(guān)節(jié)穩(wěn)定性的恢復(fù)情況。其中3例肘關(guān)節(jié)被動屈曲過程中同心圓穩(wěn)定性欠佳，其中2例使用非吸收性編織縫線縫合、錨釘修復(fù)內(nèi)側(cè)副韌帶(medical collateral ligaments,MCL)，1例放置外側(cè)鉸鏈?zhǔn)酵夤潭ㄖЪ?，術(shù)中保持肘關(guān)節(jié)屈曲90°固定鉸鏈，另12例穩(wěn)定性尚可維持。術(shù)后13例患者給予肘關(guān)節(jié)屈曲90°、前臂中立位石膏固定。

圖1 術(shù)前肘關(guān)節(jié)正側(cè)位X線片

三、功能鍛煉及隨訪

13例石膏固定患者做手指活動及肱二頭肌、肱三頭肌等長收縮訓(xùn)練；術(shù)后48 h開始進(jìn)行肘關(guān)節(jié)被動屈伸活動，及前臂旋轉(zhuǎn)活動。1例輔以外固定架固定的患者術(shù)后1～2周開始進(jìn)行功能鍛煉，術(shù)后第1周，調(diào)整鉸鏈支架中心的旋鈕，指導(dǎo)患肘做屈伸功能鍛煉，術(shù)后6～8周拆除外固定支架?？祻?fù)過程中避免肘關(guān)節(jié)過伸。 術(shù)后分別于第1天， 2周，1、3、6、12個(gè)月隨訪時(shí)拍攝患肘關(guān)節(jié)正側(cè)位X線片。術(shù)后2個(gè)月肘關(guān)節(jié)正側(cè)位X線片見圖3。觀察骨折塊愈合及異位骨化、骨關(guān)節(jié)炎等術(shù)后并發(fā)癥的發(fā)生情況；了解肘關(guān)節(jié)功能改善情況，指導(dǎo)患者進(jìn)行功能鍛煉。隨訪結(jié)束時(shí)按Mayo肘關(guān)節(jié)功能評分標(biāo)準(zhǔn)進(jìn)行療效評價(jià)。

圖3 術(shù)后2個(gè)月肘關(guān)節(jié)正側(cè)位X線片

結(jié) 果

本組隨訪14例，平均隨訪18個(gè)月(10～37個(gè)月)。骨折達(dá)臨床愈合時(shí)間為術(shù)后10～15周，平均12.4周。術(shù)后6個(gè)月，肘關(guān)節(jié)屈位(0°～20°)，伸位(130°～145°)，平均活動范圍為116.5°；旋前(60°～85°)，旋后(45°～75°)，平均旋轉(zhuǎn)范圍為126°。1例出現(xiàn)肘關(guān)節(jié)僵硬；2例患者術(shù)后6個(gè)月在影像學(xué)上出現(xiàn)異位骨化，但不影響肘關(guān)節(jié)功能。Mayo評分標(biāo)準(zhǔn)評價(jià)：優(yōu)6例，良4例，一般2例，差1例。

討 論

1996年Hotchkiss[4]首次將肘關(guān)節(jié)后脫位合并尺骨冠突和橈骨頭骨折命名為肘關(guān)節(jié)“恐怖三聯(lián)征”，該類患者多合并有周圍韌帶的損傷，屬于嚴(yán)重類型的肘關(guān)節(jié)損傷。肘關(guān)節(jié)三維結(jié)構(gòu)復(fù)雜，治療不當(dāng)會導(dǎo)致疼痛、僵硬、異位骨化、創(chuàng)傷性關(guān)節(jié)炎等并發(fā)癥。肘關(guān)節(jié)“恐怖三聯(lián)征”的主要治療目標(biāo)[5]是重建重要的骨性關(guān)節(jié)及軟組織結(jié)構(gòu)，恢復(fù)運(yùn)動關(guān)節(jié)的穩(wěn)定性，為術(shù)后早期功能鍛煉提供條件。大多數(shù)學(xué)者[6]建議對所有骨折的橈骨頭和冠突給予牢固固定，修復(fù)外側(cè)副韌帶，實(shí)現(xiàn)肘關(guān)節(jié)的解剖穩(wěn)定性。在少數(shù)情況下，對于殘存的不穩(wěn)定性可通過修復(fù)內(nèi)側(cè)副韌帶或加用鉸鏈?zhǔn)酵夤潭芄潭ㄖ委煛?/p>

目前肘關(guān)節(jié)“恐怖三聯(lián)征”常用的手術(shù)入路有外側(cè)入路、外內(nèi)側(cè)聯(lián)合入路和后側(cè)入路。國內(nèi)林國葉等[7]學(xué)者使用肘關(guān)節(jié)后方尺骨鷹嘴截骨入路治療了8例肘關(guān)節(jié)“恐怖三聯(lián)征”患者，該手術(shù)入路擴(kuò)大了手術(shù)視野，減少了對正常組織的進(jìn)一步損傷，可完成尺骨冠狀突骨折、橈骨小頭骨折及肘關(guān)節(jié)內(nèi)外側(cè)軟組織的修復(fù)。

尺骨冠突是尺骨近端干骺部向前方的延伸部分，具有維持肘關(guān)節(jié)軸向穩(wěn)定，后內(nèi)側(cè)、后外側(cè)旋轉(zhuǎn)穩(wěn)定及防止肘內(nèi)翻的重要作用，是維持肘關(guān)節(jié)前方穩(wěn)定性最主要的骨性阻擋結(jié)構(gòu)，也是防止肘關(guān)節(jié)后脫位、后外側(cè)半脫位的第一位因素[8]。冠突骨折主要的手術(shù)固定方法有套索縫合技術(shù)、微型螺釘、微型鋼板、錨釘?shù)?，具體的治療方案要根據(jù)骨折塊的大小、骨折類型及醫(yī)師的偏好來決定。Garrigues等[9]發(fā)現(xiàn)在冠突骨折中，經(jīng)骨套索縫合固定技術(shù)優(yōu)于螺釘或錨釘固定，其治療效果佳且并發(fā)癥少。Jeon等[10]尸檢發(fā)現(xiàn)在橈骨頭及韌帶完整的情況下(尤其是橈骨頭)冠突缺少40%(Ⅱ型骨折)不會發(fā)生肘關(guān)節(jié)不穩(wěn)定，認(rèn)為Ⅱ型冠突骨折屬于穩(wěn)定性骨折。最近， Papatheodorou等[11]治療了12例冠突Ⅰ型和Ⅱ型的肘關(guān)節(jié)“恐怖三聯(lián)征”患者，所有患者給予肱尺關(guān)節(jié)復(fù)位，橈骨頭的修復(fù)或假體置換，修復(fù)外側(cè)副韌帶，但冠突及前側(cè)關(guān)節(jié)囊未予修復(fù)處理，術(shù)中所有病例獲得穩(wěn)定，未修復(fù)內(nèi)側(cè)副韌帶及使用外固定架，術(shù)后患者患肢結(jié)構(gòu)及功能恢復(fù)良好。此外，Alolabi等[12]在缺少40%的冠突骨折的尸體模型中，發(fā)現(xiàn)同側(cè)尺骨鷹嘴尖部取骨植骨是重建冠突恢復(fù)正常運(yùn)動力學(xué)的有效的方法，雖然這項(xiàng)技術(shù)僅適用于單純性冠突骨折，且還處于研究階段，但論證了冠突骨折缺損導(dǎo)致肘關(guān)節(jié)的不穩(wěn)定。毫無疑問，冠突在肘關(guān)節(jié)穩(wěn)定性中發(fā)揮關(guān)鍵性作用，我們建議對冠突骨折給予積極的內(nèi)固定治療，尤其是骨折塊較大的Ⅱ型、Ⅲ型骨折(Regan-Morrey)，而有些可能引起肘關(guān)節(jié)不穩(wěn)定的Ⅰ型骨折也應(yīng)該給予有效的內(nèi)固定治療。

橈骨頭具有維持肘關(guān)節(jié)軸向及內(nèi)外翻穩(wěn)定的作用，在MCL損傷情況下其抗外翻作用尤為重要，在運(yùn)動中可通過拉緊LCL間接提供抗內(nèi)翻阻力。在肘關(guān)節(jié)“恐怖三聯(lián)征”中，橈骨頭骨折可使用鋼板固定或橈骨頭置換進(jìn)行治療。使用鋼板固定骨折塊時(shí)，需注意鋼板應(yīng)放置在“安全區(qū)”-橈骨頭的非關(guān)節(jié)面，以防術(shù)后影響前臂的旋轉(zhuǎn)功能[13]。橈骨頭置換在橈骨頭骨折中(尤其是在存在復(fù)雜類型的肘關(guān)節(jié)損傷中如：肘關(guān)節(jié)“恐怖三聯(lián)征”)的應(yīng)用一直是研究的熱點(diǎn)。Watters等[14]發(fā)現(xiàn)在肘關(guān)節(jié)“恐怖三聯(lián)征”中，與切開復(fù)位內(nèi)固定病例組相比，橈骨頭置換病例組患者的術(shù)中、術(shù)后及短期隨訪中肘關(guān)節(jié)的穩(wěn)定性優(yōu)于內(nèi)固定治療組，但橈骨頭置換組的術(shù)后關(guān)節(jié)炎發(fā)生率高于內(nèi)固定組。Ring 等也推薦肘關(guān)節(jié)“恐怖三聯(lián)征”患者采用橈骨頭置換治療。此外，Acevedo等[3]認(rèn)為當(dāng)尺骨冠突骨折<50%時(shí)，肘關(guān)節(jié)“恐怖三聯(lián)征”可以通過單純的橈骨頭關(guān)節(jié)置換和外側(cè)尺骨副韌帶修復(fù)手術(shù)進(jìn)行治療。也有學(xué)者認(rèn)為Mason Ⅲ型的橈骨頭骨折是無法重建的。因此，可對其進(jìn)行橈骨頭切除加橈骨頭置換[15]。盡管橈骨頭置換在材料、類型及技術(shù)方面都得到了快速的發(fā)展，但橈骨頭置換之后帶來的并發(fā)癥及遠(yuǎn)期療效仍然困擾著眾多學(xué)者，其中假體松動作為橈骨頭置換的一個(gè)遠(yuǎn)期并發(fā)癥，是令眾多學(xué)者擔(dān)憂的問題，尤其是青年患者[13]。在我們的病例治療組中，大多數(shù)橈骨頭骨折能夠通過內(nèi)固定獲得治療，橈骨頭置換不僅增加了患者的經(jīng)濟(jì)負(fù)擔(dān)，而且遠(yuǎn)期療效不明。因此，我們不主張進(jìn)行橈骨頭置換。

外側(cè)副韌帶是抗內(nèi)翻應(yīng)力的主要穩(wěn)定結(jié)構(gòu)，有利于支撐橈骨頭、防止肘關(guān)節(jié)發(fā)生半脫位。在肘關(guān)節(jié)“恐怖三聯(lián)征”中外側(cè)副韌帶復(fù)合體，通常自肱骨遠(yuǎn)端的起點(diǎn)處發(fā)生撕脫，可用不可吸收縫線或以帶線“錨釘”縫合固定在肱骨遠(yuǎn)端，此時(shí)檢查肘關(guān)節(jié)的穩(wěn)定性，肘關(guān)節(jié)由伸直位到屈曲位，如果屈曲未達(dá)30°～40°時(shí)即發(fā)生脫位，可以運(yùn)用同樣的方法修復(fù)損傷的內(nèi)側(cè)副韌帶[16]。 一直以來對于“恐怖三聯(lián)征”中肘關(guān)節(jié)內(nèi)側(cè)副韌帶損傷的處理存在著爭議，有學(xué)者認(rèn)為在治療后殘存不穩(wěn)定的患者可給予修復(fù)內(nèi)側(cè)副韌帶，也有學(xué)者認(rèn)為修補(bǔ)內(nèi)側(cè)韌帶結(jié)構(gòu)是手術(shù)程序中的重要環(huán)節(jié)一，仲飆等[17]認(rèn)為術(shù)前應(yīng)通過MRI檢查予充分評估肘關(guān)節(jié)內(nèi)側(cè)軟組織損傷情況，對于前束輕度撕裂而完整性存在者無需處理，但對于嚴(yán)重的起、止點(diǎn)撕脫或體部斷裂者，應(yīng)常規(guī)采用內(nèi)側(cè)入路探查修補(bǔ)。外側(cè)副韌帶是維持肘關(guān)節(jié)穩(wěn)定性的重要結(jié)構(gòu)之一，可能是肘關(guān)節(jié)脫位時(shí)是第一個(gè)被破壞的結(jié)構(gòu)[1],因此我們應(yīng)對所有的外側(cè)副韌帶給予積極有效的修復(fù)治療，同時(shí)也應(yīng)重視內(nèi)側(cè)副韌帶的損傷情況，做出恰當(dāng)?shù)奶幚怼?/p>

隨著人們對肘關(guān)節(jié)“恐怖三聯(lián)征”認(rèn)識的加深及內(nèi)固定技術(shù)的發(fā)展，鉸鏈?zhǔn)酵夤潭艿倪\(yùn)用相對減少，但有限內(nèi)固定結(jié)合鉸鏈支架治療肘關(guān)節(jié)“恐怖三聯(lián)征”既能保持肘關(guān)節(jié)的穩(wěn)定性，又能早期進(jìn)行功能鍛煉，減少并發(fā)癥的發(fā)生[18]。

總之， 肘關(guān)節(jié)“恐怖三聯(lián)征”通過積極有效的手術(shù)治療，大多數(shù)患者能夠得到滿意的結(jié)果。對于該類損傷，我們應(yīng)盡可能通過有效的內(nèi)固定重建骨及韌帶的穩(wěn)定結(jié)構(gòu)，恢復(fù)肘關(guān)節(jié)的穩(wěn)定性，及早配合正規(guī)的功能鍛煉，最大程度恢復(fù)肘關(guān)節(jié)的功能。

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[14] Watters TS, Garrigues GE, Ring D, et al. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?[J]. Clin Orthop Relat Res, 2014, 472(7): 2128-2135.

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[18] 溫曉東,李玉茂,張玉九.有限內(nèi)固定結(jié)合鉸鏈?zhǔn)酵夤潭苤委熤怅P(guān)節(jié)[J].疑難病雜志,2013,(8)：627-629.

(本文編輯：胡桂英)

孟亞軻，劉巖，葉添文，等.肘關(guān)節(jié)“恐怖三聯(lián)征”的手術(shù)治療：附14例報(bào)告[J/CD]. 中華肩肘外科電子雜志,2015,3(3):151-155.

Operative treatment of elbow joint "terrible triad":attached with report on 14 cases

MengYake,LiuYan,YeTianwen,OuyangYueping,ChenAimin,GuoYongfei.

DepartmentofOrthopaedics,theSecondMilitaryUniversityAffiliatedChangzhengHospital,Shanghai200003,China

GuoYongfei,Email:cz-gyf@163.com

Background Elbow joint "terrible triad" refers to posterior dislocation of elbow joint combined with ulna coracoid process fracture and radius head fracture, often accompanied with injuries of medial collateral ligament and/or lateral collateral ligament of elbow joint. Distal clavicular fracture combined with coracoclavicular ligament rupture frequently behave as unstable fracture, with the opportunity for fracture non-union in conservative therapy being as high as 21%. During the period from July 2010 to October 2013, our department performed operative treatment for 14 cases of elbow joint "terrible triad" with complete follow-up, and achieved satisfactory therapeutic effects. The specific process is hereby reported as follows.Method I. General materials:This group includes 14 cases (11 male cases and 3 female cases), aged 23-48 years, with an average age of 35.4 years; 5 cases in the left side, 9 cases in the right side, all suffer from closed injury. No one case suffers from related neurovascular injury. Injury causes: High falling accident 5 cases, traffic accident 3 cases, falling injury 4 cases and sport injury 2 cases. After hospital admission, according to the routine procedure, we performed elbow joint X-ray anterioposterior and lateral film, elbow joint CT scanning and three-dimensional reconstruction to judge the type of fracture and the fracture displacement condition. Ulna coronoid fracture Regan-Morrey typing , 10 cases of type Ⅲ, and 2 cases of type Ⅲ; According to Mason typing of radius head fracture, 7 cases of type Ⅲ, and 3 cases of type Ⅲ, of which 1 case is combined with ipsilateral distal radius fracture，And 1 case is combined with ipsilateral ulnar fracture; All the cases in this group are combined with injuries of medial collateral ligament and/or lateral collateral ligament of elbow joint.Ⅱ. Operative method:Allow the patient to lie flat on operating table, and place inflatable tourniquets on the proximal ends of affected limbs. Under brachial plexus block anesthesia, conventionally use elbow joint medial and lateral combined approaches, perform reduction of affected elbow joint, then in the sequence from the shallower to the deeper repair the ulna coracoid process fracture, the anterior joint capsule, the radius head fracture, the lateral collateral ligament and the starting point of common extensor tendon. The ulna coracoid process fracture is fixed by using mini-plate, lag screw, stitching anchor or rope stitching technique; radial head fracture is fixed by using kirschner wire, mini-screw and mini-plate; For all the cases, we use non-absorbable braided suture or anchor to repair their lateral collateral ligaments (LCL). Prior to incision closure, perform varus-valgus rotation test on straight position of elbow joint and cubitus valgus overload test to judge the recovery of elbow joint stability. In the process of passive flexion of elbow joint, 3 cases show poor concentric circle stability, for 2 cases of them, we use non-absorbable braided suture and anchor to repair their medial collateral ligaments (MCL); For 1 case, place lateral articulated type external fixation support, and keep elbow joint flexion 90°fixed hinge during operation; the other 12 cases can still maintain stability. After operation, 13 cases are provided with elbow joint flexion 90°and plaster fixation at neutral position of fore arms.Ⅲ. Functional exercise and follow-up:13 cases in plaster fixation perform finger movement as well as Biceps brachii muscle/Triceps brachii muscle isometric contraction training; At postoperative 48h, start passive elbow joint flexion and extension activity as well as fore arm rotation activity. At operative 1-2 week, 1 case assisted with external fixation started functional exercise; in the 1st week post operation, adjust the knob at the center of hinge support, instruct the affected elbows to perform flexion and extension function exercise; At post-operative 6th-8thweek, remove external fixation support. In the process of rehabilitation, avoid hyperextension of elbow joint. After operation, respectively in the follow-up on the 1stday, at the 2ndweek, 1stmonth, 3rdmonth, 6thmonth and 12thmonth, take X-ray anterioposterior and lateral film of affected elbow joints. Observe the healing condition of fracture fragments as well a s the occurrence of postoperative complications such as heterotopic ossification and Osteoarthritis; Investigate the improvements in elbow joint function, and instruct the patients to perform functional exercise. Upon completion of follow-up, perform evaluation of therapeutic effect according to Mayo elbow joint function scoring standard.Results 14 cases in this group obtained follow-up, with an average follow-up time of 18 months (10-37 months). The clinical fracture union time is postoperative 10-15 weeks, with an average time of 12.4 weeks. In postoperative 6 months, elbow joint flexion position (0°-20°), extension position (130°-145 °), with an average range of joint motion being 116.5°; pronation (60°-85°)supination (45°-75°), with an average rotation range of 126°. 1 case has stiff elbow joint; 2 cases show heterotopic ossification in imageological examination at the 6thmonth after operation, which, however do not affect the functions of elbow joint. Evaluation according to Mayo scoring standard: Excellent 6 case, good 4 cases, general 2 cases and poor 1 case.Conclusion Through active and effective operative treatment for elbow joint "terrible triad", most of the patients can obtain satisfactory results. For such type of injuries, we should make every effort to reconstruct stable structure of bone and ligament through effective internal fixation and recover the stability of elbow joint in combination with timely and normal functional exercise, so as to recover the functions of elbow joint to the maximum extent.

Elbow joint;Terrible triad;Fracture;Dislocation;Fixation

10.3877/cma.j.issn.2095-5790.2015.03.005

國家自然基金青年項(xiàng)目(31100988)

200003上海，第二軍醫(yī)大學(xué)附屬長征醫(yī)院骨科

郭永飛，Email：cz-gyf@163.com

2015-01-01)