成人孟氏骨折治疗的临床探讨

武云鹤 陈宾 关舒丹 王桂平 崔成喜 张宇轩 杨佳宁杨帅 龚平 张宝琦 赵龙 尚瑞松 王竹君 宋有鑫



·论著·

成人孟氏骨折治疗的临床探讨

武云鹤 陈宾 关舒丹 王桂平 崔成喜 张宇轩 杨佳宁杨帅 龚平 张宝琦 赵龙 尚瑞松 王竹君 宋有鑫

目的 探讨成人孟氏骨折临床特点及其治疗方法。方法 对30例成人孟氏骨折患者进行回顾性总结。BadoⅠ型8例、Ⅱ型15例、Ⅲ型3例、Ⅳ型4例，均为新鲜骨折，开放性骨折4例、伴桡神经损伤5例、桡骨头骨折5例。所有骨折均采用切开复位内固定治疗，尺骨骨折均采用切开复位钛板螺钉内固定，其中16例桡骨小头脱位采用闭合复位，14例桡骨小头脱位采用切开复位(分外侧副韧带修复术和环状韧带重建术)。男性21例、女性9例，年龄18～72岁，平均36.7岁。左侧患肢18例，右侧患肢12例。结果 30例患者均获随访，随访时间10～60个月，平均18.5个月。骨折愈合时间2～5个月，平均150.7 d，桡神经损伤患者术后0.75～4个月内均完全恢复。30例患者无1例出现不愈合或畸形愈合，所有结果均按Broberg和Morrey评分系统进行评定，本研究按优和良为满意，可和差为不满意进行统计。根据桡骨小头的手术情况，分为桡骨小头闭合复位组和桡骨小头切开复位组。桡骨小头闭合复位组中，平均93.8分，优10例、良4例、可2例，满意率87.5%；切开复位组中，平均92.5分，优8例、良4例、可2例，满意率85.7%。30例患者总满意率为86.7%。结论 根据本组实验结果，成人孟氏骨折应内固定治疗；尺骨骨折的解剖复位和钛板坚强内固定是取得较好疗效的主要原因，恢复尺骨正常长度，在孟氏骨折的治疗中非常的关键;在闭合复位桡骨失败时，应积极行切开复位手术，以维持桡骨稳定性及避免对肘关节造成进一步的损伤，闭合复位减少了局部创伤有利于局部软组织复原;伴随桡神经损伤者应结合患者临床症状、相关检查结果和术中患者的实际情况，在一定程度上放宽桡神经手术探查的指征。

孟氏骨折；成人；桡神经；闭合复位

孟氏骨折并不多见，约占前臂骨折的1%～2%。成人孟氏骨折和儿童孟氏骨折是不同的，其损伤机制、损伤类型、预后和治疗方法方面有明显的区别，但相对于儿童孟氏骨折，成人孟氏骨折的临床报道却相对较少。成人孟氏骨折如处理不当，并发症较多，有必要引起医务工作者足够的重视。笔者回顾性分析30例手术治疗的成人新鲜孟氏骨折患者的临床资料，旨在探讨该骨折的损伤特点、手术方法、治疗方案及预后等问题，现报道如下。

对 象 与 方 法

一、临床资料

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，年龄18～72岁，平均36.7岁。Bado Ⅰ型(伸直型)8例、Ⅱ型(屈曲型)15例、Ⅲ型(内收型)3例、Ⅳ型(特殊型)4例。所有骨折均为新鲜骨折，其中闭合骨折26例、开放骨折4例，合并桡神经损伤5例、桡骨头骨折5例，所有骨折均采用手术切开复位内固定治疗，尺骨均采用钛板螺钉固定。桡骨小头闭合复位16例、桡骨小头切开复位14例，其中切开复位后行外侧副韧带修复术9例，切开复位外侧副韧带修复加环状韧带修复重建术5例，伴桡神经损伤者5例，行桡神经探查2例。

二、手术方法

手术在臂丛麻醉、气囊止血带下进行。开放性骨折先清创，暴露尺骨骨折处，复位后采用钛板坚强内固定。非开放性骨折行尺骨切开复位钛板螺钉坚强内固定，对于Bado Ⅳ型骨折则需固定尺桡骨骨折。此后C型臂下活动前臂旋前和旋后检查，透视下观察桡骨小头情况，部分病例可自行复位(本组12例)。对于未复位者，透视下观察，桡骨小头上缘一般已降到肱骨外髁关节面水平，适当旋转前臂，并向后外方按压桡骨头(屈曲型则相反)，即可达到完全复位，将前臂置于旋后位观察桡骨小头复位稳定情况，若发现存在脱位的倾向，可用1枚2.5 mm克氏针固定肱桡关节(本组4例)。以上桡骨小头已复位且稳定者缝合切口(闭合复位组共16例)。若强行手法复位时肘关节存在明显的琴键感、桡骨小头存在骨折、闭合复位失败或不能明确已复位者切开探查(本组为切开复位组共14例)。此时，另取桡骨小头外侧切口，探查环状韧带，前臂旋前，靠近尺骨从肘后肌与尺侧伸腕肌间隙进入，切开关节囊和骨膜。为防止损伤桡神经深支，应在关节内或骨膜下剥离，显露肱骨小头和脱位之桡骨小头，探查桡骨小头、环状韧带情况。存在桡骨小头骨折的，应予以螺钉固定；对于韧带，若环状韧带挤向一侧，应认清其移位方向，以使桡骨小头复位，若环状韧带破裂，提起桡骨小头使之复位，复位后修复环状韧带(本组9例)，若环状韧带破裂严重无法修复或无法找到，可在切口内适当部位制备一深筋膜条，长8～10 cm，宽约1 cm，其蒂部应在尺骨鹰嘴的背外侧。在尺骨桡切迹下方钻孔，将筋膜条围绕桡骨颈穿过尺骨桡侧下方的切迹孔，并与蒂部做重叠缝合固定，即形成一个新的环状韧带(本组5例)。重建的环状韧带松紧度应以不妨碍桡骨头旋转，又不能滑出为宜，光滑面应对桡骨颈。桡神经损伤5例中，有2例患者桡神经损伤症状严重，且桡骨头闭合复位困难，切开复位时行桡神经探查，其中1例于术中发现桡神经深支卡在肱桡关节间，遂对桡神经进行游离、解压，修补环状韧带。术后应用长臂石膏托制动6周。Bado Ⅰ、Ⅲ、Ⅳ型骨折固定于前臂旋转中立位，屈肘110°位；Ⅱ型骨折固定于屈肘70°(半伸直位)作渐进性肘关节旋转功能锻炼，患者均接受门诊康复指导。

结 果

术后X线片显示骨折处均对位对线良好，桡骨小头完全复位。所有病例均获随访，随访时间10～60个月，平均18个月。骨折愈合时间2～5个月，平均150.7 d，桡神经损伤患者术后0.75～4个月内均完全恢复。所有病例均无1例出现不愈合或畸形愈合，所有结果均按Broberg和Morrey评分系统进行评定，95～100分为优，80～94分为良，60～79分为可，少于60分为差。本研究按优和良为满意，可和差为不满意进行统计。桡骨小头闭合复位组中，平均93.8分，优10例、良4例、可2例，满意率87.5%。切开复位组中，平均92.5分，优8例、良4例、可2例，满意率85.7%。30例患者总满意率为86.7% (表1)。

表1 桡骨头闭合复位组与切开复位组比较

讨 论

一、成人孟氏骨折的特点

本组资料显示，成人孟氏骨折以Bado Ⅱ型骨折(15例占50%)多见，这与Hotchkiss[1-2]报道的比较一致。Bado Ⅱ型骨折桡骨小头较易损伤形成三角形骨片(肱骨小头的剪切损伤所致)。成人孟氏骨折与儿童孟氏骨折在治疗方法上也存在一定的区别：成人孟氏骨折目前趋向于切开复位内固定，凡是闭合复位不能达到要求时尺骨即应切开复位，加强内固定，尺骨骨折的解剖复位和稳定固定是保证桡骨头复位及保持稳定性的关键。目前内固定以钛板加螺钉内固定为首选，因成人与儿童生理结构不尽相同，成人尺骨髓腔较宽，应力较大，克氏针固定尺骨可能使骨折端固定不够稳定，容易引起骨延迟愈合或不愈合，因此已较少用于成人固定。本研究证实钛板加螺钉内固定可以完成尺骨的解剖复位，维持尺骨术后稳定性。

二、尺骨骨折的解剖复位和坚强内固定是取得较好疗效的主要原因

在未受损伤时，尺、桡骨通过关节囊、纤维软骨盘、旋前方肌，两骨干间的骨间膜、环状韧带及旋后肌相互连接，形成一个相互协调的运动整体。在成人孟氏骨折形成过程中，尺骨骨折两端成角或错位，前臂长度失去尺骨的支撑作用。当暴力继续作用于桡骨，使桡骨头与尺骨近端间的环状韧带受到破坏，或使桡骨头脱出环状韧带，并应其受力方向而脱出，桡骨也失去了对前臂的支撑作用。致使桡骨、尺骨一同相对短缩。而尺骨骨折远折段与桡骨的连结组织，如骨间膜的远折段部分、旋前方肌、三角形纤维盘及远端关节囊均未受到明显破坏，依然能使尺骨骨折远端与桡骨保持着纵轴方向上的正常稳定状态，因此可视为一个整体。当尺骨复位坚强固定后，可起到支撑作用[3]。进而通过手法复位而使桡骨小头得到部分或完全复位。并将前臂置于旋后位获得相对稳定。对于部分复位后稳定性较差的病例(本组4例)，可通过旋转前臂，并按压桡骨头使之完全复位，并用1枚克氏针固定肱桡关节。部分病例环状韧带或软骨嵌入关节内以及桡骨小头移位较远，关节囊弹性回缩嵌占肱桡关节位置造成闭合复位失败时需切开复位，此种类型患者切忌强行复位，否则可对肘关节造成进一步的损伤。

本院30例患者均取得了较好的疗效，根据手术效果，笔者认为尺骨的解剖复位及坚强内固定对于维持桡骨小头复位后的稳定性起到了主要的作用，是治疗时取得较好疗效的主要原因，同意孙志刚提出的“恢复尺骨正常长度，在孟氏骨折的治疗中非常的关键”的理论[4]。

三、桡骨闭合失败者切开复位的重要性及注意事项

大部分患者可以通过桡骨闭合复位取得成功，但还有部分患者由于复位时存在琴键感、桡骨头存在骨折碎片、不能明确已复位等原因导致闭合复位失败。马松立等[5]提出骨折发生时桡骨头在外力作用下向前上方冲击，造成脱位，然后继续冲击关节囊，使其被撕裂成“钮扣眼样”畸形，关节囊被撕裂后，外力减缓，将脱位在关节囊外的桡骨头、颈紧紧卡在扣眼外，使之不能还纳于关节囊内，越牵拉越紧，夹挤越严重，闭合复位已难以成功。张国柱等[6]认为导致BadoⅡ型复位结果不满意的另一个因素是合并桡骨头损伤。对于Bado Ⅱ型骨折，桡骨小头较易损伤形成三角形骨片(肱骨小头的剪切损伤所致)，小骨片对桡骨的卡压作用有可能导致闭合复位无法顺利完成。此外，部分患者桡骨呈粉碎性骨折，单纯手法复位已无法维持其稳定性，需要切开进行内固定。本院涉及到的14例患者中，积极行手术治疗，取得了较好的手术效果。笔者认为在闭合复位桡骨失败时，应积极行切开复位手术，以维持桡骨稳定性及避免对肘关节造成进一步的损伤，且手术过程中，桡骨复位切口应行选择，以避免尺桡骨融合的形成。

四、修补或重建环状韧带对于术后前臂功能的预后无太大影响

对于维持桡骨小头复位后的稳定性，笔者同意尺骨的解剖复位起到了决定性作用这一观点。虽然，环状韧带对于维持桡骨小头的稳定性也起着关键作用[7]，环状韧带的重新修复对于维持桡骨小头的稳定性是有帮助的，但实际情况中，有些病例因环状韧带损伤严重无法修复，即使能修复，由于修复后的韧带松紧度把握不好，仍可能影响前臂的旋转功能。至于用筋膜条重建环状韧带，其强度及张力更加难以与正常环状韧带相比，而且易引起肘部组织粘连，另外增加了桡神经以及上尺桡关节损伤的机会，可引起异位骨化、骨桥等并发症的可能[8]。术后功能恢复满意度闭合复位组与切开复位环状韧带修补或重建组差异无统计学意义。

所以笔者支持部分学者[8-10]提出的对于桡骨小头脱位的处理应本着能闭合复位不切开复位，环状韧带能自行修复不修补，能修补不重建的原则。闭合复位让环状韧带、关节囊及周围血肿机化时粘连自行修复，而不行手术修复环状韧带，减少了局部创伤，符合微创理念，有利于局部软组织复原。

五、伴随桡神经损伤者应根据情况决定是否行探查手术

对于术前怀疑桡神经损伤的患者，目前多数学者并不主张在手术的同时进行神经探查术。认为这种神经损伤的症状一般是由于神经受牵拉所致的神经麻痹，可在6～12周内恢复功能。受伤后3个月时仍未恢复神经功能，方考虑进行手术探查[11]。另有部分学者[12]通过临床研究认为应及时对桡神经进行探查，在对5例伴桡神经深支损伤患者诊疗过程中，其中2例患者神经损伤表现严重，且桡骨头闭合复位困难。切开复位时行桡神经探查，其中1例术中发现桡神经深支卡在肱桡关节间，遂对桡神经进行游离、解压、复位。此类患者若不行神经探查，桡神经深支功能将难以恢复，可能最终只能选择功能重建，延误患者治疗。所以笔者认为应结合患者临床症状、相关检查结果和术中患者的实际情况，在一定程度上放宽桡神经手术探查的指征。

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(本文编辑：李静)

武云鹤，陈宾，关舒丹，等.成人孟氏骨折治疗的临床探讨[J/CD].中华肩肘外科电子杂志,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年河北省科技厅指令性项目(15277767D)

067000承德医学院附属医院骨外六科

宋有鑫，Email：songyouxx@sohu.com

2014-04-01)