吳關(guān) 魯誼

·論著·

肘關(guān)節(jié)鏡前外側(cè)入路的解剖學(xué)研究

吳關(guān) 魯誼

目的 初步探討肘關(guān)節(jié)鏡前外側(cè)入路向前方的變化范圍。 方法 選用10具新鮮上肢標(biāo)本，在肘關(guān)節(jié)屈曲90°下，測量近端前外側(cè)入路、前外側(cè)入路、外側(cè)入路與橈神經(jīng)的距離；測量改良后3個入路前方5mm與橈神經(jīng)的距離。結(jié)果 標(biāo)準(zhǔn)入路的近端前外側(cè)入路、前外側(cè)入路、外側(cè)入路與橈神經(jīng)的距離平均值分別為：12.8mm、8.5mm、3.8mm，改良后的近端前外側(cè)入路、前外側(cè)入路、外側(cè)入路與橈神經(jīng)的距離平均值分別為4.1mm、2.2mm、-0.5mm。結(jié)論 肘關(guān)節(jié)近端前外側(cè)入路與前外側(cè)入路之間的連線區(qū)可向前方5mm進(jìn)行操作，越靠遠(yuǎn)端距離橈神經(jīng)越近；前外側(cè)入路與外側(cè)入路距離橈神經(jīng)較近，不建議向前方改變?nèi)肼贰?/p>

肘關(guān)節(jié)鏡； 前外側(cè)入路； 解剖學(xué)

從20世紀(jì)80年代開始，肘關(guān)節(jié)鏡手術(shù)快速發(fā)展，得到了廣泛應(yīng)用。肘關(guān)節(jié)鏡的手術(shù)指征包括：肘關(guān)節(jié)游離體、肘關(guān)節(jié)僵硬、肘關(guān)節(jié)滑膜炎、肘關(guān)節(jié)軟骨損傷等。近年來，越來越多的學(xué)者嘗試應(yīng)用肘關(guān)節(jié)鏡做更加復(fù)雜的操作，如韌帶損傷修復(fù)、重建，骨折復(fù)位固定等。目前，已有多個介紹肘關(guān)節(jié)鏡下行橈骨頭骨折、肱骨小頭骨折、尺骨冠狀突骨折復(fù)位內(nèi)固定的報道[1-5]。作者于近期開展肘關(guān)節(jié)鏡下骨折復(fù)位內(nèi)固定手術(shù)，發(fā)現(xiàn)由于骨折形態(tài)、位置多變，導(dǎo)致有時通過常規(guī)的肘關(guān)節(jié)外側(cè)入路難以獲得較滿意的固定角度。由于肘關(guān)節(jié)本身間隙狹窄，周圍神經(jīng)解剖關(guān)系復(fù)雜，肘關(guān)節(jié)鏡手術(shù)中神經(jīng)損傷較為常見，且后果嚴(yán)重[6-14]。因此，作者擬通過解剖學(xué)研究，探尋在不損傷橈神經(jīng)的前提下，肘關(guān)節(jié)前外側(cè)入路是否可以比標(biāo)準(zhǔn)入路適當(dāng)偏前，或者在比常規(guī)入路更加靠前的位置打入內(nèi)固定物，以適應(yīng)骨折固定的需要。

資 料 與 方 法

一、一般資料

選用10具新鮮上肢標(biāo)本，均為男性，平均年齡58歲(43～78歲)。所有肘關(guān)節(jié)均無外部畸形、手術(shù)瘢痕及關(guān)節(jié)活動受限。試驗工具包括解剖器械(手術(shù)刀、血管鉗、組織剪、齒鑷等)，直徑4 mm斯氏針，20 ml一次性注射器，18-Gauge硬膜外針頭，游標(biāo)卡尺(精確度0.1 mm)。

二、方法

肘關(guān)節(jié)屈曲90°，上臂固定于操作臺。將重要的體表標(biāo)志逐一標(biāo)記，包括肱骨外上髁、橈骨頭等。標(biāo)記標(biāo)準(zhǔn)的肘關(guān)節(jié)鏡外側(cè)入路以及實驗選取的肘關(guān)節(jié)鏡外側(cè)入路，標(biāo)準(zhǔn)入路按照既往文獻(xiàn)描述的標(biāo)準(zhǔn)點選擇，改良入路標(biāo)記為標(biāo)準(zhǔn)入路正前方5 mm。標(biāo)準(zhǔn)入路包括近端前外側(cè)入路(肱骨外上髁近端2 cm，前方1 cm)、前外側(cè)入路(肱骨外上髁前方1 cm)、外側(cè)入路(肱骨外上髁遠(yuǎn)端3 cm，前方1 cm)。

用18-Gauge硬膜外針頭由前內(nèi)側(cè)入路穿刺，向關(guān)節(jié)內(nèi)注射生理鹽水以擴(kuò)張關(guān)節(jié)。在之前標(biāo)記的3個標(biāo)準(zhǔn)入路及3個實驗入路點上做小切口，以直血管鉗擴(kuò)張皮下組織，在肘關(guān)節(jié)屈曲90°、前臂中立位下，分別以直徑4 mm斯氏針朝向關(guān)節(jié)中心插入。剔除從上臂下1/3到前臂上1/3的所有皮膚、皮下組織，解剖橈神經(jīng)。

在肘關(guān)節(jié)屈曲90°下，以游標(biāo)卡尺測量橈神經(jīng)與相鄰斯氏針的最短距離。如斯氏針緊貼橈神經(jīng)，距離記為0；如穿過橈神經(jīng)，距離記為負(fù)值。計算五組數(shù)據(jù)的平均值作為最終距離值。平均值>2 mm視為安全。

結(jié) 果

在肘關(guān)節(jié)屈曲90°下，標(biāo)準(zhǔn)入路的近端前外側(cè)入路、前外側(cè)入路、外側(cè)入路與橈神經(jīng)的距離平均值分別為：12.8 mm、8.5 mm、3.8 mm，改良后的近端前外側(cè)入路、前外側(cè)入路、外側(cè)入路與橈神經(jīng)的距離平均值分別為4.1 mm、2.2 mm、-0.5 mm。

討 論

本研究的主要發(fā)現(xiàn)是肘關(guān)節(jié)前外側(cè)入路可以根據(jù)術(shù)中實際情況加以改變，但是僅僅局限于近端前外側(cè)入路至前外側(cè)入路之間，向前的距離盡量不超過5 mm；對于前外側(cè)入路與外側(cè)入路之間的區(qū)域，為了避免橈神經(jīng)損傷，盡量不選擇向前方改變?nèi)肼坊蜻M(jìn)行操作。

肘關(guān)節(jié)鏡入路周圍神經(jīng)密集，術(shù)中極易損傷周圍重要神經(jīng)[6, 10, 13-14]，其中最易受損的就是橈神經(jīng)[7]，最可能損傷橈神經(jīng)的入路是前外側(cè)入路。肘關(guān)節(jié)前外側(cè)入路主要包括近端前外側(cè)入路、前外側(cè)入路、外側(cè)入路。外側(cè)入路在早期應(yīng)用較多，但學(xué)者們發(fā)現(xiàn)應(yīng)用該入路術(shù)后患者易出現(xiàn)橈神經(jīng)癥狀[8]。通過解剖學(xué)研究發(fā)現(xiàn)，該入路與橈神經(jīng)最短距離在屈肘90°僅4 mm左右，且隨著肘關(guān)節(jié)屈曲角度減小而進(jìn)一步減小[1, 6, 15]。因此，越來越多的學(xué)者選用近端前外側(cè)入路作為前外側(cè)常規(guī)入路，該入路與橈神經(jīng)的距離在屈肘90°下>10 mm，損傷幾率明顯減小，而且通過該入路可獲得前方自上而下的視野，可清楚觀察肘關(guān)節(jié)前間室及內(nèi)側(cè)結(jié)構(gòu)[1, 10, 12]。

伸直肘關(guān)節(jié)會對肘關(guān)節(jié)前外側(cè)入路與橈神經(jīng)的距離產(chǎn)生顯著影響。既往的解剖學(xué)結(jié)果表明，前外側(cè)入路與橈神經(jīng)的距離會隨著肘關(guān)節(jié)伸直而減小[1,6,15]。本文中，改良入路的初衷是方便特殊類型骨折的處理，不需要伸直肘關(guān)節(jié)；或者該定點并不作為入路入點，而是作為打入內(nèi)固定物的套管通路，不需要頻繁屈伸肘關(guān)節(jié)，因此本文僅對屈肘90°位置進(jìn)行測量。

肘關(guān)節(jié)骨折是肘關(guān)節(jié)鏡較新的適應(yīng)證，最早在肘關(guān)節(jié)鏡下處理骨折可追溯到1997年[2]。肘關(guān)節(jié)鏡可處理的骨折主要包括：肱骨小頭骨折、尺骨冠狀突骨折、橈骨頭骨折等。Rolla等[3]介紹了關(guān)節(jié)鏡下復(fù)位內(nèi)固定Mason 2、3、4型橈骨頭骨折的方法，得到了滿意的短期效果。對于肱骨小頭骨折，由于骨折塊往往較大，因此復(fù)位、固定過程中常常需要2個甚至更多前外側(cè)入路進(jìn)行輔助操作[2]。Adams等[4]介紹了以導(dǎo)向器定位冠狀突骨折端經(jīng)骨固定的方法，但同樣需要盡量靠近骨折端的外側(cè)入路輔助骨折復(fù)位固定。因此，對于肘關(guān)節(jié)鏡下骨折操作，為了避免潛在的橈神經(jīng)損傷風(fēng)險，熟知前外側(cè)安全范圍極其重要。

本研究尚有一些不足之處：(1)入路的定位較模糊，雖然經(jīng)過測量，但不同實施者之間會有誤差并影響實驗結(jié)果；(2)本實驗以4 mm斯氏針代替關(guān)節(jié)鏡套筒插入關(guān)節(jié)，但是插入關(guān)節(jié)內(nèi)的位置在所有標(biāo)本中會有偏差，影響實驗結(jié)果；(3)經(jīng)過解剖后，神經(jīng)張力會有變化，距離測量會有一定的誤差。

綜上所述，可以得到以下結(jié)論：肘關(guān)節(jié)近端前外側(cè)入路與前外側(cè)入路之間的連線區(qū)可向前方5 mm進(jìn)行操作，但越靠遠(yuǎn)端距離橈神經(jīng)越近，神經(jīng)損傷風(fēng)險越大；前外側(cè)入路與外側(cè)入路之間連線區(qū)域距離橈神經(jīng)較近，不建議向前方改變?nèi)肼贰?/p>

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(本文編輯：李靜)

吳關(guān),魯誼.肘關(guān)節(jié)鏡前外側(cè)入路的解剖學(xué)研究[J/CD]. 中華肩肘外科電子雜志,2016,4(2):99-102.

Anatomyofanterolateralportalsofelbowarthroscopy

WuGuan,LuYi.

DepartmentofOrthopaedicTrauma,BeijingJishuitanHospital,Beijing100035,ChinaCorrespondingauthor:LuYi,Email:luyi_orthop@hotmail.com

Background From the 1980s, elbow arthroscopic surgery has been rapidly developing and widely applied. Indications for elbow arthroscopic surgery include: loose bodies, stiff elbow, elbow synovitis, and elbow cartilage injury etc. In recent years, more and more scholars try to apply elbow arthroscopy in more complex operations, such as ligament repair, reconstruction, and fracture fixation and so on. Currently, there are quite a few reports on reduction and fixation of radial head fracture, humerus capitellum fracture, ulna coronoid fracture under elbow arthroscopy. Recently, we started to conduct elbow arthroscopic fracture reduction and internal fixation, and found that due to the varying types of fracture morphologies and locations, the conventional lateral elbow approach sometimes cannot access satisfactory fixation angles. Due to the narrow space in the elbow joint and complex anatomical relationship of the peripheral nerves, nerve injury is common in elbow surgery and consequences are often serious. Therefore, we aim to explore better approaches to protect the radial nerve based on study of anatomical specimens. Here we used either an improved anterolateral elbow approach that entered at a more anterior position than the conventional approach, or we delivered implants at a more anterior position than the conventional approach to perform fracture fixation. Our findings are reported below.Methods Ten fresh upper limb specimens were selected, all males, mean age 58 years (43 to 78 years), all elbow joints free of external deformities, surgical scars or mobility limitation. Study tools included anatomical instruments (scalpel, forceps, scissors, toothed forceps etc.), 4 mm diameter Steinmann pins, 20 ml disposable syringes, 18-Gauge epidural needles, and vernier caliper (accuracy of 0.1 mm).Surgical procedure: flex the elbow at 90°, fix the upper arm on operation table, mark important anatomical landmarks individually including epicondyle of the humerus and radial head etc., mark the sites of conventional lateral elbow arthroscopic approach and experimental (improved) lateral elbow arthroscopic approach. Choose of the conventional approach was in accordance with previous literatures, and improved approach was 5 mm anterior to the conventional approach. Conventional approaches included proximal anterolateral approach (2 cm proximal and 1 cm anterior to the humeral epicondyle), anterolateral approach (1 cm anterior to the humeral epicondyle), and lateral approach (3 cm distal and 1 cm anterior to the humeral epicondyle). A 18-Gauge epidural needle was used for puncture via the anteromedial approach, inject normal saline into the joint to expand articular capsule, make a small incision on the previously marked 3 conventional approach sites and 3 experimental approach sites, expand subcutaneous tissues using straight forceps. Under 90° elbow flexion or forearm at neutral position respectively, insert a 4 mm diameter Steinmann pin into center of the joint, remove all skin and subcutaneous tissues of lower 1/3 upper arm and upper 1/3 forearm to dissect the radial nerve.Under 90° elbow flexion position, the shortest distance between the radial nerve and adjacent Steinmann pin was measured with a vernier caliper. If Steinmann pin was touched the radial nerve, distance was recorded as 0; if the pin was through the radial nerve, distance was recorded as negative. Final distance was calculated as average of 5 groups of measurement. An average of >2 mm was considered safe operation.Results Under 90° elbow flexion, average distances to radial nerve using the conventional approaches including proximal anterolateral approach, anterolateral approach and lateral approach were:12.8 mm,8.5 mm and 3.8 mm. These of the improved proximal anterolateral approach, anterolateral approach and lateral approach were 4.1 mm,2.2 mm and -0.5 mm respectively.Conclusions The connecting zone of the elbow proximal anterolateral approach and anterolateral approach can be moved anteriorly by 5 mm during surgical operation. The more distal, the closer to the distal radial nerve; anterolateral and posterolateral approach are too close to the radial nerve, so change of approach to anterior site is not recommended.

Elbow arthroscopy;Anterolateral approach;Anatomy

10.3877/cma.j.issn.2095-5790.2016.02.007

北京市衛(wèi)生系統(tǒng)高層次衛(wèi)生技術(shù)人才培養(yǎng)計劃(2013-3-031)

100035北京積水潭醫(yī)院運動損傷科

魯誼，Email:luyi_orthop@hotmail.com

2015-09-24)