任東 邢丹謀 馮偉 陳焱 趙志明 王歡 肖志宏

·論著·

鎖定鋼板聯(lián)合可吸收軟骨釘治療MasonⅢ型橈骨頭骨折

任東 邢丹謀 馮偉 陳焱 趙志明 王歡 肖志宏

目的評估采用解剖型鎖定加壓鋼板聯(lián)合可吸收軟骨釘治療MasonⅢ型橈骨頭骨折的臨床療效。方法回顧性分析2010年1月至2015年1月武漢市普愛醫(yī)院收治的MasonⅢ型橈骨頭骨折患者19例，其中男7例，女12例；年齡16～58歲，平均38.1歲；左側(cè)8例，右側(cè)11例。其中2例合并肱骨小頭軟骨損傷，4例合并尺骨冠突骨折，1例合并同側(cè)橈骨遠(yuǎn)端骨折。根據(jù)患者肘關(guān)節(jié)活動度、肌力、關(guān)節(jié)穩(wěn)定性和疼痛情況，按照Broberg-Morrey肘關(guān)節(jié)評分標(biāo)準(zhǔn)評估。結(jié)果所有患者均獲隨訪，隨訪時間為12～60個月，平均34個月。所有骨折均愈合，平均愈合時間12.4周。Broberg-Morrey評分為64～100分，平均88.4分；其中優(yōu)6例，良11例，可2例，優(yōu)良率為89.5%。結(jié)論采用解剖型鎖定加壓鋼板聯(lián)合可吸收軟骨釘治療MasonⅢ型橈骨頭骨折，可在重建橈骨頭的同時獲得良好的關(guān)節(jié)功能和患者滿意度。

橈骨頭骨折； 鎖定鋼板； 可吸收植入物

橈骨頭頸部骨折臨床較為常見，約占肘部骨折的1/3至1/2，其中約1/3合并有肘部其他損傷，如合并尺骨冠突骨折、肘關(guān)節(jié)脫位等，則提示損傷更為復(fù)雜嚴(yán)重，常常影響到肘關(guān)節(jié)的穩(wěn)定性。

復(fù)雜的橈骨頭骨折的手術(shù)方法包括切開復(fù)位內(nèi)固定、橈骨頭切除和橈骨頭假體置換，但目前對于最佳方式的選擇一直存有爭議。隨著對橈骨頭在維持肘關(guān)節(jié)穩(wěn)定及傳導(dǎo)前臂縱向負(fù)荷中重要作用的認(rèn)識，單純橈骨頭切除已較少采用[1-2］。橈骨小頭置換雖大多可獲得滿意的短期療效，但亦可能發(fā)生關(guān)節(jié)僵硬、假體松動、肘外翻、骨性關(guān)節(jié)炎等晚期并發(fā)癥[3］，故僅在無法保留橈骨頭時才考慮采用。

隨著復(fù)位技術(shù)和內(nèi)固定材料的進(jìn)步，橈骨頭頸解剖型鎖定鋼板和可吸收自身增強(qiáng)軟骨釘?shù)膽?yīng)用，使得部分以往認(rèn)為無法修復(fù)的橈骨頭得以保留。本文回顧性分析采用解剖型鎖定鋼板聯(lián)合可吸收軟骨釘治療MasonⅢ型橈骨頭骨折的患者資料，目的是評估解剖型鎖定鋼板聯(lián)合可吸收軟骨釘治療MasonⅢ型橈骨頭骨折的臨床療效，探討此種方式的適應(yīng)證。

資料與方法

一、一般資料

2010年1月至2015年1月武漢市普愛醫(yī)院收治并采用解剖型鎖定鋼板（DePuy Synthes公司）聯(lián)合可吸收軟骨釘（成都迪康公司）內(nèi)固定治療的粉碎性橈骨頭骨折患者19例，其中男7例，女12例；年齡16～58歲，平均38.1歲；左側(cè)8例，右側(cè)11例。致傷原因中：平地摔傷14例，高處墜落傷5例。其中2例合并肱骨小頭骨軟骨損傷，4例合并尺骨冠突骨折，1例合并同側(cè)橈骨遠(yuǎn)端骨折。受傷至手術(shù)時間3～18 d。所有患者術(shù)前均行肘關(guān)節(jié)正側(cè)位X線片及CT三維重建檢查（圖1）。

圖1 患者男，28歲，術(shù)前X線片及CT診斷為左側(cè)MasonⅢ型橈骨頭骨折 圖A為術(shù)前肘關(guān)節(jié)正側(cè)位片； 圖B為術(shù)前CT三維重建圖像

圖2 術(shù)中復(fù)位及固定情況 圖A為橈骨頭關(guān)節(jié)面復(fù)位后用可吸收軟骨釘固定，克氏針臨時固定橈骨頸；圖B為解剖型鎖定加壓鋼板固定橈骨頸

二、手術(shù)方法

手術(shù)在臂叢麻醉、氣囊止血帶下進(jìn)行，采用肘外后側(cè)Kocher切口，在肘肌和尺側(cè)腕伸肌之間進(jìn)入，切開環(huán)狀韌帶和部分旋后肌，暴露橈骨頭頸部。顯露過程中注意保持前臂旋前位，使橈神經(jīng)遠(yuǎn)離術(shù)野以避免傷及。術(shù)中小心保留附著于骨片上的骨膜，先將碎裂的橈骨頭盤狀關(guān)節(jié)面復(fù)位，用2～3枚直徑2.0 mm可吸收軟骨釘固定，釘尾埋于關(guān)節(jié)面下（圖2A）。再將頸部復(fù)位，用解剖型鎖定鋼板固定（圖2B）。有多枚骨片游離的橈骨頭骨折，可采用“on-table”技術(shù)[4］，將骨塊取出，在手術(shù)桌面上拼接，用可吸收軟骨釘固定成完整的橈骨頭，再用鎖定鋼板將其與頸部固定。對于合并Ⅱ型尺骨冠突骨折患者，可在顯露橈骨頭頸時，將橈骨近端向外側(cè)脫位，即可顯露尺骨冠突骨折端，先將其復(fù)位用微型螺釘或克氏針固定，再固定橈骨頭骨折。手術(shù)可在一個切口內(nèi)完成。對于合并肱骨小頭軟骨骨折患者，采用“線錨釘”方法固定[5-6］，即在軟骨缺損的兩側(cè)邊緣預(yù)鉆孔并導(dǎo)入縫線，將軟骨片復(fù)位后收緊縫線并打結(jié)以固定軟骨片。

三、術(shù)后處理

術(shù)后傷肢行功能位長臂石膏托固定，1周后去除石膏行支具保護(hù)下的肘關(guān)節(jié)屈伸及前臂旋轉(zhuǎn)訓(xùn)練，訓(xùn)練以主動活動為主、被動活動為輔，禁止暴力扳拉。4周后拆除支具開始行抗阻力訓(xùn)練，12周后開始行負(fù)重練習(xí)。

術(shù)后第1天開始口服塞來昔布膠囊200 mg，2次/d，連服4周，鎮(zhèn)痛同時可預(yù)防異位骨化的發(fā)生。

四、功能評價

根據(jù)患者肘關(guān)節(jié)活動度、肌力、關(guān)節(jié)穩(wěn)定性和疼痛情況，按照Broberg-Morrey肘關(guān)節(jié)評分[7］標(biāo)準(zhǔn)進(jìn)行評分，其中屈伸活動度27分，旋轉(zhuǎn)活動度13分，肌力20分，穩(wěn)定性5分，疼痛35分，滿分100分，95～100分為優(yōu)，80～94分為良，60～79分為可，60分以下為差。

結(jié) 果

本組19例患者切口均一期愈合，無一發(fā)生感染及內(nèi)固定失效。2例術(shù)后出現(xiàn)橈神經(jīng)損傷癥狀，術(shù)后4周內(nèi)完全恢復(fù)，考慮為術(shù)中牽拉所致。

術(shù)后隨訪12～60個月，平均34個月，骨折均獲得骨性愈合，愈合時間8～20周，平均12.4周，未發(fā)現(xiàn)有橈骨頭缺血壞死。

患者肘關(guān)節(jié)屈伸活動度80～140°（平均 120.8°）， 旋 轉(zhuǎn) 活 動 度60～150°（ 平 均112.4°）。所有患者未出現(xiàn)關(guān)節(jié)不穩(wěn)定。遺留肘部疼痛者6例，其中輕度4例，中度2例；肘部或腕部輕度無力者5例，其余患者肌力正常。Broberg-Morrey評分為64～100分，平均88.4分；其中優(yōu)7例，良13例，可3例，優(yōu)良率為86.9%。

3例患者術(shù)后于肘前側(cè)及外側(cè)出現(xiàn)異位骨化（圖3），2例功能為良，1例為可，分別于術(shù)后1～2年取內(nèi)固定同時行異位骨切除和關(guān)節(jié)松解（圖4），第2次術(shù)后3個月評分為優(yōu)（圖5）。1例患者因骨折線累及“安全區(qū)”，術(shù)中為求更好固定效果，將鋼板部分放置于安全區(qū)內(nèi)側(cè)，術(shù)后隨訪前臂旋后50°，旋前10°，功能為可，但因其肩關(guān)節(jié)外展可代償部分前臂旋前動作，患者并未感覺不便。1例合并同側(cè)橈骨遠(yuǎn)端骨折患者，術(shù)后早期因懼痛拒絕行功能訓(xùn)練，術(shù)后6個月時功能為可。

圖3 內(nèi)固定術(shù)后23個月，可見肘前異位骨化

圖4 術(shù)后23個月，行內(nèi)固定取出及異位骨化切除

圖5 第2次術(shù)后18個月，左肘功能情況 圖A為伸肘；圖B為屈肘；圖C為旋后；圖D為旋前

討 論

橈骨頭骨折的治療目的是重建橈骨頭的解剖結(jié)構(gòu)，恢復(fù)肘關(guān)節(jié)的外側(cè)穩(wěn)定性。對于MasonⅠ、Ⅱ型骨折的治療，學(xué)界觀點(diǎn)基本一致，即根據(jù)骨折移位情況決定行保守治療或內(nèi)固定術(shù)[8］，但對MasonⅢ、Ⅳ型骨折的治療，目前仍存爭議。因較多橈骨小頭切除后發(fā)生的肘關(guān)節(jié)外翻不穩(wěn)定，橈骨上移及繼發(fā)性下尺橈關(guān)節(jié)脫位，肘、腕部疼痛無力等并發(fā)癥，現(xiàn)已很少推薦采用。人工假體置換因手術(shù)操作簡單，中、短期療效好，現(xiàn)已得到較廣泛應(yīng)用，但尚缺乏長期隨訪的資料，且仍有部分患者出現(xiàn)假體松動、關(guān)節(jié)僵硬、骨性關(guān)節(jié)炎等并發(fā)癥。橈骨頭骨折大部分發(fā)生于青壯年（本組患者平均年齡38.1歲），部分患者觀念上不愿接受假體置換。

以往由于內(nèi)固定材料的限制，很多MasonⅢ型橈骨頭骨折內(nèi)固定效果不盡人意，部分學(xué)者認(rèn)為內(nèi)固定手術(shù)效果差于假體置換[9-10］。但隨著解剖型鎖定鋼板和微型可吸收釘?shù)膽?yīng)用，使得大部分曾經(jīng)認(rèn)為不可重建的橈骨頭骨折得以保留。可吸收釘初始強(qiáng)度、彈性模量與皮質(zhì)骨相當(dāng)，可滿足橈骨頭骨折塊的固定要求，且無需擔(dān)心普通微型螺釘退釘?shù)娘L(fēng)險。橈骨頭頸解剖型鎖定加壓鋼板在固定原理上與其他鎖定加壓鋼板類似，鋼板與螺釘之間的角穩(wěn)定性可降低骨折復(fù)位丟失的風(fēng)險，鋼板橈骨頭部的3枚鎖定釘孔設(shè)計(jì)為分散型，以增加對骨塊的把持力，減少術(shù)后松動的發(fā)生；同時該型接骨板進(jìn)行了預(yù)塑形，外形與橈骨頭頸的正常解剖結(jié)構(gòu)一致，有助于骨折復(fù)位；且鋼板邊角部位做了低切跡處理，可減少旋轉(zhuǎn)活動時對環(huán)狀韌帶的刺激。部分患者若術(shù)后發(fā)生異位骨化影響關(guān)節(jié)功能，可在骨折愈合后內(nèi)固定取出的同時行關(guān)節(jié)松解和異位骨切除，本組3例發(fā)生異位骨化患者在第2次術(shù)后關(guān)節(jié)功能得到進(jìn)一步改善。

解剖型鎖定加壓鋼板使用過程中需注意盡量將鋼板置于橈骨頭的安全區(qū)內(nèi)，即前臂中立位時，橈骨莖突和Liser結(jié)節(jié)之間所對應(yīng)的區(qū)域[11］。但對部分嚴(yán)重粉碎的骨折為使其達(dá)到更穩(wěn)定的固定，鋼板無法完全放置于安全區(qū)時，可將其置于橈骨頭前內(nèi)側(cè)，如術(shù)后可能會影響前臂旋前，肩關(guān)節(jié)外展可部分代償之。本組病例中有1例發(fā)生這種情況，術(shù)后前臂旋前活動受限，但患者自覺功能障礙并不明顯。

對MasonⅢ型橈骨頭骨折采用解剖型鎖定加壓鋼板聯(lián)合可吸收軟骨釘治療可在重建橈骨頭的同時獲得良好的關(guān)節(jié)功能和患者滿意度，提供了一種有益的治療選擇，值得臨床推廣。

[1]Ikeda M, Sugiyama K, Kang C, et al. Comminuted fractures of the radial head. Comparison of resection and internal fixation[J］. J Bone Joint Surg Am, 2005, 87（1）: 76-84.

[2]危蕾, 邢丹謀, 何文平, 等. 不同手術(shù)方法治療MasonⅢ, Ⅳ型橈骨頭骨折的療效分析[J］. 中華創(chuàng)傷骨科雜志, 2010,12（6）：530-533．

[3]Stuffmann E, Baratz ME. Radial head implant arthroplasty[J］.J Hand Surg Am, 2009, 34（4）: 745-754.

[4]Businger A, Ruedi TP, Sommer C. On-table reconstruction of comminuted fractures of the radial head[J］. Injury, 2010, 41（6）: 583-588.

[5]邢丹謀, 勘武生, 任東, 等. 可吸收自身增強(qiáng)軟骨釘治療橈骨小頭骨折[J］. 中華骨科雜志, 2013, 33（1）：50-54．

[6]任東, 邢丹謀, 馮偉, 等. 橈骨頭骨折伴肱骨小頭軟骨損傷的治療[J］. 中華手外科雜志, 2014, 30（5）：375-377．

[7]Broberg MA, Morrey BF.Resultsof delayed excision of the radial head after fracture[J］. J Bone Joint Surg Am, 1986, 68（5）: 669-674.

[8]郝有亮, 周方, 侯國進(jìn). 橈骨頭骨折的治療研究進(jìn)展[J/CD］. 中華肩肘外科電子雜志, 2016, 4（3）：186-190．

[9]Ring D. Displaced, unstable fractures of the radial head: fixation vs. replacement--what is the evidence?[J］. Injury, 2008, 39（12）: 1329-1337.

[10]范存義, 姜佩珠, 蔡培華, 等. 內(nèi)固定與假體置換治療MasonⅢ型橈骨頭骨折的比較研究[J］. 中華創(chuàng)傷骨科雜志,2006, 8（12）：1105-1108．

[11]Caputo AE, Mazzocca AD, Santoro VM. The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation[J］. J Hand Surg Am, 1998, 23（6）:1082-1090.

Anatomical LCP combined with absorbable cartilage tack in treatment of MasonⅢradial head fractures

Ren Dong, Xing Danmou, Feng Wei, Chen Yan, Zhao Zhiming, Wang Huan, Xiao Zhihong. Department of Hand Surgery, Wuhan Puai Hospital, Wuhan 430033, China

Xing Danmou,Email:13986058526@163.com

BackgroundThe radial head fracture is a common elbow fracture in clinic,accounting for approximately 1/3 to 1/2 of all elbow fractures. Furthermore, about 1/3 of radial head fractures were companied by other elbow injuries such as coronoid process fracture,elbow joint dislocation, etc. These complications suggest more severe and complex damages that often affect the stability of elbow joint. Surgical treatments for complex radial head fractures include open reduction and internal fixation, radial head resection, and radial head prosthesis replacement. However, the choice of the best method remains controversial. With the understanding of the important role radial head plays in maintaining the stability of elbow joint and the longitudinal load of forearm, the simple radial head resection has been seldomly used.The short-term effect of radial head replacement is satisfactory in most cases. However, later complications such as joint stiffness, prosthetic loosening, valgus elbow joint, osteoarthritis,etc. may occur as well. Thus, it is only used when the radial head cannot be preserved.With the development of reduction techniques and internal fixation materials and the application of radial head neck anatomical locking plates and absorbable self-enhancing cartilage tacks, some of the radial head that was used to be regarded as irreparable is preserved.In this study, the data of anatomical locking plate combined with absorbable cartilage tack in the treatment of Mason type III radial head fractures were analyzed to assess the clinical curative effect and to explore its indications.Methods（1）General data.From January 2010 to January 2015,19 patients （7 males and 12 females） with comminuted radial head fractures were treated with anatomic locking plate （DePuySynthes company） and absorbable cartilage tack （Chengdu DUCAM company）.The age ranged from 16 to 58 years with an average of 38.1 years. 8 cases had the left side affected, and 11 cases had the right side affected. Causes of injury: 14 cases of flat fall and 5 cases of high fall. The complications included 2 cases of combined injury of humeral cartilage, 4 cases of combined fracture of ulna coronoid process and 1 case of combined fracture of ipsilateral distal radius. The time of injury to surgery ranged from 3 to 18 days. All patients were examined by X-ray and CT three-dimensional reconstruction of elbow joint.（2）Operative methods.The operation was performed under brachial plexus block and pneumatic tourniquets. A posterior lateral Kocher incision was made between anconeus and cubitalis posterior, and the annular ligament and part of musculi supinator were cut open to expose radial head and neck. Attention was paid to maintain the pronation of forearm in order to keep the radial nerve away from the surgical field, which helped to prevent injury. The periosteum attached to bone was carefully retained intraoperatively. The fractured articular disc of radial head was reduced and fixed with 2-3 absorbable cartilage tacks of 2.0 mm in diameter, and the tail was buried under the articular surface. Then, the neck was reduced and fixed with the anatomical locking plate. The “On-table”technique could be used for the radial head fracture with dissociation of several fragments. The fracture fragments were taken out and stitched into a complete radial head on the surgical table followed by fixation with absorbable cartilage screws.Later, the stitched complex and neck were fixed with the locking plate. For patients with the type II fracture of ulna coronoid process, the proximal radius was dislocated laterally during the exposure of radial head to expose the fracture end of ulnar coronoid process. The fracture was reduced and fixed firstly with micro screws or Kirschner wires, and then the radial head fracture was fixed. For patients with the fracture of capitelum cartilage of humerus, the “suture anchor” method was adopted for fixation. To be specific, both sides of the cartilage defect edge were pre-drilled and penetrated with sutures.After being reduced, the cartilage slices were fixed by the tightening and knotting of sutures. （3）Postoperative treatment. The injured limb was fixed with long arm plaster cast after the operation.As the plaster was removed 1 week after the surgery, the flexion and extension training of elbow joint and the rotation training of forearm were carried out. The training was mainly based on active activities and supplemented by passive activities. Violent pulling was forbidden. The brace was removed 4 weeks after the operation, and the resistance training was initiated. The weightbearing exercise began 12 weeks later.On the first day after the operation, oral Celecoxib of 200 mg was taken twice per day for 4 weeks, which could help with analgesia and prevent heterotopic ossification simultaneously.（4）Functional evaluation. The conditions of elbow mobility, muscle strength, joint stability and pain were scored based on the Broberg-Morrey functional scoring criteria. The total score is 100 points, including 27 points for flexion and extension, 13 points for rotation mobility, 20 points for muscle strength, 5 points for stability and 35 points for pain. 95-100 points were considered as excellent; 80-94 points were considered as good; 60-79 points were considered as moderate; 60 points below were considered as poor.ResultsThe incision of 19 cases of this group obtained primary healing without any infection or interal fixator failure. Two cases had the symptom of radial nerve injury and recovered completely within 4 weeks. The injury was considered to be caused by intraoperative traction. The patients were followed up for 12-60 months with an average of 34 months. All fractures were healed by 8-20 weeks with an average of 12.4 weeks. No radial head necrosis was found. The flexion and extension mobility of elbow joint ranged from 80 to 140° （120.8°on average）, and the rotation mobility ranged from 60 to 150° （112.4°on average）. No joint instability occurred in patients. Six cases had residual pain of elbow, including 4 cases of mild pain and 2 cases of moderate pain. Five cases had mild weakness of elbow or wrist, and the rest of patients had normal muscle strength. The patients had an average Broberg-Morrey score of 88.4 points （64-100 points）, which included 7 cases of excellent, 13 cases of good and 3 cases of moderate. The good and excellent rate was 86.9%. 3 patients had heterotopic ossification in the anterior and lateral elbow, including 2 cases of goodand 1 case of moderate. The removal of internal fixation and procedures of ectopic bone resection and arthrolysis were preformed respectively 1-2 years after the initial operation. The score was excellent 3 months after the second operation. Since the “security zone” was affected by the fracture line in 1 patient, the plate was partially placed on the medial side for better fixation effect. During the postsurgical follow-up, the function was good with 50° of pronation and 10° of supination. However, the patient felt no inconvenience as shoulder abduction could compensate for part of forearm pronation.ConclusionThe treatment of Mason type III radial head fracture using anatomical locking compression plate combined with absorbable cartilage tack achieves good joint function, patient satisfaction and radial head reconstruction. Thus, this strategy provides a beneficial treatment option and is worth of clinical promotion.

Radial head fracture; Locking plate; Absorbable implant

2017-02-02）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10.3877/cma.j.issn.2095-5790.2017.02.006

430033 武漢市普愛醫(yī)院手外科

邢丹謀，Email:13986058526@163.com

任東,邢丹謀,馮偉,等.鎖定鋼板聯(lián)合可吸收軟骨釘治療MasonⅢ型橈骨頭骨折[J/CD］..中華肩肘外科電子雜志 ,2017,5（2）：108-112.