劈指伸肌总腱入路治疗桡骨头骨折的疗效分析 刘观燚 景灵勇 潘志军 陈隆军 李明 冯建翔 马维虎 宁波市第六医院骨科 浙江大学附属第二医院骨科 浙江省三门君同骨伤医院 摘 要： 目的 :探讨劈指伸肌总腱入路治疗桡骨头骨折的临床疗效。方法 :回顾性分析自 2012 年 7 月至 2015 年 5 月收治的 25 例闭合桡骨头骨折患者资料, 男 17 例, 女 8 例;年龄 2067 岁, 平均 39 岁。所有患者使用劈指伸肌总腱入路暴露桡骨头骨折, 其中钢板内固定重建 21 例, 桡骨头置换 4 例。根据 Mason 分型:型 19例, 型 6 例。术后患者获临床随访和影像学评价直至骨折愈合及肘关节功能进入平台期。结果:25 例均获随访, 时间 1256 个月, 平均 29 个月。平均屈伸范围 120, 伸直受限 10, 屈曲 135;平均前臂旋转范围 142, 旋前 75, 旋后 67。末次随访时 MEPI 评分平均 937 (80100 分) , 其中 19 例功能为优, 6 例为良。根据 Broberg 和 Morrey 系统创伤性关节炎分级:0 级 19 例, 1 级 6例, 无 2、3 级。无一例发生桡骨头骨折不愈合和内固定失败, 未见神经、血管损伤并发症, 无明显肘关节旋转功能受限。4 例出现肘关节周围异位骨化, 但活动无明显受限。4 例桡骨头假体置换患者术后未见假体松动和感染等并发症发生。结论:劈指伸肌腱入路可以提供安全、可靠的桡骨头手术暴露路径, 临床疗效满意。关键词： 肘关节; 桡骨头; 骨折; 作者简介：景灵勇, E-mail:18906628697163.com收稿日期：2017-02-22Clinical outcome analysis on using extensor digitorum communis splitting approach for the treatment of radial head fracturesLIU Guan-yi JING Ling-yong PAN Zhi-jun CHEN Long-jun LI Ming FENG Jian-xiang MA Wei hu Department of Orthopaedics Surgery, Ningbo No.6 Hospital; Abstract： Objective:To explore the clinical outcomes of internal fixation or replacement for the treatment of radial head fractures through the extensor digitorum communis splitting approach. Methods:From July 2012 to May 2015, 25 patients with radial head fractures were reviewed. There were 17 males and 8 females, ranging in age from 20 to 67 years old, with a mean age of 39 years old. Twenty one patients were treated with reconstruction of plate internal fixation, and 4 patients were treated with radial head replacement. According to Mason classification, 19 cases were type and 6 cases were type . All the patients underwent internal fixation or replacement through the extensor digitorum communis splitting approach. The patients were followed up clinically and radiographically until the beginning of fracture union and the entrance of function recovery of elbow motion into a plateau. The functional status of the elbow was evaluated using the Mayo Elbow Performance Index (MEPI) . Radiographic signs of post traumatic arthritis were rated according to the Broberg and Morrey system. Results:All the patients were followed up, and the average duration was 29 months (ranged, 12 to 56 months) . The average range of flexion and extension was 120, the extension was limited by 10, and the flexion was 135. The average forearm rotation range was 142, pronation was 75, supination was 67. The mean MEPI was 937 (ranged, 80 to 100 scores) ; according to the MEPI scoring criceria, 19 patients got an excellent functional result, 6 good. According to the Broberg and Morrey systems of traumatic arthritis, 19 patients were in grade 0, 6 in grade 1, and no patients in grade 2 or 3. No patients with nonunion of the radial head and failure of internal fixation were found. There were no complications of nerve or vascular injuries, and obvious limitation of elbow rotation. Heterotopic ossification around the elbow occurred in 4 cases, but the motion was not significantly limited. There were no complications such as prosthesis loosening and infection in 4 cases after radial head prosthesis replacement. Conclusion:The extensor digitorum communis splitting approach is an effective exposure method for internal fixation or replacement in the treatment of radial head fractures.Keyword： Elbow joint; Radial head; Fractures; Received： 2017-02-22对于部分 Mason型和大部分型桡骨头骨折均需要手术治疗, 切开复位内固定或桡骨头置换手术入路中 Kocher 入路最为常用, 是通过肘肌和尺侧腕伸肌肌间隙进入。此外, Kaplan 入路是另一种桡骨头手术入路, 它通过桡侧腕短伸肌与指伸肌总腱间隙暴露。桡骨头手术暴露所带来的损伤风险主要是损伤骨间背神经和外侧副韧带的风险, 特别是 Kocher 入路, 可能会导致肘部不稳定1。在应用 Kocher 入路手术时, 由于切口偏后外侧, 暴露桡骨头前内侧骨折片时可能比较困难, 往往需要向近端扩展, 以增加暴露范围, 但这可能会导致伸肌起点的医源性损伤, 进一步破坏肘关节稳定性。通过劈伸肌总腱入路来暴露肘部外侧首先由 Hotchkiss 描述2, 它可以提供更多可靠和广泛的暴露进入桡骨头前方, 同时可以减少外侧副韧带损伤的风险。本研究回顾性分析 2012 年 7 月至2015 年 5 月收治的 25 例闭合桡骨头骨折患者资料, 旨在确定应用这一入路进行桡骨头内固定或置换术的疗效, 探讨手术暴露是否有困难和并发症情况。1 临床资料纳入标准:成年新鲜桡骨头骨折患者, 或合并肘关节脱位和三联征;Mason3分型为型或型;手术行桡骨头骨折切开复位内固定或置换术。排除标准:开放性桡骨头骨折;合并血管神经损伤;陈旧性桡骨头骨折;成人孟氏骨折;经尺骨鹰嘴骨折脱位;Mason型桡骨头骨折;保守治疗患者;手术行桡骨头切除术;术后随访12 个月的病例。本研究共纳入 25 例, 男 17 例, 女 8 例;年龄 2067 岁, 平均 39 岁。所有患者使用劈伸肌腱入路暴露桡骨头骨折, 其中钢板内固定进行重建 21 例, 桡骨头置换 4 例。根据 Mason3分型:型 19 例, 型 6 例。合并肘关节脱位 16 例, 为改良 Mason Johnston44 型。同时伴有肘关节脱位和冠状突骨折, 即肘部损伤三联征 14 例。致伤原因:高处坠落伤 10 例, 交通伤 6 例, 摔伤 6 例, 重物压伤 3 例。所有患者为闭合性损伤, 无神经、血管损伤表现。受伤至手术时间平均 5 d (210 d) 。本研究获得本单位伦理委员会批准, 所有患者签署知情同意书。2 治疗方法手术方法因每例患者具体情况而异, 在臂丛神经阻滞麻醉下, 上无菌止血带, 桡骨头手术入路为劈指伸肌总腱入路, 患者取仰卧位, 置于肘关节屈曲前臂旋前位。劈指背伸肌总腱入路为纵行切口, 起于肱骨外髁, 首先需鉴别指伸肌总腱位于肱骨外髁的起点, 从其中间劈开, 并沿着指伸肌腹中央纵行向前臂远端延长切口, 通常 34 cm。由于桡神经行经肱肌与桡侧腕长伸肌之间, 在肱骨外上髁前方分为浅、深 2 支, 深支经桡骨颈外侧穿过旋后肌至前臂后侧, 所以劈指伸肌总腱入路远端有桡神经穿过, 有损伤可能。该入路桡骨向远端暴露范围应该控制在肱桡关节远端不超过 5 cm, 劈开分离伸肌间隙后, 切开关节囊和环状韧带显露桡骨头和桡骨颈。内侧拉钩需要注意保护骨间背神经, 注意观察外侧副韧带复合体损伤情况, 如果有必要, 可向后外侧适当延伸切口暴露并修补外侧副韧带复合体。对于部分肘部损伤三联征中冠状突尖部骨折 (前外侧关节面骨折) 可以通过劈指伸肌总腱入路向内侧暴露骨折, 并予以相应的固定, 如锚钉固定、螺钉固定或套索技术等。在暴露桡骨头骨折时需注意保护桡骨头骨片相连的滑膜、骨膜组织, 避免破坏其血运。对于粉碎性骨折, 需注意确保桡骨头所有骨折块找到, 并仔细评估桡骨头复位内固定的可行性而决定最终的手术重建方案。对于桡骨头骨折复位固定, 一般行埋头空心螺钉、微型钢板固定或两者结合固定。放置钢板时, 应尽量将钢板放置在桡骨头的“安全区”中5-6:前臂中立位下水平线偏前 65, 偏后 45, 共约 110的范围。但是, 当少数情况下需要将钢板