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CORR：张力带治疗横行尺骨鹰嘴骨折长期效果好

2014-06-13 伊文 丁香园

尺骨鹰嘴骨折张力带肘关节
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尺骨鹰嘴骨折是临床最常见的关节内骨折，克氏针张力带以及钢板固定是治疗尺骨鹰嘴骨折的主要方式，大多数的尺骨鹰嘴骨折患者经手术治疗后疗效满意，很少出现并发症。但是近期有学者对张力带固定治疗尺骨鹰嘴骨折的生物力学意义提出了质疑，其发现在生物力学实验中张力带固定以后外侧骨折皮质产生的张力并不能转化为对骨折端的压力。 荷兰的Hendrik J. A医生回顾性研究尺骨鹰嘴骨折手术治疗后10年的患者，

尺骨鹰嘴骨折是临床最常见的关节内骨折，克氏针张力带以及钢板固定是治疗尺骨鹰嘴骨折的主要方式，大多数的尺骨鹰嘴骨折患者经手术治疗后疗效满意，很少出现并发症。但是近期有学者对张力带固定治疗尺骨鹰嘴骨折的生物力学意义提出了质疑，其发现在生物力学实验中张力带固定以后外侧骨折皮质产生的张力并不能转化为对骨折端的压力。

荷兰的Hendrik J. A医生回顾性研究尺骨鹰嘴骨折手术治疗后10年的患者，发现张力带固定治疗尺骨鹰嘴骨折疗效可靠，绝大多数患者的临床结果满意。其研究结果发表在2014年6月CORR 杂志上。

作者回顾性研究1974年至1997年入院手术治疗的109例成年尺骨鹰嘴骨折患者。35例患者（34%）在随访时已经死亡，14例患者因姓名信息不详等原因缺少完整的临床数据，19患者拒绝参与研究或失访。最终有41例患者回院参与此次研究，该组患者初次尺骨鹰嘴骨折手术时间均超过10年，手术时间平均为20±6年前（范围10至32年）。

患者发生尺骨鹰嘴骨折时的平均年龄为35岁（范围18至73岁），手术指征为骨折移位超过2mm。在此次研究时，使用DASH评分评估患者主观功能结果，使用Mayo肘关节表现评分进行客观功能评定。对疼痛、功能障碍、等与残疾有关的因素使用统计分析以了解影响肘关节功能的因素。

通过多变量统计分析显示DASH只与患者年龄有关，患者骨折时年龄越小，DASH评分越好。在平均术后20年随访时，极少有患者存在肘关节疼痛。患者的肘关节平均活动弧为142°（范围110°至160°），前臂旋转角度平均为175°±7°（范围150°至180°），旋前平均 87°± 4°，旋后平均87°±6°（范围60°至90°），创伤性关节炎是影响肘关节活动度的唯一因素，肘关节创伤性关节炎越轻，患者的肘关节活动度越好。

患者的Mayo肘关节表现评分平均为98加减7分（范围65分至100分），36例患者为优，4例良，1例中。5例患者存在尺神经受压症状。所有单纯尺骨鹰嘴骨折的患者均能恢复从事受伤前的工作。



图1 A：肘关节侧位片显示尺骨鹰嘴骨折。B：使用切开复位AO张力带固定技术手术治疗后的肘关节X线。C：此次随访时的肘关节侧位X线片，没有发现肘关节关节炎以及活动受限。按照Mayo肘关节表现评分，患者功能恢复为优，疼痛评分为24.3（50分制），DASH评分为0.8。


图2 A：肘关节侧位片显示尺骨鹰嘴骨折。B：使用切开复位AO张力带固定技术手术治疗后的肘关节X线。C：此次随访时的肘关节侧位X线片，没有发现肘关节关节炎以及活动受限。按照Mayo肘关节表现评分，患者功能恢复为优，疼痛评分为23.4（50分制），DASH评分为17。

美国的Boris A. Zelle医生随刊发表了一篇评论：

尺骨鹰嘴骨折的治疗现状

尺骨鹰嘴骨折是临床常见的损伤，每年每10万人中有接近12人发生尺骨鹰嘴骨折。包括创伤骨科、上肢骨科、普通骨科医师在内的不同专业的外科医师都在进行尺骨鹰嘴骨折的手术治疗。张力带固定具有费用低廉、固定可靠的优点，可以帮助骨折愈合恢复患者肘关节功能，而在临床中，医生也使用了其他的如钢板、髓内螺钉、交锁髓内钉等在内的内固定和手术方法。钢板固定可能有利于较粉碎的和不稳定的尺骨鹰嘴骨折的处理。

尽管处理尺骨鹰嘴骨折的手术技巧非常多，但是在治疗尺骨鹰嘴骨折时仍需要考虑一些问题。内固定疼痛、手术部位感染、尺神经炎、肘关节功能障碍等并发症是手术内固定治疗尺骨鹰嘴的常见并发症。近期有学者研究发现许多骨科医师认为尺骨鹰嘴骨折的治疗非常简单并且低估了其手术并发症发生率，因此常常导致临床结果不良。虽然切开复位内固定是治疗尺骨鹰嘴骨折的常见治疗方法，但是其远期随访疗效如何却很少有文献报道。

尺骨鹰嘴骨折的治疗方向

对切开复位内固定治疗尺骨鹰嘴骨折的疗效评估需要对临床结果进行完整的随访记录。这不仅需要体格检查的资料，而且需要使用经过验证的特定部位的评分标准进行评估。为了减少信息丢失带来的临床偏倚，研究者需要尽量减少患者的失访数量。与此同时，一个设计优良的研究需要安排合适的时间长度进行随访，并记录手术相关的问题。Flinterman等人进行的这项张力带固定治疗尺骨鹰嘴骨折的研究，追踪随访患者的长期疗效，提供了有力的研究数据。

作者还使用了经过验证的结果评分方法对患者进行评估，得到的数据可以用于与其他患者人群进行比较。作者能够随访追踪到尺骨鹰嘴术后接近20年的患者，让人记忆深刻，值得赞扬。此外，作者追踪随访到的患者数量也非常多，达到68%的随访率。虽然目前有研究对张力带固定治疗尺骨鹰嘴骨折的生物力学提出了质疑，但是，此次研究得到的结果强烈的支持了临床中可以使用张力带固定治疗非粉碎性横行尺骨鹰嘴骨折。

所有患者均能重返受伤前的工作岗位，接近87%的患者临床结果优良。但是，目前的数据表明手术内固定治疗尺骨鹰嘴骨折仍对骨科医生仍具有挑战性，存在一定的并发症风险。尽管患者总体长期疗效满意，但是仍有接近7%的患者需要再次手术，而且尺神经卡压的发生率也高达13%。

如何提高尺骨鹰嘴骨折的治疗效果

克氏针钢丝张力带固定具有费用低廉疗效可靠的优势，既往已经被证实是治疗尺骨鹰嘴骨折的可靠技术。然而，张力带固定手术治疗尺骨鹰嘴骨折仍有可能出现多种不同的并发症。因此，必需强调，Filnterman等人的研究仅限于将克氏针力带固定用于横行非粉碎性尺骨鹰嘴骨折。

当尺骨鹰嘴骨折粉碎以及不稳的情况下，使用钢板固定其临床结果可能更好。以后需要研究尺骨鹰嘴骨折粉碎情况达到什么程度就是钢板内固定治疗的严格适应症，有没有哪种类型的粉碎型尺骨鹰嘴骨折仍有可能使用张力带固定。与此同时，需要对交锁髓内钉等在内的新型内植入物进行研究，仔细评估其费（用）-效（果）比，并了解其临床结果能否达到众所周知的钢丝张力带水平。

原始出处：

Flinterman HJ1, Doornberg JN, Guitton TG, Ring D, Goslings JC, Kloen P.Long-term Outcome of Displaced, Transverse, Noncomminuted Olecranon Fractures.Clin Orthop Relat Res. 2014 Jun;472(6):1955-61. doi: 10.1007/s11999-014-3481-5. Epub 2014 Feb 13.【原文下载】

Zelle BA.CORR Insights(®): Long-term Outcome of Displaced, Transverse, Noncomminuted Olecranon Fractures.Clin Orthop Relat Res. 2014 Jun;472(6):1962-3. doi: 10.1007/s11999-014-3553-6. Epub 2014 Mar 11.

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    2014-11-30 DEXTER3148

    #尺骨#

    0

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    2015-04-12 654699882_84926986

    #长期效果#

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    2015-02-28 nian.wang1982

    #鹰嘴骨折#

    0

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    2015-01-01 muzishouyi

    #张力带#

    0

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    2015-03-30 zhmscau

    #张力#

    0

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    2014-06-15 psybestwish

    #ORR#

    0

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