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(完整word版)成人肘关节骨折脱位的治疗.pdf

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1、一篇搞定：成人肘关节骨折脱位的治疗成人肘关节骨折脱位常常会出现较高比例的并发症发生率，临床上往往比较棘手。一般认为肘关节的功能性活动角度为屈曲100 旋前旋后50，但是现代3D 追踪技术发现正常人体所需的功能性活动角度要远远大于上述范围。而肘关节骨折脱位的治疗目的则是恢复和重建肘关节的功能。美国费城Temple 大学医院的 Jennings 教授在近期OCNA 杂志上对成人肘关节脱位的治疗进行了详细论述。分类和分型肘关节脱位可分为单纯性肘关节脱位以及复杂性肘关节脱位。单纯性肘关节脱位仅仅是肘关节周围的软组织损伤，尺骨鹰嘴相对肱骨远端脱位。而复杂性肘关节骨折脱位则不仅仅是软组织的损伤，常常合并肱

2、骨小头、尺骨冠突等部位的骨折，因此也被称为肘关节骨折脱位。肘关节后脱位通常是肘关节旋后位受到轴向和外翻应力。前脱位则是肘关节在屈曲时受到向前的暴力或者是肘关节过度伸直位受伤。ODriscoll 描述的Horii 环反映了肘关节脱位所合并的软组织损伤是从外向内发生（图1）。Ring 和 Jupiter 将肘关节骨折脱位分为以下4 种类型：（1）肘关节后脱位合并桡骨头骨折。（2）肘关节后脱位合并桡骨头和尺骨冠突骨折，该类型骨折也被Hotchkiss 描述为肘关节恐怖三联征。（3）经尺骨鹰嘴前脱位并骨折。4.近端Monteggia 氏骨折后脱位。图 1 肘关节脱位时软组织损伤的过程。外侧副韧带首先受

3、损，然后才是内侧副韧带，内侧副韧带可以是部分损伤（3a 型）也可以是完全损伤（3b 型）最常使用的桡骨头骨折分型是1954 年 Mason 提出的分型，Brobrg 和 Morrey 在 1987年对其进行了改良，并在1997 年有Hotchkiss 完成了最终修订，其具体细节详见表1。通常来说，1 型骨折表示的是无移位骨折，2 型骨折是指移位2 mm 的骨折，3 型骨折则是桡骨头严重粉碎性骨折。表 1 桡骨头骨折的改良Mason 分型文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3

4、S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E

5、7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3

6、L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2

7、R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z

8、3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4

9、D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7

10、M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3文档编码:CT5Z3E7H1K5 HH5E4D3L5D10 ZY8X7M2R3S3分型描述1 型无移位或轻度移位的桡骨头或桡骨颈骨折；前臂旋转受限仅仅是因为急性疼痛和肿胀，关节内骨折移位 2 mm，关节面边缘骨折2 型桡骨头或桡骨颈骨折移位2 mm，但骨折块不是严重粉碎（可以通过切开复位内固定进行修复），或者骨折部位超过关节面边缘3 型桡骨头和桡骨颈严重粉碎骨折无法修复重建，通常需要进行切除和/或关节置换尺骨冠突骨折采用Regan-Morrey 分型，1 型骨折是指冠突尖的骨折，2 型骨折是指骨折块高

11、度小于尺骨冠突50%的骨折，3 型骨折则骨折块高度超过50%。鹰嘴骨折最常采用Schatzker 分型、Mayo 分型或者AO 分型。Schatzker 分型是根据骨折部位（关节内/关节外）和骨折形态进行分型。Mayo 分型则将骨折分为无移位的稳定型骨折1 型、移位的稳定型骨折2 型和不稳定的3 型，3 型骨折常常是粉碎性骨折。手术适应证/禁忌证简单的肘关节脱位应尽快通过复位完成肘关节的对位。在复位之后立即评估肘关节的稳定性，是否在伸直位或外翻应力时出现半脱位和脱位。通常，复位后取得稳定就不需要进行手术治疗。但是对于过度肥胖、精神障碍或者气管插管的病人需要经常进行体检和X 线检查以防止出现复位

12、丢失。除了少数病例，大多数的复杂性肘关节脱位，即合并肘关节周围骨折的脱位通常必须采用手术治疗，要根据具体的骨折类型选择不同的手术适应证。因此，CT 检查对于术前计划就非常重要（图2）。文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5

13、B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

14、 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5

15、B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

16、 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5

17、B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

18、 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2图 2 肘关节后脱位。肘关节后脱位的侧位（A）和前后位X 线（B）。在平片上很难观察和评估小的关节内骨折块，但是在CT 上就可以很清楚的看到尺骨冠突骨折（C）和肱骨外上髁骨折（

19、D）1.桡骨头骨折肘关节后脱位合并桡骨头骨折非常少见，属于手术内固定的相对适应证。可以采用长臂石膏固定保守治疗，但是容易出现肘关节僵硬和前臂旋转活动受限。当选择进行手术治疗时，建议进行切开复位内固定或者一期桡骨头置换手术。对于肘关节创伤性脱位而言，桡骨头切除手术会造成桡骨向近端移位，因此属于禁忌证。几乎所有的肘关节脱位合并桡骨头骨折、尺骨冠突骨折都需要手术治疗（图3）。只有那些取得关节复位、肘关节运动不受影响、骨折块较小并且没有移位的患者才可以选择保守治疗。文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

20、ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B

21、2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

22、ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B

23、2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

24、ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B

25、2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

26、ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2图 3 肘关节恐怖三联征的侧位（A）和前后位X 线（B）。CT 显示合并桡骨头骨折（C）和尺骨冠突骨折（D）。三维重建显示肘关节脱位复位后的桡骨头骨折（E-1）和尺骨冠突骨折（E-2）。术后的前后位（F）和侧位（G）X 线，进行了桡骨头关节置换，将外侧副韧带用锚钉缝合修复到止点完成稳定的复位。通过在尺骨基底部钻2 个孔采用缝合套索的方式固定尺骨冠突骨折2.尺骨冠突骨折肘关节脱位合并单纯的尺骨冠突骨折比较少见，很多时候需要根据骨折块的大小和部位选择是否进行手术治疗。对于骨折块高度小于10%的尺骨

27、冠突骨折可以使用长臂石膏固定。但是对于骨折块大于10%的尺骨冠突骨折，那么就要像肘关节恐怖三联征一样选择手术治疗（图3）。3.尺骨鹰嘴骨折经尺骨鹰嘴骨折肘关节前脱位需要手术治疗。必须解剖复位尺骨鹰嘴的关节面，对于损伤的尺骨鹰嘴、肱骨远端、桡骨头都应在手术中同时进行修复。和Monteggia 氏骨折不同，在这一类型的损伤中，近端尺桡关节通常不会被破坏（图4）。文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2

28、文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5

29、V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2

30、文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5

31、V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2

32、文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5

33、V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2

34、图 4（A）三维重建显示经尺骨鹰嘴肘关节前脱位；（B）术后X 显示采用尺骨近端钢板固定尺骨鹰嘴，采用锚钉修复外侧副韧带，螺钉固定撕脱的内侧副韧带骨块，采用带垫圈螺钉固定尺骨冠突4.软组织损伤Odriscoll 及其同事描述了肘关节脱位时的软组织损伤是从外向内进行，首先是外侧副韧带损伤，然后在高能量暴力的作用下，内侧尺侧副韧带开始受损。当完成骨质的重建之后就要重点关注软组织的修复。环扎韧带及外侧副韧带都要进行修复，外侧韧带复合体的任何损伤都会造成旋转不稳定。但是，只有当所有的骨折和软组织结构都修复后还存在肘关节不稳定时才需要修复内侧副韧带。除此之外，也可以选择将患肢放置在铰链式外固定支架中而不修

35、复内侧副韧带。手术技巧1.术前计划术前需要详细全面的了解病史，进行体格检查和肘关节标准前后位、侧位、斜位的X 线检查。CT 检查有助于了解复杂性肘关节骨折脱位的骨折类型，指导手术方案的制定。MRI 对于新鲜肘关节骨折脱位并无太大帮助，但对于晚期肘关节不稳定的检查比较有用。在术前需要仔细检查是否存在神经功能障碍。所有的脱位在手术前都应进行复位和屈肘90 制动。患者的手术流程应按照图5 所示进行。无论是哪一种类型的骨折，医生都要做好突发意外事情的准备工作。如果最后的复位固定效果不稳定，则需要使用铰链式外固定架。如果存在桡骨头骨折，则有可能需要进行一期桡骨头关节置换。文档编码:CT5B2N5Q2X7

36、 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9

37、P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7

38、 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9

39、P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7

40、 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9

41、P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7

42、 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2图 5 复杂肘关节脱位的手术决策流程图2.术前准备和患者体位通常在全麻下进行手术，术前或者术后辅助进行神经阻滞以减少术后疼痛。有好几种患者体位可以充分显露肘关节，但是一般都是根据术者偏好选择不同体位。患者可以仰卧，将患肢横跨身体以暴露后方肘关节（图6）。在同侧肩胛骨下放置薄垫可以帮助患肢抬高。另外，也可以选择侧卧位，使用泡沫支撑患肢屈曲肘关节（图7）。无论选择哪种体位，我们都会在患肢上标注

43、桡侧、尺侧以及尺神经的位置（图6、7），因为有时医生在术中很容易就会迷失方向。铺巾之后再使用无菌止血带。文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5

44、B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

45、 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5

46、B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

47、 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5

48、B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5

49、 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2图 6 患肢仰卧，患肢自由横跨身体，在前臂与身体中间放置衬垫。标注桡侧、尺侧及尺神经（虚线）文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档

50、编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5V3Q8P5 ZP7X4G9P9E2文档编码:CT5B2N5Q2X7 HJ5V5

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