尺橈骨縱向分離課件

1、尺橈骨縱向分離-臨床病例治療探討較明顯損傷：肘脫位，橈骨上移，肘部小骨片患者，男，30歲，高處墜落傷整復(fù)后肘部表現(xiàn)為三聯(lián)征損傷橈骨頭固定，尺橈骨遠(yuǎn)端克氏針固定傷后1周，第一次手術(shù) 術(shù)后7周，橈骨頭上移，內(nèi)固定失敗，行橈骨頭切除，下尺橈克氏針拔除下尺橈關(guān)節(jié)脫位明顯橈骨頭切除后3周，行尺骨短縮2022/7/21尺骨短縮后7周復(fù)查2022/7/21 尺骨短縮后7周，3月28日及30日強(qiáng)行鍛煉時(shí)聽(tīng)到響聲，拍片示可疑尺骨骨折2022/7/21可疑尺骨骨折后2月余2022/7/21傷后5個(gè)月余Essex-Lopresti損傷Essex-Lopresti損傷是指橈骨頭骨折合并下尺橈關(guān)節(jié)脫位，是一種比較少見(jiàn)的

2、使前臂、腕及肘部同時(shí)受累的損傷。 Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation,Report of two cases. J Bone Joint Surg(Br),1951,33:244-247.Essex-Lopresti損傷的機(jī)制縱向應(yīng)力使橈骨頭撞擊肱骨小頭，應(yīng)力足夠大時(shí)，使橈骨頭骨折發(fā)生移位，然后破壞下尺橈關(guān)節(jié)和前臂骨間膜，使得整個(gè)橈骨向近端移位。治療原則Essex-Lopresti損傷需要手術(shù)治療。主要治療原則是恢復(fù)或重建橈骨長(zhǎng)度，同時(shí)復(fù)位并穩(wěn)定下尺橈關(guān)節(jié)。典型Es

3、sex-Lopresti損傷病例對(duì)該損傷早期診斷和及時(shí)治療可獲得較好功能。1.Edwards GS, Jupiter JB. Radial head fracture with acute distal radioulnar dislocation. Clin Orthop,1988, 234:61-69.2. Capuano L, Craig M, Ashcroft PG, et al. Distraction lengthening of the radius for radial longitudinal instability after distal radio-ulnar subl

4、uxation and excision of the radial head: a case report.Scand J Plast Reconstr Surg Hand Surg,2001,35:331-335.Essex-Lopresti損傷的概念擴(kuò)展Essex-Lopresti損傷破壞了前臂縱向穩(wěn)定性，骨間膜的損傷可以是急性損傷，也可以是慢性松弛和失效。對(duì)橈骨頭粉碎骨折患者，一定要考慮到有可能發(fā)展成慢性Essex-Lopresti損傷。有些病例原始損傷并不是嚴(yán)格的Essex-Lopresti損傷，但機(jī)制類(lèi)似，將該種損傷定義為尺橈骨縱向分離（longitudinal radioulna

5、r dissociation,LRUD）更合適。Trousdale RT, Amadio PC, Cooney WP, et al. Radio-ulnar dissociation, A review of twenty cases. J Bone Joint Surg(Am),1992,74:1486-1497. 患者，女，36歲1歲時(shí)橈骨頭處突出16歲時(shí)開(kāi)始?jí)浩壬窠?jīng)，伸指受限，行橈骨頭切除術(shù)現(xiàn)腕、肘部活動(dòng)時(shí)疼痛Essex-Lopresti損傷占橈骨頭骨折的1%，但目前認(rèn)為L(zhǎng)RUD損傷發(fā)病率可能比預(yù)想的要高得多。橈骨頭骨折時(shí)合并骨間膜損傷與橈骨頭骨折嚴(yán)重程度呈正相關(guān)。臨床上對(duì)該損傷認(rèn)識(shí)不足

6、，誤診和漏診率高。患者，男，32歲，高處墜落傷單看肘關(guān)節(jié)，是損傷三聯(lián)征 肘關(guān)節(jié)復(fù)位后，橈骨頭骨折成為Essex-Lopresti損傷的一部分2022/7/21術(shù)中情況術(shù)后10天2022/7/21術(shù)后7個(gè)月術(shù)后7個(gè)月對(duì)尺橈骨縱向分離急性損傷，早診斷早治療結(jié)果好。陳舊的尺橈骨縱向分離，尤其是一期切除橈骨頭后繼發(fā)前臂縱向不穩(wěn)定的病例，會(huì)引起嚴(yán)重的功能障礙，治療結(jié)果不可預(yù)期。 陳舊Essex-Lopresti損傷病例患者，男，37歲，摔傷橈骨頭切除術(shù)后應(yīng)力像肘屈伸正常，前臂旋轉(zhuǎn)受限，肘外翻不穩(wěn)，腕部疼痛 第一次術(shù)后6個(gè)月我院手術(shù)術(shù)中情況2012-10-15第一次術(shù)后6個(gè)月 行無(wú)張力下橈骨頭置換，尺骨遠(yuǎn)

7、段節(jié)段切除匹配下尺橈關(guān)節(jié)術(shù)后3個(gè)月復(fù)查2022/7/2110二次術(shù)后3個(gè)月肘屈曲減少10前臂旋轉(zhuǎn)改善明顯肘、腕部無(wú)明顯疼痛患者，男，25歲，雙上肢外傷術(shù)后3個(gè)月就診于我院原始受傷后影像資料：右側(cè)孟氏骨折，左側(cè)Essex-Lopresti損傷第一次術(shù)后傷后3個(gè)月到我院就診影像資料2012-10-31就診重新手術(shù)后2012-11-9在我院手術(shù)：行無(wú)張力下橈骨頭置換尺骨遠(yuǎn)段節(jié)段切除匹配下尺橈關(guān)節(jié)重新術(shù)后CT檢查2022/7/21術(shù)后6周復(fù)查2012-12-26術(shù)后6周復(fù)查體位像復(fù)查結(jié)果：原始資料男，45歲，高處墜落致傷左上肢術(shù)后5個(gè)月到我院就診術(shù)后2個(gè)月及5個(gè)月術(shù)后5個(gè)月肘關(guān)節(jié)屈曲115，伸直0前臂

8、旋轉(zhuǎn)嚴(yán)重 受限肘、腕關(guān)節(jié)活動(dòng)時(shí)疼痛明顯 2013-10-16術(shù)中資料2022/7/212013-10-16術(shù)中資料術(shù)后資料2022/7/21術(shù)后1個(gè)月復(fù)查術(shù)后1個(gè)月復(fù)查活動(dòng)時(shí)肘關(guān)節(jié)疼痛核心問(wèn)題：如何防止橈骨持續(xù)上移以往絕大多數(shù)學(xué)者將DRUJ穿針固定與橈骨頭切開(kāi)復(fù)位內(nèi)固定/橈骨頭金屬假體置換作為治療LRUD的主要方法，認(rèn)為修復(fù)上述兩個(gè)結(jié)構(gòu)就足以維持前臂的穩(wěn)定性而無(wú)需修復(fù)或重建骨間膜中央束。如何防止橈骨持續(xù)上移在臨床上，有些病例（未恢復(fù)骨間膜的完整性）出現(xiàn)肱橈關(guān)節(jié)過(guò)度磨損，產(chǎn)生疼痛和關(guān)節(jié)退變。如何防止橈骨持續(xù)上移1.隨著對(duì)骨間膜在前臂穩(wěn)定作用重要性的認(rèn)識(shí)，目前主張修復(fù)LRUD的所有損傷結(jié)構(gòu)以恢復(fù)前

9、臂正常穩(wěn)定性，即除了修復(fù)或重建橈骨頭及矯正下尺橈關(guān)節(jié)，需要重建骨間膜。2.對(duì)于橈骨頭骨折但未能確診為L(zhǎng)RUD者，密切隨診，若證實(shí)為L(zhǎng)RUD，則按LRUD治療。目前防止橈骨持續(xù)上移-相關(guān)報(bào)告1.修補(bǔ)骨間膜2.重建骨間膜3.下尺橈關(guān)節(jié)融合-單骨化4.肱骨小頭置換-金屬假體表面置換5個(gè)月后復(fù)查結(jié)果without pain. pronation of 35 and supination of 45, with grip strength of 65 lb compared with 100lb on the noninjured side. 3. The elbow x-ray ：a healed r

10、adial head fracture, without collapse, with K-wires in place4. the wrist x-ray ：an intact DRUJ. 5.There was no heterotopic bone in the forearm.Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/DislocationsJoseph M. Failla, MD, Jon Jacobson, MD, Marnix

11、 van Holsbeeck, MD,Detroit, MI(J Hand Surg 1999;24A:257266. Copyright 1999 bythe American Society for Surgery of the Hand. Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/DislocationsJoseph M. Failla, MD, Jon Jacobson, MD, Marnix van Holsbeeck, MD,D

12、etroit, MIDuring surgical treatment of the Essex-Lopresti injury, however, herniation of the anterior compartment muscles caused separation of the torn edges of the central third IOM, which could have prevented anatomic healing.Interosseous membrane repair, however, could have potential complication

13、s, such as forearm stiffness or synostosis.RECONSTRUCTION OF THE INTEROSSEOUS LIGAMENT OF THE FOREARM REDUCES LOAD ON THE RADIAL HEAD IN CADAVERSJournal of Hand Surgery (British and European Volume, 2003) 28B: 3: 2672701.This study evaluated forearm load transfer following interosseous ligament reco

14、nstruction with an Achilles tendon allograft in a cadaveric model with the radial head intact. Interosseous ligament reconstruction reduced proximal radius loading by transferring force to the proximal ulna, but force transfer by the reconstruction was only half that by the intact ligament.2. In these cases, performing both a radialhead arthroplasty and either an interosseous ligament repair or reconstruction may restore more normal forearm loading.目前文獻(xiàn)中重建前臂骨間膜的材料1.跟腱2.半腱肌肌腱3.掌長(zhǎng)肌肌腱4. 骨-髕韌帶