肘关节内翻—后内侧旋转不稳定的手术疗效分析

殷照阳 殷建 孙晓 霍永峰 盛路新

肘关节内翻—后内侧旋转不稳定的手术疗效分析

殷照阳1殷建2孙晓1霍永峰1盛路新1

目的探讨创伤性肘关节内翻-后内侧旋转不稳定的术后疗效。方法2011年6月至2015年12月连云港市第一人民医院收治创伤性肘关节内翻-后内侧旋转不稳定患者10例（10个肘），其中男6例、女4例，平均年龄34.8岁（20～67岁）。术后早期功能锻炼，采用Mayo肘关节功能评分系统（Mayo elbow performance score，MEPS）评价肘关节功能。定期复查X线片，采用Broberg和Morrey肘关节退行性关节炎X射线分级进行评价。结果所有患者肘关节骨折3个月后获得愈合，肘关节活动稳定，8例无疼痛症状，1例静止时偶有疼痛，1例活动时疼痛。肘关节活动伸直平均角度（29.6±11.4）°，屈曲平均角度（113.6±10.2）°，旋前平均（55.2±13.6）°，旋后平均（40.2±9.2）°。1例术后2个月开始出现骨化性肌炎，半年后予以手术松解，满足日常生活需要。根据MEPS评分结果优7例、良1例、中2例、差0例，优良率80%。结论肘关节内翻-后内侧旋转不稳定一期手术治疗至关重要，根据不同损伤类型制定个性化治疗方案有利于关节功能恢复。

肘关节； 外科手术； 骨折固定术

肘关节内翻-后内侧旋转不稳定是由于肘关节受到内翻、后内侧旋转及轴向的应力导致外侧副韧带复合体从肱骨外髁止点撕脱，肱骨远端滑车撞击尺骨冠状突内侧面，引起以冠状突内侧面骨折为基础合并冠状突、桡骨头或尺骨近端骨折为特点的损伤类型。此种类型肘关节损伤临床上少见，一期手术治疗不当而导致的肘关节功能障碍较为多见，而二期再次矫形手术的效果难以令人满意，所以一期手术治疗至关重要。自2011年6月至2015年12月连云港市第一人民医院收治创伤性肘关节内翻-后内侧旋转不稳定患者10例，疗效满意，报道如下。

资料与方法

一、 一般资料

本组患者共10例（10个肘），其中男6例、女4例，平均年龄34.8岁（20～67岁）。均为优势肘，且无既往肘关节手术史。损伤原因：骑车摔伤4例、车祸4例、高处坠落伤1例、运动损伤1例。按O'Driscoll分型分为：ⅡA型3例、ⅡB型4例、ⅡC型3例。合并伤包括：合并桡骨小头骨折1例（Mason Ⅲ型）、合并桡骨远端骨折3例。

二、纳入及排除标准

纳入标准：①放射线检查证实存在冠状突内侧面骨折基础损伤，合并或不合并尺骨鹰嘴骨折、肘关节脱位，具有明确手术指征；②受伤至手术时间＜3周；③肘关节闭合性损伤；④无心、肺功能障碍等明显手术禁忌证；⑤术前无认知障碍，不影响术后随访。

排除标准：①陈旧性肘关节骨折脱位；②合并神经、血管损伤的病例；③既往肘关节手术病史；④随访资料不完整或不配合治疗的患者。

三、术前评估

术前应着重注意软组织肿胀情况，有无脱位和前臂骨筋膜室综合症，有无血管、神经损伤。术前常规检查肘关节前后位、侧位及肘关节三维CT重建，重点观察肱骨内外侧髁有无撕脱骨折片影，冠状突骨折的部位及大小。肘关节MRI检查提高了内外侧韧带损伤程度诊断的正确率。术前如有脱位应首先予以手法复位，然后屈肘90°位制动，卧床患肢抬高以减轻软组织的肿胀程度。

四、手术方法

手术修复的顺序为先内后外，即先固定冠状突骨折块。冠状突内侧面骨折或涉及高耸结节的骨块予以克氏针、螺钉或钢板固定，冠状突尖部骨折予以“套锁”固定，然后探查内侧韧带复合体，前束肱骨或尺骨止点撕脱或撕脱骨折予以锚钉缝线编织固定。前臂施加内翻应力，术中透视证实有无明显的外侧肱桡关节增宽，明显增宽提示外侧韧带复合体断裂，予以切开骨缝合或带线锚钉修复，再次透视下检查外侧肱桡关节间隙，然后施加前臂旋前、轴向应力检查有无肘关节半脱位。如果仍然存在外侧肱桡间隙增宽或肘关节半脱位，予以肘关节同心圆支架固定，透视下确定肘关节旋转中心，肱骨和尺骨拧入Schaze螺钉并组装肘关节同心圆铰链式外固定支架（同心圆铰链外固定支架的作用主要是保护修复的骨与软组织结构）。桡骨头及桡骨远端骨折予以钢板及螺钉固定。

五、术后处理

术后患肢肘关节支具固定3周，每天屈伸锻炼2～3次。外固定支架固定术后第1天即可进行肘关节屈伸活动，但是术后3周内肘关节伸直不宜超过30°，以后逐渐增加肘关节屈伸活动度。术后6周拆除外固定支架，固定尺骨冠状突尖部的克氏针待术后3个月骨折愈合后予以拔出。术后口服吲哚美辛共计6周以预防肘关节骨化性肌炎。

六、评价指标

术后评估应用Mayo肘关节功能评分系统（Mayo elbow performance score，MEPS）［1］对肘关节功能进行评价，其主要内容包括四个方面：肘关节疼痛程度、屈伸活动度、稳定性及日常功能。术后定期复查X线片，采用Broberg和Morrey肘关节退行性关节炎X射线分级［2］进行评价。

结 果

10例患者均获得随访，平均随访（13.8±3.6）个月（6～22个月）。患者术前、术后及术后6个月影像学资料见图1-6，10例肘关节骨折术后3个月后获得骨性愈合，且肘关节活动稳定，1例偶有疼痛，1例活动后疼痛。最后一次随访9例肘关节活动伸直平均（29.6±11.4）°，屈曲平均（113.6±10.2）°，旋前平均（55.2±13.6）°，旋后平均（40.2±9.2）°，满足日常生活需要。1例术后2个月开始出现骨化性肌炎，半年后肘关节活动受限明显，予以手术松解，效果满意，满足日常生活需要。本组10例患者无骨与软组织感染，无神经、血管损伤症状。采用MEPS评价肘关节功能，平均82分（62～92分），优7例、良1例、中2例、差0例，优良率80%。Broberg和Morrey肘关节创伤性关节炎评估结果，8例无退行性改变，2例出现1级改变，未出现2级或3级创伤性关节炎改变。

图1 肘关节骨折术前三维CT成像后面观

图2 肘关节骨折术前三维CT成像前面观

图3 肘关节骨折术后正位X线片

图4 肘关节骨折术后侧位X线片

图5 肘关节骨折术后6个月正位X线片

图6 肘关节骨折术后6个月侧位X线片

讨 论

肘关节不稳定根据部位分为外翻不稳定、内翻不稳定、前侧不稳定和后外侧旋转不稳定，而在创伤引起的肘关节不稳中，后外侧旋转不稳定最为常见，内翻-后内侧旋转不稳定相对较为少见［3-6］，容易漏诊或误诊，此类骨折脱位治疗不当容易出现肘关节僵硬、创伤性骨性关节炎和肘内翻。肘关节内翻-后内侧旋转不稳定的损伤机制是肘关节受到轴向、内翻、后内侧旋转应力而发生肘关节内翻、前臂旋前并向后内侧旋转，导致外侧韧带复合体从肱骨外侧髁撕脱或撕脱骨折，滑车撞击冠状突内侧面引起冠状突内侧面骨折、合并或不合并内侧副韧带前束损伤后的肘关节骨折脱位。此种类型损伤后肘关节极度不稳，如果采用保守治疗或者冠状突骨折不固定的手术方式，最终肘关节功能均不满意［7-10］。也有学者认为需在麻醉下进行肘关节屈伸活动，若发现肱尺关节半脱位，施加内翻应力时肱桡关节间隙增大，须进行手术治疗［11-12］。

肘关节周围软组织韧带结构包括内侧韧带、外侧韧带复合体及前方的关节囊结构。肘关节前方关节囊结构对于肘关节稳定性的影响相对较小。内侧韧带包括前、后、横束，其中后、横束与关节囊融合在一起，起到加强关节囊的作用，而前束起于肱骨内上髁，止于尺骨冠状突基底部的高耸结节，是维持肘关节内侧稳定、防止肘关节外翻最为重要的结构。外侧韧带复合体包括外侧韧带结构和伸肌、旋后肌等结构，复合体对维持关节外侧的稳定约起50%的作用［13］，伸肌起协同作用。外侧韧带包括桡侧副韧带和环状韧带，桡侧副韧带起于肱骨外上髁的外下方，发出纤维组织一部分止于桡骨环状韧带，另一部分止于尺骨冠突的外下方为桡侧尺副韧带，后者对于维持肘关节后外侧稳定有重要作用［14-15］。肘关节后外侧伸肌结构在前臂旋后位时保持前臂稳定并防止前臂外旋脱位，力学实验证实即使切断肘关节后外侧所有软组织结构，肘关节旋后位仍可以降低关节脱位趋势，这为术后前臂旋后位固定提供了依据。

目前在处理肘关节内翻-后内侧旋转不稳定时，对于手术入路、骨折的固定方式、是否修复内侧和外侧副韧带、是否加用铰链式外固定支架等方面仍未达成共识。肘关节内侧手术入路最常用的是“过顶”入路，固定冠状突骨折更加方便，冠状突大的块骨折可以选择螺钉、3.0 mm空心螺钉或“T”型钢板固定，小的骨折块可予以“套索”、锚钉、克氏针连同附着的软组织固定于原骨折处。如骨折块太碎，则取出游离碎片，缝合前关节囊及肱肌腱。关于与前关节囊相连的尺骨冠状突小骨折块应用螺钉或“套索”固定，哪种技术固定效果更佳尚无定论。肘关节结构性稳定系统分为四个柱，内侧柱由肱尺关节内侧和内侧副韧带复合体组成，前侧柱由冠状突、桡骨头前部及前方关节囊组成，肱肌提供辅助作用。冠状突位于肱骨远端滑车的前方，其主要作用是对抗上臂肌肉牵拉尺骨向后的力量，同时也是对抗外伤导致肘关节内翻的骨性结构，而当冠状突骨折或缺失超过50%即可引起肘关节不稳，出现肘关节复发性脱位或半脱位［16］。冠状突基底部是内侧副韧带前束的止点。王友华等［17］发现当冠状突骨折累及高度达到1/2时必然导致前束损伤，此时重建冠状突对比修复和不修复前束韧带的肘关节的稳定性，发现肘关节在屈曲 0°、30°、60°、90°和120°时，外翻角度的显著增加提示了肘关节的不稳，证实内侧副韧带前束在肘关节活动过程中对抗外翻旋转应力起到非常重要的作用。O'Driscoll Ⅲ型冠状突骨折多合并复杂肘关节损伤，冠状突粉碎性骨折难以复位时，需取自体髂骨重建冠状突，且重建冠状突的高度至少达到原来高度1/2，从而获得肘关节前方的骨性阻挡以维持肘关节的稳定性，但如果同时合并桡骨头骨折，无论尺骨冠状突骨折块多小均可能增加肘关节的不稳［14］。因此，冠状突同时参与组成肘关节前柱和内侧柱，其基底部是内侧副韧带前束的止点，后者在肘关节活动过程中对抗外翻旋转应力起到非常重要的作用，重建冠状突的高度和修复内侧副韧带，对于术后肘关节的稳定性有决定性的作用。

关于内侧副韧带是否需要一期修复存在争议，有学者认为复位固定冠状突骨块时应一期探查内侧副韧带前束，如果发现断裂应予以修复或重建，修复断裂的内侧副韧带明显增加了肘关节的稳定性。但有学者认为内侧副韧带并非必须修复［18］，外侧韧带复合体作用更为重要，只要固定冠状突骨折块和肘关节外侧结构（桡骨头骨折块和外侧韧带复合体），肘关节多数可获得稳定，无需一期修复内侧副韧带。本组病例冠状突内侧面骨折块较大，多连带内侧副韧带前束一同移位，术中复位固定冠状突骨折块即可。肘关节内翻-后内侧旋转不稳定时常伴有外侧副韧带复合体损伤，肘关节外侧副韧带复合体损伤表现为肱骨止点处撕脱骨折或韧带撕脱，也可能是韧带体部的断裂，以前者最为常见，韧带止点处撕脱予以锚钉修复固定；若是韧带体部断裂，宜选择韧带重建，尺骨远、近端重建的骨道应位于尺骨旋后肌嵴的桡骨头近缘水平及远端15 mm的桡骨头颈交界处水平，而肱骨外侧髁骨道的位置可以通过尺骨骨道穿过一根缝线，在屈伸肘关节的过程中，确定其在外上髁周围的等距点［19-21］，即肱骨外上髁前下方4点左右，也就是肱骨小头外侧面的圆心点。值得注意的是桡侧尺副韧带重建时尺骨骨道离肘关节越远，内翻稳定性越好，离肘关节越近，肘关节后外侧稳定性越好，术中应根据具体情况酌情考虑。本组术中探查10例外侧副韧带均有损伤，均为桡侧副韧带肱骨止点撕脱或撕脱骨折，予以带线锚钉编织韧带后固定，透视下行肘关节内翻应力检查，6例仍然出现肱桡间隙明显增宽，加用同心圆外架固定。根据肘关节内翻后内侧旋转不稳定的受伤机制，首先伤及肘关节后外侧结构导致后外侧复合体的撕脱骨折或韧带撕脱，术中是否需要常规探查修复尚无定论，有学者认为内翻-后内侧旋转不稳术中修复外侧副韧带难以牢固固定，需予以肘关节外固定支架固定以保护修复的软组织，否则应制动患肢 1个月［22］。Ring［23］在术中不做切开修复，固定冠状突骨折后予以肘关节同心圆外固定支架固定，取得了良好效果。作者发现术中切开修复后外侧韧带复合体且未使用同心圆外架的患者，术后每日主动屈伸功能锻炼2～3次防止肘关节僵硬，骨折愈合后肘关节功能满意且无肘关节不稳。虽然术中未使用同心圆支架固定可能会导致术后早期活动时出现肘关节不稳，但是通过术后肘关节的功能锻炼可以明显降低肘关节半脱位的发生率，有学者也作了相似报道［24］。因而，术中是否需要进行内侧副韧带修复，仍需要生物力学及临床进一步研究和大宗病例的对照和随访，而外侧副韧带损伤多主张予以探查修复。

对于是否使用肘关节同心圆外固定支架，作者的经验是在肘关节内侧柱修复后，对外侧韧带复合体进行加强缝合，如果仍然不稳则加用铰链式外固定支架。外固定支架的作用在于保持肘关节的同心圆活动，同时保护修复的骨与软组织结构［25］，也便于早期功能锻炼［26］，但是旋转中心的定位非常重要，轻度的偏移则会明显增加肘关节活动时的应力。相对于外固定支架，更倾向于手术探查修复后外侧韧带复合体，大多数肘关节可获得稳定，而使用同心圆外固定支架可能出现更多的并发症，如旋转中心偏离过大致肘关节功能锻炼时关节面磨损，桡神经损伤、钉道感染、松动等。

肘关节内翻-后内侧旋转不稳定较少发生桡骨头骨折，偶尔伴有鹰嘴骨折。桡骨头骨折的治疗方法根据基于Mason分型，Ⅰ型骨折移位小予以保守治疗；Ⅱ型骨折予以手术复位内固定，固定骨折块尽可能选择螺钉固定，若涉及整个桡骨头骨折可选择钢板固定，钢板需放置于桡骨头“安全区”内，而当桡骨头骨折快较小（小于桡骨头25%）且不累及乙状切迹时可考虑桡骨头骨块切除；Ⅲ型骨折粉碎选择桡骨头置换。对于无法修复的桡骨头骨折，决定进行桡骨头切除时应充分评估肘关节的稳定性，目前多数学者认为桡骨头粉碎骨折同时合并内侧副韧带损伤，不宜进行桡骨头切除，否则易导致肘关节严重不稳，如果行桡骨头切除前提是内侧副韧带完整。

肘关节功能的恢复情况与术后康复期的功能锻炼密切相关。术后应早期进行功能锻炼，否则会导致关节僵硬，但是如果在稳定性和早期活动这两者之间作选择，应优先考虑关节的稳定性，矫正僵硬比慢性不稳定的肘关节相对要简单。总之，术前应对肘关节骨与软组织的损伤程度做充分的评估，根据不同患者骨与软组织损伤的不同情况制定个性化手术方案。骨性结构的坚强固定、软组织结构的修复以及术后正确的功能锻炼是治疗创伤性肘关节骨折脱位并取得满意效果的必备条件。

［1］Ates Y, Atlihan D, Yildirim H. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid［J］.J Bone Joint Surg Am, 1996, 78（6）:969.

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

［3］O'Driscoll SW. Acute, recurrent and chronic elbow instabilities［M］//Norris TR. Orthopaedic knowledge update:shoulder and elbow 2. Rosemont:AAOS, 2002: 313-323.

［4］O'Driscoll SW. Coronoid fractures［M］//Norris RT. Orthopaedic knowledge update: shoulder and elbow 2. Rosemont: AAOS, 2002:379-384.

［5］O'Driscoll SW. Recurrent instability of the elbow［M］//Wolfe SW, Hotchkiss RN, Pederson WC, et al. Green's operative hand surgery. 6th ed. Philadelphia: Churchill Livingstone, 2011:887-902．

［6］0'Driscoll SW, Jupiter JB, Cohen MS, et a1. Difficult elbow fractures: peals and pitfalls［J］. Instr Course Lect, 2003, 52:113-134．

［7］Sanchez-Sotelo J, O'Driscoll SW, Morrey BF. Medial oblique compression fracture of the coronoid process of the ulna［J］. J Shoulder Elbow Surg, 2005, 14（1）: 60-64．

［8］Doornberg JN, Ring D. Coronoid fracture patterns［J］. J Hand Surg Am, 2006, 3l（1）: 45-52．

［9］Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process［J］. J Bone Joint Surg Am, 2006, 88（10）:2216-2224.

［10］Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process: surgical technique［J］. J Bone Joint Surg Am, 2007, 89 （2）: 267-283．

［11］殷建, 霍永峰, 盛路新,等. 复杂肘关节骨折脱位的手术治疗［J］. 实用骨科杂志, 2015, 21（10）: 929-932.

［12］Beingessner DM, Dunning CE, Stacpoole RA, et a1. The effect of eoronoid fractures on elbow kinematics and stability［J］．Clin Biomech （Bristol, Avon）, 2007, 22（2）: 183-190.

［13］杨运平, 徐达传, 赵卫东, 等. 肘关节后外侧旋转不稳定的解剖与生物力学研究［J］. 医用生物力学, 2000, 15（2）: 111．

［14］Morrey BF, An KN. Stability of the elbow: osseous constraints［J］. J Shoulder Elbow Surg, 2005, （1）:174-178.

［15］O'driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation. A spectrum of instability［J］. Clin Orthop Relat Res, 1992（280）: 186-197.

［16］Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading［J］. J Bone Joint Surg Am, 2000, 82-A（12）:1749-1753.

［17］王友华, 汤锦波, 周学军, 等. 尺骨冠突骨折对肘关节稳定性的影响［J］．中华骨科杂志, 2005, 25（3）: 155-158．

［18］Forthman C, Henket M, Ring DC. Elbow dislocation with intraarticular fracture: the results of operative treatment without repair of the medial collateral ligament［J］. J Hand Surg Am,2007, 32（8）: 1200-1209.

［19］闫辉, 崔国庆, 刘玉雷, 等. 肘关节外侧尺骨韧带重建或修复手术治疗后外侧旋转不稳的初步结果［J］. 中华医学杂志,2011, 91（23）: 1595-1599．

［20］Shemesh S, Loebenberg MI, Kosasahvilli Y, et al. Posterolateral rotatory instability of the elbow［J］. Harefuah, 2014, 153（5）:261-265, 305.

［21］Yadao MA, Savoie FR, Field LD. Posterolateral rotatory instability of the elbow［J］. Instr Course Lect, 2004: 607-614.

［22］查晔军, 蒋协远, 公茂琪. 肘关节内翻-后内侧旋转不稳定的诊断与治疗［J］. 中华创伤骨科杂志, 2012, 14（1）：68-72．

［23］Ring D. Fractures of the coronoid process of the ulna［J］. J Hand Surg Am, 2006, 31（10）: 1679-1689.

［24］Duckworth AD, Kulijdian A, McKee MD, et a1. Residual subluxation of the elbow after dislocation or fracture. dislocation:treatment with active elbow exercises and avoidance of varus stress［J］. J Shoulder Elbow Surg, 2008, 17: 276-280．

［25］Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation［J］. J Bone Joint Surg Am,2002, 84-A（9）: 1630-1635.

［26］Stavlas P, Jensen SL, Søjbjerg JO. Kinematics of the ligamentous unstable elbow joint after application of a hinged external fixation device: a cadaveric study［J］. J Shoulder Elbow Surg, 2007, 16（4）: 491-496.

Yin Jian, Email:yinjian0511@163.com

Operative effect analysis of varus posteromedial rotatory instability of elbow joint

Yin Zhaoyang1, Yin Jian2,Sun Xiao1, Huo Yongfeng1, Sheng Luxin1.1Department of Orthopaedics, Lianyungang First People's Hospital,Lianyungang 222000, China;2Department of Orthopaedics, the Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 211100, China

BackgroundThe varus-posteromedial instability of elbow joint refers to the injury characterized by fractures of the medial surface of coronoid process combined with fractures of coronal process, radial head or proximal ulna. The fractures are caused by the avulsion of lateral collateral ligament from the insertion of external humeral condyle and the impingement of the medial surface of ulnar coronoid process by distal humeral trochlea due to varus, posteromedial and axial stresses on elbow joint. This type of elbow injury is rare in clinic. The elbow joint dysfunction is commonly seen if treated improperly at the first stage.Unfortunately, the effect of orthomorphia at the second stage is rarely satisfactory. Hence, the first stage operation is critical. From June 2011 to December 2015, 10 patients with traumatic varus-posteromedial rotatory instability were treated in the First People's Hospital of Lianyungang and obtained satisfactory results.Methods（1）General data. There were 10 patients （6 males and 4 females） in the group, and the average age was 34.8 years （20-67 years）. The dominate elbow joint was affected for all cases, and no patient had previous history of elbow surgery. The causes of injury included 4 cases of bicycle fall, 4 cases of traffic accident, 1 case of high fall and 1 case of athletic injury. According to the O' Driscoll classification, there were 3 cases of type IIA fractures, 4 cases of type IIB fractures and 3 cases of type IIC fractures. Thecombined injuries included 1 case of radial head fracture （Mason type III） and 3 cases of distal radial fracture.（2）Inclusive and exclusive criteria. Inclusive criteria: ① The presence of medial surface of coronoid process fracture with or without olecranon fracture or elbow joint dislocation confirmed by radiological examination suggested definite indication of operation; ②The time from injury to surgery ＜3 weeks ;③ Closed injuries of elbow joint；④ No obvious surgical contraindication such as cardio or pulmonary dysfunction;⑤ No preoperative cognitive impairment that affected postoperative follow ups. Exclusive criteria: ① Oboslete fracturedislocations of elbow joint; ② Combined neurovascular injuries; ③ Previous history of elbow joint surgery; ④ Incomplete follow-up data or patients who did not cooperate with treatment.（3）Preoperative evaluation. Special attentions should be paid preoperatively to the swelling of soft tissue and the presence of dislocation, compartment syndrome of forearm, or neurovascular injury. Preoperative routine examinations including anteroposterior and lateral views of elbow joint and three-dimensional CT reconstruction of elbow joint were conducted to mainly observe the presence of avulsion fractures at medial and lateral condyles of humerus and the location and size of coronoid fragment. Elbow MRI examination improved the diagnostic accuracy of the extent of medial and lateral ligament injury. If there was elbow joint dislocation before operation,manual reduction should be performed firstly. The elbow was then fixed in 90° of flexion, and the affected limb was raised in bed to reduce the swelling of soft tissue. （4）Operative method. The order of surgical repair was from inside to outside as described below. The fracture fragments of coronoid process were fixed firstly. The fractures of the medial surface of coronoid process or fracture fragments involving Sublime tubercle were fixed with Kirschner wires, screws or plates. Fractures of the apex of coronoid process were treated with “Lasso” fixation. Afterwards,the medial ligament complex was explored, and the anterior humeral or ulnar avulsion or the avulsion fracture was fixed with suture anchor. Varus stress was applied on the forearm to check whether the space of lateral radioulnar joint increased significantly under intraoperative fluoroscopy. The remarkable increment suggested the disruption of lateral ligament complex,which required open suture and/or suture anchor fixation. The gap of lateral radioulnar joint was checked again under fluoroscopy, and pronation and axial pressure was applied on the forearm to check whether there was elbow joint subluxation. If the increased lateral radioulnar joint space or elbow joint subluxation still exist, the elbow joint should be fixed by concentric circle bracket. As the rotating center of elbow joint was confirmed under fluoroscopy, the placement of Schaze screws on humerus and ulna and the assembly of hinged elbow external fixator （for protections of repaired bone and tissue structure） were executed subsequently. The fractures of radial head and distal radius were fixed with plates and screws. （5）Postoperative management.After operation, the affected limb was fixed with elbow brace for 3 weeks. Flexion and extension exercises were performed 2-3 times per day. The elbow flexion and extension activities were allowed on the 1st day after external fixation, but the range of elbow extension should not exceed 30° within 3 weeks after surgery. Later, the range of flexion and extension motions of elbow joint was gradually increased. The external fixator was removed 6 weeks after operation, and the Kirschner wire used for the fixation of ulnar coronoid process tip was removed when the fracture healed 3 months after operation. Oral indomethacin was given postoperatively for 6 weeks to prevent the myositis ossificans of elbow joint. （6）Evaluation index. Mayo elbow performance score （MEPS） was used for the postoperative evaluation of elbow function, which mainly included four aspects: level of pain, range of elbow flexion and extension, stability and daily function. The X-ray films were taken regularly for postoperative examinations, and the degenerative arthritis of elbow joint was evaluated by Morrey and Broberg classification. Results All patients were followed up for an average of （13.8±3.6） months （6-22 months）. Ten cases of fractures

bony union and achieved stable elbow joint movement 3 months after operation. There were one case of occasional pain and one case of pain after exercise. During the last follow up,9 cases of fracture had an average elbow extension angle of （29.6±11.4）°, an average elbow flexion angle of （113.6±10.2）°, an average pronation angle of （55.2±13.6）° and an average supination angle of （40.2±9.2）°. These results met the needs of daily life. Myositis ossificans occurred in 1 patient 2 months after operation. 6 months later, the elbow joint movement was remarkably limited. With arthrolysis, the operative effect was satisfactory, which met the needs of daily life. In this group of patients, no bone and soft tissue infection or neurovascular injury symptom was found. The elbow function was evaluated by MEPS, and the mean score was 82 points （62-92 points）. There were 7 excellent cases, 1 good case , 2 moderate cases and 0 poor case . The good and excellent rate was 80%. According to the elbow traumatic arthritis evaluation by Broberg and Morrey classification, there were 8 cases of no degenerative change, 2 cases of Grade 1 degenerative change and 0 case of Grade 2 or 3 degenerative change.ConclusionThe stage-one operative treatment is critical for the varus-posteromedial instability of elbow joint, and the individualized treatment based on injury types is beneficial to the recovery of joint function.The assessment of damage levels of elbow bone and soft tissue should be sufficiently made before operation. The individual operative plan is made based on the bone and soft tissue injury of patient. The rigid fixation of bone structure, the proper repair of soft tissue structure and the correct postoperative functional exercise are essential conditions for the successful treatment of traumatic elbow fracture-dislocation.

Elbow joint； Rotational instability； Facture fixation

10.3877/cma.j.issn.2095-5790.2017.03.004

连云港市卫计委面上项目（201703）；南京医科大学科技发展基金（2016NJMU156）

工作单位: 222000 连云港市第一人民医院骨科1；211100 南京医科大学附属江宁医院骨科2

殷建，Email:yinjian0511@163.com

2017-02-04）

（本文编辑：李静；英文编辑：陈建海、张晓萌、张立佳）

殷照阳,殷建,孙晓,等. 肘关节内翻—后内侧旋转不稳定的手术疗效分析［J/CD］.中华肩肘外科电子杂志,2017,5（3）：173-179.