1、,What Is Your Diagnosis?,Monteggia fractures,Concept,The Monteggia fracture is a fracture of the proximal or middle third of the ulna, associated with a dislocation of the radial head. In severe injuries there can be associated fractures of the radial head and coronoid process.,Concept,1814年Monteggi
2、a首先描述了这种骨折类型，是指尺骨上1/3骨折合并桡骨头向前脱位的一种联合损伤 。 1967年Bado进一步完善 Monteggias骨折的概念，即任何部位的尺骨骨折合并桡骨头脱位。 后来随着人们对这种损伤机制的进一步研究使该损伤概念的范围逐渐扩大将桡骨头各方向脱位合并不同水平的尺骨骨折或尺、桡骨双骨折都列入住。 实用骨科学第三版（胥少汀2005）,Incidence,约占全身骨折的0.8%。该损伤可见于各年龄人群，但以儿童和少年多见。The Monteggia fracture can be considered a rare injury as accounts for only 25%
3、of all proximal forearm fractures Korner J, Lill H, Josten C. Monteggiaverletzungen. In: Josten C,LillH,eds.Ellenbogenverletzungen.Darmstadt:Steinkopff,Darmstadt, 2002:12336.,1、韧带： 环状、方形、斜形、骨间膜 2、神经： 桡神经深支、尺神经,Mechanism of injury,Monteggia fractures may result from low-energy injuries such as falls
4、from a standing height onto the outstretched hand with the forearm going into forced pronation, or high-energy injuries, for example falls from height, road traffic accidents or blows to the forearm.,Classification,Bado 1967年将Monteggia fractures分为四种类型 Type 1：Fracture of the proximal or middle third
5、of the ulna with anterior dislocation of the radial head with the apex of the fracture facing anteriorly. Type 2：Fracture of the proximal or middle third of the ulna with posterior or posterolateral dislocation of the radial head with the apex of the fracture facing posteriorly. Type 3：Fracture of t
6、he ulnar metaphysis with lateral dislocation of the radial head. Type 4：Fracture of the proximal or middle third of the ulna and fracture of the proximal third of the radius with anterior dislocation of the radial head Dormans等(1990)提出了第V型即前臂旋前时桡骨头脱位，旋后时自动复位。,分型？,Presentation&Diagnosis,Pain, immobil
7、ity and deformity are common features and the forearm is characteristically held in a position of hyperpronation (Bado, 1967). 1、外伤史。 2、畸形、肿胀、疼痛、活动功能障碍、骨檫音。 3、X 光片可明确骨折的分型。 4、注意有没有桡神经深支的损伤。桡神经深支损伤后，可出现垂腕，虎口背侧感觉减退或消失体征。,诊断与鉴别诊断,X线检查：Monteggia fractures are easily overlooked due to the prominence of t
8、he ulna fracture。 虽然Monteggias骨折在临床上不常见，但其漏诊率可高达20.8%。 张兴倜等实用创伤外科M济南：济南出版社，1999：972 所以X线片必须包括肘关节及腕关节。,诊断与鉴别诊断,Smith征很有诊断价值即在正常情况下，桡骨头纵轴（桡骨头和桡骨颈中心画一直线）延长线应通过肱骨小头的骨化中心，否则呈阳性，表示桡骨头有脱位 。必要时加拍健侧肘部X线片以作对比，并应按孟氏骨折处理否则桡骨头有可能再脱位。 （标准的正侧位片）,有文献报道认为成人尺、桡骨双骨折合并桡骨头脱位患者，桡骨头易复位，但也容易再脱位，在拍X线片时可能出现假象。因此，X线片检查示无脱位患者也
9、须认真查体，触摸肘外侧是否有压痛，检查桡骨小头与肱骨外髁解剖关系是否正常，桡骨小头是否稳定。对怀疑者无论X线片上是否有脱位表现均应按孟氏骨折处理。,治疗目标,稳定的骨折固定及桡骨头复位，早期活动，恢复前臂旋转屈伸功能，预防并发症发生。,治疗原则,矫正尺骨畸形，防止畸形和旋转，以及维持桡骨头稳定。,治疗方法,一、手法复位（小儿新鲜闭合性孟氏骨折） 二、手术治疗（先后问题） 历史： Speed（1940）主张切开复位并内固定尺骨，同时重建环状韧带。 Evans（1949）主张旋后位复位并维持68w。 Bado（1967）同意Evans观点，认为保守治疗是新鲜孟氏骨折的最好治疗办法。 Boyd和Bo
10、als（1969）建议加压钢板或髓内钉坚强固定尺骨，但桡骨头应闭合复位，除非闭合复位失败，否则并无切开复位的指征。,治疗方法,Closed reduction maneuvers are not always successful and can cause secondary damage to the nerves and soft tissues(compartment syndrome). The so-called golden standard treatment of the Monteggia dislocation is the open reduction and inte
11、rnal fixation of the ulna fracture accompanied by closed reduction of the radial head.Christoph Josten, Susanne Freitag,Monteggia and Monteggia-like-lesions:Classification, Indication, and Techniques in Operative Treatment ,European Journal of Trauma and Emergency Surgery,2008,治疗方法,过去治疗孟氏骨折常采用闭合复位及石
12、膏制动，但现在认为闭合复位仅对小儿患者疗效较好。成人孟氏骨折治疗仍存在着争议，推荐对尺骨骨折行切开复位、加压钢板内固定及对桡骨头脱位进行闭合复位。田伟，积水潭实用骨科学，2007,治疗方法,手术指征 手法复位失败或复位后不稳定重新移位者； 尺骨多段骨折及桡骨小头骨折者； 尺骨开放性骨折需作清创者； 多发性骨折需要切开复位； 伴有神经损伤者。 陈旧性损伤，肘关节伸届功能受限及前臂旋转障碍者。,治疗方法,Treatment of the Ulna FractureAfter osteosynthesis of the ulna using a 3.5-mm lowcontact dynamic c
13、ompression plate, the radial head frequently goes back to its anatomical position .An angle stable plate does not provide any advantages. Korner H, Diederichs G, Arzdorf M, Lill H, Josten C, Schneider E,Linke B. A biomechanical evaluation of methods of distal humerus fracture fixation using locking
14、compression plates versusconventional reconstruction plates. J Orthop Trauma 2004;18:28693.Korner J, Lill H, Muller LP, Rommens PM, Schneider E, Linke B.The LCP concept in the operative treatment of distal humerus fractures-biological, biomechanical and surgical aspects. Injury 003;34:B2030. Korner
15、et al. mentioned that in three cases the medial positioning of the dorsal plate causes an nonphysiological dorsal angulation of the ulna. This leads to a dorsal subluxation of the radial head.Therefore, dorsalradial plate application is the best choice. Korner J, Hoffmann A, Rudig L, Mller LP, Hessm
16、ann M, Lill H,Josten C, Rommens PM. Monteggia injuries in adults: critical analysis of injury pattern, management and results. Unfallchirurg 2004;11:102640.,a, b) A 57-year-old woman with Bado Type II, Jupiter Type IIc, Mason type II fracture.,c, d) Treatment with lowcontact dynamic compression plat
17、e, resection of a little radial head fragment, and refixation of the radial capsule and ligament by anchors.,eh) Functional outcome 5 months after primary osteosynthesis.,治疗方法,Treatment of the Ulna FractureA huge defect of the ulna should be reconstructed by bone graft. The bone graft in turn should
18、 be attached on the medial side to avoid a radioulnar synostosis.The tension band wiring should be used only if there is a simple oblique fracture of the olecranon or if osteosynthesis of the ulna using the plate has failed,治疗方法,Treatment of the luxation of the Radial Head An open reduction of the r
19、adial head is usually not necessary and should only be done if a subluxation of the radial head remains. In this case, a reconstruction of the Lig. anulare could be tried by suture. Lill, H, Korner J, Josten C. Luxationen und Instabilitten In:Josten C, Lill H, eds. Ellenbogenverletzungen. Darmstadt:
20、Steinkopff, 2002;11821. A persistent radial head luxation is usually caused by an insufficiently stabilized fracture of the ulna or by soft tissue interpositioning in the radioulnar joint. 环状韧带重建有大腿阔筋膜、尺骨背侧桡侧（前臂）深筋膜、肱二头肌腱、肱三头肌腱、掌长肌腱等等。 经过多年的争论，趋于一致的意见是桡骨头脱位并无手术的必要。如尺骨内固定坚强，亦无必要重建环状韧带。王亦璁，骨与关节损伤(第四版)
21、，2007,治疗方法,术前有桡神经损伤症状，不主张同时进行神经探查。 尺骨粉碎：要获得解剖长度难度很大，可借助于桡骨头稳定复位后。 桡尺骨双骨折：不主张一个切口同时显露。,治疗方法,切口：Boyd切口，兼顾尺骨骨折和桡骨头脱位。,A 通过一个切口显露桡骨头脱位和尺骨骨折,治疗方法,Boyd切口,B 游离深筋膜条，其基地位于桡骨颈平面,治疗方法,Boyd切口,C 桡骨近端脱位已复位，在桡骨颈部位缝合新的环状韧带，加压钢板固定尺骨骨折,治疗方法,切口：改良Henry切口。,A、切口；B、筋膜已经切开，显露外侧的肱桡肌和内侧的肱二头肌、肱肌，纤维束已经切开，以便在内侧的肱二头肌腱、旋前圆肌和外侧的肱
22、桡肌之间向深部分离。,治疗方法,切口：改良Henry切口。,C、进入深部显露桡神经，保护桡神经及其感觉支，结扎、切断桡侧返支动脉。,治疗方法,切口：改良Henry切口。,D、虚线表示准备沿关节囊做的切口，即旋后肌内侧缘显露桡骨小头和桡骨近端。,治疗方法,切口：改良Henry切口。,E、前臂旋后，翻转旋后肌，完成入路，经过旋后肌的桡神经得以保护。,治疗方法,儿童孟氏骨折： 型：根据尺骨损伤来确定治疗方案,手术指征：1、尺骨复位失败2、桡骨头复位失败,治疗方法,儿童闭合复位，只要桡骨头复位可以维持，10左右的成角是可以接受的。,治疗方法,儿童孟氏骨折： 型：治疗目的，复位桡骨头，恢复尺骨对线。闭合
23、复位常可取得较满意的结果。 型：手术治疗的比例高达12%，但非手术治疗几乎对所有患者有效。 型：较大年龄的儿童推荐使用钢板固定桡骨骨折，可采用Henry切口，关节内有软组织嵌插可用Boyd切口,治疗方法,儿童：陈旧性？先天性？,儿童陈旧性孟氏骨折,伴尺骨较大成角、桡骨小头脱出关节并过度生长等严重畸形的陈旧性孟氏骨折临床少见。手术治疗目前尚无统一、规范、疗效可靠的方法。,治疗方法,儿童陈旧性孟氏骨折 several operative procedures have been proposedligament reconstruction韧带重建ulnar corrective osteotom
24、y尺骨截骨矫形术ulnar bending osteotomy尺骨弯曲（成角）截骨术 combined ulnar bending and lengthening osteotomy尺骨弯曲截骨合并延长术 gradual lengthening and angulation of the ulna尺骨逐步延长和成角术 ulnar osteotomy combined with radial shortening尺骨截骨合并桡骨短缩术 rotation osteotomy of the radius桡骨旋转截骨术 ulnar osteotomy and anular ligament recon
25、struction尺骨截骨合并韧带重建术Koichi Nakamura, Kazuhiko Hirachi, Shigeharu Uchiyama, Masatoshi Takahara, Akio Minami, Toshihiko Imaeda and Hiroyuki Kato, Long-Term Clinical and Radiographic Outcomes After Open Reduction for Missed Monteggia Fracture-Dislocations in Children,J Bone Joint Surg Am. 2009;91:1394-
26、1404. doi:10.2106/JBJS.H.00644,1983-2005年 22例陈旧性孟氏骨折,Each patient had been managed with open reduction of the radial head combined with a posterior bending elongation ulnar osteotomy and anular ligament reconstruction.,A twelve-year-old girl reported that she had fallen from a bar at the age of six
27、years.,open reduction with use of a posterior angulation and elongation ulnar osteotomy and anular ligament reconstruction with use of the remnant of the anular ligament augmented by the forearm fascia（前臂深筋膜）,屈曲16，延长13mm，术后6年随访病人没有不适，X片示桡骨头复位良好，没有骨性关节炎改变，术后MEPI（Mayo Elbow Performance Index）评分是100.,结
28、果：在开放复位时，年龄越大同时伤后到手术时间间隔长，其结果越差。手术年龄小于12岁，或受伤到切开复位的时间间隔小于3年的患者行切开复位，预期达到良好的临床和放射学结果，没有出现桡骨小头的半脱位或者肘关节骨性关节炎的改变。,治疗方法,小儿陈旧性孟氏骨折 TWO CASE REPORT：Stable relocation of the radial head without annular ligament reconstruction using the Ilizarov technique. Kawoosa et al. Journal of Medical Case Reports 2010
29、, 4:344,治疗方法,Sketch showing planning for reduction of the radial head with hyperangulation of the regenerate in the anteriorposterior and lateral planes.,Postoperative radiograph during disraction lengthening（牵张延长） The regenerated bone healed at an average rate of three weeks/cm,Radiograph taken at
30、two years after surgery showing relocation of the radial head,治疗方法,At follow-up two years after surgery,治疗方法,尺骨延长、桡骨缩短双截骨刘威，伴严重畸形的小儿陈旧性孟氏骨折修复重建，中国修复重建外科杂志2008年8月第22卷第8期,治疗方法, 尺骨楔形截骨块大小的确定：尺骨截骨均采用底为成角畸形顶点，尖对畸形最凹处的楔形截骨，用1张透光性较好的纸，沿骨皮质将畸形尺骨描下来(图2)，以畸形最明显处为界分别画出远、近段尺骨的纵轴线M、N，两线交角a即为尺骨畸形角度。于尺骨畸形最凹点A向M、N作
31、垂线并延长，分别与凸侧皮质相交于B、C点，根据几何学中的等角定理，AB与AC的夹角B等于a，测出B、C两点间长度，根据x线片上的比例尺换算出实际长度，即为楔形截骨的楔形底长度。 桡骨短缩长度的确定：于尺骨冠状突基底作一尺骨近段纵轴线的垂线，该垂线与桡骨近段纵轴线交点至桡骨小头凹的长度，除以2即为桡骨短缩截骨的长度。,治疗方法,3个月后,Reported complications,malunion畸形愈合; nonunion骨不连; infection感染; Refracture after Hardware Removal内固定拆除后再骨折; redislocation of radial
32、head桡骨头再脱位; proximal radio-ulnar synostosis近端的桡尺骨融合; posterolateral rotator instability of the ulnohumeral joint肱尺关节后外侧的旋转不稳; instability of the distal radio-ulnar joint远端桡尺关节不稳; osteoarthrosis following malunion of coronoid process冠状突畸形愈合导致骨关节病; nerve injuries神经损伤; failure of one-third tubular plat
33、es1/3管型钢板失效.,康复要点,The refracture incidence of the ulna after metal removal ranges between 4 and 25% . We recommend not removing the material for 1824 months. Korner J, Lill H, Josten C. Monteggiaverletzungen. In: Josten C,Lill H, eds. Ellenbogenverletzungen. Darmstadt: Steinkopff,Darmstadt, 2002:123
34、36.,Good or excellent results after Monteggia fracture occur due to correctly classifying the type of fracture and providing a stable anatomical reduction.Despite good care, the complication rate of Monteggia fracture is high . It is not uncommon that there is a remaining loss of range of motion of
35、the elbow after Monteggia fracture; this demands treatment by open arthrolysis to improve the range of motion.,What Is Your Diagnosis?,内固定术后复查X光,孟氏骨折虽非常见，但别遗忘了它！,Thanks for listening,Type 1(anterior) Monteggia fracture 前侧型或伸直型,Mechanism of injury 型孟氏骨折既可因跌倒、过伸、前臂极度旋前所造成，亦可因尺骨背侧的直接打击所造成。多见于儿童。（Evans、
36、Bado）60% 过伸理论（过伸、牵拉、骨折）,Type 2(posterior) Monteggia fracture 后侧型或屈曲型,Mechanism of injury Peurose(1951)描述了此型骨折的创伤机制，他认为相似于肘关节后脱位，但此种类型骨折尺骨上端附着的韧带较尺骨骨质更为坚固 。当暴力作用时，肘关节呈微屈曲状，前臂旋前位置。多见于成年人。15%,The classification of Type II Bado injuries into four subtypes by Jupiter et al. Jupiter JB, Leibovic SJ, Ribba
37、ns W, Wilk R. The posterior Monteggia lesion. J Orthop Trauma 1991;5:395402.,Type 2a: Intra-articular fracture of the olecranon with a fracture of the coronoid process. Type 2b:Extra-articular fracture of the olecranon without an involvement of the coronoid process. Type 2c: Proximal fracture of the
38、 ulna. Type 2d: Proximal multifragment fracture of the ulna.,Type 3(lateral) Monteggia fracture 外侧型或内收型,Mechanism of injury Bado(1967) 认为该型骨折是由肘内侧面的直接打击伤所造成的。此种损伤仅见于儿童而成人鲜见。20%,肘关节呈伸展位，前臂呈旋前位，由于上下外力传导至肘部在肘内侧向外侧作用。该型尺骨骨折多呈纵形劈裂或青枝骨折，移位不明显，容易被忽略误诊。,Type 4 Monteggia fracture 特殊型,radial head is subluxed in this picture,Mechanism of injury 多数学者认为，其损伤机制与伸直型骨折相同，但又合并桡骨骨折，可能在桡骨头脱位后，桡骨又受到第二次创伤所致。5%,
