目的：介绍一种以上尺桡关节分离程度为分型依据的新鲜儿童孟氏骨折新分型,探讨及评价该新分型指导临床治疗方式选择的疗效。方法采用前瞻性研究方法,对2007年1月至2012年12月收治的125例新鲜儿童孟氏骨折患者进行了研究,采用孟氏骨折新分型标准对患者进行分型,各分型内患者按门诊号或住院号的单双进行分组：单号为 A组,患者先接受闭合手法复位进行治疗,若闭合手法复位失败则转为手术治疗；双号为 B组,患者均接受手术治疗。其中,属于新分型中Ⅰ型的患者共66例,接受闭合手法复位治疗的共37例(ⅠA组),接受手术治疗的共31例(ⅠB组,包括ⅠA组中2例闭合手法复位失败者)；属于新分型中Ⅱ型的患者共55例,接受闭合手法复位治疗的共26例(ⅡA组),接受手术治疗的共44例(ⅡB 组,包括ⅡA 组中15例闭合手法复位失败者)；属于新分型中Ⅲ型的患者共4例,接受闭合手法复位治疗的共2例(ⅢA组),接受手术治疗的共4例(ⅢB组,包括ⅢA组中2例闭合手法复位失败者)。按 H SS肘关节功能评分标准对各组患者治疗6个月后肘关节功能的优良率进行统计分析。对于闭合手法复位失败的患者,肘关节功能优良率视为差。结果9例患者失去随访,116例患者获得随访(随访率92.8%),随访时间9~31个月(平均18.9个月),其中属于新分型Ⅰ型的共61例,新分型Ⅱ型的共51例,新分型Ⅲ型的共4例,接受闭合手法整复的共60例,接受手术治疗的共75例(包括闭合手法复位失败的19例)。12例合并桡神经损伤的患者,在桡骨头复位后8~12周均开始恢复。ⅠA组中优28例,良2例,可2例,差2例,优良率88.2%；ⅠB组中优25例,良2例,可2例,差0例,优良率93.1%；两组患者优良率比较,差异无统计学意义(P=0.822)。ⅡA组中优1例,良3例,可5例,差15例,优良率16.7%；ⅡB 组中优34例,良2例,可6例,差0例,优良率85.7%；两组患者优良率比较,差异有统计学意义(P =0.000)。ⅢA组中优0例,良0例,可0例,差2例,优良率0.0%；ⅢB组中优2例,良1例,可1例,差0例,优良率75.0%；两组患者优良率比较,差异无统计学意义(P=0.400)。结论以上尺桡关节分离程度为分型依据的新鲜儿童孟氏骨折新分型指导临床治疗方式的选择,能取得不错的临床疗效,其中属于新分型Ⅰ型者应首选闭合手法复位治疗,属于新分型Ⅱ型及Ⅲ型者,应首选手术治疗。
目的：介紹一種以上呎橈關節分離程度為分型依據的新鮮兒童孟氏骨摺新分型,探討及評價該新分型指導臨床治療方式選擇的療效。方法採用前瞻性研究方法,對2007年1月至2012年12月收治的125例新鮮兒童孟氏骨摺患者進行瞭研究,採用孟氏骨摺新分型標準對患者進行分型,各分型內患者按門診號或住院號的單雙進行分組：單號為 A組,患者先接受閉閤手法複位進行治療,若閉閤手法複位失敗則轉為手術治療；雙號為 B組,患者均接受手術治療。其中,屬于新分型中Ⅰ型的患者共66例,接受閉閤手法複位治療的共37例(ⅠA組),接受手術治療的共31例(ⅠB組,包括ⅠA組中2例閉閤手法複位失敗者)；屬于新分型中Ⅱ型的患者共55例,接受閉閤手法複位治療的共26例(ⅡA組),接受手術治療的共44例(ⅡB 組,包括ⅡA 組中15例閉閤手法複位失敗者)；屬于新分型中Ⅲ型的患者共4例,接受閉閤手法複位治療的共2例(ⅢA組),接受手術治療的共4例(ⅢB組,包括ⅢA組中2例閉閤手法複位失敗者)。按 H SS肘關節功能評分標準對各組患者治療6箇月後肘關節功能的優良率進行統計分析。對于閉閤手法複位失敗的患者,肘關節功能優良率視為差。結果9例患者失去隨訪,116例患者穫得隨訪(隨訪率92.8%),隨訪時間9~31箇月(平均18.9箇月),其中屬于新分型Ⅰ型的共61例,新分型Ⅱ型的共51例,新分型Ⅲ型的共4例,接受閉閤手法整複的共60例,接受手術治療的共75例(包括閉閤手法複位失敗的19例)。12例閤併橈神經損傷的患者,在橈骨頭複位後8~12週均開始恢複。ⅠA組中優28例,良2例,可2例,差2例,優良率88.2%；ⅠB組中優25例,良2例,可2例,差0例,優良率93.1%；兩組患者優良率比較,差異無統計學意義(P=0.822)。ⅡA組中優1例,良3例,可5例,差15例,優良率16.7%；ⅡB 組中優34例,良2例,可6例,差0例,優良率85.7%；兩組患者優良率比較,差異有統計學意義(P =0.000)。ⅢA組中優0例,良0例,可0例,差2例,優良率0.0%；ⅢB組中優2例,良1例,可1例,差0例,優良率75.0%；兩組患者優良率比較,差異無統計學意義(P=0.400)。結論以上呎橈關節分離程度為分型依據的新鮮兒童孟氏骨摺新分型指導臨床治療方式的選擇,能取得不錯的臨床療效,其中屬于新分型Ⅰ型者應首選閉閤手法複位治療,屬于新分型Ⅱ型及Ⅲ型者,應首選手術治療。
목적：개소일충이상척뇨관절분리정도위분형의거적신선인동맹씨골절신분형,탐토급평개해신분형지도림상치료방식선택적료효。방법채용전첨성연구방법,대2007년1월지2012년12월수치적125례신선인동맹씨골절환자진행료연구,채용맹씨골절신분형표준대환자진행분형,각분형내환자안문진호혹주원호적단쌍진행분조：단호위 A조,환자선접수폐합수법복위진행치료,약폐합수법복위실패칙전위수술치료；쌍호위 B조,환자균접수수술치료。기중,속우신분형중Ⅰ형적환자공66례,접수폐합수법복위치료적공37례(ⅠA조),접수수술치료적공31례(ⅠB조,포괄ⅠA조중2례폐합수법복위실패자)；속우신분형중Ⅱ형적환자공55례,접수폐합수법복위치료적공26례(ⅡA조),접수수술치료적공44례(ⅡB 조,포괄ⅡA 조중15례폐합수법복위실패자)；속우신분형중Ⅲ형적환자공4례,접수폐합수법복위치료적공2례(ⅢA조),접수수술치료적공4례(ⅢB조,포괄ⅢA조중2례폐합수법복위실패자)。안 H SS주관절공능평분표준대각조환자치료6개월후주관절공능적우량솔진행통계분석。대우폐합수법복위실패적환자,주관절공능우량솔시위차。결과9례환자실거수방,116례환자획득수방(수방솔92.8%),수방시간9~31개월(평균18.9개월),기중속우신분형Ⅰ형적공61례,신분형Ⅱ형적공51례,신분형Ⅲ형적공4례,접수폐합수법정복적공60례,접수수술치료적공75례(포괄폐합수법복위실패적19례)。12례합병뇨신경손상적환자,재뇨골두복위후8~12주균개시회복。ⅠA조중우28례,량2례,가2례,차2례,우량솔88.2%；ⅠB조중우25례,량2례,가2례,차0례,우량솔93.1%；량조환자우량솔비교,차이무통계학의의(P=0.822)。ⅡA조중우1례,량3례,가5례,차15례,우량솔16.7%；ⅡB 조중우34례,량2례,가6례,차0례,우량솔85.7%；량조환자우량솔비교,차이유통계학의의(P =0.000)。ⅢA조중우0례,량0례,가0례,차2례,우량솔0.0%；ⅢB조중우2례,량1례,가1례,차0례,우량솔75.0%；량조환자우량솔비교,차이무통계학의의(P=0.400)。결론이상척뇨관절분리정도위분형의거적신선인동맹씨골절신분형지도림상치료방식적선택,능취득불착적림상료효,기중속우신분형Ⅰ형자응수선폐합수법복위치료,속우신분형Ⅱ형급Ⅲ형자,응수선수술치료。
Objective It is widely accepted that the closed reduction should be performed in priority in the choices of treatment for the fresh Monteggia fractures of the children.If the closed reduction failed,surgical intervention should be chosen.However,although most of the patients with the closed reduction can reach satisfactory outcomes,it is possible that the reduction may be failed and exacerbate the psychic trauma of the patients and their parents.Moreover,excessive repeated closed reduction could also make more disruption of local soft tissue around the elbow joint.Based on many years clinical observation,we introduced a new clinical classification for fresh Monteggia fracture of children,including three types:type 1 ulnar fracture with mild separation of the upper radioulnar joint and subdislocation of the humeroradial joint,type 2 ulnar fracture with severe separation of the upper radioulnar joint and complete dislocation of the humeroradial joint,and type 3 fractures of both ulnar and radius with dislocation of the radial head.We recommend closed reduction for the type I inj ury, and surgical intervention for type 2 and 3 fractures.Methods In the present study,125 patients of acute Monteggia fractures from Jan 2007 to Dec 2012 were discussed according to the classification mentioned above. During this follow-up,9 patients were lost to follow up,1 1 6 patients were successfully followed for 9 to 31 months (mean,18.9 months).The rate of follow-up was 92.8%.In this 116 patients,49 were left elbow injuries,and 67 were right elbow injuries.12 patients were associated with the radial nerve injury.Their ages ranged from 1 to 14 years (mean,4.7 years). Time since injury ranged from 1 hour to 26 hours (mean,4.2 hours).(1)Inclusion criteria:①Patients suffered from Monteggia fractures according to the new classification,aged less than 1 8 years②Time since inj ury <3 weeks③Fresh fracture,not treated by other hospital (2 )Exclusion criteria:①open fracture;②complicated by acute compartment syndrome which need emergency intervention;③any disease history threatening life,such as malignant tumors;④severe mental disease or disability to live himself in daily life;⑤poor in compliance or deny to participate in the trial program;⑥participated in other trial program in 1 month before the follow-up;⑦any conditions that researcher considered would influence the effectiveness or safety of the trial.All fractures were classified according to the new classification system.Then the patients were randomized into two groups based on their ID number of outpatient or inpatient.Those with odd ID number were allocated to group A,and those with even ID number were distributed into group B.Patients in group A were in the treatment of closed reduction. Operation would be performed if closed reduction failed. Patients in group B were treated by operation.Sixty six fractures were classified as type Ⅰ.GroupⅠA had 37 patients who received closed manipulation.GroupⅠB were composed of 3 1 patients who received surgical operation.Fifty five cases were classified as type Ⅱ,26 cases in group ⅡA,and 44 cases in group ⅡB.The reduction failed in 1 5 cases from the group ⅡA.Only four cases were classified as type Ⅲ.Two cases originally arranged in group ⅢA failed in the closed treatment,so all the 4 cases of type Ⅲ were in group ⅢB. The clinical outcomes were analyzed during the 6 months after the initial treatment.(3 )Treatment Methods:①Closed Reduction Group:The deformity of the ulnar or radius was first corrected,then the dislocation of the radial head was reduced.The patient was placed in supine position,after the brachial plexus block or general anesthesia,the shoulder was abducted with the extended elbow and the supination of the forearm.Two assistants held the distal upper arm and the wrist joint,respectively. The surgeon held the ends of the fracture site,and pressed the ulnar fracture ends in the opposite direction of the angular deformation by lifting and pressing methods,which could make the angular and overlap deformity corrected.Then the surgeon pressed the radial head in the opposite direction of dislocation and reduced the radial head.The reduction was considered as successful if the raidal head did not dislocate again while the elbow was slightly flexed.For patients with both ulnar and radius fractures,the ulnar and radius overlap and angular deformity should be first corrected,and then the dislocation of the radial head was restored.The reduction could be performed twice more following the failure of the first reduction.②Operation group:This group were treated by open reduction and internal fixation.Boyd incision was made along the posterior-lateral side of the elbow joint with a length of 10 cm.The skin,subcutaneous tissue and fascia were cut,then the ulnar and radius were visible.The fractures were anatomically reduced and fixed with plates.Then the radial head was reduced with the elbow flexed to 90 degrees.A 1.4mm Kirschner wire was inserted into the posterior elbow side along the radius canal to fix the humeroradial joint.The cast was immobilized at the elbow in the flexion of 90 degrees.The Kirschner wire was removed 6 weeks postoperatively and functional exercise began.The plates were removed 3 months postoperatively.③Management of the radial nerve inj ury:1 2 patients were combined with radial nerve inj ury, but were not treated by the nerve exploration.Only drugs were used to restore the nerve function.The symptoms started to recover during the 8 to 1 2 weeks after the restoration of the radial head.Results 1 1 6 patients were followed up.The mean period of the follow-up was 18.9 months (range,9-31 months).Nine cases were lost to follow up.The rate of the follow-up was 92.8%.Sixty one cases from typeⅠ,51 cases from type Ⅱand 4 cases from type Ⅲ were successfully followed up.The functional outcome was evaluated using the HSS scoring.The outcome would be regarded as bad if closed reduction failed in group A.There were no significant differences both between group ⅠA and ⅠB (P =0.822>0.05),and between group ⅢA and ⅢB (P =0.40>0.05).The difference between groupⅡA andⅡB was statistically significant (P =0.00<0.05 ).Discussion Though multiple classification systems for Monteggia fracture exist in clinical application,the Bado classification is most commonly used,which divides the Monteggia fracture into 4 types according to the direction of radial head dislocation in the imaging examination.For its neglect of the separation of the upper radioulnar joint,the Bado classification can not guide the prime clinical choice.Through the long-term clinical observation,we found that the operation would be needed because the closed reduction frequently failed in those patients with the so-called complete dislocation of the humeroradial joint,which was shown by X-ray that the distance between the radial side of the coronoid process and the medial side of the radial head was larger or equal to the width of the radial head in anteroposterior position of the elbow,or the inferior border of the radial head totally were separated with the superior border of the ulnar in lateral position. Comparatively,the mild separation of the upper radioulnar joint may be generally treated by the closed reduction.Severe separation of the upper radiounlar joint is mostly caused by high energy trauma, which could make the annular ligament totally ruptured and lose its constraint of the radial head.The ruptured annular ligament and the adjacent soft tissue would be entrapped into the joint space,which could impede the restoration of the radial head.Even the closed reduction was successfully performed, the unstable ends of the ulnar fracture site might be easily displaced after the fixation of the splint or cast.However,the patients with the mild separation of the upper radioulnar joint usually suffered the relatively lower energy trauma.In addition,the radial head epiphysis of the children were more fragile compared with their ligaments.Therefore,those radial heads were dislocated from the inferior border of the annular ligament,and the rupture of the annular ligament did not occur in most of those patients.After the correction of the greenstick fracture deformity or displacement,their radial head could always be restored to its position,and good clinical outcomes would be obtained due to their low possibility of redisplacement or redislocation.Conclusions The new classification method can facilitate the treatment for the Monteggia fracture.Closed reduction should be the prime choice for the type Ⅰfracture,and operation would be recommended for the typeⅡ and Ⅲ fractures.It could obtain satisfactory clinical outcomes to choose the appropriate treatment according to the new classification system.Meanwhile,unnecessary iatrogenic inj ury could be avoided.Considering that the sample size of our study is limited,more observation and investigation need to be further performed.
