【专题文献】粉碎性桡骨头骨折内固定与切除之比较
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Comminuted Fractures of the Radial Head: Comparison of Resection and Internal Fixation Surgical Technique
By Masayoshi Ikeda, MD, PhD, Kazuhiro Sugiyama, MD, Chonte Kang, MD, Tomonori Takagaki, MD, and Yoshinori Oka, MD, PhD
粉碎性桡骨头骨折：切除与内固定的对比
ABSTRACT
BACKGROUND:Satisfactory internal fixation of comminuted radial head fractures is often difficult to achieve, and radial head resection has been the accepted treatment. In this study, we compared the results of radial head resection with those of open reduction and internal fixation in patients with a comminuted radial head fracture.
摘要
背景：桡骨头粉碎性骨折内固定的效果常难以令人满意，因此，常进行桡骨头切除术。在本研究中， 我们对桡骨头粉碎性骨折采用切除与内固定的结果进行了对比。
METHODS:
Twenty-eight patients with a Mason type-III radial head fracture (some with associated injuries) were enrolled in the study. Fifteen patients underwent radial head resection as the initial treatment (Group I), and thirteen patients underwent open reduction and internal fixation (Group II). The age at the operation averaged 41.1 and 38.2 years, respectively, and the duration of follow-up averaged ten and three years, respectively. The outcomes were assessed on the basis of pain, motion, radiographic findings, and strength measured with Cybex testing. The overall outcome was rated with the functional rating score described by Broberg and Morrey and with the American Shoulder and Elbow Surgeons Elbow Assessment Form.
方法：本研究中共28例Mason- III桡骨头骨折（部分有合并伤）。15例采用桡骨头切除为初始治疗（组1）。13例采用切开复位内固定（组2）。两组的平均年龄分别为41.1岁和38.2岁，随访时间分别为10年和3年。随访结果根据疼痛、活动、放射学表现、Cybex测试力量试验等进行评估。总体结果采用Broberg 和Morrey的功能等级评分和美国肩肘外科肘关节评估表进行评定。
RESULTS:
Elbow motion averaged 15.5° (extension loss) to 131.4° (flexion) in Group I and 7.1° to 133.8° in Group II. The carrying angle and ulnar variance averaged 8.2° and 1.9 mm in Group I and 1.5° and 0.5 mm in Group II. Compared with Group II, Group I had a loss of strength in extension, pronation, and supination (p < 0.01). The Broberg and Morrey functional rating score averaged 81.4 points in Group I and 90.7 points in Group II (p = 0.0034). The score on the American Shoulder and Elbow Surgeons Elbow Assessment Form averaged 87.3 points in Group I and 94.6 points in Group II (p = 0.0031).
结果：组1的肘关节活动度平均为15.5°（伸直丢失）～131.4°（屈曲），组2为7.1° ～133.8°。组1的携带角和尺骨变异分别为8.2°和1.9mm，组2为1.5°和0.5mm。组1的伸直、旋前、旋后力量小于组2（p< 0.01)。组1的Broberg 和Morrey的功能等级评分平均为81.4分，而组2为90.7分(p = 0.0034)。美国肩肘外科肘关节评估表的分数在组1为87.3分，组2为94.6分(p = 0.0031)。
CONCLUSIONS:
The patients in whom the comminuted radial head fracture was treated with open reduction and internal fixation had satisfactory joint motion, with greater strength and better function than the patients who had undergone radial head resection. These results support a recommendation for open reduction and internal fixation in the treatment of this fracture.
结论：桡骨头粉碎性骨折的病人，采用切开复位内固定者较桡骨头切除者具有满意的关节活动，力量更强，功能更好。根据该结果，推荐对桡骨头粉碎性骨折采用切开复位内固定。
INTRODUCTION
The operative treatment of displaced comminuted radial head fractures, such as a Mason type-III fracture1, has been controversial because there is conflicting evidence supporting both resection and open reduction and internal fixation2-6. However, in our study, we concluded that if a comminuted radial head fracture could be stabilized satisfactorily with internal fixation, the results after open reduction and internal fixation with regard to strength and overall functional outcome were better than those after radial head resection.
介绍
移位型桡骨头粉碎性骨折（Mason- III）的治疗是有争议的，因为不管是桡骨头切除还是切开复位内固定均有支持的证据。但是根据我们的研究，我们认为，如果粉碎的桡骨头骨折可以通过内固定获得满意的稳定，其力量和总体功能结果均优于桡骨头切除。
In recent years, the advent of the self-tapping cannulated Herberttype screws and low-profile mini-plates has made internal fixation of comminuted fractures of small bones possible. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow following fixation of type-III radial head fractures. Our current approach to the fixation of a comminuted fracture either with cannulated Herbert-type screws or with a combination of a low-profile mini-plate and cannulated Herbert-type screws is described below.
近年来，随着自攻空心Herbert钉和低切迹迷你钢板的发明，粉碎性小骨骨折内固定已成为可能。精细的手术技术加上坚强的内固定，允许Mason- IIHerbert钉I型桡骨头粉碎性骨折术后进行前臂和肘关节早期活动。我们将桡骨头粉碎性骨折单独采用Herbert钉或联合低切迹钢板进行固定的方法介绍如下。
FIG. 1
Patient positioning and skin incision. The upper arm is slightly abducted, the elbow extended, and the forearm pronated on the hand table.
图1 患者体位及皮肤切口。 患肢轻度外展，肘关节伸展，前臂内旋置于手外科台。
All fractures are not internally fixed with the same procedure because of the variations in the type and severity of the fracture and the associated injuries. Furthermore, we have pursued a refined technique to fix these fractures rigidly and less invasively, and with adaptations that are necessary to manage each fracture.
所有的骨折并不采用相同的方法进行内固定，因为骨折的类型和严重程度以及伴随伤均不同。而且，我们对每个骨折都采用了精细的技术进行骨折坚强固定，微创、个体化治疗。
SURGICAL TECHNIQUE
The patient is placed under general anesthesia and is positioned supine on the operating table with the arm supported on a hand table. A tourniquet is applied, and the arm is prepared and draped while, at the same time, the ipsilateral iliac crest is prepared and draped for cancellous bone-graft harvest. The upper arm is slightly abducted, the elbow extended, and the forearm pronated on the hand table (Fig. 1).
手术技术
患者全麻后仰卧于手术床，上肢置于手外台。上止血带，辅巾，同时同侧髂嵴辅巾，以备取骨。上肢轻度外展，肘关节伸展，前臂旋前（图1）。
Figs. 2-A, 2-B, and 2-C Access to the radial head. Fig. 2-A A short lateral approach beginning at the lateral epicondyle and ending a few centimeters distal to the radial neck.
图2－A，2－B，2－C。桡骨头入路。图2－A。外侧小切口，从肱骨外上髁向下延伸至桡骨颈。
After the arm is exsanguinated, a short Kocher lateral approach is made beginning at the lateral epicondyle and ending a few centimeters distal to the radial neck (Fig. 2-A). Then, the interval between the anconeus and the extensor carpi ulnaris or between the lower muscle fibers of the extensor carpi ulnaris is entered and the lateral collateral ligament complex is exposed (Fig. 2-B). A longitudinal incision is made in the anterior part of the lateral collateral ligament along its fibers extending from the lateral condyle to just distal to the radial neck through the annular ligament and capsule (Fig. 2-C). Thus, the longitudinal continuity of the lateral ligament complex is not disturbed. The fracture is identified, following irrigation of the intra-articular hematoma (Figs. 3 and 4).
上肢驱血后，做Kocher切口，从肱骨外上髁至桡骨颈远侧数厘米（图2A）。于肘后肌与尺侧腕伸肌之间或下方的尺侧腕伸肌纤维之间显露外侧副韧带（图2B），从外侧髁至桡骨颈远端沿外侧副韧带纤维前方做纵形切口，切开环状韧带和关节囊（图2C）。这样就可以不用破坏外侧副韧带的纵向连续性。确定骨折，冲洗去除关节内血肿（图3，4）。
FIG. 2-B
The interval between the anconeus and extensor carpi ulnaris is entered, and the radial
collateral ligament complex is exposed.
图2－B。于肘肌与尺侧腕伸肌之间进入，显露桡侧副韧带。
The fractured radial head fragments should not be detached from any remaining synovial or periosteal soft-tissue attachments, which can be used as checkreins to facilitate alignment and reduction. Any fragment that is tilted and impacted into the shaft is gently elevated to the anatomical level as a core fragment (Fig. 5, A). The remaining fragments are then reassembled to the core fragment. During the reduction process, cancellous bone defects may be encountered at the isthmus, between the neck and the shaft. Cancellous bone grafts should be used to fill these defects. The reduced fracture fragments are held with small forceps or tenacular clamps, or are temporarily fixed with 1.0-mm Kirschner wires (Fig. 5, B). When the fractured radial head fragments are large enough to hold a Herbert screw, they are fixed to each other (Fig. 5, C). The radial head is then fixed to the shaft with two lowprofile mini-plates (Stryker Leibinger, Freiburg, Germany)7. A Tshaped low-profile mini-plate, with a 0.55-mm profile height, and 1.7-mm-diameter screws are used. The screw head has a low profile and is countersunk into the plate. Two plates are applied opposite one another, ideally from the lower corner of the radial head to the shaft. The plates are bent to conform to the contour of the radial neck (Fig. 5, D). On the radial shaft, the screws should perforate the opposite cortex, and, on the radial head, the tips of the screws are inserted into subchondral bone but do not perforate the opposite articular cartilage. Placement of the plates is not limited to the socalled safe zone because they are applied to the lower corner of the radial head and are too thin to impinge on the proximal radioulnar joint with forearm rotation (Fig. 6). Any associated small fragments can be fixed with screws, and a thin marginal osteochondral fragment can also be secured with a plate if it is too thin to be fixed with a Herbert screw.
不要切断任何桡骨头碎片上的滑膜或骨上的软组织，这有助于复位和维持对位。轻轻抬高倾斜或嵌插的骨片，恢复至核心骨片的解剖高度（图5A），再将其余碎片装配至核心骨片。复位过程中，于桡骨颈与桡骨干之间的峡部可能有松质骨缺损，可以用松质骨充填骨缺损。复位的小骨片以小骨钳或骨镊维持，或以1mm的克氏针固定（图5B）。如果桡骨头的骨块够大，就可以用Herbert螺钉进行相互固定（图5C）。然后再将桡骨头用两块低切迹迷你板(Stryker Leibinger, Freiburg, Germany)固定至骨干。钢板要进行预弯，使之与桡骨颈外形一致（图5D）。于桡骨干处，螺钉要穿透对侧皮质，于桡骨头处，螺钉要位于软骨下，不要穿透对侧软骨。钢板的位置可以不必局限于安全区，因为它们用在桡骨头下方的切迹处，且由于很薄，当前臂旋转时，不会撞击桡尺关节（图6）。小的碎片均可以螺钉固定，如果骨软骨边缘碎片太薄，无法用Herbert螺钉进行固定的，也可以用钢板固定。
After fixation, the alignment and mobility of the radial head are examined both radiographically and by manually manipulating the forearm (Fig. 7). A suction drain tube is placed in the joint. The opening in the lateral collateral ligament and the annular ligament are repaired with number-1 nonabsorbable braided sutures. When the lateral collateral ligament has been avulsed from the lateral condyle, it is reattached with an anchoring system (GII Quick Anchor Plus System; DePuy Mitek, Johnson and Johnson, Raynham, Massachusetts).
固定后，体检并透视检查桡骨头的复位和活动情况（图7），关节内放置引流管。1号不吸收缝线编织缝合外侧副韧带和环状韧带。如果外侧副韧带从外侧髁上撕脱，用锚钉进行固定(GII Quick Anchor Plus System; DePuy Mitek, Johnson and Johnson, Raynham, Massachusetts)。
If there is an associated injury of the ulnar collateral ligament, it is repaired with number1 nonabsorbable braided sutures or an anchoring system through a medial approach. Prior to fixation of the radial head fracture, stay sutures are placed in the torn ulnar collateral ligament and then they are tied firmly only after fracture fixation. If the ulnar collateral ligament is repaired first, it sometimes becomes difficult to fix the fracture of the radial head. With the elbow at a right angle and the forearm in neutral rotation, a long-arm splint is applied. Two days after the operation, the suction drain is removed and the splint is changed to a long-arm cylinder cast to allow rotation exercises of the forearm, with the elbow held in a right angle position. Two weeks after the operation, the cast is changed to a hinged brace and active elbow movement is started. To protect the elbow from a lateral load, the brace is worn for four weeks. Depending on the stability, passive extension exercises of the elbow are initiated four to six weeks after the operation. The low-profile mini-plates are usually removed between five and seven months after repair (Fig. 8).
如果合并尺侧副韧带损伤，可以做内侧切口，用1号不吸收缝合线编织缝合，或用锚钉固定。于桡骨头固定前穿好缝线，于桡骨头固定后再拉紧缝线。如果先修复尺侧副韧带，有时固定桡骨头会变得很困难。肘关节屈曲90°前臂旋转中立位长夹板固定。两天后拔除引流管，更换为长臂管形石膏，肘关节直角固定，前臂可进行旋转功能锻炼。术后两周更换为肘关节绞链式支具，进行肘关节主动锻炼。为防止肘关节的横向负荷，支具戴4周。于术后4－6周，根据稳定性进行肘关节被动活动。术后5－7个月去除钢板（图8）。
FIG. 2-C
A longitudinal incision is made in the anterior part of the lateral collateral ligament along
its fibers extending from the lateral condyle to just distal to the radial neck through the
annular ligament and capsule.
图2－C。从外侧髁向桡骨颈方向沿外侧副韧带前缘纵形切开，切开环状韧带和关节囊，
FIG. 3
Anteroposterior radiograph demonstrating a Mason type-III radial head fracture.
图3。前后位X线片显示为Mason III型骨折
FIG. 4
Intraoperative photograph showing a Mason type-III radial head fracture consisting of two large fragments and a marginal fragment.
图4 术中照片显示该Mason III型骨折有两个大骨块和一个边缘骨块。
FIG. 5
The surgical process of reduction and internal fixation. A: The impacted and displaced fragments are reduced, preserving any attached synovial and periosteal membrane. B: The fracture fragments are elevated and reduced and temporarily fixed with thin Kirschner wires. Cancellous bone chips are used to graft any osseous defects. C: The large radial head fragments are fixed with two Herbert screws. D: Then the head and the shaft are connected with use of two low-profile mini-plates opposite one another.
图5
骨折复位内固定过程。A，复位嵌插与移位的骨片，保留骨块上的滑膜和骨膜。B，抬高复位骨块，临时以克氏针固定。骨缺损以松质骨进行植骨。C，大的桡骨头骨片以两枚Herbert螺钉固定。D，桡骨头与骨干通过两块低切迹迷你钢板相对固定。
FIG. 6
Fixation is achieved with two Herbert screws and two low-profile mini-plates.
图6：用两枚Herbert螺钉和两块低切迹迷你钢板固定。
FIG. 7
Postoperative anteroposterior radiograph of the fracture in Figure 6 after
fixation.
图7：图6骨折内固定术后。
FIG. 8
Intraoperative photograph showing a Mason type-III radial head fracture five months after fixation. A: Status of exploration. The plate is covered by synovial membrane. B: After plate removal.
图8。术中照片显示Mason III型桡骨头骨折术后5个月。A：探查显示钢板被滑膜包裹。B：钢板去除后。
FIG. 9
Mason type-III radial head fracture patterns. A: Fracture of the entire radial neck. The head is completely displaced from the shaft. B: An entire articular head fracture consisting of more than two large fragments. All fragments are completely displaced from the shaft. C: A fracture with a tilted and impacted articular segment.
图9
Mason –III型桡骨头骨折模式。A：桡骨颈完全骨折，桡骨头完全移位。B：桡骨头完全关节内骨折，由超过两块的大骨块组成。所有的骨块均完全移位。C：伴有关节骨块倾斜和嵌插。
FIG. 10 (CONTINUED)
Internal fixation of a comminuted radial head fracture with cannulated Herbert-type screws. A: Anteroposterior radiograph demonstrating a Mason type-IV fracture associated with a coronoid fracture. B: Intraoperative photograph showing the radial head fracture consisting of four large fragments. C: The fragments are reduced and fixed with guidewires. D: A cannulated Herbert-type screw is driven into the fragments. E: Three screws are used. The screws must penetrate and rigidly engage the opposite cortex of the shaft distally. The coronoid fracture was also fixed with a small screw through an anterior approach.
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图10
桡骨头粉碎性骨折以空心Herbert螺钉进行固定。A：正位片显示桡骨头Mason –IV型骨折伴有冠状突骨折。B：术中见桡骨头骨折由四块大骨块组成。C：骨块复位并以导针固定。D：一枚空心Herbert螺钉拧入骨折块中。E：用了三枚螺钉。螺钉必须穿透远端的对侧皮质，牢牢固定。冠状突骨折通过前路以一枚小螺钉固定。
Fig. 11-A A large tilted and impacted head fragment with a marginal articular fragment. Fig. 11-B The large head fragment is reduced and fixed with two cannulated Herbert-type screws, and the marginal articular fragment is fixed with a low-profile mini-plate.
图11
A：一个大的倾斜嵌插骨块和关节边缘碎块。B：大的桡骨头骨块以两枚Herbert螺钉固定，关节边缘骨块以一块低切迹迷你钢板固定。
CRITICAL CONCEPTS
INDICATIONS:
• Fresh displaced and comminuted fractures of the radial head, such as the following Mason type-III fractures: (A) a fracture of the entire radial neck, (B) an articular fracture involving the entire radial head in which all fragments are displaced completely from the shaft, or (C) a fracture with a tilted and impacted articular segment and some displaced articular fragments, which has the appearance of a Mason type-II fracture radiographically. When the displaced articular fragments are reduced, the tilted and impacted fragments must be elevated to completely restore head congruity (Fig. 9).
关键概念
适应症：
•新鲜的桡骨头移位粉碎骨折，如下面的Mason –III型骨折：A，桡骨颈骨折。B，桡骨头完全关节内骨折，骨块移位。C，骨块倾斜嵌插，伴有移位骨块。X线上表现为Mason –II型骨折。当移位的骨块复位时，必须抬高嵌插的骨块，以完全恢复桡骨头的外形（图9）。
• Mason type-IV fracture variations, which are defined as Mason type-III fractures associated with a fracture of the elbow, such as a coronoid fracture, and/or an elbow dislocation.
•Mason –IV型骨折变异，桡骨头为Mason –III型骨折，同时伴有肘关节骨折，如冠状突骨折或伴有肘关节脱位。
CONTRAINDICATIONS:
• Patients who are over seventy years of age, with poor general health, or those who will not participate in the postoperative rehabilitation protocol.
• Patients with comminuted fractures of the radial head who present more than four weeks after injury. With these patients, there is a risk of ectopic bone formation and the poor condition of the osteochondral fragments prevents effective reduction and fixation.
禁忌症
•年龄超过70岁，或术后不愿进行康复训练者。
•桡骨头粉碎性骨折已超过4周者，这些病人异位骨化的危险较高，同时骨软骨碎片难以进行复位固定。
PITFALLS:
• While placement of the plates is not limited to the “safe zone,” they should not be applied on the crown of the articular surface of the radial head. Even though the low-profile mini-plate is unlikely to impinge on the proximal radioulnar joint, it should be applied below the equator, to the lower corner of the radial head.
陷阱
桡骨头钢板的放置不要局限于安全区，但也不要放在关节面上。虽然低切迹的钢板不易引起上尺桡关节撞击，也要用在赤道下、桡骨头的下切迹处。
• Two plates should be used to connect the head and the shaft. These plates are placed opposite one another so that impaction between the head and the shaft can be achieved, creating some inherent stability. They should be bent to conform to the contour of the radial neck, so as to be flush with the surface. Instead of dual plating, an option is to use the cannulated Herbert-type screws as core fixation and additional low-profile mini-plate fixation for a small fragment or a marginal fracture fragment. Another option that may be used is multiple cannulated Herberttype screws. When they are used to connect the head fragment(s) to the shaft, the distal end of the screws should penetrate and rigidly engage the cortex of the shaft. However, advancing the screw too far might tilt and deform the radial head because of impaction of the head fragment against the shaft (Fig. 10).
•用两块板连接桡骨头与桡骨干，钢板要相对放置，以使头与干可以嵌紧，恢复部分即刻稳定。钢板要进行塑形，以适应桡骨颈的外形，使之与关节面处于同一平面。也可以用Herbert螺钉固定核心骨块，再以低切迹钢板固定边缘骨块或小骨块。也可以用多枚Herbert螺钉进行固定。当用Herbert螺钉固定桡骨头与骨干时，螺钉要穿透骨干处的对侧皮质。然而，如果螺钉拧得太进去，由于桡骨头骨块嵌入桡骨干，可能引起桡骨头变形和倾斜。• If there is an osseous defect between the radial head and shaft, cancellous bone should be grafted into the defect. The cancellous bone chips are inserted beneath the elevated fragment during reduction. If there is a central bone defect in the radial head and shaft, a strut cancellous bone block is inserted into the medullary canal and the head is reduced to it and the shaft and is fixed with low-profile mini-plates.
如果在桡骨头与桡骨干之间有骨缺损，可以用松质骨进行植骨。复位时，骨块抬高后，将松质骨植于其下。如果桡骨头和桡骨干中央骨缺损，可取一块松质骨块嵌入骨干的髓腔内，然后将桡骨头复位于骨块和骨干上，再以低切迹钢板固定。• The goal of the operation is accurate reduction and rigid internal fixation, which will allow early motion exercises of the forearm and elbow after surgery. However, shortening the neck approximately 1 to 2 mm can be allowed if the rotational alignment is acceptable. It is not necessary to completely reduce slight impaction of the head on the shaft; however, tilting should be corrected (Fig. 11).
•手术的目的在于精确的复位和坚强的固定，以允许早期功能锻炼。如果旋转力线可以接受，短缩1－2mm是可以接受的。轻度的嵌插没必要完全复位，但倾斜必须纠正（图11）。
• When there is an associated ulnar collateral ligament injury, it should be repaired with number-1 nonabsorbable braided sutures or a suture anchor system with use of a medial approach. Prior to fixation of the radial head fracture, the sutures are placed in the torn ulnar collateral ligament. Then they are firmly fastened after fixation because, once the ulnar collateral ligament is repaired, it is sometimes difficult to fix the fracture of the radial head.
•如果伴有尺侧副韧带损伤，可以做一个内侧切口，用1号不可吸收线进行编织缝合或锚钉固定。于桡骨头固定前穿好缝线，于桡骨头固定后再拉紧缝线。如果先修复尺侧副韧带，有时固定桡骨头会变得很困难。REFERENCES
1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42:123-32.
2. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5:1-10.
3. Kuntz DG Jr, Baratz ME. Fractures of the elbow. Orthop Clin North Am. 1999;30:37-61.
4. Morrey BF. Radial head fracture. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p 341-64.
5. Mezera K, Hotchkiss RN. Radial head fractures. In: Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures in adults. Volume 1. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2001. p 940-52.
6. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84:1811-5.
7. Ikeda M, Yamashina Y, Kamimoto M, Oka Y. Open reduction and internal fixation of comminuted fractures of the radial head using low-profile mini-plates. J Bone Joint Surg Br. 2003;85:1040-4.
By Masayoshi Ikeda, MD, PhD, Kazuhiro Sugiyama, MD, Chonte Kang, MD, Tomonori Takagaki, MD, and Yoshinori Oka, MD, PhD
粉碎性桡骨头骨折：切除与内固定的对比
ABSTRACT
BACKGROUND:Satisfactory internal fixation of comminuted radial head fractures is often difficult to achieve, and radial head resection has been the accepted treatment. In this study, we compared the results of radial head resection with those of open reduction and internal fixation in patients with a comminuted radial head fracture.
摘要
背景：桡骨头粉碎性骨折内固定的效果常难以令人满意，因此，常进行桡骨头切除术。在本研究中， 我们对桡骨头粉碎性骨折采用切除与内固定的结果进行了对比。
METHODS:
Twenty-eight patients with a Mason type-III radial head fracture (some with associated injuries) were enrolled in the study. Fifteen patients underwent radial head resection as the initial treatment (Group I), and thirteen patients underwent open reduction and internal fixation (Group II). The age at the operation averaged 41.1 and 38.2 years, respectively, and the duration of follow-up averaged ten and three years, respectively. The outcomes were assessed on the basis of pain, motion, radiographic findings, and strength measured with Cybex testing. The overall outcome was rated with the functional rating score described by Broberg and Morrey and with the American Shoulder and Elbow Surgeons Elbow Assessment Form.
方法：本研究中共28例Mason- III桡骨头骨折（部分有合并伤）。15例采用桡骨头切除为初始治疗（组1）。13例采用切开复位内固定（组2）。两组的平均年龄分别为41.1岁和38.2岁，随访时间分别为10年和3年。随访结果根据疼痛、活动、放射学表现、Cybex测试力量试验等进行评估。总体结果采用Broberg 和Morrey的功能等级评分和美国肩肘外科肘关节评估表进行评定。
RESULTS:
Elbow motion averaged 15.5° (extension loss) to 131.4° (flexion) in Group I and 7.1° to 133.8° in Group II. The carrying angle and ulnar variance averaged 8.2° and 1.9 mm in Group I and 1.5° and 0.5 mm in Group II. Compared with Group II, Group I had a loss of strength in extension, pronation, and supination (p < 0.01). The Broberg and Morrey functional rating score averaged 81.4 points in Group I and 90.7 points in Group II (p = 0.0034). The score on the American Shoulder and Elbow Surgeons Elbow Assessment Form averaged 87.3 points in Group I and 94.6 points in Group II (p = 0.0031).
结果：组1的肘关节活动度平均为15.5°（伸直丢失）～131.4°（屈曲），组2为7.1° ～133.8°。组1的携带角和尺骨变异分别为8.2°和1.9mm，组2为1.5°和0.5mm。组1的伸直、旋前、旋后力量小于组2（p< 0.01)。组1的Broberg 和Morrey的功能等级评分平均为81.4分，而组2为90.7分(p = 0.0034)。美国肩肘外科肘关节评估表的分数在组1为87.3分，组2为94.6分(p = 0.0031)。
CONCLUSIONS:
The patients in whom the comminuted radial head fracture was treated with open reduction and internal fixation had satisfactory joint motion, with greater strength and better function than the patients who had undergone radial head resection. These results support a recommendation for open reduction and internal fixation in the treatment of this fracture.
结论：桡骨头粉碎性骨折的病人，采用切开复位内固定者较桡骨头切除者具有满意的关节活动，力量更强，功能更好。根据该结果，推荐对桡骨头粉碎性骨折采用切开复位内固定。
INTRODUCTION
The operative treatment of displaced comminuted radial head fractures, such as a Mason type-III fracture1, has been controversial because there is conflicting evidence supporting both resection and open reduction and internal fixation2-6. However, in our study, we concluded that if a comminuted radial head fracture could be stabilized satisfactorily with internal fixation, the results after open reduction and internal fixation with regard to strength and overall functional outcome were better than those after radial head resection.
介绍
移位型桡骨头粉碎性骨折（Mason- III）的治疗是有争议的，因为不管是桡骨头切除还是切开复位内固定均有支持的证据。但是根据我们的研究，我们认为，如果粉碎的桡骨头骨折可以通过内固定获得满意的稳定，其力量和总体功能结果均优于桡骨头切除。
In recent years, the advent of the self-tapping cannulated Herberttype screws and low-profile mini-plates has made internal fixation of comminuted fractures of small bones possible. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow following fixation of type-III radial head fractures. Our current approach to the fixation of a comminuted fracture either with cannulated Herbert-type screws or with a combination of a low-profile mini-plate and cannulated Herbert-type screws is described below.
近年来，随着自攻空心Herbert钉和低切迹迷你钢板的发明，粉碎性小骨骨折内固定已成为可能。精细的手术技术加上坚强的内固定，允许Mason- IIHerbert钉I型桡骨头粉碎性骨折术后进行前臂和肘关节早期活动。我们将桡骨头粉碎性骨折单独采用Herbert钉或联合低切迹钢板进行固定的方法介绍如下。
FIG. 1
Patient positioning and skin incision. The upper arm is slightly abducted, the elbow extended, and the forearm pronated on the hand table.
图1 患者体位及皮肤切口。 患肢轻度外展，肘关节伸展，前臂内旋置于手外科台。
All fractures are not internally fixed with the same procedure because of the variations in the type and severity of the fracture and the associated injuries. Furthermore, we have pursued a refined technique to fix these fractures rigidly and less invasively, and with adaptations that are necessary to manage each fracture.
所有的骨折并不采用相同的方法进行内固定，因为骨折的类型和严重程度以及伴随伤均不同。而且，我们对每个骨折都采用了精细的技术进行骨折坚强固定，微创、个体化治疗。
SURGICAL TECHNIQUE
The patient is placed under general anesthesia and is positioned supine on the operating table with the arm supported on a hand table. A tourniquet is applied, and the arm is prepared and draped while, at the same time, the ipsilateral iliac crest is prepared and draped for cancellous bone-graft harvest. The upper arm is slightly abducted, the elbow extended, and the forearm pronated on the hand table (Fig. 1).
手术技术
患者全麻后仰卧于手术床，上肢置于手外台。上止血带，辅巾，同时同侧髂嵴辅巾，以备取骨。上肢轻度外展，肘关节伸展，前臂旋前（图1）。
Figs. 2-A, 2-B, and 2-C Access to the radial head. Fig. 2-A A short lateral approach beginning at the lateral epicondyle and ending a few centimeters distal to the radial neck.
图2－A，2－B，2－C。桡骨头入路。图2－A。外侧小切口，从肱骨外上髁向下延伸至桡骨颈。
After the arm is exsanguinated, a short Kocher lateral approach is made beginning at the lateral epicondyle and ending a few centimeters distal to the radial neck (Fig. 2-A). Then, the interval between the anconeus and the extensor carpi ulnaris or between the lower muscle fibers of the extensor carpi ulnaris is entered and the lateral collateral ligament complex is exposed (Fig. 2-B). A longitudinal incision is made in the anterior part of the lateral collateral ligament along its fibers extending from the lateral condyle to just distal to the radial neck through the annular ligament and capsule (Fig. 2-C). Thus, the longitudinal continuity of the lateral ligament complex is not disturbed. The fracture is identified, following irrigation of the intra-articular hematoma (Figs. 3 and 4).
上肢驱血后，做Kocher切口，从肱骨外上髁至桡骨颈远侧数厘米（图2A）。于肘后肌与尺侧腕伸肌之间或下方的尺侧腕伸肌纤维之间显露外侧副韧带（图2B），从外侧髁至桡骨颈远端沿外侧副韧带纤维前方做纵形切口，切开环状韧带和关节囊（图2C）。这样就可以不用破坏外侧副韧带的纵向连续性。确定骨折，冲洗去除关节内血肿（图3，4）。
FIG. 2-B
The interval between the anconeus and extensor carpi ulnaris is entered, and the radial
collateral ligament complex is exposed.
图2－B。于肘肌与尺侧腕伸肌之间进入，显露桡侧副韧带。
The fractured radial head fragments should not be detached from any remaining synovial or periosteal soft-tissue attachments, which can be used as checkreins to facilitate alignment and reduction. Any fragment that is tilted and impacted into the shaft is gently elevated to the anatomical level as a core fragment (Fig. 5, A). The remaining fragments are then reassembled to the core fragment. During the reduction process, cancellous bone defects may be encountered at the isthmus, between the neck and the shaft. Cancellous bone grafts should be used to fill these defects. The reduced fracture fragments are held with small forceps or tenacular clamps, or are temporarily fixed with 1.0-mm Kirschner wires (Fig. 5, B). When the fractured radial head fragments are large enough to hold a Herbert screw, they are fixed to each other (Fig. 5, C). The radial head is then fixed to the shaft with two lowprofile mini-plates (Stryker Leibinger, Freiburg, Germany)7. A Tshaped low-profile mini-plate, with a 0.55-mm profile height, and 1.7-mm-diameter screws are used. The screw head has a low profile and is countersunk into the plate. Two plates are applied opposite one another, ideally from the lower corner of the radial head to the shaft. The plates are bent to conform to the contour of the radial neck (Fig. 5, D). On the radial shaft, the screws should perforate the opposite cortex, and, on the radial head, the tips of the screws are inserted into subchondral bone but do not perforate the opposite articular cartilage. Placement of the plates is not limited to the socalled safe zone because they are applied to the lower corner of the radial head and are too thin to impinge on the proximal radioulnar joint with forearm rotation (Fig. 6). Any associated small fragments can be fixed with screws, and a thin marginal osteochondral fragment can also be secured with a plate if it is too thin to be fixed with a Herbert screw.
不要切断任何桡骨头碎片上的滑膜或骨上的软组织，这有助于复位和维持对位。轻轻抬高倾斜或嵌插的骨片，恢复至核心骨片的解剖高度（图5A），再将其余碎片装配至核心骨片。复位过程中，于桡骨颈与桡骨干之间的峡部可能有松质骨缺损，可以用松质骨充填骨缺损。复位的小骨片以小骨钳或骨镊维持，或以1mm的克氏针固定（图5B）。如果桡骨头的骨块够大，就可以用Herbert螺钉进行相互固定（图5C）。然后再将桡骨头用两块低切迹迷你板(Stryker Leibinger, Freiburg, Germany)固定至骨干。钢板要进行预弯，使之与桡骨颈外形一致（图5D）。于桡骨干处，螺钉要穿透对侧皮质，于桡骨头处，螺钉要位于软骨下，不要穿透对侧软骨。钢板的位置可以不必局限于安全区，因为它们用在桡骨头下方的切迹处，且由于很薄，当前臂旋转时，不会撞击桡尺关节（图6）。小的碎片均可以螺钉固定，如果骨软骨边缘碎片太薄，无法用Herbert螺钉进行固定的，也可以用钢板固定。
After fixation, the alignment and mobility of the radial head are examined both radiographically and by manually manipulating the forearm (Fig. 7). A suction drain tube is placed in the joint. The opening in the lateral collateral ligament and the annular ligament are repaired with number-1 nonabsorbable braided sutures. When the lateral collateral ligament has been avulsed from the lateral condyle, it is reattached with an anchoring system (GII Quick Anchor Plus System; DePuy Mitek, Johnson and Johnson, Raynham, Massachusetts).
固定后，体检并透视检查桡骨头的复位和活动情况（图7），关节内放置引流管。1号不吸收缝线编织缝合外侧副韧带和环状韧带。如果外侧副韧带从外侧髁上撕脱，用锚钉进行固定(GII Quick Anchor Plus System; DePuy Mitek, Johnson and Johnson, Raynham, Massachusetts)。
If there is an associated injury of the ulnar collateral ligament, it is repaired with number1 nonabsorbable braided sutures or an anchoring system through a medial approach. Prior to fixation of the radial head fracture, stay sutures are placed in the torn ulnar collateral ligament and then they are tied firmly only after fracture fixation. If the ulnar collateral ligament is repaired first, it sometimes becomes difficult to fix the fracture of the radial head. With the elbow at a right angle and the forearm in neutral rotation, a long-arm splint is applied. Two days after the operation, the suction drain is removed and the splint is changed to a long-arm cylinder cast to allow rotation exercises of the forearm, with the elbow held in a right angle position. Two weeks after the operation, the cast is changed to a hinged brace and active elbow movement is started. To protect the elbow from a lateral load, the brace is worn for four weeks. Depending on the stability, passive extension exercises of the elbow are initiated four to six weeks after the operation. The low-profile mini-plates are usually removed between five and seven months after repair (Fig. 8).
如果合并尺侧副韧带损伤，可以做内侧切口，用1号不吸收缝合线编织缝合，或用锚钉固定。于桡骨头固定前穿好缝线，于桡骨头固定后再拉紧缝线。如果先修复尺侧副韧带，有时固定桡骨头会变得很困难。肘关节屈曲90°前臂旋转中立位长夹板固定。两天后拔除引流管，更换为长臂管形石膏，肘关节直角固定，前臂可进行旋转功能锻炼。术后两周更换为肘关节绞链式支具，进行肘关节主动锻炼。为防止肘关节的横向负荷，支具戴4周。于术后4－6周，根据稳定性进行肘关节被动活动。术后5－7个月去除钢板（图8）。
FIG. 2-C
A longitudinal incision is made in the anterior part of the lateral collateral ligament along
its fibers extending from the lateral condyle to just distal to the radial neck through the
annular ligament and capsule.
图2－C。从外侧髁向桡骨颈方向沿外侧副韧带前缘纵形切开，切开环状韧带和关节囊，
FIG. 3
Anteroposterior radiograph demonstrating a Mason type-III radial head fracture.
图3。前后位X线片显示为Mason III型骨折
FIG. 4
Intraoperative photograph showing a Mason type-III radial head fracture consisting of two large fragments and a marginal fragment.
图4 术中照片显示该Mason III型骨折有两个大骨块和一个边缘骨块。
FIG. 5
The surgical process of reduction and internal fixation. A: The impacted and displaced fragments are reduced, preserving any attached synovial and periosteal membrane. B: The fracture fragments are elevated and reduced and temporarily fixed with thin Kirschner wires. Cancellous bone chips are used to graft any osseous defects. C: The large radial head fragments are fixed with two Herbert screws. D: Then the head and the shaft are connected with use of two low-profile mini-plates opposite one another.
图5
骨折复位内固定过程。A，复位嵌插与移位的骨片，保留骨块上的滑膜和骨膜。B，抬高复位骨块，临时以克氏针固定。骨缺损以松质骨进行植骨。C，大的桡骨头骨片以两枚Herbert螺钉固定。D，桡骨头与骨干通过两块低切迹迷你钢板相对固定。
FIG. 6
Fixation is achieved with two Herbert screws and two low-profile mini-plates.
图6：用两枚Herbert螺钉和两块低切迹迷你钢板固定。
FIG. 7
Postoperative anteroposterior radiograph of the fracture in Figure 6 after
fixation.
图7：图6骨折内固定术后。
FIG. 8
Intraoperative photograph showing a Mason type-III radial head fracture five months after fixation. A: Status of exploration. The plate is covered by synovial membrane. B: After plate removal.
图8。术中照片显示Mason III型桡骨头骨折术后5个月。A：探查显示钢板被滑膜包裹。B：钢板去除后。
FIG. 9
Mason type-III radial head fracture patterns. A: Fracture of the entire radial neck. The head is completely displaced from the shaft. B: An entire articular head fracture consisting of more than two large fragments. All fragments are completely displaced from the shaft. C: A fracture with a tilted and impacted articular segment.
图9
Mason –III型桡骨头骨折模式。A：桡骨颈完全骨折，桡骨头完全移位。B：桡骨头完全关节内骨折，由超过两块的大骨块组成。所有的骨块均完全移位。C：伴有关节骨块倾斜和嵌插。
FIG. 10 (CONTINUED)
Internal fixation of a comminuted radial head fracture with cannulated Herbert-type screws. A: Anteroposterior radiograph demonstrating a Mason type-IV fracture associated with a coronoid fracture. B: Intraoperative photograph showing the radial head fracture consisting of four large fragments. C: The fragments are reduced and fixed with guidewires. D: A cannulated Herbert-type screw is driven into the fragments. E: Three screws are used. The screws must penetrate and rigidly engage the opposite cortex of the shaft distally. The coronoid fracture was also fixed with a small screw through an anterior approach.
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图10
桡骨头粉碎性骨折以空心Herbert螺钉进行固定。A：正位片显示桡骨头Mason –IV型骨折伴有冠状突骨折。B：术中见桡骨头骨折由四块大骨块组成。C：骨块复位并以导针固定。D：一枚空心Herbert螺钉拧入骨折块中。E：用了三枚螺钉。螺钉必须穿透远端的对侧皮质，牢牢固定。冠状突骨折通过前路以一枚小螺钉固定。
Fig. 11-A A large tilted and impacted head fragment with a marginal articular fragment. Fig. 11-B The large head fragment is reduced and fixed with two cannulated Herbert-type screws, and the marginal articular fragment is fixed with a low-profile mini-plate.
图11
A：一个大的倾斜嵌插骨块和关节边缘碎块。B：大的桡骨头骨块以两枚Herbert螺钉固定，关节边缘骨块以一块低切迹迷你钢板固定。
CRITICAL CONCEPTS
INDICATIONS:
• Fresh displaced and comminuted fractures of the radial head, such as the following Mason type-III fractures: (A) a fracture of the entire radial neck, (B) an articular fracture involving the entire radial head in which all fragments are displaced completely from the shaft, or (C) a fracture with a tilted and impacted articular segment and some displaced articular fragments, which has the appearance of a Mason type-II fracture radiographically. When the displaced articular fragments are reduced, the tilted and impacted fragments must be elevated to completely restore head congruity (Fig. 9).
关键概念
适应症：
•新鲜的桡骨头移位粉碎骨折，如下面的Mason –III型骨折：A，桡骨颈骨折。B，桡骨头完全关节内骨折，骨块移位。C，骨块倾斜嵌插，伴有移位骨块。X线上表现为Mason –II型骨折。当移位的骨块复位时，必须抬高嵌插的骨块，以完全恢复桡骨头的外形（图9）。
• Mason type-IV fracture variations, which are defined as Mason type-III fractures associated with a fracture of the elbow, such as a coronoid fracture, and/or an elbow dislocation.
•Mason –IV型骨折变异，桡骨头为Mason –III型骨折，同时伴有肘关节骨折，如冠状突骨折或伴有肘关节脱位。
CONTRAINDICATIONS:
• Patients who are over seventy years of age, with poor general health, or those who will not participate in the postoperative rehabilitation protocol.
• Patients with comminuted fractures of the radial head who present more than four weeks after injury. With these patients, there is a risk of ectopic bone formation and the poor condition of the osteochondral fragments prevents effective reduction and fixation.
禁忌症
•年龄超过70岁，或术后不愿进行康复训练者。
•桡骨头粉碎性骨折已超过4周者，这些病人异位骨化的危险较高，同时骨软骨碎片难以进行复位固定。
PITFALLS:
• While placement of the plates is not limited to the “safe zone,” they should not be applied on the crown of the articular surface of the radial head. Even though the low-profile mini-plate is unlikely to impinge on the proximal radioulnar joint, it should be applied below the equator, to the lower corner of the radial head.
陷阱
桡骨头钢板的放置不要局限于安全区，但也不要放在关节面上。虽然低切迹的钢板不易引起上尺桡关节撞击，也要用在赤道下、桡骨头的下切迹处。
• Two plates should be used to connect the head and the shaft. These plates are placed opposite one another so that impaction between the head and the shaft can be achieved, creating some inherent stability. They should be bent to conform to the contour of the radial neck, so as to be flush with the surface. Instead of dual plating, an option is to use the cannulated Herbert-type screws as core fixation and additional low-profile mini-plate fixation for a small fragment or a marginal fracture fragment. Another option that may be used is multiple cannulated Herberttype screws. When they are used to connect the head fragment(s) to the shaft, the distal end of the screws should penetrate and rigidly engage the cortex of the shaft. However, advancing the screw too far might tilt and deform the radial head because of impaction of the head fragment against the shaft (Fig. 10).
•用两块板连接桡骨头与桡骨干，钢板要相对放置，以使头与干可以嵌紧，恢复部分即刻稳定。钢板要进行塑形，以适应桡骨颈的外形，使之与关节面处于同一平面。也可以用Herbert螺钉固定核心骨块，再以低切迹钢板固定边缘骨块或小骨块。也可以用多枚Herbert螺钉进行固定。当用Herbert螺钉固定桡骨头与骨干时，螺钉要穿透骨干处的对侧皮质。然而，如果螺钉拧得太进去，由于桡骨头骨块嵌入桡骨干，可能引起桡骨头变形和倾斜。• If there is an osseous defect between the radial head and shaft, cancellous bone should be grafted into the defect. The cancellous bone chips are inserted beneath the elevated fragment during reduction. If there is a central bone defect in the radial head and shaft, a strut cancellous bone block is inserted into the medullary canal and the head is reduced to it and the shaft and is fixed with low-profile mini-plates.
如果在桡骨头与桡骨干之间有骨缺损，可以用松质骨进行植骨。复位时，骨块抬高后，将松质骨植于其下。如果桡骨头和桡骨干中央骨缺损，可取一块松质骨块嵌入骨干的髓腔内，然后将桡骨头复位于骨块和骨干上，再以低切迹钢板固定。• The goal of the operation is accurate reduction and rigid internal fixation, which will allow early motion exercises of the forearm and elbow after surgery. However, shortening the neck approximately 1 to 2 mm can be allowed if the rotational alignment is acceptable. It is not necessary to completely reduce slight impaction of the head on the shaft; however, tilting should be corrected (Fig. 11).
•手术的目的在于精确的复位和坚强的固定，以允许早期功能锻炼。如果旋转力线可以接受，短缩1－2mm是可以接受的。轻度的嵌插没必要完全复位，但倾斜必须纠正（图11）。
• When there is an associated ulnar collateral ligament injury, it should be repaired with number-1 nonabsorbable braided sutures or a suture anchor system with use of a medial approach. Prior to fixation of the radial head fracture, the sutures are placed in the torn ulnar collateral ligament. Then they are firmly fastened after fixation because, once the ulnar collateral ligament is repaired, it is sometimes difficult to fix the fracture of the radial head.
•如果伴有尺侧副韧带损伤，可以做一个内侧切口，用1号不可吸收线进行编织缝合或锚钉固定。于桡骨头固定前穿好缝线，于桡骨头固定后再拉紧缝线。如果先修复尺侧副韧带，有时固定桡骨头会变得很困难。REFERENCES
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3. Kuntz DG Jr, Baratz ME. Fractures of the elbow. Orthop Clin North Am. 1999;30:37-61.
4. Morrey BF. Radial head fracture. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p 341-64.
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