旋前复位法治疗桡骨小头半脱位的基础与临床研究
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摘要
目的：通过对幼儿肘关节解剖学研究和旋前、旋后复位法治疗桡骨小头半脱位的临床疗效观察，探讨桡骨小头半脱位的最佳复位手法。
方法：基础选择6具小儿尸体标本，共12例肘关节，进行相关的解剖研究。对小儿肘关节桡骨头、颈和环状韧带进行解剖观察测量。
临床收集临床上首次被确诊为桡骨小头半脱位，小于6岁的患者。随机运用旋前复位法和旋后复位法2种复位方法中的一种对患者进行治疗，每隔5分钟检查患肢功能恢复情况。15分钟后如果肘关节功能未能恢复正常则重复第一次复位方法，30分钟后患者仍未恢复肘关节功能，则此复位方法失败。再采取另一种复位方法。假如患者两种复位方法均失败，建议用x线进行检查。对复位过程中疼痛程度进行Mops评分，由患者家属进行评分。
结果：基础桡骨头明显大于桡骨颈，桡骨头与桡骨颈矢状径比为1.26±0.021，桡骨头与桡骨颈横径比值1.25±0.016，环状韧带上、下缘比值1.01±0.10。
临床临床共收治76例桡骨小头半脱位患者，其中旋前复位组39例复位成功39例(复位成功率为100％)，而旋后复位组中37例复位成功29例(复位成功率为78.4％)，旋前复位组疼痛评分为4.17±1.35，旋后复位组疼痛评分为7.05±1.60。
结论：通过小儿肘关节解剖学研究，结合临床的桡骨小头半脱位复位方法比较研究结果，我们认为旋前复位法是桡骨小头半脱位的首选复位方法。
Objective: according to anatomic research the infant elbow joint andclinical observation of hyperpronation and supination treatment radialhead subluxation, to explore the best reduction method of radial headsubluxation.
Methods: Basic: thought choice of six human cadacer specimens, total 12embalmed cadsver's elbows.the radial head and neck, annular ligamentwere observed and measured. All of statistic was treated with SPSS13.0.
Clinical: this study involved of children younger than 6years ofage with a clinical the first diagnosis of radial head subluxationpatients were randomized to undergo reduction by one of the two methodsabout supination and hyperpronation, followed every 5 minutes for checkof elbow function, the initial procedure was repeated if baselinefunctioning did not return 15 minutes after the initial reduction attempt.failure of that technique 30 minutes after the initial reduction attemptresulted in a cross-over to the alternate method of reduction. thealternate procedure was repeated if baseline functioning did notattempted. if the patient failed toth techniques, radiaography of theelbow was perforemed. at the same time, we will let patient' s familymembers used the modifle objective pain score to evaluated pain in thereduction processed.
Results: Basic: the sagittal and transverse diameter of the radial headwere large than the diameters of the radial neck. ratio about 1.26±0.021 and 1.25±0. 016. the superior and inferior lengths of the annular ligamentwere approximately similar, ratio about 1.01±0.10.
Clinical: a total of 76 patients were enrolled in the study.Demographic characteristics of each groph were similar. 39 of 39 patientsrandomized to hyperpronation were reduced successfully (100％) versus 29of 37 patients randomized to supination (78.4％).in the grouphyperpronation the assessment of pain about 4.17±1.35. in the groupsupination the assessment of pain about 7.05±1.60.
Conclusions: in the reduction of radial head subluxations, thehyperpronation technique was successful more often than supination. sowe think the hyperpronation is best reduction method.
方法：基础选择6具小儿尸体标本，共12例肘关节，进行相关的解剖研究。对小儿肘关节桡骨头、颈和环状韧带进行解剖观察测量。
临床收集临床上首次被确诊为桡骨小头半脱位，小于6岁的患者。随机运用旋前复位法和旋后复位法2种复位方法中的一种对患者进行治疗，每隔5分钟检查患肢功能恢复情况。15分钟后如果肘关节功能未能恢复正常则重复第一次复位方法，30分钟后患者仍未恢复肘关节功能，则此复位方法失败。再采取另一种复位方法。假如患者两种复位方法均失败，建议用x线进行检查。对复位过程中疼痛程度进行Mops评分，由患者家属进行评分。
结果：基础桡骨头明显大于桡骨颈，桡骨头与桡骨颈矢状径比为1.26±0.021，桡骨头与桡骨颈横径比值1.25±0.016，环状韧带上、下缘比值1.01±0.10。
临床临床共收治76例桡骨小头半脱位患者，其中旋前复位组39例复位成功39例(复位成功率为100％)，而旋后复位组中37例复位成功29例(复位成功率为78.4％)，旋前复位组疼痛评分为4.17±1.35，旋后复位组疼痛评分为7.05±1.60。
结论：通过小儿肘关节解剖学研究，结合临床的桡骨小头半脱位复位方法比较研究结果，我们认为旋前复位法是桡骨小头半脱位的首选复位方法。
Objective: according to anatomic research the infant elbow joint andclinical observation of hyperpronation and supination treatment radialhead subluxation, to explore the best reduction method of radial headsubluxation.
Methods: Basic: thought choice of six human cadacer specimens, total 12embalmed cadsver's elbows.the radial head and neck, annular ligamentwere observed and measured. All of statistic was treated with SPSS13.0.
Clinical: this study involved of children younger than 6years ofage with a clinical the first diagnosis of radial head subluxationpatients were randomized to undergo reduction by one of the two methodsabout supination and hyperpronation, followed every 5 minutes for checkof elbow function, the initial procedure was repeated if baselinefunctioning did not return 15 minutes after the initial reduction attempt.failure of that technique 30 minutes after the initial reduction attemptresulted in a cross-over to the alternate method of reduction. thealternate procedure was repeated if baseline functioning did notattempted. if the patient failed toth techniques, radiaography of theelbow was perforemed. at the same time, we will let patient' s familymembers used the modifle objective pain score to evaluated pain in thereduction processed.
Results: Basic: the sagittal and transverse diameter of the radial headwere large than the diameters of the radial neck. ratio about 1.26±0.021 and 1.25±0. 016. the superior and inferior lengths of the annular ligamentwere approximately similar, ratio about 1.01±0.10.
Clinical: a total of 76 patients were enrolled in the study.Demographic characteristics of each groph were similar. 39 of 39 patientsrandomized to hyperpronation were reduced successfully (100％) versus 29of 37 patients randomized to supination (78.4％).in the grouphyperpronation the assessment of pain about 4.17±1.35. in the groupsupination the assessment of pain about 7.05±1.60.
Conclusions: in the reduction of radial head subluxations, thehyperpronation technique was successful more often than supination. sowe think the hyperpronation is best reduction method.
引文
1 肖兵，张运．桡骨小头半脱位的病因及治疗研究进展[J]．云南中医中药杂志，2004，25(3)：38—42
2 梁振兴．14岁儿童双侧桡骨小头半脱位[J]．中医正骨，1994．6(1)：46
3 Anki M, Okamura K, Yamashita T. snapping annular ligament of the elbow joint in the throwing arms of young brothers[J]. Arthroscopy, 2003.19(8): e4-7
4 郭建君，赵海燕，王平．成人桡骨头脱位[J]．山东中医杂志，1999．18(8)：372
5 Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations[J]. Pediatrics, 1998,102:e10.
6 McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: Comparing two methods of reduction[J]. Acad Emerg Med, 1999,6: 715-718
7 Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes[J]. Ann Emerg Med, 1990,19: 1019-1023.
8 Teach ST, Schutzman SA. Prospective study of recurrent radial head subluxation[J]. Arch Pediatr Adolesc Med, 1996,150: 164- 166.
9 Thomas G. Wadsworth. The elbow[J]. Churchill livingstone, 1982.148-149
10 Shabat s, folman y. the role of sonography in detecting radial head subluxation in a chilid[J], J Clin Ultrasound, 2005,33(4): 187-189.
11 何丰良．拔伸牵引屈曲复位法治疗创伤性小儿桡骨小头半脱位的经验[J]．四川中医，1996．14(9)：49．
12 冯国平，马可，鲍秀艳．旋前复位法治疗桡骨头骨折的解剖学基础[J]．chinese journal of clinical anatomy, 1999.2(17): 146-148
13 Jonqschaap HC, Younqson GG, Beattie TF. The epidemiology of radial head subluxation (pulled elbow) in Aberdeen city area[J].health bull(edinb).1990, 48(2):58-61
14 程延．牵拉肘研究进展[J]．实用手外科杂志，2005．12(19)：249-250
15 张安桢，武春发．中国骨伤科学[M]．北京：人民卫生出版社，1988，417—419
16 张希彬，张世明．中国骨伤科学[M]．成都：四川科技出版社，1991，518—519
17 salter rb. zaltz c. anatomic inverstigations of the mechanism of injury and pathologic anatomy of "pull elbow" in young children[J]clin orthopaedic and research. 1971,77(2): 134
18 ryan rj, et al. internal derangement of the radial head of radial neck diameters infetuses with reference to radial head subluxation in children[J], bone JT Surg. 1969, 51(4): 781
19 metha L. subluxation of radial head in children with refentence to radial head and neck diameters J Indian Med Ass[J]. Indian Med assoc. 1972,59(6): 238-239
20 赵林昌，叶蒙福．幼儿肘关节解剖学特征和桡骨小头半脱位[J]．南京医科大学学报，1995，15(2)：328
21 张敬东，彭明惺，刘利君．牵拉肘机制的有关解剖学观测[J]．中国骨伤，2003．11(16)：652-654
22 王亦璁．骨与关节损伤[M]．北京：人民卫生出版社，2004，627—628
23 房晓彬．小儿桡骨小头半脱位的原因分析[J]．中华小儿外科杂志，1995，16(3)：174
24 李建博，刘绍俊，傅光华．前臂被动过度旋前是桡骨小头半脱位的原因[J]．中华骨科杂志，1990，10(3)：206-207
25 Kosuwon W, Mahaisavariya B, Saengnipanthkul S, et al. Ultranonography of pulled elbow. [J] Bone Joint Surg(Br).1993.75:421-422
26 Moon C, Boris P, Lawrence R. Ultrasonography of the annular ligament partial tear and recurrent "pull elbow" [J].pediatr radiol. 2004.34:999-1004
27 欧波．17例小儿桡骨小头半脱位误诊原因分析及处理[J]．china and foreign medical journal，2006．4(7)：37
28 王永桥，张龙君，陈建良．桡骨头半脱位的x线片表现[J]．中国骨伤，2004．5(17)：308-309
29 Frumkin K. Nursemaid' s elbow: a radiographic demonstration[J]. Ann emerg reed. 1985.14(7):690-693
30 王洪金，庞桂根．名老中医苏宝恒诊治桡骨小头半脱位的经验[J]．中医正骨，1994，(1)：33
31 Snyder hs. Radiographic changes with radial head subluxation in children[J]. J Emerg Med. 1990, (3):265-9.
32 Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation[J]. Am J Dis child. 1985.139:1194-1197
33 鲍呈元．儿童桡骨小头半脱位350例诊治体会[J]．青海医药杂志，2004，34(9)：15
34 朱福林．前旋前臂法整复桡骨小头半脱位[J]．中国中医骨伤科杂志，1991，(1)：35
35 陶锡东．小儿牵拉肘整复体位的认识[J]．内蒙古中医药，1997．16(4)：27
36 Daniel A, Marc Y, Barbara M, randomized comparison of pain perception during radial head subluxation reduction using supination-flexion[J]. pediatric emergency care. 2006.4(22):235-238
1 王亦璁．骨与关节损伤[M]．北京：人民卫生出版社，2004，627—628
2 Jonqschaap HC, Younqson GG, Beattie TF. The epidemiology of radial head subluxation (pulled elbow) in Aberdeen city area. health bull(edinb) [J]. 1990, 48(2):58-61
3 Thomas G. Wadsworth. The elbow. Churchill livingstone. 1982.148-149
4 Robert E, Kaplan, Kathleen A. Recurrent Nursemaid' s elbow(annular ligament displacement) treatment via telephone[J]. pediatrics. 2002,110:171-174
5 Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes[J]. Ann Emerg Med 1990;19:1019- 1023.
6 Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation[J]. Am J Dis child. 1985.139:1194-1197
7 鲍呈元．儿童桡骨小头半脱位350例诊治体会[J]．青海医药杂志．2004，34(9)：15
8 Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations[J]. Pediatrics 1998;102:e10.
9 McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: Comparing two methods of reduction[J]. Acad Emerg Med 1999;6:715 - 718
10 朱福林．前旋前臂法整复桡骨小头半脱位[J]．中国中医骨伤科杂志，1991，(1)：35
11 陶锡东．小儿牵拉肘整复体位的认识[J]．内蒙古中医药，1997．16(4)：27
12 Daniel A, Marc Y, Barbara M, randomized comparison of pain perception during radial head subluxation reduction using supinationflexion[J]. pediatric emergency care. 2006.4(22):235-238
2 梁振兴．14岁儿童双侧桡骨小头半脱位[J]．中医正骨，1994．6(1)：46
3 Anki M, Okamura K, Yamashita T. snapping annular ligament of the elbow joint in the throwing arms of young brothers[J]. Arthroscopy, 2003.19(8): e4-7
4 郭建君，赵海燕，王平．成人桡骨头脱位[J]．山东中医杂志，1999．18(8)：372
5 Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations[J]. Pediatrics, 1998,102:e10.
6 McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: Comparing two methods of reduction[J]. Acad Emerg Med, 1999,6: 715-718
7 Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes[J]. Ann Emerg Med, 1990,19: 1019-1023.
8 Teach ST, Schutzman SA. Prospective study of recurrent radial head subluxation[J]. Arch Pediatr Adolesc Med, 1996,150: 164- 166.
9 Thomas G. Wadsworth. The elbow[J]. Churchill livingstone, 1982.148-149
10 Shabat s, folman y. the role of sonography in detecting radial head subluxation in a chilid[J], J Clin Ultrasound, 2005,33(4): 187-189.
11 何丰良．拔伸牵引屈曲复位法治疗创伤性小儿桡骨小头半脱位的经验[J]．四川中医，1996．14(9)：49．
12 冯国平，马可，鲍秀艳．旋前复位法治疗桡骨头骨折的解剖学基础[J]．chinese journal of clinical anatomy, 1999.2(17): 146-148
13 Jonqschaap HC, Younqson GG, Beattie TF. The epidemiology of radial head subluxation (pulled elbow) in Aberdeen city area[J].health bull(edinb).1990, 48(2):58-61
14 程延．牵拉肘研究进展[J]．实用手外科杂志，2005．12(19)：249-250
15 张安桢，武春发．中国骨伤科学[M]．北京：人民卫生出版社，1988，417—419
16 张希彬，张世明．中国骨伤科学[M]．成都：四川科技出版社，1991，518—519
17 salter rb. zaltz c. anatomic inverstigations of the mechanism of injury and pathologic anatomy of "pull elbow" in young children[J]clin orthopaedic and research. 1971,77(2): 134
18 ryan rj, et al. internal derangement of the radial head of radial neck diameters infetuses with reference to radial head subluxation in children[J], bone JT Surg. 1969, 51(4): 781
19 metha L. subluxation of radial head in children with refentence to radial head and neck diameters J Indian Med Ass[J]. Indian Med assoc. 1972,59(6): 238-239
20 赵林昌，叶蒙福．幼儿肘关节解剖学特征和桡骨小头半脱位[J]．南京医科大学学报，1995，15(2)：328
21 张敬东，彭明惺，刘利君．牵拉肘机制的有关解剖学观测[J]．中国骨伤，2003．11(16)：652-654
22 王亦璁．骨与关节损伤[M]．北京：人民卫生出版社，2004，627—628
23 房晓彬．小儿桡骨小头半脱位的原因分析[J]．中华小儿外科杂志，1995，16(3)：174
24 李建博，刘绍俊，傅光华．前臂被动过度旋前是桡骨小头半脱位的原因[J]．中华骨科杂志，1990，10(3)：206-207
25 Kosuwon W, Mahaisavariya B, Saengnipanthkul S, et al. Ultranonography of pulled elbow. [J] Bone Joint Surg(Br).1993.75:421-422
26 Moon C, Boris P, Lawrence R. Ultrasonography of the annular ligament partial tear and recurrent "pull elbow" [J].pediatr radiol. 2004.34:999-1004
27 欧波．17例小儿桡骨小头半脱位误诊原因分析及处理[J]．china and foreign medical journal，2006．4(7)：37
28 王永桥，张龙君，陈建良．桡骨头半脱位的x线片表现[J]．中国骨伤，2004．5(17)：308-309
29 Frumkin K. Nursemaid' s elbow: a radiographic demonstration[J]. Ann emerg reed. 1985.14(7):690-693
30 王洪金，庞桂根．名老中医苏宝恒诊治桡骨小头半脱位的经验[J]．中医正骨，1994，(1)：33
31 Snyder hs. Radiographic changes with radial head subluxation in children[J]. J Emerg Med. 1990, (3):265-9.
32 Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation[J]. Am J Dis child. 1985.139:1194-1197
33 鲍呈元．儿童桡骨小头半脱位350例诊治体会[J]．青海医药杂志，2004，34(9)：15
34 朱福林．前旋前臂法整复桡骨小头半脱位[J]．中国中医骨伤科杂志，1991，(1)：35
35 陶锡东．小儿牵拉肘整复体位的认识[J]．内蒙古中医药，1997．16(4)：27
36 Daniel A, Marc Y, Barbara M, randomized comparison of pain perception during radial head subluxation reduction using supination-flexion[J]. pediatric emergency care. 2006.4(22):235-238
1 王亦璁．骨与关节损伤[M]．北京：人民卫生出版社，2004，627—628
2 Jonqschaap HC, Younqson GG, Beattie TF. The epidemiology of radial head subluxation (pulled elbow) in Aberdeen city area. health bull(edinb) [J]. 1990, 48(2):58-61
3 Thomas G. Wadsworth. The elbow. Churchill livingstone. 1982.148-149
4 Robert E, Kaplan, Kathleen A. Recurrent Nursemaid' s elbow(annular ligament displacement) treatment via telephone[J]. pediatrics. 2002,110:171-174
5 Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes[J]. Ann Emerg Med 1990;19:1019- 1023.
6 Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation[J]. Am J Dis child. 1985.139:1194-1197
7 鲍呈元．儿童桡骨小头半脱位350例诊治体会[J]．青海医药杂志．2004，34(9)：15
8 Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations[J]. Pediatrics 1998;102:e10.
9 McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: Comparing two methods of reduction[J]. Acad Emerg Med 1999;6:715 - 718
10 朱福林．前旋前臂法整复桡骨小头半脱位[J]．中国中医骨伤科杂志，1991，(1)：35
11 陶锡东．小儿牵拉肘整复体位的认识[J]．内蒙古中医药，1997．16(4)：27
12 Daniel A, Marc Y, Barbara M, randomized comparison of pain perception during radial head subluxation reduction using supinationflexion[J]. pediatric emergency care. 2006.4(22):235-238