儿童肘关节X线片中肱桡关系的研究
摘要
儿童肘关节部位的损伤占全身各部位创伤发生率的第一位，常见的损伤包括肱骨髁上骨折、肱骨外髁骨折、肱骨远端全骨骺分离、桡骨头脱位(包括Monteggia骨折)、肱骨外髁骨折合并肘关节脱位、肱骨髁间骨折、肘关节脱位等。但是，儿童缺乏表达能力，常常不能清晰叙述受伤方式。由于畏惧心理，局部肿胀及关节主、被动活动受限均可导致X线片投照位置不标准，而且肘关节结构的复杂性和骨骺骨化中心出现时间的不同，给肘关节部位损伤的诊断带来一定困难。这些原因造成儿童肘部损伤有很高的误诊、漏诊率，国内外均有大量的文献报道。其中，肱骨远端全骨骺分离的误诊率在儿童全身骨折中占居首位，常误诊为肘关节脱位。
肘部X线片中的肱桡关系是诊断和鉴别不同损伤的重要参考依据。国内外几乎所有的文献包括一些权威的书籍、杂志都遵循“桡骨近端(桡骨颈)纵轴延长线，无论肘关节在任何位置都通过肱骨小头骨骺中心”这一诊断标准。然而，我们在临床上发现肘部X线片中的肱桡关系受诸多因素影响，如不同体位、前臂旋转、肘关节屈伸不同位置、投照位置变化、以及年龄因素等均会影响其结果。
目的 目前国内尚未见到对儿童肘关节X线片中的肱桡关系进行深入研究的报道。为了验证上述“标准”的准确性与有效性，避免或减少儿童肘部损伤的误诊与漏诊，设计本课题，对儿童正常关节不同位置的X线片进行观察、测量与分析。
郑州大学2003届硕士毕业论文
儿童肘关节X线片中肚挠关系的研究
方法拍摄100例1.3一10岁儿童的正常肘关节和16例32侧儿童尸体
上肢标本肘关节X线片。拍摄前臂旋后90“、旋后45。、旋转O。、旋前
45。时的肘关节前后位(正位)X线片。并拍摄屈肘30“、60”、90。、
120“时的肘关节侧位X线片。
观察挠骨颈纵轴延长线与肪骨小头骨髓的关系，它们之间的关系有四
种:挠骨颈的纵轴延长线通过肪骨小头骨箭中心称为“中心相交”;延
长线不通过肮骨小头骨髓中心称为“非中心性相交”;延长线与胧骨小头
骨骸相切称为“相切”;延长线与胧骨小头骨髓相离称为“相离”。对
非中心相交、相切、相离的X线片测量其挠骨颈纵轴延长线距肪骨小头骨
髓中心的垂直距离，称为“头一颈距”。分别比较性别、年龄、侧别、前臂不
同旋转位、不同屈肘位、正常儿童与尸体儿童的胧挠关系。
结果在肘关节伸直、前臂旋后90。位的前后位(正位)X线片上，
69%RCL为中心相交，31%为非中心相交;旋后45。时，1 00%RCL为非中
心相交;旋转0“时，82%RCL为非中心相交，16%相切，2%相离;旋前
45“时，33%RCL为非中心相交，33%相切，34%相离。在肘关节侧位X线
片上，屈肘30“位时，无一例中心相交，有82%的RCL为非中心相交，n%
相切，7%相离。而且年龄越小，头一颈距越大。屈肘60“、90。、120。位
时，RCL中心相交者分别为”%、90%、95%，非中心相交者分别为26%、
10%、5%，屈肘60“位时相切者仅为1%。
肪挠关系在正位X线片前臂不同的旋转角度的差异有统计学意义，P
<0.05。肪挠关系在侧位X线片前臂不同的屈曲角度的差异有统计学意义，
尸<0.05。正常儿童正位与侧位X线片上胧挠关系的差异有统计学意义，P
<0.05。正位X线片中性别、年龄、侧别肪挠关系及头一颈距之间的差异均
无统计学意义，P>0.05。不同年龄肘关节侧位X线片中屈肘30。时头一颈距
的差异有统计学意义，P<0.05。正常儿童活体与尸体肘关节正位X线片中
头一颈距的差异无统计学意义，P>0.05
结论
1.肘关节伸直位的前后位(正位)X线片上的
损伤无重要参考价值。
RCL
护一一.一
对于诊断儿童肘关节
郑州大学2003届硕士毕业论文
儿童肘关节X线片中胶挠关系的研究
2.屈肘90“、120“位的肘关节侧位X线片上的RCL对于诊断儿童肘关节
损伤有参考价值。
3.屈肘30“位的肘关节侧位X线片上，年龄越小，其头一颈距越大。
4.”挠骨近端(挠骨颈)纵轴延长线，无论肘关节在任何位置都通过胧骨小头
骨髓中心”这一沿用己久的诊断儿童肘关节损伤的标准是错误的。
The injuries of the elbow joint come to the first in incidence of injuries occurring in children, which include the humeral supracondylar fractures, lateral humeral condylar fractures, the total separation of the physis from the distal end of the humerus, the dislocation of the radial head (including the Monteggia fracture), fractures of the lateral humeral condyles along with the dislocation of the elbow joint, humeral intercondylar fractures, the dislocation of the elbow joint. The injured children cannot tell the accident of injuries clearly. The standard radiographic projection of the elbow joint is difficult to be obtained because of the fear of the children, the local swelling of the elbow joint, the limitation of the passive motion of the involved elbow joint. The structural complexity of the elbow joint and discrepancy of the appearing time of the ossification center of the physis lead to the difficulty in the correct diagnosis of the injuries of the elbow joint. The incidence of misdiagnosis and missed diagnosis are considerably high according to several reports both in China and abroad for those reasons above. And the incidence of misdiagnosis of the total separation of the physis from the distal end of the humerus is the highest among the childhood fractures which are often misdiagnosed as the dislocation of the elbow joint.
The X-ray radiocapitellar line(RCL) of elbow joint is an important reference factor in the diagnosis and differential diagnosis of the elbow injuries. It appears in almost all the related papers and authoritative textbooks that a line extending the longitudinal axis of the proximal end of radius (radial neck) should pass through the center of the ossification center of the humeral capitellum in all degrees of flexion of the elbow irrespective of the radiographic projection of the elbow and it has be used as a general criterion in diagnosing the elbow fractures. But we found that the results of the radiographic RCL of elbow joint were often affected by some factors such as the different position, the rotation of the forearm, different degrees of the flexion of the elbow, changes in the radiographic projection and the age.
Objective Up to now, no intensive study of the RCL of elbow joint in children has been
reported both at home and abroad. This study was designed to verify the accuracy and effectiveness of that criterion so avoiding or inducing the misdiagnosis and missed diagnosis of the elbow injuries in children. The observation, measurement and analysis of the radiographs of the elbow in different position of the normal children were performed.
Methods The radiographs of the elbow of 100 normal children(aging from 2 years old to 10.5 years old) and 32 elbow specimens of childhood cadavers were obtained. The radiographs with anteroposterior views of the elbow joint in 90 degrees of supination, 45 degrees of supination, zero degree of rotation, 45 degrees of pronation of the forearm were obtained as well as the lateral views of the elbow in 30 degrees, 60 degrees, 90 degrees, 120 degrees of flexion of the elbow. The classification of the position between the extension line of the longitudinal axis of the radial neck and the physis of the humeral capitellum falls into four types: centre intersection, non-centre intersection, tangent, non-intersection. The centre intersection means the extension line of the longitudinal axis of the radial neck passes through the center of the physis of the humeral capitellum. The non-centre intersection means the extension line passes through the physis rather than the center of the physis. The tangent means the extension line passes through the physis at a tangent. The non-intersection means the extension line does not pass through the center of the physis. The vertical distances (so called head-neck distance) between the extension line of the longitudinal axis of the radial neck and the center of the physis of the humeral capitellum were measured on the radiographs with the types of non-centre intersection, tangent, non-intersection
肘部X线片中的肱桡关系是诊断和鉴别不同损伤的重要参考依据。国内外几乎所有的文献包括一些权威的书籍、杂志都遵循“桡骨近端(桡骨颈)纵轴延长线，无论肘关节在任何位置都通过肱骨小头骨骺中心”这一诊断标准。然而，我们在临床上发现肘部X线片中的肱桡关系受诸多因素影响，如不同体位、前臂旋转、肘关节屈伸不同位置、投照位置变化、以及年龄因素等均会影响其结果。
目的 目前国内尚未见到对儿童肘关节X线片中的肱桡关系进行深入研究的报道。为了验证上述“标准”的准确性与有效性，避免或减少儿童肘部损伤的误诊与漏诊，设计本课题，对儿童正常关节不同位置的X线片进行观察、测量与分析。
郑州大学2003届硕士毕业论文
儿童肘关节X线片中肚挠关系的研究
方法拍摄100例1.3一10岁儿童的正常肘关节和16例32侧儿童尸体
上肢标本肘关节X线片。拍摄前臂旋后90“、旋后45。、旋转O。、旋前
45。时的肘关节前后位(正位)X线片。并拍摄屈肘30“、60”、90。、
120“时的肘关节侧位X线片。
观察挠骨颈纵轴延长线与肪骨小头骨髓的关系，它们之间的关系有四
种:挠骨颈的纵轴延长线通过肪骨小头骨箭中心称为“中心相交”;延
长线不通过肮骨小头骨髓中心称为“非中心性相交”;延长线与胧骨小头
骨骸相切称为“相切”;延长线与胧骨小头骨髓相离称为“相离”。对
非中心相交、相切、相离的X线片测量其挠骨颈纵轴延长线距肪骨小头骨
髓中心的垂直距离，称为“头一颈距”。分别比较性别、年龄、侧别、前臂不
同旋转位、不同屈肘位、正常儿童与尸体儿童的胧挠关系。
结果在肘关节伸直、前臂旋后90。位的前后位(正位)X线片上，
69%RCL为中心相交，31%为非中心相交;旋后45。时，1 00%RCL为非中
心相交;旋转0“时，82%RCL为非中心相交，16%相切，2%相离;旋前
45“时，33%RCL为非中心相交，33%相切，34%相离。在肘关节侧位X线
片上，屈肘30“位时，无一例中心相交，有82%的RCL为非中心相交，n%
相切，7%相离。而且年龄越小，头一颈距越大。屈肘60“、90。、120。位
时，RCL中心相交者分别为”%、90%、95%，非中心相交者分别为26%、
10%、5%，屈肘60“位时相切者仅为1%。
肪挠关系在正位X线片前臂不同的旋转角度的差异有统计学意义，P
<0.05。肪挠关系在侧位X线片前臂不同的屈曲角度的差异有统计学意义，
尸<0.05。正常儿童正位与侧位X线片上胧挠关系的差异有统计学意义，P
<0.05。正位X线片中性别、年龄、侧别肪挠关系及头一颈距之间的差异均
无统计学意义，P>0.05。不同年龄肘关节侧位X线片中屈肘30。时头一颈距
的差异有统计学意义，P<0.05。正常儿童活体与尸体肘关节正位X线片中
头一颈距的差异无统计学意义，P>0.05
结论
1.肘关节伸直位的前后位(正位)X线片上的
损伤无重要参考价值。
RCL
护一一.一
对于诊断儿童肘关节
郑州大学2003届硕士毕业论文
儿童肘关节X线片中胶挠关系的研究
2.屈肘90“、120“位的肘关节侧位X线片上的RCL对于诊断儿童肘关节
损伤有参考价值。
3.屈肘30“位的肘关节侧位X线片上，年龄越小，其头一颈距越大。
4.”挠骨近端(挠骨颈)纵轴延长线，无论肘关节在任何位置都通过胧骨小头
骨髓中心”这一沿用己久的诊断儿童肘关节损伤的标准是错误的。
The injuries of the elbow joint come to the first in incidence of injuries occurring in children, which include the humeral supracondylar fractures, lateral humeral condylar fractures, the total separation of the physis from the distal end of the humerus, the dislocation of the radial head (including the Monteggia fracture), fractures of the lateral humeral condyles along with the dislocation of the elbow joint, humeral intercondylar fractures, the dislocation of the elbow joint. The injured children cannot tell the accident of injuries clearly. The standard radiographic projection of the elbow joint is difficult to be obtained because of the fear of the children, the local swelling of the elbow joint, the limitation of the passive motion of the involved elbow joint. The structural complexity of the elbow joint and discrepancy of the appearing time of the ossification center of the physis lead to the difficulty in the correct diagnosis of the injuries of the elbow joint. The incidence of misdiagnosis and missed diagnosis are considerably high according to several reports both in China and abroad for those reasons above. And the incidence of misdiagnosis of the total separation of the physis from the distal end of the humerus is the highest among the childhood fractures which are often misdiagnosed as the dislocation of the elbow joint.
The X-ray radiocapitellar line(RCL) of elbow joint is an important reference factor in the diagnosis and differential diagnosis of the elbow injuries. It appears in almost all the related papers and authoritative textbooks that a line extending the longitudinal axis of the proximal end of radius (radial neck) should pass through the center of the ossification center of the humeral capitellum in all degrees of flexion of the elbow irrespective of the radiographic projection of the elbow and it has be used as a general criterion in diagnosing the elbow fractures. But we found that the results of the radiographic RCL of elbow joint were often affected by some factors such as the different position, the rotation of the forearm, different degrees of the flexion of the elbow, changes in the radiographic projection and the age.
Objective Up to now, no intensive study of the RCL of elbow joint in children has been
reported both at home and abroad. This study was designed to verify the accuracy and effectiveness of that criterion so avoiding or inducing the misdiagnosis and missed diagnosis of the elbow injuries in children. The observation, measurement and analysis of the radiographs of the elbow in different position of the normal children were performed.
Methods The radiographs of the elbow of 100 normal children(aging from 2 years old to 10.5 years old) and 32 elbow specimens of childhood cadavers were obtained. The radiographs with anteroposterior views of the elbow joint in 90 degrees of supination, 45 degrees of supination, zero degree of rotation, 45 degrees of pronation of the forearm were obtained as well as the lateral views of the elbow in 30 degrees, 60 degrees, 90 degrees, 120 degrees of flexion of the elbow. The classification of the position between the extension line of the longitudinal axis of the radial neck and the physis of the humeral capitellum falls into four types: centre intersection, non-centre intersection, tangent, non-intersection. The centre intersection means the extension line of the longitudinal axis of the radial neck passes through the center of the physis of the humeral capitellum. The non-centre intersection means the extension line passes through the physis rather than the center of the physis. The tangent means the extension line passes through the physis at a tangent. The non-intersection means the extension line does not pass through the center of the physis. The vertical distances (so called head-neck distance) between the extension line of the longitudinal axis of the radial neck and the center of the physis of the humeral capitellum were measured on the radiographs with the types of non-centre intersection, tangent, non-intersection
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48. Rogers L.F. Radiology of Skeletal Trauma. Vol Ⅱ ,New york:Chwrhill Livingstone 1982,439.
49. Storen G. Traumatic.disloiation of the radial head as an isolaed lesion in children. Acta Clin Scand. 1969,116-144
50. Frumkin K. Nursemaid's elbow: a radiographic demonstration. Ann Emerg Med 1985 Jul;14(7):690-3.
51．徐晓峰，沈铁城，刘锦波，等．成人创伤性孤立性桡骨头脱位．中华骨科杂志．2002,20：85-87．
52．蒲文生．儿童肘关节损伤的X线诊断分析．中外医用放射技术 1997；3：53-54
53．李晓峰；薛清．外伤致儿童肘关节肱骨小头骺离骨折的X线诊断．齐齐哈尔医学院学报 1997；18：276
54．许开喜．儿童肘关节创伤的X线诊断．中外医用放射技术 1998；1：38-39
55．方锦山．儿童肘关节损伤X线漏误诊的回顾性分析．中外医用放射技术 1998；3：90-91．
56．徐浩然．儿童肱骨下端全骺分离9例误诊原因分析．南通医学院学报 1998；183：
396．
57．赵成业；周祥．小儿110例肘关节骨折X线分析．实用放射学杂志 1998；14：46-47．
58．郭世绂，临床骨科解剖学，第一版，天津：天津科学技术出版社，1988．458．
59. Sferopoulos NK, Anagnostopoulos D. Anterior dislocation of the elbow in a child with congenital posterior dislocation of the radial head. A case report. Acta Orthop Belg 1999 Sep;65(3):378-81.
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46. Welk LA, Adler RS. Case report 725. Posterior displacement of proximal end of the right radius and capitulum with supracondylar fracture causing a displaced fracture rather than a fracture dislocation. Skeletal Radiol 1992;21(3): 198-200
47. Skibo L, Reed MH. A criterion for a tree lateral radiograph of the elbow in children. Can Assoc Radiol J 1994 Aug;45(4):287-91
48. Rogers L.F. Radiology of Skeletal Trauma. Vol Ⅱ ,New york:Chwrhill Livingstone 1982,439.
49. Storen G. Traumatic.disloiation of the radial head as an isolaed lesion in children. Acta Clin Scand. 1969,116-144
50. Frumkin K. Nursemaid's elbow: a radiographic demonstration. Ann Emerg Med 1985 Jul;14(7):690-3.
51．徐晓峰，沈铁城，刘锦波，等．成人创伤性孤立性桡骨头脱位．中华骨科杂志．2002,20：85-87．
52．蒲文生．儿童肘关节损伤的X线诊断分析．中外医用放射技术 1997；3：53-54
53．李晓峰；薛清．外伤致儿童肘关节肱骨小头骺离骨折的X线诊断．齐齐哈尔医学院学报 1997；18：276
54．许开喜．儿童肘关节创伤的X线诊断．中外医用放射技术 1998；1：38-39
55．方锦山．儿童肘关节损伤X线漏误诊的回顾性分析．中外医用放射技术 1998；3：90-91．
56．徐浩然．儿童肱骨下端全骺分离9例误诊原因分析．南通医学院学报 1998；183：
396．
57．赵成业；周祥．小儿110例肘关节骨折X线分析．实用放射学杂志 1998；14：46-47．
58．郭世绂，临床骨科解剖学，第一版，天津：天津科学技术出版社，1988．458．
59. Sferopoulos NK, Anagnostopoulos D. Anterior dislocation of the elbow in a child with congenital posterior dislocation of the radial head. A case report. Acta Orthop Belg 1999 Sep;65(3):378-81.
60．李景学，孙鼎元．骨关节X线诊断学．第一版．北京：人民卫生出版社，1978．76．
61．王晓，张世清，刘洋等，儿童肘关节X线片中的肱桡关系．骨与关节损伤杂志，2001，16(5)：324～326．