骨科英文书籍精读（94）｜肘关节脱位（3）
Complications
Complications are common; some are potentially so serious that the patient with a dislocation or a fracture-dislocation of the elbow must be observed with the closest attention.
EARLY
Vascular injury
The brachial artery may be damaged. Absence of the radial pulse is a warning. If there are other signs of ischaemia, this should be treated as an emergency. Splints must be removed and the elbow should be straightened somewhat. If there is no improvement, an arteriogram is performed; the brachial artery may have to be explored.
Nerve injury
The median or ulnar nerve is sometimes injured. Spontaneous recovery usually occurs after 6–8 weeks.
LATE
Stiffness
Loss of 20 to 30 degrees of extension is not uncommon after elbow dislocation; fortunately this is usually of little functional significance. The most common cause of undue stiffness is prolonged immobilization. In the management of all elbow injuries the joint should be moved as soon as possible, with due consideration to stability of the fractures and soft tissues and without undue passive stretching of the soft tissues. For injuries requiring prolonged splintage, a hinged elbow brace, or on some occasions a hinged external fixator, can allow some movement in the flexionextension plane whilst protecting against collateral stress.
Persistent stiffness of severe degree can often be improved by anterior capsular release. However, operative treatment should not be rushed; remember that sometimes the stiffness is due to myositis ossificans, which is usually undetectable on plain x-ray examination until a month or more after injury.
Heterotopic ossification (myositis ossificans)
Heterotopic bone formation may occur in the damaged soft tissues in front of the joint. It is due to muscle bruising or haematoma formation; however the precise pathogenesis is not known. In former years ‘myositis ossificans’ was a fairly common complication of elbow injury, usually associated with forceful reduction and overenthusiastic passive movement of the elbow. Nowadays it is rarely seen, but it is as well to be alert for signs such as slight swelling, excessive pain and tenderness around the front of the elbow, along with tardy recovery of active movements.
X-ray examination is initially unhelpful; soft-tissue ossification is usually not visible until 4–6 weeks after injury. If the condition is suspected, exercises are stopped and the elbow is splinted in comfortable flexion until pain subsides; gentle active movements and
continuous passive motion are then resumed. Antiinflammatory drugs may help to reduce stiffness; they are also used prophylactically to reduce the risk of heterotopic bone formation.
A bone mass which markedly restricts movement and elbow function can be excised, though not before the bone is fully ‘mature’, i.e. has well-defined cortical margins and trabeculae (as seen on x-ray).
Unreduced dislocation
A dislocation may not have been diagnosed; or only the backward displacement corrected, leaving the olecranon process still displaced sideways. Up to 3 weeks from injury, manipulative reduction is worth attempting but care is needed to avoid fracturing one of the bones. Other than this, there is no satisfactory treatment. Open reduction can be considered, but a wide soft tissue release is required, which predisposes to yet further stiffness. Alternatively, the condition can be left, in the hope that the elbow will regain a useful range of movement. If pain is a problem, the patient can be offered an arthrodesis or an arthroplasty.
Recurrent dislocation
This is rare unless there is a large coronoid fracture or radial head fracture. If recurrent elbow instability occurs, the lateral ligament and capsule can be repaired or re-attached to the lateral condyle. A cast with the elbow at 90 degrees is worn for 4 weeks.
Osteoarthritis
Secondary osteoarthritis is quite common after severe fracture-dislocations. In older patients, total elbow replacement can be considered.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
potentially /pəˈtenʃəli/adv. 可能地，潜在地
The brachial artery肱动脉 /'brekɪəl/adj. 臂的，臂状的
somewhat /ˈsʌmwʌt/adv. 有点，稍微pron. 某物；几分
with due consideration to stability of the fractures and soft tissues 考虑到骨折和软组织的稳定性
due /duː/n. 应付款；应得之物adj. 到期的；预期的；应付的；应得的
undue /ˌʌnˈduː/adj. 过度的，过分的；不适当的；未到期的
flexionextension 屈伸
myositis ossificans,骨化性肌炎
Heterotopic ossification异位性骨化 /,hetərə'tɔpik/adj. 异位的；
precise pathogenesis确切发病机制
/ˌpæθəˈdʒenɪsɪs/n. 发病机理；发病原
tardy /ˈtɑːrdi/n. 迟到adj. 缓慢的，迟缓的；迟到的
subside /səbˈsaɪd/vi. 平息；减弱；沉淀；坐下
resume /rɪˈzuːm/vt. （中断后）重新开始，继续
prophylactically adv. 预防地；预防上
excise /ɛk'saɪz/v. 切除；删除；
Alternatively /ɔːlˈtɜːrnətɪvli/adv. 要不，或者；非此即彼；二者择一地；作为一种选择
arthrodesis or an arthroplasty.关节融合术或关节成形术。
/ɑ:'θrɔdəsis/ /,ɑ:θrəu'plæsti/
recurrent /rɪˈkɜːrənt/adj. 复发的；周期性的，经常发生的
recurrent elbow instability 复发性肘关节不稳定
百度翻译：
并发症
并发症是常见的；有些可能非常严重，以至于必须密切注意观察肘关节脱位或骨折脱位的患者。
早期并发症
血管损伤
肱动脉可能受损。没有径向脉冲是一个警告。如果有其他缺血迹象，这应该作为紧急情况处理。夹板必须去掉，肘部应该稍微伸直。如果没有改善，则进行动脉造影；可能需要探查肱动脉。
神经损伤
正中神经或尺神经有时会受伤。自然恢复通常发生在6-8周后。
晚期并发症
僵硬
肘关节脱位后失去20到30度的伸展并不少见；幸运的是，这通常没有什么功能意义。过度僵硬最常见的原因是长时间的固定。在治疗所有肘关节损伤时，应尽快移动关节，充分考虑骨折和软组织的稳定性，不要过度被动拉伸软组织。对于需要长时间夹板固定的损伤，铰链式肘撑，或在某些情况下铰链式外固定器，可以允许在屈伸平面上进行一些运动，同时防止侧支应力。
严重程度的持续僵硬可以通过前囊松解来改善。然而，手术治疗不应仓促；记住，有时僵硬是由于骨化性肌炎所致，通常在受伤后一个月或更长时间后才能在平片上发现。
异位骨化（骨化性肌炎）
关节前受损软组织可发生异位骨形成。这是由于肌肉瘀伤或血肿形成，但确切的发病机制尚不清楚。骨化性肌炎是肘关节损伤常见的并发症，常伴有肘关节用力复位和过度被动运动。现在很少见到，但也要警惕肘部前部的轻微肿胀、过度疼痛和压痛，以及活动性活动恢复缓慢等迹象。
X光检查最初是没有帮助的；软组织骨化通常是在受伤后4-6周才能看到的。如果怀疑有这种情况，停止运动，用夹板将肘部固定在舒适的屈曲位置，直到疼痛消退；轻柔的主动运动和
然后恢复连续的被动运动。抗炎药可能有助于减轻僵硬；它们也可用于预防性降低异位骨形成的风险。
可以切除明显限制运动和肘关节功能的骨块，但不能在骨骼完全“成熟”之前切除，即具有清晰的皮质边缘和小梁（如x光片所示）。
未复位脱位
脱位可能没有被诊断出来，或者只是向后移位得到纠正，使得鹰嘴突仍然侧向移位。受伤后3周内，手法复位是值得尝试的，但需要注意避免骨折的一块骨头。除此之外，没有令人满意的治疗方法。可以考虑切开复位，但需要广泛的软组织松解，这容易导致进一步僵硬。或者，也可以保留这种情况，希望肘部能够恢复有效的活动范围。如果疼痛是个问题，病人可以接受关节融合术或关节置换术。
复发性脱位
这是罕见的，除非有一个大冠状骨折或桡骨头骨折。如果复发性肘关节不稳，外侧韧带和关节囊可以修复或重新附着在外侧髁突上。肘部呈90度角的石膏固定4周。
骨关节炎
继发性骨关节炎在严重骨折脱位后相当常见。对于老年患者，可以考虑全肘关节置换术。