骨科英文书籍精读（93）｜肘关节脱位（2）
Treatment
UNCOMPLICATED DISLOCATION
The patient should be fully relaxed under anaesthesia. The surgeon pulls on the forearm while the elbow is slightly flexed. With one hand, sideways displacement is corrected, then the elbow is further flexed while the olecranon process is pushed forward with the thumbs.Unless almost full flexion can be obtained, the olecranon is not in the trochlear groove.
After reduction, the elbow should be put through a full range of movement to see whether it is stable. The distal nerves and circulation are checked again. In addition, an x-ray is obtained to confirm that the joint is reduced and to disclose any associated fractures.
The arm is held in a collar and cuff with the elbow flexed above 90 degrees. After 1 week the patient gently exercises his elbow; at 3 weeks the collar and cuff is discarded. Elbow movements are allowed to return spontaneously and are never forced. The long-term results are usually good.
DISLOCATION WITH ASSOCIATED FRACTURES
Coronoid process
Coronoid fractures have been classified by Regan and Morrey as:
Type I Avulsion of the tip. A benign enough injury, but it can represent a substantial soft-tissue injury of the elbow
Type II A single or comminuted fracture of the coronoid with 50 percent or less involved. This is usually not repaired surgically, as the elbow remains stable
Type III A single or comminuted fracture involving more than 50 percent. If the elbow is unstable after reduction, then fixation is usually needed.
Medial epicondyle
An avulsed medial epicondyle is, for practical purposes, a medial ligament disruption. If the epicondylar fragment is displaced, it must be reduced and fixed back in position. The arm and wrist are splinted with the elbow at 90 degrees; after 3 weeks movements are begun under supervision.
Head of radius
The combination of ligament disruption and a type II or III radial head fracture is an unstable injury; stability is restored only by healing or repair of the ligaments and restoration of the radial pillar – either by fracture fixation or (in the case of a comminuted fracture) by prosthetic replacement of the radial head. The medial collateral ligament may also be repaired to protect the radial head fixation or implant from undue valgus stress.
Olecranon process
In the rare forward dislocation of the elbow, the olecranon process may fracture; a large piece of the olecranon is left behind as a separate
fragment. Open reduction with internal fixation is the best treatment.
Side-swipe injuries
These severe fracture-dislocations are often associated with damage to the large vessels of the arm. The priorities are repair of any vascular injury, skeletal stabilization and soft tissue coverage. This is demanding surgery, necessitating a high level of expertise, and is best undertaken in a unit specialising in upper limb injuries.
Persistent instability
In cases where the elbow remains unstable after the bone and joint anatomy has been restored, a hinged external fixator can be applied in
order to maintain mobility while the tissues heal.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
trochlear groove.滑车沟。
trochlear /'trɑklɪɚ/n. 滑车神经（等于trochlear nerve）adj. 滑车的；轮状的；软骨轮的
groove /ɡruːv/n. [建] 凹槽，槽；最佳状态；惯例vt. 开槽于vi. 形成沟槽
discard/dɪˈskɑːrd/n. 抛弃；被丢弃的东西或人vt. 抛弃；放弃；丢弃vi. 放弃
Avulsion /ə'vʌlʃən/n. 扯开，撕裂；扯离的部分
benign /bɪˈnaɪn/adj. 良性的；和蔼的，亲切的；吉利的
substantial /səbˈstænʃl/n. 本质；重要材料adj. 大量的；实质的；内容充实的
for practical purposes,实际上，对实用性来讲
pillar /ˈpɪlər/n. 柱子，柱形物；栋梁；墩vt. 用柱支持
undue/ˌʌnˈduː/adj. 过度的，过分的；不适当的；未到期的
swipe /swaɪp/v. 挥起（物体）击打；偷窃；刷（磁卡）n. 挥击；抨击
priority/praɪˈɔːrəti/n. 优先；优先权；[数] 优先次序；优先考虑的事
This is best undertaken in a unit specialising in upper limb injuries.最好在专门治疗上肢损伤的单位进行。
a hinged external fixator铰链式外部固定架
/hɪndʒ/n. 铰链，折叶；关键，
百度翻译：
治疗
单纯脱位
病人应在麻醉下完全放松。当手肘轻微弯曲时，外科医生拉动前臂。一方面，纠正侧移，然后肘关节进一步弯曲，同时尺骨鹰嘴过程向前推进拇指。除非几乎可以完全屈曲，鹰嘴不在滑车沟内。
复位后，肘关节应进行全方位运动，以观察其是否稳定。再次检查远端神经和循环。此外，还获得了一张x光片，以确认关节减少并显示任何相关的骨折。
手臂用衣领和袖口固定，肘部弯曲90度以上。1周后，患者轻轻地锻炼肘部；3周后，丢弃衣领和袖口。肘关节的运动可以自发地恢复，绝不是强迫的。长期效果通常是好的。
脱位伴骨折
冠状突
冠状骨折被Regan和Morrey分为：
Ⅰ型舌尖撕脱伤。一个足够良性的损伤，但它可以代表肘部严重的软组织损伤
II型：冠状骨单发或粉碎性骨折，累及50%或更少。这通常不需要手术修复，因为肘关节保持稳定
III型：单发或粉碎性骨折，占50%以上。如果肘关节复位后不稳定，通常需要固定。
内侧上髁
撕裂的内侧上髁实际上是指内侧韧带断裂。如果上髁碎片移位，必须复位固定。手臂和手腕用夹板与肘部成90度夹板固定；3周后，在监督下开始活动。
桡骨头
韧带断裂和II型或III型桡骨头骨折是一种不稳定的损伤；只有通过愈合或修复韧带和修复桡骨头柱，才能恢复稳定性——骨折固定或（粉碎性骨折的情况下）桡骨头假体置换。内侧副韧带也可以修复，以保护桡骨头固定或植入物不受过度外翻应力的影响。
鹰嘴突
在罕见的肘关节前脱位中，鹰嘴突可能会骨折；鹰嘴的一大块被留下作为一个单独的部分
碎片。切开复位内固定是最佳治疗方法。
侧面擦伤
这些严重的骨折脱位常伴有手臂大血管的损伤。首要任务是修复任何血管损伤、骨骼稳定和软组织覆盖。这是一项要求很高的手术，需要高水平的专业知识，最好是在专门负责上肢损伤的单位进行。
持续不稳定
在骨骼和关节解剖恢复后，如果肘部仍然不稳定，可以使用铰链式外固定器
以保持组织愈合时的活动性。