桡骨小头半脱位PPT课件

桡骨头半脱位,邢台县医院骨科许浈铖,1,.,Whats桡骨头半脱位？,2,.,专业回答,牵拉肘，也被称作环状韧带移位或桡骨头半脱位，是儿童常见的骨科损伤。IntheUnitedStates,theincidenceofemergencydepartmentvisitsforpulledelbowisestimatedat2.7per1000personsyoungerthan18yearsofage.Themedianageatpresentationis2years.在美国，未成年人急诊就诊中牵拉肘的发生率大约在2.7/1000.相关报道的中位年龄为2岁。Theinjuryisuniquetoinfantsandyoungchildrenbecausetheradialheadislessbulbousthanitisinolderpersonsandmayeasilybecomedisplaced.牵拉肘特别常见于婴幼儿和青少年，因为幼儿的桡骨头还未发育像成人那样的圆球状桡骨头，所以很容易移位。Reductionofapulledelbowisasafeprocedurethatcanbeperformedintheoutpatientsetting.复位牵拉肘是相对安全的操作，完全可以在门诊进行。Theannularligamentencirclestheneckoftheradiusandholdsittightlyinplaceagainsttheulna),therebymaintainingthepositionoftheproximalradiusinrelationtotheulnaandthecapitellumofthedistalhumeruswhileallowing180-degreerotation.环状韧带包绕桡骨颈使其紧邻尺骨，从而维持桡骨与毗邻尺骨以及肱骨远端肱骨小头的相对位置，同时可以完成180旋转。Whenthereisforcefullongitudinaltraction,suchaswhenachildispulledorliftedbythearm,theradialheadispulledunderneaththeannularligament.在强大的纵向（轴向）牵拉下，比如提拉幼儿手臂或用手臂引体向上时，桡骨头会被牵拉至环状韧带下方。,3,.,大多数孩子的病史中可能有过被牵拉的情况,4,.,5,.,环状韧带嵌压的环状韧带,环状韧带包绕桡骨颈，并维持桡骨紧邻尺骨,轴向牵拉时，桡骨头包埋在环状韧带下,6,.,首先，明确孩子的病史及体检与诊断一致。Thechildshistorymayincludeawitnessedeventofforcefultraction;however,othermechanismsofinjuryhavealsobeendescribed.孩子的病史中可能有过被牵拉的情况；然而，其它的损失机制也有描述过。Physicalexaminationshouldrevealpseudoparalysis,withthechildvoluntarilykeepingthelimbstilltominimizediscomfort.体格检查会发现假性神经麻痹，而孩子为了减少不适会自主保持上肢制动。Therewillalsobepainwithmovement,mostoftenrelatedtosupinationandpronationratherthantoflexionandextension.活动时疼痛，旋前或旋后较屈伸更易产生。Inmostcasestherewillbetendernesstopalpationonthelateralsideoftheelbow;however,absenceofthistendernessdoesnotruleoutthediagnosis.多数情况下触诊肘关节外侧可及虚空感，即使未及虚空感也不能排除该诊断。Anaffectedchildholdstheelbowinaslightlyflexedposition,withthehandpronated.受伤的孩童将被迫保持肘关节轻微屈曲位并维持手掌旋前位。Furtherexaminationshouldalsorevealanormal-lookingelbowwithouteffusion,bruising,orobviousdeformity.更进一步的检查则会发现肘关节外形正常，无突出，无挫伤或明显的畸形。Radiographsarealmostalwaysnormalincasesofpulledelbow,soradiographyshouldbereservedforcasesinwhichthediagnosisisnotclear.,7,.,牵拉肘的影像学检查几乎都是正常的，所以只有在诊断不明确时才考虑进行影像学检查。However,positioningtheelbowinpreparationforradiographyisoftentherapeuticinreducingthedisplacement.然而，在放置体位来进行影像学检查时，往往对复位移位有帮助。Contraindications禁忌征ThecontraindicationstoperformingareductionarefewandareusuallyeasilyRecognized.复位的禁忌征很少且容易鉴别。Ifachildhasahistoryandphysicalexaminationthatareconsistentwithfracture,suchasdeformity,swelling,orbruisingoftheelboworahistoryofafallontothearmfromasubstantialheight,thenaradiographshouldbeobtainedtoevaluateforfracture.如果孩子的病史或体格检查与骨折吻合，比如畸形，肿胀或肘关节挫伤或有高处摔落手臂着地的外伤史，则应行影像学检查来判断是否骨折。Iftheradiographdoesnotrevealfractureoreffusion,thenreductionmaybeconsidered.如果影像学检查未发现骨折或突出，则可以考虑手法复位。,8,.,Inonestudy,reductionwasachievedonthefirstattemptin95%ofpatientswhounderwentrandomizationtohyperpronationascomparedwith77%ofpatientswhounderwentrandomizationtosupination.在一项研究中，随机予以过度旋前手法首次复位成功的比例是95%，而旋后手法则为77%。SupinationTechnique旋后手法Toperformthesupinationtechnique,seatthechildontheparentorcaregiverslap,withthechildfacingyou.Claspboththehandandelbowoftheaffectedarm(图.3).采用旋后手法时，让孩子坐在家长或监护人的大腿上面对着操作者。扣住患肢的手和肘。Yourfingersorthumbshouldoverlietheradialhead.Neitherthepositioningofyourfingersorthumbnorthestartingpositionoftheaffectedarmiscriticaltothesuccessoftheprocedure.操作者的手指后大拇指应压在桡骨头上。无论是操作者的手指或大拇指位置或患肢的初始位置对于复位成功都至关重要。,9,.,Supinateandflextheforearmuntilyoufeeltheligamentmovebackintoposition(图.4).Youmayfeelorhearaclickastheligamentisreduced.旋前屈曲前臂直到感觉环状韧带移回至正常位置。环状韧带复位时操作者可以感觉或听到轻微的咔哒声。Ifthereductionissuccessful,thechildshouldbepainfreeandabletomovethearmnormallyin5to30minutes,includingbeingabletoreachforanobjectabovethehead.如果复位成功，孩子便会不痛并能在5-30分钟内自如活动，包括碰触高过头顶的物体。HyperpronationTechnique过度旋前法Hyperpronationcanbetheprimarymethodusedtoreduceapulledelbow,oritcanbeusedifthesupinationtechniquehasfailed.Seatthechildontheparentsorcaregiverslap,withthechildfacingyou.However,ifanyotherabnormalitiesarepresent,suchasevidenceofinfection,reductionshouldnotbeattemptedandimmediateevaluationofthecauseandappropriatetreatmentshouldbeinitiated.但是，如果合并其它任何疾病，比如感染，则不能予以复位而应立即评估造成疾病的原因同时立即予以适当的治疗。,10,.,Preparation准备Noequipmentisrequiredforthereductionofapulledelbow.Theclinicianshandsshouldbewashedthoroughlyaspartofstandardprecautions.复位肘关节无需准备任何设备。临床医生彻底洗手应该是标准注意事项的一部分。Procedure操作Topreparetheparentorcaregiver,explainthatsomediscomfortmaybeassociatedwiththeprocedure.操作前告知家长或监护人，操作过程中可能会造成一些不适。Thechildmaycryorscreamforseveralminutesaftertheradialheadhasbeenrelocatedtoitsproperposition.桡骨头复位至正常位置后孩子可能会哭或喊叫一会。Twotechniquescanbeusedtocorrectapulledelbow.二种手法可以用来纠正牵拉肘。Thesupinationtechniquehastypicallybeenusedforreductionofpulledelbow;however,somestudiescomparingthesupinationwiththehyperpronationtechniquehaveshownthathyperpronationismoresuccessful.旋后法早已被用作为经典的牵拉肘复位手法；然而，一些研究比较了旋后手法与过度旋前手法发现过度旋前法效果更好。,11,.,复位肘关节可以首选过度旋前法或在旋后手法未能复位时再选择过度旋前手法。让孩子坐在家长或监护人的大腿上，面对着操作者。Claspthehandoftheaffectedarmasyouwouldinahandshake(图.5).Useyourfreehandtosupportthepatientselbow.握住患肢像握手那样。用另一只手拖住患者的肘部。Hyperpronatethepatientswrist(图.6).Youmayfeelorhearaclickastheligamentisreduced.旋前患者手腕。韧带复位时可以感觉或听到轻微的咔哒声。Ifthereductionissuccessful,thechildshouldbepainfreeandabletomovethearmnormallyin5to30minutes,includingbeingabletolifttheaffectedarmabovethehead.如果复位成功，孩子便会不痛并能在5-30分钟内自如活动，包括碰触高过头顶的物体。Troubleshooting处理难题Mostreductionsofapulledelbowwillbesuccessfulafterasingleattempt.大多数的牵拉肘都能一次复位成功。,12,.,Ifaninitialattemptfails,theproceduremayberepeatedorthealternatetechniquemaybeused.如果初次复位失败，可以再次尝试复位或换一种复位手法。Iftheelbowhasnotbeenreducedafterthreeorfourattempts,reexaminethearmcarefullyfromshouldertofingertipsandobtainaradiographtoruleoutfracture.如果尝试3-4次后仍无法复位肘关节，则应再次仔细检查从肩膀至手指并予以行影像学检查来排除骨折。However,whenthecauseoftheinjuryordisplacementisafall,whenthecircumstancesoftheinjuryareunclear,orwhenitisdifficulttoperformathoroughexaminationbecausethechildisuncooperative,itisprudenttoobtainaradiographbeforethethirdorfourthattemptatreduction.然而，当造成损伤或移位的原因是摔落，或损伤的周围环境不清楚或则是因为孩子不配合而无法进行彻底的体格检查时，在尝试进行第三或第四次复位前为谨慎起见应进行影像学检查。Afterobtainingaradiograph,splinttheelbowatanangleofapproximately90degrees(evenifthechildpresentswiththearmmorefullyextended)andreferthechildtoanorthopedicsurgeon.影像学检查后，用夹板固定肘关节在大约90的位置（即使孩子开始的手臂是过伸位的），然后将孩子转诊至骨科医生。,13,.,Inthemajorityofsuchcases,theaffectedelbowwillreducespontaneouslyduringtheperiodofimmobilization.对于多数此类情况，受伤的肘关节会在制动期间自发复位。Aftercare操作后护理Whenapulledelbowhasbeensuccessfullyreduced,aft