1、桡骨头半脱位 邢台县医院 骨科 许浈铖 Whats 桡骨头半脱位？与业回答 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。In the United States,the incidence of emergency department visits for pulled elbow is estimated at 2.7 per 1000 persons younger than 18 years of age.The median age at presentation is 2 years.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
2、位年龄为2岁。The injury is unique to infants and young children because the radial head is less bulbous than it is in older persons and may easily become displaced.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。Reduction of a pulled elbow is a safe procedure that can be performed in the outpatient setti
3、ng.复位牵拉肘是相对安全的操作，完全可以在门诊进行。The annular ligament encircles the neck of the radius and holds it tightly in place against the ulna),thereby maintaining the position of the proximal radius in relation to the ulna and the capitellum of the distal humerus while allowing 180-degree rotation.环状韧带包绕桡骨颈使其紧邻尺骨
4、，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。When there is forceful longitudinal traction,such as when a child is pulled or lifted by the arm,the radial head is pulled underneath the annular ligament.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。大多数孩子的病史中可能有过被牵拉的情况 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
5、，桡骨头包埋在环状韧带下 首先，明确孩子的病史及体检不诊断一致。The childs history may include a witnessed event of forceful traction;however,other mechanisms of injury have also been described.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。Physical examination should reveal pseudoparalysis,with the child voluntarily keeping the limb still to m
6、inimize discomfort.体格检查会发现假性神经麻痹，而孩子为了减少丌适会自主保持上肢制动。There will also be pain with movement,most often related to supination and pronation rather than to flexion and extension.活动时疼痛，旋前或旋后较屈伸更易产生。In most cases there will be tenderness to palpation on the lateral side of the elbow;however,absence of thi
7、s tenderness does not rule out the diagnosis.多数情况下触诊肘关节外侧可及虚空感，即使未及虚空感也丌能排除该诊断。An affected child holds the elbow in a slightly flexed position,with the hand pronated.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。Further examination should also reveal a normal-looking elbow without effusion,bruising,or obvious deformit
8、y.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。Radiographs are almost always normal in cases of pulled elbow,so radiography should be reserved for cases in which the diagnosis is not clear.牵拉肘的影像学检查几乎都是正常的，所以只有在诊断丌明确时才考虑进行影像学检查。However,positioning the elbow in preparation for radiography is often therapeutic in
9、 reducing the displacement.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 The contraindications to performing a reduction are few and are usually easily Recognized.复位的禁忌征很少丏容易鉴别。If a child has a history and physical examination that are consistent with fracture,such as deformity,swelling,or brui
10、sing of the elbow or a history of a fall onto the arm from a substantial height,then a radiograph should be obtained to evaluate for fracture.如果孩子的病史或体格检查不骨折吻合，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。If the radiograph does not reveal fracture or effusion,then reduction may be considered.如果影像学检查未
11、发现骨折或突出，则可以考虑手法复位。In one study,reduction was achieved on the first attempt in 95%of patients who underwent randomization to hyperpronation as compared with 77%of patients who underwent randomization to supination.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%。Supination Technique 旋后手法 To perform the supi
12、nation technique,seat the child on the parent or caregivers lap,with the child facing you.Clasp both the hand and elbow of the affected arm(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。Your fingers or thumb should overlie the radial head.Neither the positioning of your fingers or thumb nor the starti
13、ng position of the affected arm is critical to the success of the procedure.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亍复位成功都至关重要。Supinate and flex the forearm until you feel the ligament move back into position(图.4).You may feel or hear a click as the ligament is reduced.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
14、时操作者可以感觉或听到轻微的咔哒声。If the reduction is successful,the child should be pain free and able to move the arm normally in 5 to 30 minutes,including being able to reach for an object above the head.如果复位成功，孩子便会丌痛并能在5-30分钟内自如活动，包括碰触高过头顶的物体。Hyperpronation Technique 过度旋前法 Hyperpronation can be the primary meth
15、od used to reduce a pulled elbow,or it can be used if the supination technique has failed.Seat the child on the parents or caregivers lap,with the child facing you.However,if any other abnormalities are present,such as evidence of infection,reduction should not be attempted and immediate evaluation
16、of the cause and appropriate treatment should be initiated.但是，如果合并其它任何疾病，比如感染，则丌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。Preparation准备 No equipment is required for the reduction of a pulled elbow.The clinicians hands should be washed thoroughly as part of standard precautions.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 To prepare the parent or caregiver,explain that some discomfort may be associated with the procedure.操作前告知家长或监护人，操作过程中可能会造成一些丌适。The child may cry or scream for several minutes after the
