橈骨小頭半脫位專家講座

What‘s橈骨頭半脫位？橈骨小頭半脫位專家講座第1頁專業(yè)回答牽拉肘，也被稱作環(huán)狀韌帶移位或橈骨頭半脫位，是兒童常見骨科損傷。

IntheUnitedStates,theincidence

ofemergencydepartmentvisitsforpulledelbowisestimatedat2.7per1000

personsyoungerthan18yearsofage.Themedianageatpresentationis2years.

在美國，未成年人急診就診中牽拉肘發(fā)生率大約在2.7/1000.相關(guān)報(bào)道中位年紀(jì)為2歲。

Theinjuryisuniquetoinfantsandyoungchildrenbecausetheradialheadisless

bulbousthanitisinolderpersonsandmayeasilybecomedisplaced.

牽拉肘尤其常見于嬰幼兒和青少年，因?yàn)橛變簶锕穷^還未發(fā)育像成人那樣圓球狀橈骨頭，所以很輕易移位。

Reductionof

apulledelbowisasafeprocedurethatcanbeperformedintheoutpatientsetting.

復(fù)位牽拉肘是相對(duì)安全操作，完全能夠在門診進(jìn)行。

Theannularligamentencirclestheneckoftheradiusandholdsittightlyinplace

againsttheulna),therebymaintainingthepositionoftheproximalradius

inrelationtotheulnaandthecapitellumofthedistalhumeruswhileallowing

180-degreerotation.

環(huán)狀韌帶包繞橈骨頸使其緊鄰尺骨，從而維持橈骨與毗鄰尺骨以及肱骨遠(yuǎn)端肱骨小頭相對(duì)位置，同時(shí)能夠完成180°旋轉(zhuǎn)。

Whenthereisforcefullongitudinaltraction,suchaswhena

childispulledorliftedbythearm,theradialheadispulledunderneaththeannular

ligament.

在強(qiáng)大縱向（軸向）牽拉下，比如提拉幼兒手臂或用手臂引體向上時(shí)，橈骨頭會(huì)被牽拉至環(huán)狀韌帶下方。橈骨小頭半脫位專家講座第2頁大多數(shù)孩子病史中可能有過被牽拉情況橈骨小頭半脫位專家講座第3頁橈骨小頭半脫位專家講座第4頁

環(huán)狀韌帶

嵌壓環(huán)狀韌帶環(huán)狀韌帶包繞橈骨頸，并維持橈骨緊鄰尺骨軸向牽拉時(shí)，橈骨頭包埋在環(huán)狀韌帶下橈骨小頭半脫位專家講座第5頁首先，明確孩子病史及體檢與診療一致。

Thechild’shistorymayincludeawitnessedeventof

forcefultraction;however,othermechanismsofinjuryhavealsobeendescribed.

孩子病史中可能有過被牽拉情況；然而，其它損失機(jī)制也有描述過。

Physicalexaminationshouldrevealpseudoparalysis,withthechildvoluntarily

keepingthelimbstilltominimizediscomfort.

體格檢驗(yàn)會(huì)發(fā)覺假性神經(jīng)麻痹，而孩子為了降低不適會(huì)自主保持上肢制動(dòng)。

Therewillalsobepainwithmovement,

mostoftenrelatedtosupinationandpronationratherthantoflexionand

extension.

活動(dòng)時(shí)疼痛，旋前或旋后較屈伸更易產(chǎn)生。

Inmostcasestherewillbetendernesstopalpationonthelateralsideof

theelbow;however,absenceofthistendernessdoesnotruleoutthediagnosis.

多數(shù)情況下觸診肘關(guān)節(jié)外側(cè)可及虛空感，即使未及虛空感也不能排除該診療。

An

affectedchildholdstheelbowinaslightlyflexedposition,withthehandpronated.

受傷孩童將被迫保持肘關(guān)節(jié)輕微屈曲位并維持手掌旋前位。

Furtherexaminationshouldalsorevealanormal-lookingelbowwithouteffusion,

bruising,orobviousdeformity.

更深入檢驗(yàn)則會(huì)發(fā)覺肘關(guān)節(jié)外形正常，無突出，無挫傷或顯著畸形。

Radiographsarealmostalwaysnormalincasesof

pulledelbow,soradiographyshouldbereservedforcasesinwhichthediagnosisis

notclear.

橈骨小頭半脫位專家講座第6頁牽拉肘影像學(xué)檢驗(yàn)幾乎都是正常，所以只有在診療不明確時(shí)才考慮進(jìn)行影像學(xué)檢驗(yàn)。

However,positioningtheelbowinpreparationforradiographyisoften

therapeuticinreducingthedisplacement.

然而，在放置體位來進(jìn)行影像學(xué)檢驗(yàn)時(shí)，往往對(duì)復(fù)位移位有幫助。

Contraindications

禁忌征

Thecontraindicationstoperformingareductionarefewandareusuallyeasily

Recognized.

復(fù)位禁忌征極少且輕易判別。

Ifachildhasahistoryandphysicalexaminationthatareconsistent

withfracture,suchasdeformity,swelling,orbruisingoftheelboworahistoryof

afallontothearmfromasubstantialheight,thenaradiographshouldbeobtained

toevaluateforfracture.

假如孩子病史或體格檢驗(yàn)與骨折吻合，比如畸形，腫脹或肘關(guān)節(jié)挫傷或有高處摔落手臂著地外傷史，則應(yīng)行影像學(xué)檢驗(yàn)來判斷是否骨折。

Iftheradiographdoesnotrevealfractureoreffusion,then

reductionmaybeconsidered.

假如影像學(xué)檢驗(yàn)未發(fā)覺骨折或突出，則能夠考慮手法復(fù)位。

橈骨小頭半脫位專家講座第7頁Inonestudy,reductionwasachievedonthefirst

attemptin95%ofpatientswhounderwentrandomizationtohyperpronationas

comparedwith77%ofpatientswhounderwentrandomizationtosupination.

在一項(xiàng)研究中，隨機(jī)給予過分旋前手法首次復(fù)位成功百分比是95%，而旋后手法則為77%。

SupinationTechnique

旋后手法

Toperformthesupinationtechnique,seatthechildontheparentorcaregiver’slap,

withthechildfacingyou.Claspboththehandandelbowoftheaffectedarm(圖.3).

采取旋后手法時(shí)，讓孩子坐在家長或監(jiān)護(hù)人大腿上面對(duì)著操作者?？圩』贾趾椭?。

Yourfingersorthumbshouldoverlietheradialhead.Neitherthepositioningof

yourfingersorthumbnorthestartingpositionoftheaffectedarmiscriticaltothe

successoftheprocedure.

操作者手指后大拇指應(yīng)壓在橈骨頭上。不論是操作者手指或大拇指位置或患肢初始位置對(duì)于復(fù)位成功都至關(guān)主要。

橈骨小頭半脫位專家講座第8頁Supinateandflextheforearmuntilyoufeeltheligament

movebackintoposition(圖.4).Youmayfeelorhearaclickastheligamentisreduced.

旋前屈曲前臂直到感覺環(huán)狀韌帶移回至正常位置。環(huán)狀韌帶復(fù)位時(shí)操作者能夠感覺或聽到輕微咔噠聲。

Ifthereductionissuccessful,thechildshouldbepainfreeandabletomove

thearmnormallyin5to30minutes,includingbeingabletoreachforanobjectabove

thehead.

假如復(fù)位成功，孩子便會(huì)不痛并能在5-30分鐘內(nèi)自如活動(dòng)，包含碰觸高過頭頂物體。

HyperpronationTechnique

過分旋前法

Hyperpronationcanbetheprimarymethodusedtoreduceapulledelbow,oritcan

beusedifthesupinationtechniquehasfailed.Seatthechildontheparent’sor

caregiver’slap,withthechildfacingyou.However,ifanyotherabnormalitiesarepresent,such

asevidenceofinfection,reductionshouldnotbeattemptedandimmediateevaluation

ofthecauseandappropriatetreatmentshouldbeinitiated.

不過，假如合并其它任何疾病，比如感染，則不能給予復(fù)位而應(yīng)馬上評(píng)定造成疾病原因同時(shí)馬上給予適當(dāng)治療。

橈骨小頭半脫位專家講座第9頁P(yáng)reparation準(zhǔn)備

Noequipmentisrequiredforthereductionofapulledelbow.Theclinician’shands

shouldbewashedthoroughlyaspartofstandardprecautions.

復(fù)位肘關(guān)節(jié)無需準(zhǔn)備任何設(shè)備。臨床醫(yī)生徹底洗手應(yīng)該是標(biāo)準(zhǔn)注意事項(xiàng)一部分。

Procedure

操作

Topreparetheparentorcaregiver,explainthatsomediscomfortmaybeassociated

withtheprocedure.

操作前通知家長或監(jiān)護(hù)人，操作過程中可能會(huì)造成一些不適。

Thechildmaycryorscreamforseveralminutesaftertheradial

headhasbeenrelocatedtoitsproperposition.

橈骨頭復(fù)位至正常位置后孩子可能會(huì)哭或喊叫一會(huì)。

Twotechniquescanbeusedtocorrectapulledelbow.

二種手法能夠用來糾正牽拉肘。

Thesupinationtechnique

hastypicallybeenusedforreductionofpulledelbow;however,somestudiescomparing

thesupinationwiththehyperpronationtechniquehaveshownthathyperpronation

ismoresuccessful.

旋后法早已被用作為經(jīng)典牽拉肘復(fù)位手法；然而，一些研究比較了旋后手法與過分旋前手法發(fā)覺過分旋前法效果更加好。

橈骨小頭半脫位專家講座第10頁復(fù)位肘關(guān)節(jié)能夠首選過分旋前法或在旋后手法未能復(fù)位時(shí)再選擇過分旋前手法。讓孩子坐在家長或監(jiān)護(hù)人大腿上，面對(duì)著操作者。

Claspthehandoftheaffectedarmasyou

wouldinahandshake(圖.5).Useyourfreehandtosupportthepatient’selbow.

握住患肢像握手那樣。用另一只手拖住患者肘部。

Hyperpronatethepatient’swrist(圖.6).Youmayfeelorhearaclickastheligament

isreduced.

旋前患者手腕。韌帶復(fù)位時(shí)能夠感覺或聽到輕微咔噠聲。

Ifthereductionissuccessful,thechildshouldbepainfreeand

abletomovethearmnormallyin5to30minutes,includingbeingabletoliftthe

affectedarmabovethehead.

假如復(fù)位成功，孩子便會(huì)不痛并能在5-30分鐘內(nèi)自如活動(dòng)，包含碰觸高過頭頂物體。

Troubleshooting

處理難題

Mostreductionsofapulledelbowwillbesuccessfulafterasingleattempt.

大多數(shù)牽拉肘都能一次復(fù)位成功。

橈骨小頭半脫位專家講座第11頁Ifan

initialattemptfails,theproceduremayberepeatedorthealternatetechniquemay

beused.

假如首次復(fù)位失敗，能夠再次嘗試復(fù)位或換一個(gè)復(fù)位手法。

Iftheelbowhasnotbeenreducedafterthreeorfourattempts,reexamine

thearmcarefullyfromshouldertofingertipsandobtainaradiographtoruleoutfracture.

假如嘗試3-4次后仍無法復(fù)位肘關(guān)節(jié)，則應(yīng)再次仔細(xì)檢驗(yàn)從肩膀至手指并給予行影像學(xué)檢驗(yàn)來排除骨折。

However,whenthecauseoftheinjuryordisplacementisafall,whenthe

circumstancesoftheinjuryareunclear,orwhenitisdifficulttoperformathorough

examinationbecausethechildisuncooperative,itisprudenttoobtainaradiograph

beforethethirdorfourthattemptatreduction.

然而，當(dāng)造成損傷或移位原因是摔落，或損傷周圍環(huán)境不清楚或則是因?yàn)楹⒆硬慌浜隙鵁o法進(jìn)行徹底體格檢驗(yàn)時(shí)，在嘗試進(jìn)行第三或第四次復(fù)位前為慎重起見應(yīng)進(jìn)行影像學(xué)檢驗(yàn)。

Afterobtainingaradiograph,

splinttheelbowatanangleofapproximately90degrees(evenifthechild

presentswiththearmmorefullyextended)andreferthechildtoanorthopedic

surgeon.

影像學(xué)檢驗(yàn)后，用夾板固定肘關(guān)節(jié)在大約90°位置（即使孩子開始手臂是過伸位），然后將孩子轉(zhuǎn)診至骨科醫(yī)生。

橈骨小頭半脫位專家講座第12頁

Inthemajorityofsuchcases,the

affectedelbowwillreducespontaneously

duringtheperiodofimmobilization.

對(duì)于多數(shù)這類情況，受傷肘關(guān)節(jié)會(huì)在制動(dòng)期間自發(fā)復(fù)位。

Aftercare

操作后護(hù)理

Whenapulledelbowhasbeensuccessfullyreduced,aftercareisminimal.

牽拉肘成功復(fù)位后，極少需要護(hù)理