《桡骨小头半脱位》PPT课件.pptx

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1、桡骨头半脱位邢台县医院 骨科许浈铖Whats 桡骨头半脱位？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。Theinjuryisuniquetoinfantsan

2、dyoungchildrenbecausetheradialheadislessbulbousthanitisinolderpersonsandmayeasilybecomedisplaced.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。Theannularligamentencirclestheneckoftheradiusandho

3、ldsittightlyinplaceagainsttheulna),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,suchaswhenachildispulledorliftedbythe

4、arm,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。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，桡骨头包埋在环状韧带下首先，明确孩子的病史及体检与诊断一致。The childs history may include a witnessed event offorceful traction;however,other mechanisms of injury have als

5、o 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 voluntarilykeeping the limb still to minimize discomfort.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。There will also be pain with movement,most often related to supination and pronation rather th

6、an to flexion andextension.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 ofthe elbow;however,absence of this tenderness does not rule out the diagnosis.多数情况下触诊肘关节外侧可及虚空感，即使未及虚空感也不能排除该诊断。Anaffected child holds the elbow in a slightly flexed position,with t

7、he 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 deformity.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 ofpulled elbow,so radiography should be reserved for cases in which

8、the diagnosis isnot clear.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,positioning the elbow in preparation for radiography is oftentherapeutic in 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 easi

9、lyRecognized.复位的禁忌征很少且容易鉴别。If a child has a history and physical examination that are consistentwith fracture,such as deformity,swelling,or bruising of the elbow or a history ofa fall onto the arm from a substantial height,then a radiograph should be obtainedto evaluate for fracture.如果孩子的病史或体格检查与骨折吻

10、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,thenreduction may be considered.如果影像学检查未发现骨折或突出，则可以考虑手法复位。In one study,reduction was achieved on the firstattempt in 95%of patients who underwent randomization to hyperpronation ascompared with 77%of

11、 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 supination 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

12、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 ofyour fingers or thumb nor the starting position of the affected arm is critical to thesuccess 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于复位成功都至关重要。Supinate and flex the forearm until

13、you feel the ligamentmove 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 movethe arm normally in 5 to 30 minutes,including being able to reach for a

14、n object abovethe head.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。Hyperpronation Technique过度旋前法Hyperpronation can be the primary method used to reduce a pulled elbow,or it canbe used if the supination technique has failed.Seat the child on the parents orcaregivers lap,with the child facing you.However,

15、if any other abnormalities are present,suchas evidence of infection,reduction should not be attempted and immediate evaluationof 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。Preparation准备No equipment is required for the reduction of a pul

16、led elbow.The clinicians handsshould 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 associatedwith 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不适。The child may cry or scream for seve

17、ral minutes after the radialhead has been relocated to its proper position.桡骨头复位至正常位置后孩子可能会哭或喊叫一会。Two techniques can be used to correct a pulled elbow.二种手法可以用来纠正牵拉肘。The supination techniquehas typically been used for reduction of pulled elbow;however,some studies comparingthe supination with the hyp

18、erpronation technique have shown that hyperpronationis more successful.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。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。Clasp the hand of the affected arm as youwould in a handshake(图.5).Use your free hand to support the patients elbow.握住

19、患肢像握手那样。用另一只手拖住患者的肘部。Hyperpronate the patients wrist(图.6).You may feel or hear a click as the ligamentis reduced.旋前患者手腕。韧带复位时可以感觉或听到轻微的咔哒声。If the reduction is successful,the child should be pain free andable to move the arm normally in 5 to 30 minutes,including being able to lift theaffected arm abo

20、ve the head.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Most reductions of a pulled elbow will be successful after a single attempt.大多数的牵拉肘都能一次复位成功。If aninitial attempt fails,the procedure may be repeated or the alternate technique maybe used.如果初次复位失败，可以再次尝试复位或换一种复位手法。If the elbow has

21、 not been reduced after three or four attempts,reexaminethe arm carefully from shoulder to fingertips and obtain a radiograph to rule outfracture.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,when the cause of the injury or displacement is a fall,when thecircumstances of the injury are uncl

22、ear,or when it is difficult to perform a thoroughexamination because the child is uncooperative,it is prudent to obtain a radiographbefore the third or fourth attempt at reduction.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。After obtaining a radiograph,splint the

23、 elbow at an angle of approximately 90 degrees(even if the childpresents with the arm more fully extended)and refer the child to an orthopedicsurgeon.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。In the majority of such cases,theaffected elbow will reduce spontaneouslyduring the period of imm

24、obilization.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When a pulled elbow has been successfully reduced,aftercare is minimal.牵拉肘成功复位后，很少需要护理。Childrenmay resume normal activity as soon as they wish.孩子可以很快恢复正常活动。However,parents and caregiversshould be advised that the condition may recur,and the clinici

25、an should explainhow the risk of recurrent subluxation can be minimized.For example,advise caregiversto avoid pulling on the arms and lifting or swinging the child by the arms.然而，应告知家长或监护人脱位可能会再发，而临床医生应解释如何来降低半脱位的发生。比如，告知监护人避免牵拉孩子的手臂以及避免用手臂引体向上或摆荡。Clinicians may also consider providing family members with instructions on howto reduce a pulled elbow at home,particularly if this is not the first time the childhas had pulled elbow.临床医生也可以考虑提供给患者家属一些在家手法复位牵拉肘的手法指导，尤其是那些反复发生牵拉肘的孩子。常用复位方法旋后法中屈曲旋后患者的手和手臂过度旋前手法中握住患者的手复位牵拉肘时将患者腕关节过度旋前谢谢祝大家新年快乐，万事如意，福如东海，寿比南山等。