橈骨小頭半脫位課件

1、橈骨頭半脫位,邢臺縣醫(yī)院 骨科許湞鋮,What‘s 橈骨頭半脫位？,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，是兒童常見的骨科損傷。In the United States, the incidence of emergency department visits for pulled elbow is estimated at 2.7 per 1000 persons younger than 1

2、8 years of age.The median age at presentation is 2 years.在美國，未成年人急診就診中牽拉肘的發(fā)生率大約在2.7/1000.相關(guān)報道的中位年齡為2歲。The injury is unique to infants and young children because the radial head is lessbulbous than it is in older perso

3、ns and may easily become displaced.牽拉肘特別常見于嬰幼兒和青少年，因為幼兒的橈骨頭還未發(fā)育像成人那樣的圓球狀橈骨頭，所以很容易移位。Reduction of a pulled elbow is a safe procedure that can be performed in the outpatient setting.復(fù)位牽拉肘是相對安全的操作，完全可以在門診進(jìn)行。The ann

4、ular ligament encircles the neck of the radius and holds it tightly in placeagainst the ulna), thereby maintaining the position of the proximal radiusin relation to the ulna and the capitellum of the distal humerus whi

5、le allowing180-degree rotation.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)端肱骨小頭的相對位置，同時可以完成180°旋轉(zhuǎn)。When there is forceful longitudinal traction, such as when a child is pulled or lifted by the arm, the radial head is pu

6、lled underneath the annular ligament.在強(qiáng)大的縱向（軸向）牽拉下，比如提拉幼兒手臂或用手臂引體向上時，橈骨頭會被牽拉至環(huán)狀韌帶下方。,大多數(shù)孩子的病史中可能有過被牽拉的情況,環(huán)狀韌帶 嵌壓的環(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，橈骨頭包埋在環(huán)狀韌帶下,首先，明確孩子的病史及體檢與診斷一致。The child’s h

7、istory 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過被牽拉的情況；然而，其它的損失機(jī)制也有描述過。Physical examination should reveal pseudoparalysis, with the

8、 child voluntarilykeeping the limb still to minimize discomfort.體格檢查會發(fā)現(xiàn)假性神經(jīng)麻痹，而孩子為了減少不適會自主保持上肢制動。There will also be pain with movement, most often related to supination and pronation rather than to flexion and

9、60;extension.活動時疼痛，旋前或旋后較屈伸更易產(chǎn)生。In most cases there will be tenderness to palpation on the lateral side of the elbow; however, absence of this tenderness does not rule out the diagnosis.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

10、不能排除該診斷。An affected child holds the elbow in a slightly flexed position, with the hand pronated.受傷的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。Further examination should also reveal a normal-looking elbow without effusion,bruising,

11、 or obvious deformity.更進(jìn)一步的檢查則會發(fā)現(xiàn)肘關(guān)節(jié)外形正常，無突出，無挫傷或明顯的畸形。Radiographs are almost always normal in cases of pulled elbow, so radiography should be reserved for cases in which the diagnosis is not clear.,牽拉肘的影像學(xué)檢查

12、幾乎都是正常的，所以只有在診斷不明確時才考慮進(jìn)行影像學(xué)檢查。However, positioning the elbow in preparation for radiography is often therapeutic in reducing the displacement.然而，在放置體位來進(jìn)行影像學(xué)檢查時，往往對復(fù)位移位有幫助。Contraindications禁忌征The contraindicatio

13、ns to performing a reduction are few and are usually easilyRecognized.復(fù)位的禁忌征很少且容易鑒別。If a child has a history and physical examination that are consistent with fracture, such as deformity, swelling, or bruising of

14、 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.如果孩子的病史或體格檢查與骨折吻合，比如畸形，腫脹或肘關(guān)節(jié)挫傷或有高處摔落手臂著地的外傷史，則應(yīng)行影像學(xué)檢查來判斷是否骨折。If the rad

15、iograph does not reveal fracture or effusion, then reduction may be considered.如果影像學(xué)檢查未發(fā)現(xiàn)骨折或突出，則可以考慮手法復(fù)位。,In one study, reduction was achieved on the first attempt in 95% of patients who underwent randomizatio

16、n to hyperpronation as compared with 77% of patients who underwent randomization to supination.在一項研究中，隨機(jī)予以過度旋前手法首次復(fù)位成功的比例是95%，而旋后手法則為77%。Supination Technique旋后手法To perform the supination technique, seat the chil

17、d on the parent or caregiver’s lap,with the child facing you. Clasp both the hand and elbow of the affected arm (圖. 3).采用旋后手法時，讓孩子坐在家長或監(jiān)護(hù)人的大腿上面對著操作者?？圩』贾氖趾椭?。Your fingers or thumb should overlie the radial head. Neith

18、er 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應(yīng)壓在橈骨頭上。無論是操作者的手指或大拇指位置或患肢的初始位置對于復(fù)位成功都至關(guān)重要。,Supinate and flex the forearm u

19、ntil you feel the ligament move back into position (圖. 4). You may feel or hear a click as the ligament is reduced.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)位時操作者可以感覺或聽到輕微的咔噠聲。If the reduction is successful, the child should be

20、pain free and able to move the arm normally in 5 to 30 minutes, including being able to reach for an object abovethe head.如果復(fù)位成功，孩子便會不痛并能在5-30分鐘內(nèi)自如活動，包括碰觸高過頭頂?shù)奈矬w。Hyperpronation Technique過度旋前法Hyperpronation can

21、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 parent’s orcaregiver’s lap, with the child facing you. However, if any other abnormali

22、ties are present, such as evidence of infection, reduction should not be attempted and immediate evaluation 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，則不能予以復(fù)位而應(yīng)立即評估造成疾病的原因同時立

23、即予以適當(dāng)?shù)闹委煛?Preparation準(zhǔn)備No equipment is required for the reduction of a pulled elbow. The clinician’s handsshould be washed thoroughly as part of standard precautions.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)注意事項的一部分。Procedure操作T

24、o prepare the parent or caregiver, explain that some discomfort may be associatedwith the procedure.操作前告知家長或監(jiān)護(hù)人，操作過程中可能會造成一些不適。The child may cry or scream for several minutes after the radial head has been reloca

25、ted to its proper position.橈骨頭復(fù)位至正常位置后孩子可能會哭或喊叫一會。Two techniques can be used to correct a pulled elbow.二種手法可以用來糾正牽拉肘。The supination technique has typically been used for reduction of pulled elbow; however, some

26、studies comparing the supination with the hyperpronation technique have shown that hyperpronation is more successful.旋后法早已被用作為經(jīng)典的牽拉肘復(fù)位手法；然而，一些研究比較了旋后手法與過度旋前手法發(fā)現(xiàn)過度旋前法效果更好。,復(fù)位肘關(guān)節(jié)可以首選過度旋前法或在旋后手法未能復(fù)位時再選擇過度旋前手法。讓孩子

27、坐在家長或監(jiān)護(hù)人的大腿上，面對著操作者。Clasp the hand of the affected arm as you would in a handshake (圖. 5). Use your free hand to support the patient’s elbow.握住患肢像握手那樣。用另一只手拖住患者的肘部。Hyperpronate the patient’s wrist (圖. 6). You may

28、 feel or hear a click as the ligamentis reduced.旋前患者手腕。韌帶復(fù)位時可以感覺或聽到輕微的咔噠聲。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 t

29、o lift the affected arm above the head.如果復(fù)位成功，孩子便會不痛并能在5-30分鐘內(nèi)自如活動，包括碰觸高過頭頂?shù)奈矬w。Troubleshooting處理難題Most reductions of a pulled elbow will be successful after a single attempt.大多數(shù)的牽拉肘都能一次復(fù)位成功。,If an initial

30、attempt fails, the procedure may be repeated or the alternate technique maybe used.如果初次復(fù)位失敗，可以再次嘗試復(fù)位或換一種復(fù)位手法。If the elbow has not been reduced after three or four attempts, reexamine the arm carefully from should

31、er to fingertips and obtain a radiograph to rule outfracture.如果嘗試3-4次后仍無法復(fù)位肘關(guān)節(jié)，則應(yīng)再次仔細(xì)檢查從肩膀至手指并予以行影像學(xué)檢查來排除骨折。However, when the cause of the injury or displacement is a fall, when the circumstances of the injury are

32、 unclear, or when it is difficult to perform a thorough examination because the child is uncooperative, it is prudent to obtain a radiograph before the third or fourth attempt at reduction.然而，當(dāng)造成損傷或移位的原因是摔落，或損

33、傷的周圍環(huán)境不清楚或則是因為孩子不配合而無法進(jìn)行徹底的體格檢查時，在嘗試進(jìn)行第三或第四次復(fù)位前為謹(jǐn)慎起見應(yīng)進(jìn)行影像學(xué)檢查。After obtaining a radiograph, splint the elbow at an angle of approximately 90 degrees (even if the child presents with the arm more fully extended)

34、 and refer the child to an orthopedic surgeon.影像學(xué)檢查后，用夾板固定肘關(guān)節(jié)在大約90°的位置（即使孩子開始的手臂是過伸位的），然后將孩子轉(zhuǎn)診至骨科醫(yī)生。,In the majority of such cases, the affected elbow will reduce spontaneously during the period of i

35、mmobilization.對于多數(shù)此類情況，受傷的肘關(guān)節(jié)會在制動期間自發(fā)復(fù)位。Aftercare操作后護(hù)理When a pulled elbow has been successfully reduced, aftercare is minimal.牽拉肘成功復(fù)位后，很少需要護(hù)理。Children may resume normal activity as soon as they wish.孩子可以很快恢復(fù)正

36、常活動。However, parents and caregivers should be advised that the condition may recur, and the clinician should explain how the risk of recurrent subluxation can be minimized. For example, advise caregivers 

37、to avoid pulling on the arms and lifting or swinging the child by the arms.然而，應(yīng)告知家長或監(jiān)護(hù)人脫位可能會再發(fā)，而臨床醫(yī)生應(yīng)解釋如何來降低半脫位的發(fā)生。比如，告知監(jiān)護(hù)人避免牽拉孩子的手臂以及避免用手臂引體向上或擺蕩。Clinicians may also consider providing family members with instructions

38、 on how to reduce a pulled elbow at home, particularly if this is not the first time the child has had pulled elbow.臨床醫(yī)生也可以考慮提供給患者家屬一些在家手法復(fù)位牽拉肘的手法指導(dǎo)，尤其是那些反復(fù)發(fā)生牽拉肘的孩子。,常用復(fù)位方法,旋后法中屈曲旋后患者的手和手臂,過度旋前手法中握住患者的手復(fù)位牽拉肘時