孟氏骨折(Monteggia Fractures)-双语学习

A Monteggia fracture is not a simple fracture. It is a fracture of the proximal ulna along with a dislocation of the radial head. It can happen in both children and adults. However, it is one of the most common missed injuries in children seen in the emergency room. Along with the ulna fracture, the radial head may be dislocated or subluxed, and this problem may not be clear on x-rays. If this injury is missed, the child will probably need a large surgery later on to deal with is big problem. To check, a line drawn from the proximal radius should bisect the capitellum in all x-ray views. If there is ever any doubt, get x-rays of the other side to compare. It should be made a practice to look at the radius and the radial head when there is a fracture of the proximal ulna, so as to not miss the diagnosis of Monteggia fracture. The position of the radial head in relation to the capitellum should be examined.

孟氏骨折不是单纯的骨折。近端尺骨骨折伴桡骨小头脱位。这种情况多见于儿童和成人。然而，这是急诊最常见的儿童漏诊伤之一。伴随尺骨骨折的桡骨小头脱位或半脱位，在X线上可能不明确，如果漏诊，患儿以后可能需要大手术来处理。X线检查时，桡肱小头线常平分桡骨小头。如果有疑问，用健侧的X光片进行比较。当尺骨近端骨折时，应注意观察桡骨和桡骨头，以免漏诊Monteggia骨折，并检查桡骨头相对于肱骨头的位置。

The treatment of a Monteggia fracture depends on the age of the patient. In general, pediatric patients will have a closed reduction of the ulna and closed reduction of the radial head performed. In adult patients, open reduction and internal fixation of the ulna with a dorsal plate, and closed reduction of the radial head will be performed.

Monteggia骨折的治疗取决于患者的年龄。一般来说，小儿患者进行尺骨和桡骨小头闭合复位。在成人患者中，采用背侧钢板切开复位内固定尺骨，闭合复位桡骨小头。

The most common type of Monteggia fracture is an anterior Monteggia fracture. That means that the apex of the fracture is anterior, and the radial head goes anteriorly. The anterior Monteggia fracture is more common in children. Posterior Monteggia fractures constitute 70–80% of Monteggia fractures in adults.

最常见的Monteggia骨折类型是前Monteggia骨折。这意味着骨折的顶点在前部，桡骨小头前脱位，前Monteggia骨折在儿童中更常见。后Monteggia骨折占成人Monteggia骨折的70-80％。

There are four types of Monteggia fractures. These fractures are classified according to the direction of displacement of the radial head. The radial head has two relations. One is the relation with the capitellum, and the other is the relation with the proximal radioulnar joint. When the radial head subluxes or dislocates, it does so from these two joints. When this happens, the radial head becomes free. This means that the radius is not connected to the capitellum or the superior radioulnar joint.

有四种类型的Monteggia骨折。根据桡骨小头的移位方向对骨折进行分类。桡骨小头有两个关系：一个是与肱骨头的关系，另一个是与上尺桡关节的关系。当桡骨小头半脱位或脱位时，它与这两个关节位置发生变化。当发生脱位时，桡骨小头活动度变大，意味着桡骨未与肱骨头或上尺桡关节连接。

Type I is a fracture of the middle or proximal third of the ulna with anterior dislocation of the radial head. It has the identifying characteristic that the apex of the ulna fracture is anterior. This is the most common of all types, especially in children (about 60%). For children, the fractured ulna and the dislocation of the radial head should be reduced, and the elbow should be immobilized in flexion and supination. When the elbow is flexed, especially more than 90 degrees, the biceps will relax. However, the circulation then needs to be watched.

I型是尺骨中部或近端三分之一的骨折，伴有桡骨小头前脱位。尺骨骨折的特点是骨折顶点在前，这是所有类型中最常见的，尤其是儿童(约60%)。对于儿童，应复位尺骨骨折和桡骨小头脱位，肘关节在屈曲和旋后位固定。因为在肘弯曲时，尤其是超过90度，二头肌会放松，但要注意观察血运。

Type II is the posterior type of Monteggia fracture. This is the most common type of Monteggia fracture seen in adults. About 15% all Monteggia fractures are type II posterior. It is also associated with higher complication rate and carries the worst prognosis. The fracture pattern is a fracture of the middle or proximal third of the ulna with posterior dislocation of the radial head. A defining characteristic is that the apex of the fracture is posterior. To treat, the elbow should be immobilized in extension.

II型是Monteggia骨折的后型。这是成人中最常见的孟氏骨折类型。所有Monteggia骨折中约有15％是II型骨折。它还与较高的并发症发生率相关，并且预后最差。骨折特点是尺骨的中间或近端三分之一的骨折，伴桡骨小头后脱位。一个明确的特征是骨折的顶点在后部。治疗时，肘部应固定在伸直位。

Type III is the lateral Monteggia fracture. These account for about 20% of all Monteggia fractures. The fracture pattern is a proximal ulna fracture with lateral dislocation of the radial head.

III型为外侧孟氏骨折。这种骨折约占所有Monteggia骨折的20%。骨折特点为近端尺骨骨折，桡骨小头侧方脱位。

Type IV is a rare type of Monteggia fracture, and only accounts for about 5% of all Monteggia fractures. The fracture pattern is a fracture of the proximal ulna with anterior dislocation of the radial head, and also a fracture of the proximal third of the radius below the bicipital tuberosity. In this case, there is an extra fracture of the radius that needs to be attended to. Every patient will need surgery for a type IV Monteggia fracture, even children.

IV型是一种罕见的Monteggia骨折，仅占所有Monteggia骨折的5％。骨折特点是尺骨近端骨折，桡骨小头前脱位，并且合并桡骨近三分之一二头肌结节下的骨折。在这种情况下，需要注意的是桡骨的骨折，IV型Monteggia骨折的患者都需要手术治疗，包括儿童。

The posterior interosseous nerve is adjacent to the radial neck, placing it as risk for a traction injury with dislocation of the proximal radius. Nerve injury that involves the posterior interosseous nerve is not uncommon with Monteggia fractures. Because of this, patients with Monteggia fractures should have a neurovascular examination done. The patient should be asked to “hitchhike” and extend the fingers. The wrist should be in dorsiflexion when the patient extends their fingers. In the case of an interosseous nerve injury, the finger extensors will not be working, and the patient will not be able to perform the tasks asked above.

骨间后神经与桡骨颈相邻，所以在近端桡骨脱位牵引时容易受伤。在Monteggia骨折中合并骨间后神经的损伤并不少见。因此，Monteggia骨折的患者应进行神经血管检查。让患者做“搭便车”并伸展手指手势，当患者伸出手指时，手腕应处于背屈状态。在骨间后神经损伤时，手指伸肌将不起作用，患者将不能完成上述动作。

If the posterior interosseous nerve is injured, the patient should simply be observed. If there is a posterior interosseous nerve injury with a Monteggia fracture, the fracture needs to be reduced and stabilized, as does the radial head dislocation. However, the nerve should not be explored, rather just observed. Typically with Monteggia fractures, the nerve injury is a neuropraxia. This can be expected to resolve itself in 6–12 weeks, and should simply be observed during this time. If the nerve injury does not resolve, EMG and nerve studies should be done after the period of observation.

如骨间后神经有损伤，应注意观察。在Monteggia骨折合并有骨间后神经损伤时，骨折和桡骨小头脱位需要复位和固定。然而，在Monteggia骨折伴神经损伤中，常常是由于神经缺血导致，大多数在6-12周内恢复，可在此期间可先观察不必探查，如果神经损伤无恢复，应在观察期后进行肌电图和神经探查。

For Monteggia fractures in children, the ulnar shaft fracture should be checked carefully. Any time that there is an ulnar shaft fracture or any fracture of the proximal ulna, the radial head position should be looked at. It should be observed that the radial head is reduced to the capitellum, and it should be noted that the subluxation may be subtle. Recognition of a Monteggia fracture in children is important. Early appropriate treatment is much easier than treating a missed radial head dislocation.

对于儿童的Monteggia骨折，应仔细检查尺骨干骨折。在有尺骨干或尺骨近端骨折的都应该注意桡骨小头的位置。值得注意的是，桡骨小头与肱骨头的位置，半脱位可能不易被观察到。识别儿童的Monteggia骨折很重要，桡骨小头脱位的早期治疗比错过治疗时机容易的多。

The treatment for adult patients with Monteggia fractures is to perform an open reduction internal fixation of the ulna. Then, when the ulna is properly aligned and fixed, the radial head will reduce by itself. After fixation of the ulnar fracture, if the radial head is still not reduced, then assess the ulnar reduction. Check for malalignment or malreduction of the ulna. It is imperative to restore the length and the proper alignment of the ulna, so that the radial head can be reduced. If the ulna is malaligned, then the radial head will remain subluxed. In these cases, radial head instability may be caused by non-anatomic reduction of the ulna or by interposition of the annular ligament. However, the fracture of the ulna may be too comminuted and it may not be reduced properly, and may then need bone grafting later on for healing.

成人孟氏骨折的治疗方法是切开复位内固定尺骨，当尺骨正确复位并固定后，桡骨小头会自行复位。固定尺骨骨折后，如果桡骨小头仍未复位，则应评估尺骨复位情况，检查尺骨是否复位不良。只有恢复尺骨的长度和正确的位置，才能使桡骨小头复位。如果尺骨复位不好，那么桡骨小头将保持半脱位状态。在这些病例中，桡骨小头不稳定可能是由于尺骨非解剖复位或环形韧带的嵌入造成的。另外，如果尺骨骨折过于粉碎，无法进行适当的复位，可能需要植骨治疗。

A Monteggia variant associated with radial head fracture, in addition to dislocation of the radial head and fracture of the ulna, can be a problem. If this is the scenario, the radial head fracture is usually fixed or replaced, and a prosthesis is used to replace the radial head in the elderly, especially if the fracture is comminuted. Then, the subluxation of the radial head is reduced and the fractured ulna is fixed as usual.

除了桡骨小头脱位和尺骨骨折外，一种变异的Monteggia骨折是合并桡骨小头骨折。如果是这种情况，桡骨小头骨折通常需要固定或置换。在老年人，尤其是粉碎骨折时，需要使用假体置换桡骨小头，然后，复位桡骨小头的半脱位，正常固定骨折的尺骨。

For children, the radial head ossifies around the age of 4. The treatment for children with types I, II, and III Monteggia fractures is to perform a closed reduction of the ulna, in order to restore the length of the ulna, and a closed reduction of the radial head. Closed reduction is much more successful in children compared to adults. For anterior Monteggia fractures, the elbow is immobilized in flexion and supination. For posterior Monteggia fractures, the elbow is immobilized in extension. Ulnar fixation with a rod or plate is only needed in older patient with unstable fractures.

对于儿童来说，桡骨小头在4岁左右开始骨化。对于I型、II型、III型Monteggia骨折患儿的治疗方法是闭合复位尺骨，恢复尺骨长度，闭合复位桡骨小头，与成人相比，儿童闭合复位成功率更高。对于前孟氏骨折，肘关节在屈曲和旋后位固定。对于后孟氏骨折，肘关节在伸直位固定。只有在老年患者不稳定的尺骨骨折中使用用杆或板固定。

To treat a missed or neglected Monteggia fracture in children, an osteotomy of the ulna should be performed, and also a lengthening with correction of the angulation. Then, reduction of the radial head in addition to plating of the ulna should be performed. The patient may need an open reduction of the radial head.

对于延误治疗的儿童孟氏骨折，应进行尺骨截骨术，并延长长度与纠正角度。除固定尺骨外，还应复位桡骨小头，常需要切开复位桡骨小头。

All type IV Monteggia fractures, both in children and adults, will require surgery to treat. For children with type IV fractures, closed reduction of the radial head with intramedullary pin fixation of the radius and ulnar shaft should be performed. The radius and ulnar shaft fractures are stabilized surgically in order to give a lever arm for reduction of the radial head. In this type of fracture, the radial head subluxation may be missed or unappreciated because the focus is usually on the multiple forearm fractures.

所有IV型Monteggia骨折，无论是儿童还是成人，都需要手术治疗。对于IV型骨折患儿，应进行桡骨小头的闭合复位，并采用桡骨尺骨轴的髓内钉固定。通过手术固定桡骨和尺骨干骨折，以便提供用于桡骨小头复位的杠杆臂。在这种类型的骨折中，由于只关注多个前臂骨折，桡骨小头半脱位可能被遗漏。

Surgery is also done in cases where proper ulna length is not achievable, the ulna is not able to be reduced, or the radial head is not able to be reduced. In these situations, and IM rod or a plate is used.

在无法恢复适当的尺骨长度时，尺骨或桡骨小头不能复位的情况下也可以进行手术，在这些情况下，使用IM杆或板。

孟氏骨折

孟氏骨折脱位