王紅莉 孔祥燕

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·論著·

創(chuàng)傷性肘關(guān)節(jié)僵硬的圍手術(shù)期護(hù)理及康復(fù)治療

王紅莉 孔祥燕

目的 探討創(chuàng)傷性肘關(guān)節(jié)僵硬患者圍手術(shù)期護(hù)理及康復(fù)治療要點(diǎn)。方法 2010年1月至2014年12月，北京大學(xué)人民醫(yī)院創(chuàng)傷骨科采用開放式肘關(guān)節(jié)松解結(jié)合鉸鏈?zhǔn)酵夤潭苤委焺?chuàng)傷性肘關(guān)節(jié)僵硬患者8例。非常嚴(yán)重僵硬(活動范圍≤30°)2例，嚴(yán)重僵硬(活動范圍30°～60°)6例。Mayo肘關(guān)節(jié)功能評分45～75分，平均53.8分。其中3例患者術(shù)前合并尺神經(jīng)卡壓癥狀。術(shù)前開始給予心理護(hù)理；術(shù)后給予患肢傷口護(hù)理、疼痛護(hù)理、外固定架針道護(hù)理及針對性功能鍛煉治療。結(jié)果 8例患者均得到11～61個月隨訪，平均隨訪時間35.4個月?；颊咧怅P(guān)節(jié)活動度平均105°。Mayo評分70～95分，平均85.0分。3例患者合并尺神經(jīng)卡壓中的2例尺神經(jīng)損傷癥狀完全緩解，1例殘留部分手內(nèi)在肌萎縮。所有8例患者均無肘關(guān)節(jié)不穩(wěn)定現(xiàn)象，術(shù)后未出現(xiàn)其他并發(fā)癥。結(jié)論 采用開放式肘關(guān)節(jié)松解結(jié)合鉸鏈?zhǔn)酵夤潭苤委焺?chuàng)傷性肘關(guān)節(jié)僵硬，要嚴(yán)格輔助圍手術(shù)期各項護(hù)理及康復(fù)治療，可以有效改善肘關(guān)節(jié)活動范圍，可促進(jìn)肘關(guān)節(jié)功能恢復(fù)。

創(chuàng)傷；肘關(guān)節(jié)；僵硬；護(hù)理；康復(fù)

肘關(guān)節(jié)是由肱尺、肱橈和上尺橈關(guān)節(jié)組成的復(fù)合關(guān)節(jié)。創(chuàng)傷后關(guān)節(jié)囊瘢痕攣縮、關(guān)節(jié)周圍的異位骨化以及長期固定等是造成肘關(guān)節(jié)僵硬的常見原因[1]。早期肘關(guān)節(jié)僵硬可以采用保守治療，而對于保守治療無效的患者可行開放肘關(guān)節(jié)松解術(shù)。但由于患者術(shù)后往往會因?yàn)樘弁床荒苡行浜瞎δ苠憻?，即使術(shù)中進(jìn)行了徹底松解，獲得了滿意的活動范圍，也可能出現(xiàn)活動范圍的再次丟失。輔助使用鉸鏈?zhǔn)酵夤潭苡兄诜乐剐g(shù)后關(guān)節(jié)囊攣縮,幫助患者術(shù)后進(jìn)行早期功能鍛煉，能有效預(yù)防肘關(guān)節(jié)僵硬術(shù)后復(fù)發(fā)。2010年1月至2014年3月，北京大學(xué)人民醫(yī)院創(chuàng)傷骨科采用開放性肘關(guān)節(jié)松解結(jié)合鉸鏈?zhǔn)酵夤潭苤委熈藙?chuàng)傷性肘關(guān)節(jié)僵硬8例患者，取得了滿意的療效，現(xiàn)將圍手術(shù)期護(hù)理及康復(fù)報道如下。

資 料 與 方 法

一、一般資料

本組8例患者，其中男性3例，女性5例。年齡17～61歲，平均38.3歲。原始損傷肘關(guān)節(jié)脫位4例，橈骨頭骨折1例，肱骨髁上骨折1例，髁間骨折2例。手術(shù)距離初次損傷時間10～36個月，平均18.2個月。根據(jù)肘關(guān)節(jié)僵硬的Morrey分型[2]：非常嚴(yán)重僵硬(活動范圍≤30°)2例，嚴(yán)重僵硬(活動范圍30°～60°)6例。根據(jù)Mayo肘關(guān)節(jié)功能評分[3]：45～75分，平均53.8分。其中3例患者術(shù)前合并尺神經(jīng)卡壓癥狀。

二、手術(shù)方法

本組患者均采用全身麻醉。手術(shù)經(jīng)內(nèi)、外側(cè)聯(lián)合入路，松解關(guān)節(jié)囊，肌腱及切除異位骨化。常規(guī)松解前置尺神經(jīng)。透視下定位肘關(guān)節(jié)的旋轉(zhuǎn)中心，于旋轉(zhuǎn)中心打入2 mm克氏針。使用Stryker DJD II(dynamic joint distractor)外固定架，肱骨和尺骨側(cè)各打入2枚外固定架螺針，螺針需與定位旋轉(zhuǎn)中心的克氏針在同一平面且相互平行。使用夾鉗將螺針和外固定架連接固定后，旋轉(zhuǎn)外固定架的牽開螺釘裝置牽開肘關(guān)節(jié)間隙。

三、護(hù)理要點(diǎn)

①術(shù)前心理護(hù)理：評估患者對疾病的認(rèn)識，根據(jù)病情進(jìn)行健康教育。告知患者手術(shù)的目的和效果，術(shù)后可能出現(xiàn)的不適及對策，講解功能鍛煉的重要性，制定康復(fù)計劃。鼓勵患者積極配合手術(shù)，術(shù)后護(hù)理及康復(fù)訓(xùn)練，以達(dá)到滿意的治療效果。②術(shù)后患肢護(hù)理：臥床期間，患者取平臥位，患肢用軟枕抬高，輔以由遠(yuǎn)端向近端輕柔按摩患肢，以促進(jìn)靜脈回流，減輕肢體腫脹。下地活動時，給予患肢前臂吊帶懸吊。評估患肢皮溫、血運(yùn)、感覺和運(yùn)動狀況，判斷有無尺神經(jīng)損傷癥狀。③術(shù)后疼痛護(hù)理：采取理療與藥物同時進(jìn)行的長期鎮(zhèn)痛措施。給予患肢手術(shù)部位冰袋冷敷，每日3次，每次20 min。同時本組患者術(shù)前無胃腸道潰瘍病史，術(shù)后住院期間給予靜脈輸注氟比洛芬酯鎮(zhèn)痛治療，每日2次，每次50 mg。對于爆發(fā)痛，疼痛評分≥4分的患者，可肌注鹽酸哌替啶50 mg。患者出院后口服賽來昔布，每日2次，每次200 mg。④術(shù)后針道護(hù)理：早期功能鍛煉后會出現(xiàn)針道部位的滲出，應(yīng)及時更換敷料。使用75%乙醇消毒針道周圍皮膚，每日2次。告知患者要保持患肢及外固定架的清潔，不能隨意觸摸針道及外固定架，如果針道部位出現(xiàn)膿性滲出物或針道周圍皮膚紅腫，則可疑為針道感染，應(yīng)及時向醫(yī)生報告，以防外固定架松動。⑤術(shù)后功能鍛煉：自術(shù)后第1天開始，每日移除外固定架的固定桿，幫助患者被動進(jìn)行肘關(guān)節(jié)屈曲和伸直位的等長訓(xùn)練，每日3～5組，每組5～10次，鼓勵患者進(jìn)行主動的前臂旋轉(zhuǎn)練習(xí)。鍛煉前后配合使用止疼藥和冷敷，以緩解疼痛。同時加強(qiáng)心理護(hù)理，給予患者充分的鼓勵與肯定，有利于增強(qiáng)患者康復(fù)信心，提高康復(fù)效果。此外根據(jù)術(shù)前肘關(guān)節(jié)僵硬是屈曲型或伸直型，夜間可將肘關(guān)節(jié)固定于最大的伸直位或屈曲位[4]。還應(yīng)重視肩關(guān)節(jié)、腕關(guān)節(jié)和手部各關(guān)節(jié)的主動活動，防止廢用性肌萎縮和關(guān)節(jié)僵硬出現(xiàn)。術(shù)后4周，鼓勵患者進(jìn)行肘關(guān)節(jié)主動屈伸活動。術(shù)后6～8周，去除外固定架。

結(jié) 果

8例患者隨訪11～61個月(平均35.4個月)?；颊哧P(guān)節(jié)活動度平均為105°。Mayo評分70～95分，平均85.0分。3例合并尺神經(jīng)炎患者中2例癥狀完全緩解，1例殘余部分手內(nèi)在肌萎縮。8例患者均無肘關(guān)節(jié)不穩(wěn)定表現(xiàn)。術(shù)后無其他并發(fā)癥。典型病例，見圖1～8。

討 論

術(shù)前向患者交代手術(shù)的目的、效果、康復(fù)計劃,使其了解疾病的治療、護(hù)理及功能鍛煉的方案,可以緩解緊張情緒、消除顧慮、樹立康復(fù)信心。尤其要向患者說明術(shù)后早期積極的康復(fù)鍛煉對日后關(guān)節(jié)功能恢復(fù)非常重要，最終的治療效果一定程度上取決于患者自身，取決于其參加康復(fù)治療的態(tài)度。同時，也要向患者及家屬強(qiáng)調(diào)肘關(guān)節(jié)的康復(fù)過程的時間較長，往往需要3～6個月，使其做好思想準(zhǔn)備。

圖1 術(shù)前屈曲 圖2 術(shù)前伸直 圖3 外架后屈曲 圖4 外架后伸直 圖5 術(shù)后2 d屈曲 圖6 術(shù)后2 d伸直 圖7 術(shù)后1年屈曲 圖8 術(shù)后1年伸直

術(shù)后通過患肢抬高和手法按摩，可以促進(jìn)靜脈回流，減輕患肢腫脹，緩解疼痛。特別要評估尺神經(jīng)的功能，觀察是否存在前臂尺側(cè)和環(huán)小指麻木或刺痛，并檢查手部內(nèi)在肌的功能。因?yàn)橹馑山夂蟪霈F(xiàn)尺神經(jīng)卡壓癥狀很常見，特別是術(shù)前屈肘嚴(yán)重受限，術(shù)后改善明顯的，多數(shù)患者可逐漸緩解[5]。如果術(shù)后立即出現(xiàn)尺神經(jīng)卡壓癥狀，應(yīng)立即通知醫(yī)生，必要時手術(shù)探查。本組8例患者均在術(shù)中進(jìn)行了尺神經(jīng)松解前置，有效地預(yù)防了術(shù)后尺神經(jīng)并發(fā)癥的發(fā)生。肘關(guān)節(jié)松解術(shù)后患者疼痛一般比較劇烈，功能鍛煉也會加重患者的疼痛和不適感，因此需要積極的鎮(zhèn)痛治療。采取冷敷與藥物同時長期鎮(zhèn)痛的措施，可以降低患者疼痛分值，減少爆發(fā)痛的發(fā)生頻率。

當(dāng)術(shù)后早期進(jìn)行功能鍛煉時，需要將關(guān)節(jié)間隙牽開，外固定架針道部位皮膚肌肉張力較大，活動后會出現(xiàn)針道部位滲出，應(yīng)及時更換敷料。同時每日使用75%乙醇消毒針道周圍皮膚，可以預(yù)防針道感染。通過健康教育，指導(dǎo)患者了解預(yù)防針道感染的重要性，提高預(yù)防針道感染的意識，學(xué)會預(yù)防針道感染的方法。

強(qiáng)調(diào)早期進(jìn)行功能鍛煉，同時要注意每次活動時應(yīng)在患者可忍受的范圍內(nèi)達(dá)到肘關(guān)節(jié)最大的屈伸運(yùn)動范圍，爭取與手術(shù)中所達(dá)到的范圍基本相同。還要注意的是松解術(shù)后，關(guān)節(jié)周圍軟組織的延展性和順應(yīng)性需要長時間的牽拉和運(yùn)動才能恢復(fù)，因此在夜間休息后經(jīng)過鍛煉獲得的肘關(guān)節(jié)活動度會出現(xiàn)一定程度的丟失，可以在鍛煉之間的間歇安裝固定桿將肘關(guān)節(jié)交替固定于最大的屈曲位和伸直位。患者往往會因此出現(xiàn)焦慮和失望，應(yīng)針對患者的心理狀態(tài)給予及時的心理護(hù)理和專業(yè)知識的講解。

小 結(jié)

肘關(guān)節(jié)是創(chuàng)傷后最易發(fā)生僵硬的關(guān)節(jié)之一，10%～15%的患者肘部創(chuàng)傷后出現(xiàn)肘關(guān)節(jié)僵硬[6]。肘關(guān)節(jié)僵硬治療的目的是恢復(fù)肘關(guān)節(jié)功能，消除活動性疼痛。開放性松解術(shù)是治療肘關(guān)節(jié)僵硬的常用方法，可明顯改善肘關(guān)節(jié)的活動范圍。護(hù)理重點(diǎn)是做好患者心理護(hù)理、患肢護(hù)理和針道護(hù)理，重視術(shù)后疼痛和外固定架的管理，同時指導(dǎo)并幫助患者做好院內(nèi)、外的功能鍛煉，定期復(fù)查。

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(本文編輯：李靜)

王紅莉，孔祥燕.創(chuàng)傷性肘關(guān)節(jié)僵硬的圍手術(shù)期護(hù)理及康復(fù)治療[J/CD].中華肩肘外科電子雜志,2015,3(2):102-105.

Perioperative nursing care and rehabilitation for patients with traumatic elbow joint stiffness

WangHongli，KongXiangyan.

DepartmentofTraumaticOrthopedics,PekingUniversityPeople′sHospital,PekingUniversitytrafficMedicinecenter,Beijing100044，China

KongXiangyan，Email:kxy1766@163.com

Background The elbow joint is a composite joint consisted of the humeroulnar joint,humeroradial joint,and proximal radioulnar joint.The causes for elbow joint stiffness include joint capsule scar contracture,ectopic ossification around the joint and long-term immobilization.The conservative treatment can be applied to early elbow joint stiffness.The open elbow release surgery is applicable for patients who do not respond to conservative therapy.Although satisfactory range of motion is obtained after complete release,the loss of range of motion may occur again if the patients don′t exercise due to pain.The assistance of hinged external fixator helps to prevent joint capsule scar contracture,promote early function exercise,and effectively prevent relapse of elbow joint stiffness.In this study,we reported the perioperative nursing care and rehabilitation in 8 cases who presented good outcomes after open release surgery combined with hinged external fixator for traumatic elbow joint stiffness in the department of traumatic orthopedics in the Peking University-affiliated People′s Hospital from January 2010 to March 2014.Methods General data:8 cases including 3 males and 5 females with a mean age of 38.3 years ranged from 17-61 years were included in the group.4 cases had primary injury caused by dislocation of elbow joint.1 case had radial head fracture.1 had supracondylar fracture of humerus.2 had intercondylar fracture.The time from the initial injury to the surgery ranged from 10-36 months,with a mean of 18.2 months.According to Morrey classification of elbow joint stiffness,2 cases had very severe stiffness (range of motion ≤30°); 6 cases had severe stiffness (range of motion 30°-60°).According to Mayo scale for elbow function,the score ranged from 45-75,with a mean of 53.8.Three cases of them had complicated entrapment of the ulnar nerve.Surgery method:All patients of the group were subject to general anesthesia.The surgery with medial and lateral approaches were performed to release the capsular ligament and tendon,and remove the ectopic ossification.Normal release was performed for the prepositioned ulnar nerve.The center of rotation of the elbow joint was positioned under fluoroscopy.2-mm Kirschner wire was inserted in the center of rotation.Stryker Dynamic Joint Distractor (DJD II) was used for external fixation.2 screws for external fixation were inserted from the humerus and ulna,respectively.The screws should be in parallel with the Kirschner wire in the same plane.The screws were connected with the external fixator using clamp.The elbow joint gap was open by rotating the retractor.Key points for nursing:(1) Psychological nursing before surgery:The patients were subject to health education based on the assessment of patients′ understanding of the condition.Patients were informed of the surgery objective and outcome,possible discomforts after surgery and relative measures and the importance of function exercise.Rehabilitation plan was made for patients.They are also motivated to cooperate during surgery,postoperative nursing care and rehabilitation so that good results could be obtained.(2) Postoperative nursing for affected extremity:During stay in bed,the patients were on the horizontal position with soft pillow elevating the affected extremity.The affected extremity was gently massaged from the distal to the proximal end to promote vein reflux.When the patients are able to get out of the bed,the forearm was supported by strap.The temperature,blood supply,feelings and mobility were assessed to determine whether symptoms of nerve injury developed.(3) Pain management after surgery:Long-term physical therapy and drugs were used to relieve pain.The cold pack was applied to the affected extremity three times per day,20 min once.The patients in the group had no history of gastrointestinal ulcer before surgery.The patients were intravenously administered with flurbiprofen axetil twice at a dose of 50 mg during stay after surgery.In case of flare of pain,people with pain score ≥4 were intramuscularly administered with 50 mg pethidine hydrochloride.After discharge,the patients were orally administered with celecoxib,200 mg once,twice per day.(4) Nursing of approaches after surgery:The dressings were immediately changed if exudate was observed after function exercise at early period.75% alcohol was used to sterilize skin around the approaches,twice per day.The patients were told to keep the affected extremity and external fixator clean.The approaches and external fixator should not be touched at will.If purulent exudate on the approach or red swelling around the approach skin was observed,it was suspected as approach infection.This should be immediately reported to the physician to avoid loosening of external fixator.(5) Function exercise after surgery:1 day after surgery,the fixing pole was removed from the external fixator to help patients to do passive isometric exercise at elbow joint flexion and extension,3 to 5 sets a day,5-10 repeats per set.The patients were motivated to do active forearm rotation exercise.The pain killers and cold packs were combined to ease pain before and after exercise.The psychological nursing was strengthened for patients.Adequate encouragement and positive assessment were provided to patients to increase their confidence in rehabilitation,thereby increasing rehabilitation benefits.Furthermore,based on the types of elbow joint stiffness such as flexion stiffness and extension stiffness,the elbow jont was immobilized at maximum extension or flexion position at night.Adequate attention should be attached to the active motion of the shoulder joint,wrist joint and other joints of the hand.4 weeks after the surgery,patients were motivated to do active elbow joint flexion activities.6-8 weeks after surgery,the external fixator was removed.Results 8 cases were followed up for 11-61 months (with a mean of 35.4 months).The mean range of joint was 105°.The score for Mayo was 70-95,with a mean of 85.0.Two of 3 cases with complicated ulnar neuritis had complete response,and the other one had contraction in the residual intrinsic muscle of hand.Instable characteristics were not observed in all 8 cases.There were no other complications after surgery.Conclusion The elbow joint is one of the joints that are most likely to develop post-traumatic stiffness.10%-15% patients develop joint stiffness after trauma.The aim of treatment for elbow joint stiffness is to recover the function of elbow joint and relive mobility-induced pain.The open release surgery is a common option for elbow joint stiffness.It can obviously imporve the range of motion of the elbow joint.The key for nursing is associated with psychological nursing and nursing of the affected extremity.Another important thing is pain management and nursing for approaches for the external fixator.Also,the patients should have exercise,regular follow-up during stay in the hospital or after discharge,thereby improving the outcome of surgery.

Trauma;Elbow;Stiffness;Nursing;Rehabilitation

10.3877/cma.j.issn.2095-5790.2015.02.007

國家自然科學(xué)基金(31371210)；教育部創(chuàng)新團(tuán)隊項目(IRT1021)；衛(wèi)生公益性行業(yè)科研專項基金(201002014)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

孔祥燕，Email：kxy1766@163.com

2015-04-12)