1、.橈骨頭半脫位.Whats 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 18 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.相關報道的中位年齡為2歲。The

2、injury is unique to infants and young children because the radial head is lessbulbous than it is in older persons 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.復位牽拉肘是相對安

3、全的操作，完全可以在門診進行。The annular 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 while 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

4、肱骨遠端肱骨小頭的相對位置，同時可以完成180旋轉。When there is forceful longitudinal traction, such as when a child is pulled or lifted by the arm, the radial head is pulled underneath the annular ligament.在強大的縱向（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

5、帶下.首先，明確孩子的病史及體檢與診斷一致。The childs history may include a witnessed event offorceful 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，其它的損失機制也有描述過。Physical examination should reveal pseudoparalysis, with the child voluntarilykeeping the limb still to minimize d

6、iscomfort.體格檢查會發(fā)現假性神經麻痹，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 andextension.活動時疼痛，旋前或旋后較屈伸更易產生。In most cases there will be tenderness to palpation on the lateral side ofthe elbow; however, absence of this tendern

7、ess does not rule out the diagnosis.多數情況下觸診肘關節(jié)外側可及虛空感，即使未及虛空感也不能排除該診斷。Anaffected 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, or obvious deformity.更進一步的檢

8、查則會發(fā)現肘關節(jié)外形正常，無突出，無挫傷或明顯的畸形。Radiographs are almost always normal in cases ofpulled elbow, so radiography should be reserved for cases in which the diagnosis isnot clear.牽拉肘的影像學檢查幾乎都是正常的，所以只有在診斷不明確時才考慮進行影像學檢查。However, positioning the elbow in preparation for radiography is oftentherapeutic in reducing

9、 the displacement.然而，在放置體位來進行影像學檢查時，往往對復位移位有幫助。Contraindications禁忌征The contraindications to performing a reduction are few and are usually easilyRecognized.復位的禁忌征很少且容易鑒別。If a child has a history and physical examination that are consistentwith fracture, such as deformity, swelling, or bruising of th

10、e elbow or a history ofa fall onto the arm from a substantial height, then a radiograph should be obtainedto evaluate for fracture.如果孩子的病史或體格檢查與骨折吻合，比如畸形，腫脹或肘關節(jié)挫傷或有高處摔落手臂著地的外傷史，則應行影像學檢查來判斷是否骨折。If the radiograph does not reveal fracture or effusion, thenreduction may be considered.如果影像學檢查未發(fā)現骨折或突出，則可以

11、考慮手法復位。.In one study, reduction was achieved on the firstattempt in 95% of patients who underwent randomization to hyperpronation ascompared with 77% of patients who underwent randomization to supination.在一項研究中，隨機予以過度旋前手法首次復位成功的比例是95%，而旋后手法則為77%。Supination Technique旋后手法To perform the supination tech

12、nique, seat the child on the parent or caregivers 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. Neither the positioning ofyour fingers or thumb nor the starting posi

13、tion of the affected arm is critical to thesuccess of the procedure.操作者的手指后大拇指應壓在橈骨頭上。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位成功都至關重要。.Supinate and flex the forearm until you feel the ligamentmove 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)狀韌帶復位時操作者可

14、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 movethe arm normally in 5 to 30 minutes, including being able to reach for an object abovethe head.如果復位成功，孩子便會不痛并能在5-30分鐘內自如活動，包括碰觸高過頭頂的物體。Hyperpronation Technique過度旋前法Hyperpronation can be the primary method used

15、 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, if any other abnormalities are present, suchas evidence of infection, reduction should not be attempted and immediate evaluationof t

16、he cause and appropriate treatment should be initiated.但是，如果合并其它任何疾病，比如感染，則不能予以復位而應立即評估造成疾病的原因同時立即予以適當的治療。.Preparation準備No equipment is required for the reduction of a pulled elbow. The clinicians handsshould be washed thoroughly as part of standard precautions.復位肘關節(jié)無需準備任何設備。臨床醫(yī)生徹底洗手應該是標準注意事項的一部分。Pr

17、ocedure操作To 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 radialhead has been relocated to its proper position.橈骨頭復位至正常位置后孩子可能會哭或喊叫一會。Two techniques can be used to

18、 correct a pulled elbow.二種手法可以用來糾正牽拉肘。The supination techniquehas typically been used for reduction of pulled elbow; however, some studies comparingthe supination with the hyperpronation technique have shown that hyperpronationis more successful.旋后法早已被用作為經典的牽拉肘復位手法；然而，一些研究比較了旋后手法與過度旋前手法發(fā)現過度旋前法效果更好。.

19、復位肘關節(jié)可以首選過度旋前法或在旋后手法未能復位時再選擇過度旋前手法。讓孩子坐在家長或監(jiān)護人的大腿上，面對著操作者。Clasp the hand of the affected arm as youwould in a handshake (圖. 5). Use your free hand to support the patients elbow.握住患肢像握手那樣。用另一只手拖住患者的肘部。Hyperpronate the patients wrist (圖. 6). You may feel or hear a click as the ligamentis reduced.旋前患者手

20、腕。韌帶復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 andable to move the arm normally in 5 to 30 minutes, including being able to lift theaffected arm above the head.如果復位成功，孩子便會不痛并能在5-30分鐘內自如活動，包括碰觸高過頭頂的物體。Troubleshooting處理難題Most reductions of a pulled elbow will be suc

21、cessful after a single attempt.大多數的牽拉肘都能一次復位成功。.If aninitial attempt fails, the procedure may be repeated or the alternate technique maybe used.如果初次復位失敗，可以再次嘗試復位或換一種復位手法。If the elbow has not been reduced after three or four attempts, reexaminethe arm carefully from shoulder to fingertips and obtain

22、a radiograph to rule outfracture.如果嘗試3-4次后仍無法復位肘關節(jié)，則應再次仔細檢查從肩膀至手指并予以行影像學檢查來排除骨折。However, when the cause of the injury or displacement is a fall, when thecircumstances of the injury are unclear, or when it is difficult to perform a thoroughexamination because the child is uncooperative, it is prudent

23、 to obtain a radiographbefore the third or fourth attempt at reduction.然而，當造成損傷或移位的原因是摔落，或損傷的周圍環(huán)境不清楚或則是因為孩子不配合而無法進行徹底的體格檢查時，在嘗試進行第三或第四次復位前為謹慎起見應進行影像學檢查。After obtaining a radiograph,splint the 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.影像學檢查后，用夾板固定肘關節(jié)在大約90的位置（即使孩子開始的手臂是過伸位的），然后將孩子轉診至骨科醫(yī)生。.In the majority of such cases, theaffected elbow will reduce spontaneouslyduring the period of immobilization.對于多數此類情況，受傷的肘關節(jié)會在制動期間自發(fā)復位。Aftercare操作后護理When a pulled elbow has been successfully reduced,