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肱骨小头剥脱性骨软骨炎

A lateral elbow joint-surface problem in young throwers and gymnasts — how it is found, when it heals with rest, and when surgery is needed.

一名年轻的棒球投手因疼痛而紧抓肘部外侧。
肱骨小头剥脱性骨软骨炎影响年轻投掷运动员和体操运动员的外侧肘部,由关节面的反复负荷引起。 Kieran Hirpara 4.0

本页面由机器翻译,尚未经临床医生审核。英文版本为权威版本。

您正在感受到的症状

这通常表现为肘部外侧的钝痛和酸痛,往往难以精确定位。活动通常会加重疼痛,尤其是投掷、体操或任何对手臂施加负荷的动作,而休息后疼痛会缓解。许多年轻运动员会注意到肘部无法完全伸直;最后几度伸直的丧失很常见,且往往在疼痛成为真正问题之前就会出现。

如果关节面的一部分开始松动,肘部可能会出现卡顿、弹响或锁定,并在活动后肿胀。真正的锁定发作(肘部卡住并暂时无法移动)通常意味着一小块软骨和骨碎片已断裂并游离在关节内。该病症最常影响从事投掷运动(棒球、板球)或体操的青少年,在这些运动中,肘部外侧会反复受到冲击。

实际发生了什么

肘关节的外侧是一个圆形的骨性凸起,称为肱骨小头,其表面覆盖着光滑的软骨。在发育中的肘关节反复承受重负荷时,该软骨下方的一小块骨组织可能失去血液供应并开始软化。这就是剥脱性骨软骨炎,或称OCD。其上方的软骨可能保持完整并愈合,或者该骨块可能出现裂纹、抬起,最终分离形成游离体。

请注意不要将此与一种较轻微、可自行纠正的儿童疾病帕纳病(Panner's disease)混淆。帕纳病影响年龄较小的儿童(通常小于10岁),通过休息可自行缓解,且不会留下永久性损伤。真正的OCD发生在年龄较大的儿童和青少年中,如果骨块脱落,可能导致永久性关节损伤。

软骨的状态至关重要。稳定的病变(软骨仍牢固附着,骨骺板仍未闭合)仅通过休息就有真正的愈合机会。不稳定的病变(出现裂纹、抬起或已游离)通常无法自行愈合,通常需要手术。

我们能做什么

Kieran Hirpara 医生领导我们在 Mater Private Hospital Rockhampton 的上肢诊疗服务,我们引导患者从全科医生(GP)转诊开始,通过对其病史、体格检查和影像学检查进行清晰的评估。对于长期存在的肘部问题,我们通常首先采用非手术治疗,仅当休息和康复无法提供足够的缓解时才进行手术。

对于稳定的病灶,首要且最重要的步骤是简单地 停止加重病情的活动(不投掷,手臂不负重) 持续数月,并在扫描显示骨骼愈合后逐步恢复活动。对于骨骺尚未闭合的年轻运动员,许多此类病灶可通过这种方式完全愈合。休息并非“无所事事”;它就是治疗。

当病灶不稳定、已形成游离体,或经休息后仍无法稳定时,通常建议进行手术。这几乎总是通过关节镜(微创)手术完成,具体选择取决于病灶情况:

  • 清理并刺激愈合: 移除受损碎片,并在暴露的骨面上钻出微小孔洞(微骨折术),以形成一层新的愈合组织。这对于较小的病灶效果良好。
  • 固定碎片: 如果游离碎片较大且质量良好,有时可以通过钉或螺钉将其复位固定。
  • 重建缺损表面: 对于较大的病灶,特别是位于关节边缘的病灶,可以移植健康的软骨-骨柱来重建表面(一种移植手术)。

您的外科医生将根据病灶的大小、位置以及软骨是否可挽救来决定采用上述哪种方案,通常以磁共振成像(MRI)扫描为指导。

预期情况

预后通常良好,尤其是在问题被早期发现且病灶仍保持稳定时。许多患有稳定病灶的年轻患者通过休息即可愈合,并重返运动。对于不稳定病灶的手术治疗,大多数患者可获得良好的疼痛缓解和有益的活动度恢复,且大多数运动员能够重返运动,尽管这可能需要数月时间以及结构化的康复计划。

一些坦率的注意事项。较大的病灶、累及关节外缘的病灶,以及骨骺已闭合的肘关节,预后往往较差,更可能需要手术。部分患者可能残留一定程度的完全伸展受限,且从长期来看,显著的病灶可能会略微增加日后发生肘关节炎的风险,这正是早期识别和保护关节至关重要的原因。

何时就医

  • 年轻投掷运动员或体操运动员持续的外侧肘部疼痛,若休息一两周后仍未缓解;在继续训练前应进行评估。
  • 肘关节完全伸直功能丧失: 无法完全伸直肘关节是一个值得检查的早期警示信号。
  • 卡滞、弹响或肘关节锁定: 这提示可能有骨片松动,需要进行影像学检查。
  • 活动后反复出现的肿胀。
  • 对于骨骼尚未发育成熟的运动员,上述任何症状都值得及时关注,因为在骨骺尚未闭合时发现的病变,无需手术即可愈合的可能性最大。

深入探讨

Advanced reading: the deeper science (optional)

本节内容超出了您自身治疗决策所需的范围。肱骨小头骨软骨炎分离值得额外阅读,因为它在很大程度上是生长中肘部的“沉默”疾病:当年轻投掷手因疼痛足以促使他们就诊时,病变往往已进展到最简

其普遍程度高于症状所提示的水平

筛查结果与门诊就诊情况呈现出不同的图景。在 2,433 名青少年棒球运动员中,包括潜在病例在内的肱骨小头骨软骨炎分离患病率为 3.4%。受累运动员开始运动的年龄更早,运动持续时间更长,且经历过更多的肘部疼痛 [1]。

“包括潜在病例”是关键的限定条件。相当一部分病变是通过检查而非因运动员主诉而被发现的,这意味着在这群本就不愿报告疼痛的运动员中,疼痛是一个滞后且不可靠的信号。

延误改变了可采取的治疗措施

其后果直接体现在治疗选择上。在258名青少年中,症状持续时间较长的患者观察到晚期病变,然而一旦病变需要手术,与重返运动场最相关的因素是治疗的具体细节,而非病程持续时间 [2]。

两项影像学发现可预测非手术治疗将失败:桡骨头增大以及投掷侧骨骼年龄相较于非投掷侧更为成熟,这两者在245名患者中均与晚期疾病相关 [3]。两者均描述了一个已在负荷下发生重塑的肘关节,这是一种结构性陈述,而非症状性陈述。

这正是对伴有持续性肘痛的年轻投掷手进行影像学检查,而非将其作为软组织问题处理,并认真对待双侧差异的理由所在。

对于稳定病灶,较小的手术操作已足够

当碎片稳定且缺损较小时,争议在于仅清理缺损,还是额外在缺损下方钻孔以促进纤维软骨修复。在327例患者中,单纯清创术和微骨折术均显著改善了疼痛、活动范围、结局评分及运动恢复情况,且仅行清创术即可达到可比的中期疗效,因此对于相对较小的缺损,清创术是一种合理的方法 [4]。

对于较大或不稳定的病灶,治疗策略随之改变

当骨软骨碎片已脱落或骨缺损范围较大时,表面需要被替换而非仅仅修整,通常通过移植软骨-骨复合体(骨软骨自体移植)来实现。该方法有效,但有一个重要的限定条件。

汇总 492 例患者的数据,术后管理后重返运动的比例总体较高,且与清创术或固定术相比,患者在 骨软骨自体移植术后更有可能恢复到术前最高运动水平 [5]。然而,一项针对 470 例骨软骨自体移植术后患者的 2024 年综述在确认重返运动率较高的同时,发现应告知运动员 可能以较低的运动水平重返赛场或需要改变场上位置,并且 外侧病灶位置可能对预后产生负面影响 [6]。

这两种说法同时成立,且这一区别对年轻运动员至关重要:重返该运动项目的可能性较大;但重返该运动中的原有角色并不保证。病灶的大小和位置,而非在合理手术方式之间的选择,才是决定预后的主要因素。

参考文献

[1] Kida Y, Morihara T, Kotoura Y, Hojo T, Tachiiri H, Sukenari T, et al. Prevalence and clinical characteristics of osteochondritis dissecans of the humeral capitellum among adolescent baseball players. Am J Sports Med. 2014;42(8):1963-71. https://doi.org/10.1177/0363546514536843

[2] Cheng C, Milewski MD, Nepple JJ, Reuman HS, Nissen CW. Predictive role of symptom duration before the initial clinical presentation of adolescents with capitellar osteochondritis dissecans on preoperative and postoperative measures: a systematic review. Orthop J Sports Med. 2019;7(2). https://doi.org/10.1177/2325967118825059

[3] Funakoshi T, Furushima K, Miyamoto A, Kusano H, Horiuchi Y, Itoh Y. Predictors of unsuccessful nonoperative management of capitellar osteochondritis dissecans. Am J Sports Med. 2019;47(11):2691-8. https://doi.org/10.1177/0363546519863349

[4] McLaughlin RJ, Leland DP, Bernard CD, Sanchez-Sotelo J, Morrey ME, O'Driscoll SW, et al. Both debridement and microfracture produce excellent results for osteochondritis dissecans lesions of the capitellum: a systematic review. Arthrosc Sports Med Rehabil. 2021;3(2):e593-e603. https://doi.org/10.1016/j.asmr.2020.10.002

[5] Westermann RW, Hancock KJ, Buckwalter JA, Kopp B, Glass N, Wolf BR. Return to sport after operative management of osteochondritis dissecans of the capitellum: a systematic review and meta-analysis. Orthop J Sports Med. 2016;4(6). https://doi.org/10.1177/2325967116654651

[6] Lane G, Smith MV, Goldfarb CA, Coronado RA, Bowman EN. Outcomes and return to sport after osteochondral autograft transplantation for osteochondritis dissecans of the capitellum: a systematic review. JSES Rev Rep Tech. 2024;4(3):563-70. https://doi.org/10.1016/j.xrrt.2024.02.011


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