118-肱骨远端骨折(英文)
骨科疾病分类
1.开放性骨折的分类(Gustilo) 2.骨骺损伤分类(Salter & Harris) 3.骨骺损伤的特殊类型 4.锁骨外侧端骨折分类(Rockwood) 5.肩锁关节脱位分类(Rockwood) 6.肩锁关节损伤分类(Allman) 7.肱骨近端骨折分类(Neer) 8.盂肱指数 9.肘部骨骺出现和闭合年龄 10.儿童肱骨内髁骨折分类(Kilfoyle,1965) 11.肱骨远端髁间骨折分类(Riseborough) 12.肱骨内、外髁骨折（Milch,1964） 13.Baumann角 14.肘部提携角（Carrying angle） 15.儿童肘关节侧位X线象测量 16.肱骨小头骨骺滑 17.脏关节脂肪垫征 18.儿童肱骨内上髁骨折分类 19.儿童肱骨外髁骨折分类 20.尺内鹰嘴骨折分类 21.尺骨鹰嘴骨折分类 22.桡骨头骨折分类 23.桡骨头骨折分类 24.桡骨颈部骨折分类 25.儿童桡骨头骨折分类 26.Monteggia骨折分类 27.尺桡骨远端长度比较 28.尺桡骨远端形态测量 29.桡骨远端骨折分类 30.Colles骨折 31.桡骨远端关节内骨折分类 32.桡骨远端关节内骨折分类 33.手关节侧位X线象 34.腕关节不稳定的X线测量 35.腕舟骨骨折分类 36.腕舟骨骨折分类 37.月骨无菌性坏死分类 38.月骨无菌性坏死 39.第一掌骨基部骨折分类 40.第一掌腕关
肱骨远端C型骨折
One-third tubular-hook-plate osteosynthesis for olecranon osteotomies in distal humerus type-C fractures:A preliminary report of results and complications K.Schmidt-Horlohe´*,P.Wilde,A.Bonk,L.Becker,R.HoffmannDepartment for Trauma Surgery and Orthopedic Surgery,Berufsgenossenschaftliche Unfallklinik Frankfurt am Main,Friedberger Landstrasse430,60389,Germany Fixing fractures of the distal humerus is one of the mostchallenging procedures in operative trauma care,particularlywhen articular comminution and diminished bone quality arepresent.Adequate exposure of the fracture fragments is needed toallow precise anatomic reduction and proper placement of theimplants.The importance of an early initiation of physical therapyis frequently reported.1–3A large variety of approaches to the distalhumerus has been proposed.4–7However,it is generally agreedthat the best exposure is achieved using a transolecranonapproach,first described by MacAusland in1915.2,4,8,9Thearticular surface exposed via an olecranon osteotomy($60%)isnearly doubled compared with that achieved using the bilatero-tricipital(26%)or triceps-splitting approach(35%),respective-ly.10,11Nevertheless,approach-related complications are frequentand derogate the ing a simple transverse osteotomyand reconstruction with the tension band-wire technique,nonunionrates of up to30%and loss of reduction in60%of patients werereported.7Even with sophisticated approach and osteotomytechniques,complication rates up to14%with respect to theosteotomy remain considerably high,most often represented bynonunion orfixation failure.9,12–16Faced with an increasingpopulation at risk of sustaining distal humerus fractures due todemographic trends,it is of outstanding importance to reduceapproach-related complications.17–19Few clinical and biomechani-cal studies showed promising results using platefixation ofolecranon osteotomies.20–22The one-third tubular-hook-platetechnique was successfully used in treating olecranon fractures.23Low complication rates and excellent clinical results were reported,suggesting the suitability forfixation in osteotomies.This study attempted to determine the usefulness and compli-cation rates of the one-third tubular-hook-plate technique in thetreatment of olecranon osteotomies in distal humerus fractures.Injury,Int.J.Care Injured43(2012)295–300A R T I C L E I N F OArticle history:Accepted27June2011Keywords:Distal humerusFractureOpen reductionApproachOsteotomyOlecranonHook plateFixationFailureA B S T R A C TIntroduction:Distal humerus fractures are rare and challenging to treat.Anatomic reduction of thearticular surface and stable osteosynthesis are mandatory for satisfactory results.The transolecranonapproach allows superior visualisation of the joint.However,controversy exists regarding how best tofixthe osteotomy.The purpose of the present study was to investigate the eligibility of a one-third tubularhook plate for osteosynthesis of olecranon osteotomies in distal humerus type-C fractures.Patients and methods:A consecutive series of34patients who were treated through an olecranonosteotomy and underwentfixation using a one-third tubular hook plate were identified.Thirty-onepatients(17females,14males)with a median age of50years(14–87,standard deviation(SD)18.3)wereavailable for a comprehensive assessment after a mean of12.3months(6–20,SD3.7).Using theArbeitsgemeinschaft fu¨r Osteosynthesefragen(AO)classification,six(19.4%)fractures were categorisedas type C2and25(80.6%)were categorised as C3.Physical and radiological examinations wereperformed.The Mayo Elbow Performance Score(MEPS)and the Disabilities of the Arm,Shoulder andHand score(DASH)were evaluated.Results:Mean extension–flexion ROM was found to be1028(50–1458,SD25).Pronation and supinationwere only slightly compromised.The mean MEPS was87.2points(50–100,SD12.4).Fourteen patients(45.2%)were rated as excellent,and15(48.4%)were rated as good.One patient was rated fair,and onepatient was rated as poor,respectively.Mean DASH score was24.4points(0–65,SD20.3).Complicationsregarding the osteotomy occurred in seven patients(22.5%).Revision surgery was necessary infive cases(16%).At follow-up,all osteotomies went on to d joint degeneration(Broberg I)was found in10patients(32.2%).Implant removal was carried out in15patients(48.4%).Conclusion:Based on this study,the osteosynthesis of olecranon osteotomies using a one-third tubularhook plate can be regarded as a safe procedure with a low complication rate.The implant needed iswidely available and cost-efficient,in contrast to specially designed plates or nails.ß2011Elsevier Ltd.All rights reserved.*Corresponding author.Tel.:+49694752841;fax:+49694752223.E-mail address:kay.schmidt-horlohe@bgu-frankfurt.de(K.Schmidt-Horlohe´).Contents lists available at ScienceDirectInjuryj o ur n a l ho m e p a g e:w w w.e l s e vi e r.c om/l o c a t e/i nj u r y0020–1383/$–see front matterß2011Elsevier Ltd.All rights reserved.doi:10.1016/j.injury.2011.06.418Patients and methodsInclusion and exclusionThirty-four skeletally mature patients with operatively treated isolated type-C fractures of the distal humerus(Arbeitsge-meinschaft fu¨r Osteosynthesefragen(AO)classification)24seen during the period from December2005until January2010were identified retrospectively.Patients who were skeletally immature at the time of injury as well as fractures treated by implants other than angular-stable plates or those who underwentfixation through an approach other than olecranon osteotomy were excluded.Patients with accompanying injuries of the elbow(i.e., olecranon or radial head fracture)were also excluded.Only patients who underwent open reduction and internalfixation (ORIF)of the distal humerus via a transolecranon approach and refixation involving a one-third tubular hook plate were included.The study protocol was reviewed and approved by the Institutional Review Board of the department involved.Each patient provided written and informed consent.Thirty-two patients met the inclusion criteria.One patient died for reasons not related to the index procedure.As a result,31 patients(97%)were available for a comprehensive assessment.Clinical and radiological assessmentThe assessment included a review of the patient charts and detection of complications that arose during the treatment course. Complications were grouped as minor and major:they were deemed major if significant impairment resulted or surgical intervention was needed.At follow-up,a standard physical examination was performed.In addition to range-of-motion (ROM)measurement and testing the stability of the elbow joint, the Mayo Elbow Performance Score(MEPS)25and the Disabilities of the Arm,Shoulder and Hand score(DASH)26as elbow-and limb-specific questionnaires were surveyed.Postoperative antero-posterior and lateral radiographs were used to evaluate the quality of osteotomy reduction andfixation.A step or gap of<2mm at the articular surface of the olecranon was considered satisfactory.27Union was defined as replacement of the radiolucent osteotomy site with bone on antero-posterior and lateral radiographs.Nonunion of the osteotomy was defined as radiolucency beyond the6th postoperative month in association with pain.Assessment of degenerative changes followed the classification system of Broberg:grade0=normal elbow,grade I=slight joint space narrowing with minimum osteophyte forma-tion,grade II=moderate joint space narrowing with moderate osteophyte formation and grade III=severe degenerative changes with gross destruction of the joint.28Heterotopic ossifications(HOs) were classified using the Hastings rating scale,with class I being HO without functional limitation;class II,subtotal limitations in one or two planes;and class III,ankylosis of the joint.29The duration of the operative procedures was not evaluated for this study because it was mainly influenced by the treatment of the distal humerus fracture rather than repair of the olecranon osteotomy.The frequency of implant removal with respect to the olecranon was recorded.Surgical techniqueThe surgical procedure was performed with the patient under general anaesthesia,in the supine position,with the involved arm on an armrest.A tourniquet was used,depending on the surgeon’s ing a posterior midline incision,medially and laterally full-thicknessflaps were developed.The ulnar nerve was identified and mobilised routinely;however,anterior transposition was carried out depending on the position of the implant at the medial epicondyle.After blunt dissection of the triceps at the medial and lateral intermuscular septae,medial visualisation of the olecranon joint was performed to identify the bare area.Depending on surgeons’preference,an interfragmentary screw hole for refixation was drilled before performing the ing a thin oscillating saw,an apex-distal configured osteotomy of the olecranon was created,approximately2.5cm distal to the olecranon tip.The V-shaped pattern theoretically improves rotational stability and increases the bone surface for improved healing.The osteotomy was completed by fracturing the last third of the ulna,creating an irregular osteochondral fracture line for improved interdigitation and facilitated reduction. Reduction andfixation of the distal humerus fracture were performed using anatomically contoured,angular-stable implants (LCP distal humerus plates system,Synthes,Umkirch,Germany) with use of the standard Arbeitsgemeinschaft fu¨r Osteosynthese-fragen/American Society for Internal Fixation(AO/ASIF)tech-nique.30At the conclusion of the procedure,temporary reduction of the olecranon fragment was secured using K-wires.Definitive fixation was achieved using a one-third tubular hook plate.By cutting off the terminal plate link,leaving two spikes,and bending the terminal plate link to a hook,the plate was thenfitted to the individual anatomy of the olecranon.Following a wing-like incision of the distal insertion of the triceps tendon,the hooks were placed near the tip of the olecranon,carefully avoiding irritation of the olecranon fossa.Subsequently,compression was created at the osteotomy site by using eccentrically placed shaft screws.Thereafter,the olecranon fragment was additionallyfixed and compression was increased through a so-called beam screw extending through the plate and olecranon distally to the anterior cortex near the base of the coronoid(Fig.1).The triceps incision and the intermuscular approach werefinally adapted with No.1 resorbable sutures.Postoperative protocolAt24–48h,the subcutaneous drain was removed.Immobilisa-tion was carried out if necessary,depending onfixation stability at the distal humerus.Early physiotherapy with unrestricted exten-sion andflexion were allowed with respect to olecranon osteotomy osteosynthesis.Full weight-bearing exercises were performed when radiological fracture and osteotomy healing were verified.Statistical analysisStatistical analyses were performed with the Predictive Analytics Software(PASW)Statistics18software package(SPSS Inc.,Chicago,IL,USA).Data are represented as means and standard deviations.ResultsThis study investigated31patients with osteotomies of the olecranonfixed with a one-third tubular hook plate.The average age of the17women and14men was50years(14–87,standard deviation(SD)18.3).The dominant arm was involved in11cases (35.5%).Six(19.4%)fractures of the distal humerus were classified as C2,and25(80.6%)were classified as C3type.Eight fractures (25.8%)were grade I,and two fractures(6.5%)were grade II open (Gustilo classification).31After a mean of12.3months(6–20,SD 3.7),the patients were followed up.In all patients,the olecranon osteosynthesis was considered stable by the surgeon,and thus did not interfere with the rehabilitation protocol.However,due to distal humerusK.Schmidt-Horlohe´et al./Injury,Int.J.Care Injured43(2012)295–300 296osteosynthesis,immobilisation of the elbow was needed in five patients for 20days (7–42,SD 20.2).The mean extension–flexion arc of motion at the time of follow-up was found to be 1028(50–1458,SD 25).There was a mean extension deficit of À208(À58to 408,SD 13.7)in 28patients,whereas extension was not compromised in only three patients.Mean flexion was 1228(80–1458,SD 19.4).With 818external (15–908,SD 16.6)and 858internal rotation (70–908,SD 7.3),forearm motion was almost ing the MEPS,14patients (45.2%)were rated as excellent and 15(48.4%)as good.One patient was rated as fair,and one patient was rated as poor.The mean MEPS score was 87.2points (50–100,SD 12.4).The mean DASH score was 24.4points (0–65,SD 20.3).With respect to the olecranon osteotomy,a total of 11complications occurred in seven patients (22.5%).The details of the two minor and five major complications are displayed in Table 1.Surgical interventions concerning the olecranon osteotomy were necessary in five cases (16%).All nonunions and mechanical failures went on to union after revision surgery.As measured from the postoperative radiographs,there were no osteotomies with a gap or step of more than 2mm at the articular surface.Degenerative changes of the elbow joint at stage I (according to Broberg)were found in 10patients (32.2%).Heterotopic bone formation was present in four patients (two type-I patients and two IIa patients,according to Hastings classification).At final follow-up,the hook plate had already been removed in 15patients (48.4%).Implant removal was performed upon patient request.The hook plate was reported as bothersome in only two cases (6.4%).DiscussionThe purpose of the study presented was to determine the usefulness and complication rates of the one-third tubular-hook-plate technique in the treatment of olecranon osteotomies in distal humerus fractures.Although nearly 81%of the patients presented with type-C3fractures,14excellent and 15good results were found in the MEPS.The mean MEPS score was found to be 87.2points and the mean DASH score was 24.4points.All osteosynthesis of the olecranon osteotomy were considered stable to allow early initiation of physical therapy by the treating surgeon.In total,11complications occurred in seven patients (22.5%).Surgical intervention due to complications was necessary in five cases (16%).The implant was reported as bothersome with subsequent implant removal in two patients.Intra-articular fractures of the distal humerus are rare and difficult to treat.However,good functional results can be obtained when anatomic and stable joint reconstruction is achieved,and early initiation of physical therapy is realised.1,3,8,32–37Therefore,adequate visualisation of the articular surface is of major importance.Several approaches to the distal humerus have been advocated.There remains controversy as to whether these fractures should be treated through a triceps-sparing,triceps-splitting or transolecranon approach.The articular surface exposed is maximised using the transolecranon approach,emphasising its suitability as the gold standard in complex distal humerus fractures.2,4,8,10,11,13,38If total elbow arthroplasty is considered as a treatment option,the transolecranon approach should be considered critical because it interrupts the extensormechanismFig.1.Technique for one-third tubular hook plate:(a)cutting the plate link,(b)plate with spikes,(c)bending,(d)and (e)one-third tubular hook plate finished for refixation ofthe osteotomy.K.Schmidt-Horlohe´et al./Injury,Int.J.Care Injured 43(2012)295–300297and refixation is hindered by the ulnar stem.In this situation, precise preoperative planning including multiplanar computed tomography(CT)reconstruction is mandatory.The bilaterotrici-pital approach described by Alonso-Lames allows the surgeon to explore the articular situation,with the option to extend the procedure to an olecranon osteotomy if ORIF seems possible.Enthusiasm for the transolecranon approach is somewhat limited by the various complications resulting from the osteotomy and itsfixation.However,the functional results found in our study were excellent or good in the vast majority of patients(>90%)(Fig.2).On the one hand,thesefindings might be explainable by the new angular-stable fixation device for the distal humerus,allowing an early initiation of physical therapy in nearly all patients.Similar clinical results were found in previous studies dealing with angular stable osteosynth-esis.16,39–41On the other hand,the quality of restoration of the distal humerus articular surface might have been influenced positive by visualisation through the transolecranon approach.5,42 As in all patients the hook-plate osteosynthesis was considered as stable,the approach did not hinder the rehabilitation protocol.In contrast to the promising functional results,we found an overall complication rate of22.5%related to the osteotomy.InFig.2.Case of a33-year-old patient who suffered from a I8open C2fracture of the distal humerus.(a)preoperative X-ray,(b)osteosynthesis of the distal humerus fracture with the LCP distal humerus plate system(Synthes,Umkirch,Germany)and refixation of the osteotomy with a one-third tubular hook plate(c)functional result after1year. Table1Detailed description of the two minor andfive major complications.Type of complication Total(n)%Complications in detail(potential coincidental)n%Patient ID Minor2 6.4Delayed union2 6.425;30Screw loosening1 3.225Major516.0Bothersome implant a2 6.47;10Non-union2 6.412;22Dislocation412.93;7;12,22a Necessitating removal.K.Schmidt-Horlohe´et al./Injury,Int.J.Care Injured43(2012)295–300298detail,two patients suffered minor andfive major complications. The amount of minor complications seems to be negligible as the postoperative and rehabilitative course was not affected.Addi-tional surgery concerning the osteotomy andfixation was necessary in thefive patients with major complications(16%).Comparing13patients with olecranon osteotomies and13 patients treated with a triceps split approach for the treatment of open supracondylar fractures,McKee et al.observed improved scores on the DASH and Mayo Elbow questionnaire following use of the triceps split technique.43However,the same author found no differences concerning ROM and strength between the triceps split and transolecranon approach in a later study;tension band-wire removal was necessary in27%of the osteotomy group.44 Accordingly,Ring et al.found symptoms related to tension band wiring in13%.45Using intramedullary screw and tension band wiring for osteosynthesis of the olecranon osteotomy,Tak et al. report19%symptomatic implants necessitating removal.46K-wire migration was found in31%of the series published by Gupta, leading the authors to recommend intramedullary screwfixa-tion.47However,due to the angulation of the proximal ulna and the large variety in intramedullary canal diameter,intramedullary screwfixation must be considered with caution.4,5,48,49 Removal of symptomatic implants at the olecranon was performed in two patients(6.4%)in our series,which is remarkably less than in the studies aforementioned.Thesefindings are comparable with those of Coles et al.,who found symptomatic osteotomyfixation in8%.The removal rate of symptomatic implants was distributed equally between intramedullary screw and platefixation in his study($6.5%).5Since Gainor found30%nonunion in transverse osteotomies,it is now well accepted that the olecranon osteotomy should be performed in a chevron style to maximise the bony contact area.7 In addition,the chevron-style technique,combined with an osteochondral fracture line,facilitates anatomic reduction and theoretically improves rotational stability.4,5,45,46We are in concert with this statement and routinely use an apex distal chevron-style osteotomy.The nonunion rate reported in the literature is nearly identical with the rate found in our study and ranges from6.4%to9%.12–14 Hewins and Gofton reported low complication rates of6%and0% using3.5-mm reconstruction plates.14,20However,using implants other than a3.5-mm reconstruction plate(i.e.,tension band wiring and intramedullary screw),Gofton found25%nonunions at the osteotomy site.Using tension band wiring for refixation of both intra-and extra-articular osteotomies,Sane et al.reported36%of patients to have non-anatomic reductions.15By contrast,Coles et al.observed fixation failure with dislocation in only two patients(3%)in whom fixation was carried out by use of intramedullary screws.Dislocation of the olecranon osteotomy was encountered in four patients(12.9%)of our series.In all four patients,unrestricted ROM exercises were permitted.At least in two patients,compli-ance might have been questionable.In another patient,the beam screw did not penetrate the anterior cortex of the coronoid process, thereby weakening the construct stability.The rate of wound infection is reported with up to10%in the literature.12,46,50Much to our delight,we found no infections in our cohort although more than32%of the fractures were grade I and II open.In summary,the encountered complications in our population described remain manageable,particularly when compared with complex reconstructive issues at the distal humerus as a result of inadequate articular visualisation.Our data indicate that plate fixation of olecranon osteotomies is a suitable method.Biomechanical studies strongly support the use of plates.There are some potential advantages to the use of plate osteosynthesis for olecranon osteotomies.In a biomechanical study,a significantly smaller displacement was found when comparing tension band wiring and posterior plating of osteotomies in embalmed human ulna.22,51This might become important in the context of early active-motion therapy.The limitations of our study are related to the inherent weakness of a retrospective review and the relatively small number of patients.There was no comparison with techniques other than the olecranon osteotomy approach involving use of a one-third tubular hook plate.Sufficient anatomic reduction of the olecranon was achieved in all patients.However,results were evaluated using plain radiographs in two planes.A threshold of a2-mm articular step or gap was used on the basis of Murphy et al., who found significantly more degenerative elbow joint changes in patients with incongruences above2mm.27Due to geometrically determined effects,small amounts of displacement may not have been detected.This should also be recognised as a limitation.It needs to be mentioned that the functional results are mainly influenced by the fracture of the distal humerus,rather than the approach used.In addition,the short duration of follow-up might have contributed to the low incidence of osteoarthritis,which is known to develop after many years.The strengths of the study include standardised treatment of the distal humerus fracture with latest-generation angular-stable plates,performance of olecranon osteosynthesis with one single technique and the inclusion of consecutive patients.The use of standard and validated outcome measurements should also be judged as a strength.For future research,prospective randomised trials including different approaches and,in case of osteotomy,different types of osteotomy refixation in larger sample sizes are needed.Only C3 fractures should be included to homogenise the study cohort.In addition,the treatment of the distal humerus fracture should be performed using a single type of implant to exclude potential confounding factors.Evaluating the approaches and related complications,the future studies ought to focus on the osteotomy complications rather than functional result,as this is mainly influenced by the distal humerus fracture itself.ConclusionsExposure is enhanced by olecranon osteotomy,which facilitates reduction and internalfixation of complex distal humerus fractures,thereby improving the quality of anatomic reconstruc-tion and enabling superior outcome.One-third tubular-hook-plate osteosynthesis after chevron-shaped olecranon osteotomies achieves high primary stability with relatively few complications, thus not interfering with an active ROM postoperative protocol in distal humerus fractures.In addition,the implant is marked by its cost-effectiveness and widespread availability.Anatomically pre-shaped and angular-stable plates as well as specially designed nails might be suitable for refixation of osteotomies,but they are much more expensive.52–54Nonunion and failure rates are in concert with previous studies but the need for implant removal is remarkably decreased. Reviewing our31patients,we feel comfortable in recommending the one-third tubular-hook-plate osteosynthesis of olecranon osteotomies as a simple and safe procedure.Conflicts of interestThe authors of the paper‘‘One-third tubular hook plate osteosynthesis for olecranon osteotomies in distal humerus type C fractures:a preliminary report of results and complications’’state that there are no conflicts of interest.K.Schmidt-Horlohe´et al./Injury,Int.J.Care Injured43(2012)295–300299References1.Korner J,Lill H,Muller LP,Hessmann M,Kopf K,Goldhahn J,et al.Distalhumerus fractures in elderly patients:results after open reduction and internalfixation.Osteoporos Int2005;16(Suppl.2):S73–9.2.Jupiter JB,Neff U,Holzach P,Allgower M.Intercondylar fractures of thehumerus.An operative approach.J Bone Joint Surg Am1985;67:226–39.3.Letsch R,Schmit-Neuerburg KP,Sturmer KM,Walz M.Intraarticular fractures ofthe distal humerus.Surgical treatment and results.Clin Orthop Relat Res 1989;(241):238–44.4.Pollock JW,Athwal GS,Steinmann SP.Surgical exposures for distal humerusfractures:a review.Clin Anat2008;21:757–68.5.Coles CP,Barei DP,Nork SE,Taitsman LA,Hanel DP,Bradford Henley M.Theolecranon osteotomy:a six-year experience in the treatment of intraarticular fractures of the distal humerus.J Orthop Trauma2006;20:164–71.6.Cottias P,Camara KB,Clavert P,Kahn JL,Liverneaux PA.Digastric olecranonosteotomy:feasibility study of a new approach to the elbow.Surg Radiol Anat 2010;32:485–9.7.Gainor BJ,Moussa F,Schott T.Healing rate of transverse osteotomies of theolecranon used in reconstruction of distal humerus fractures.J South Orthop Assoc1995;4:263–8.8.Gupta R.Intercondylar fractures of the distal humerus in adults.Injury1996;27:569–72.9.Henley MB.Intra-articular distal humeral fractures in adults.Orthop Clin NorthAm1987;18:11–23.10.Dakoure PW,Ndiaye A,Ndoye JM,Sane AD,Niane MM,Seye SI,et al.Posteriorsurgical approaches to the elbow:a simple method of comparison of the articular exposure.Surg Radiol Anat2007;29:671–4.11.Wilkinson JM,Stanley D.Posterior surgical approaches to the elbow:a com-parative anatomic study.J Shoulder Elbow Surg2001;10:380–2.12.Kundel K,Braun W,Wieberneit J,Ruter A.Intraarticular distal humerusfractures.Factors affecting functional outcome.Clin Orthop Relat Res 1996;(332):200–8.13.Henley MB,Bone LB,Parker B.Operative management of intra-articular frac-tures of the distal humerus.J Orthop Trauma1987;1:24–35.14.Gofton WT,Macdermid JC,Patterson SD,Faber KJ,King GJ.Functional outcomeof AO type C distal humeral fractures.J Hand Surg Am2003;28:294–308. 15.Sane AD,Dakoure PW,Dieme CB,Kinkpe CV,Dansokho AV,Ndiaye A,et al.Olecranon osteotomy in the treatment of distal humeral fractures in adults: anatomical and functional evaluation of the elbow in14cases.Chir Main 2009;28:93–8.16.Schmidt-Horlohe K,Bonk A,Wilde P,Becker L,Hoffmann R.Functional resultsafter osteosynthesis of the distal humerus fracture with an anatomically precontoured,angular-stable double plate system.Z Orthop Unfall 2010;148:300–8.17.Palvanen M,Kannus P,Niemi S,Parkkari J.Secular trends in distal humeralfractures of elderly women:nationwide statistics in Finland between1970and 2007.Bone2010;46:1355–8.18.Palvanen M,Kannus P,Niemi S,Parkkari J.Secular trends in the osteoporoticfractures of the distal humerus in elderly women.Eur J Epidemiol1998;14:159–64.19.Palvanen M,Niemi S,Parkkari J,Kannus P.Osteoporotic fractures of the distalhumerus in elderly women.Ann Intern Med2003;139.p.W-W61.20.Hewins EA,Gofton WT,Dubberly J,MacDermid JC,Faber KJ,King GJ.Platefixation of olecranon osteotomies.J Orthop Trauma2007;21:58–62.21.Petraco DM,Koval KJ,Kummer FJ,Zuckerman JD.Fixation stability of olecranonosteotomies.Clin Orthop Relat Res1996:181–5.22.Tejwani NC,Garnham IR,Wolinsky PR,Kummer FJ,Koval KJ.Posterior olecra-non plating:biomechanical and clinical evaluation of a new operative tech-nique.Bull Hosp Jt Dis2002;61:27–31.23.Schmidt-Horlohe´K,Wilde P,Becker L,Reimertz C,Bonk A,Hoffmann R.Functional and radiological results after modified one-third tubular-hook plate osteo-synthesis in olecranon fracture treatment(Abstract).German Medical Science GMS Publishing House;2009.DocWI65-1126.24.Mu¨ller M,Nazarian S,Koch P.The AO classification of long bones.Berlin HeidelberNew York:Springer;1987.25.Morrey BF,An KN.Evaluation of the elbow.3rd ed.Philadelphia,London,NewYork,St.Louis,Sydney,Toronto:WB Sounders Company;2000.26.Hudak PL,Amadio PC,Bombardier C.Development of an upper extremityoutcome measure:the DASH(disabilities of the arm,shoulder and hand) [corrected].The Upper Extremity Collaborative Group(UECG).Am J Ind Med 1996;29:602–8.27.Murphy DF,Greene WB,Dameron Jr TB.Displaced olecranon fractures in adultsclinical evaluation.Clin Orthop Relat Res1987:215–23.28.Broberg MA,Morrey BF.Results of delayed excision of the radial head afterfracture.J Bone Joint Surg Am1986;68:669–74.29.Hastings2nd H,Graham TJ.The classification and treatment of heterotopicossification about the elbow and forearm.Hand Clin1994;10:417–37.30.Ruedi T,Buckley R,Moran C.AO principles of fracture managment.AO Publishing;2007.31.Gustilo RB,Anderson JT.Prevention of infection in the treatment of onethousand and twenty-five open fractures of long bones:retrospective and prospective analyses.J Bone Joint Surg Am1976;58:453–8.32.Papaioannou N,Babis GC,Kalavritinos J,Pantazopoulos T.Operative treatmentof type C intra-articular fractures of the distal humerus:the role of stability achieved at surgery onfinal outcome.Injury1995;26:169–73.33.Holdsworth BJ,Mossad MM.Fractures of the adult distal humerus.Elbowfunction after internalfixation.J Bone Joint Surg Br1990;72:362–5.34.John H,Rosso R,Neff U,Bodoky A,Regazzoni P,Harder F.Operative treatment ofdistal humeral fractures in the elderly.J Bone Joint Surg Br1994;76:793–6. 35.Lill H,Josten C.Proximal and distal humerus fractures in advanced age.Orthopade2000;29:327–41.36.Ring D,Jupiter JB.Fractures of the distal humerus.Orthop Clin North Am2000;31:103–13.37.Huang TW,Wu CC,Fan KF,Tseng IC,Lee PC,Chou YC.Tension band wiring forolecranon fractures:relative stability of Kirschner wires in various configura-tions.J Trauma2010;68:173–6.38.Helfet DL,Kloen P,Anand N,Rosen HS.Open reduction and internalfixation ofdelayed unions and nonunions of fractures of the distal part of the humerus.J Bone Joint Surg Am2003;85-A:33–40.39.Greiner S,Haas NP,Bail HJ.Outcome after open reduction and angular stableinternalfixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system.Arch Orthop Trauma Surg2008;128:723–9.40.Rubberdt A,Surke C,Fuchs T,Frerichmann U,Matuszewski L,Vieth V,et al.Preformed plate-fixation system for type AO13C3distal humerus fractures: clinical experiences and treatment results taking access into account.Unfall-chirurg2008;111:308–22.41.Reising K,Hauschild O,Strohm PC,Suedkamp NP.Stabilisation of articularfractures of the distal humerus:early experience with a novel perpendicular plate system.Injury2009;40:611–7.42.Huang TL,Chiu FY,Chuang TY,Chen TH.The results of open reduction andinternalfixation in elderly patients with severe fractures of the distal humerus:a critical analysis of the results.J Trauma2005;58:62–9.43.McKee MD,Kim J,Kebaish K,Stephen DJ,Kreder HJ,Schemitsch EH.Functionaloutcome after open supracondylar fractures of the humerus.The effect of the surgical approach.J Bone Joint Surg Br2000;82:646–51.44.McKee MD,Wilson TL,Winston L,Schemitsch EH,Richards RR.Functionaloutcome following surgical treatment of intra-articular distal humeral frac-tures through a posterior approach.J Bone Joint Surg Am2000;82-A:1701–7.45.Ring D,Gulotta L,Chin K,Jupiter JB.Olecranon osteotomy for exposure offractures and nonunions of the distal humerus.J Orthop Trauma2004;18: 446–9.46.Tak SR,Dar GN,Halwai MA,Kangoo KA,Mir BA.Outcome of olecranonosteotomy in the trans-olecranon approach of intra-articular fractures of the distal humerus.Ulus Travma Acil Cerrahi Derg2009;15:565–70.47.Gupta R,Khanchandani P.Intercondylar fractures of the distal humerus inadults:a critical analysis of55cases.Injury2002;33:511–5.[48].Rouleau DM,Faber KJ,Athwal GS.The proximal ulna dorsal angulation:aradiographic study.J Shoulder Elbow Surg2010;19:26–30.49.Wang AA,Mara M,Hutchinson DT.The proximal ulna:an anatomic study withrelevance to olecranon osteotomy and fracturefixation.J Shoulder Elbow Surg 2003;12:293–6.50.Srinivasan K,Agarwal M,Matthews SJ,Giannoudis PV.Fractures of the distalhumerus in the elderly:is internalfixation the treatment of choice?Clin Orthop Relat Res2005:222–30.51.Fyfe IS,Mossad MM,Holdsworth BJ.Methods offixation of olecranon fractures.An experimental mechanical study.J Bone Joint Surg Br1985;67:367–72. 52.Athwal GS,Hoxie SC,Rispoli DM,Steinmann SP.Precontoured parallel platefixation of AO/OTA type C distal humerus fractures.J Orthop Trauma 2009;23:575–80.53.Koslowsky TC,Mader K,Dargel J,Schadt R,Koebke J,Pennig D.Olecranonfracturefixation with a new implant:biomechanical and clinical consider-ations.Injury2009;40:618–24.54.Nowak TE,Mueller LP,Sternstein W,Burkhart KJ,Reuter M,Mueller LA,et al.Dynamic analysis of olecranon osteosyntheses—an in vitro comparison of two osteosynthesis systems.Biomed Tech(Berl)2008;53:86–90.K.Schmidt-Horlohe´et al./Injury,Int.J.Care Injured43(2012)295–300 300。
肱骨干骨折(fracture of the shaft of the humerus)(1)
概述肱骨外科颈远端1cm以下至肱骨髁部上方2cm以上为肱骨干。
肱骨干骨折（fracture of the shaft of the humerus）多见于青壮年，好发于中部，其次为下部，上部最少。
中下1/3段后外侧有桡神经沟，有由臂丛神经后束发出的桡神经经内后方紧贴骨面斜向外前方进入前臂，此处骨折易合并桡神经损伤，下1/3骨折易发生骨不连。
病因和发病机制1、直接暴力常发生于交通及工伤事故，多见于中1/3，多为粉碎或横行骨折。
2、间接暴力跌倒时因手掌或肘部着地所致，多见于下1/3，骨折线为斜形或螺旋形。
3、旋转暴力新兵训练中，少数新战士投手榴弹突然间前臂及肱骨远端向前及内旋，而肩部及肱骨近端未能前旋，不协调应力作用于肱骨中段，导致投掷的扭转螺旋骨折。
好发于中下1/3处，骨折线为螺旋形。
肱骨干骨折端的移位除与暴力方向及肢体重力有关外，更与肌肉的收缩直接有关。
当骨折位于肱骨干上部、三角肌止点之上时，骨折近端受胸大肌、背阔肌和大圆肌的牵拉向前内移位，远端受三角肌牵拉向上外移位；肱骨干中部骨折，骨折处位于三角肌止点以下时，近端因三角肌和喙肱肌收缩向外前移位，远端因肱二头肌、肱三头肌收缩向上移位；肱骨干下部骨折，两端肌肉拉力基本平衡，移位方向取决于外力方向、肢体所处位置及重力等。
临床表现受伤后上臂出现疼痛、肿胀、畸形，皮下淤斑，上肢活动障碍。
若合并桡神经损伤可出现腕下垂、拇指不能外展、掌指关节不能自主伸直、前臂旋后障碍，手背桡侧皮肤感觉减退或消失。
实验室及其他检查1、查体可发现假关节活动，骨摩擦感，骨传导音减弱或消失；2、X线摄片可确定骨折的类型、移位方向。
坎贝尔第三卷(英文版)-肱骨远端骨折
Canale & Beaty: Campbell's Operative Orthopaedics,11th ed.ElsevierDISTAL HUMERAL FRACTURESFractures of the distal humerus remain a challenging problem despite advances in technique and implants.These injuries often involve articular comminution, and many occur in older patients with osteoporotic bone.Joint function often is compromised because of stiffness, pain, and weakness. Rarely is a “normal” elbow the outcome after these fractures, but outcomes have been improved with advances in implant technology,surgical approaches, and rehabilitation protocols. Most distal humeral fractures in adults must be treated operatively, in contrast to fractures of the proximal humerus or humeral shaft. Nonoperative treatment with the “bag of bones” technique may be reasonable in an elderly patient with significant medical comorbidities.The complexity of distal humeral fractures in adults is reflected in the attempts at classifying the variety of injuries possible in this location. The AO/OTA classification, if all subgroup classifications are used, defines 61 types, although the three kinds of articular involvement are the most commonly used designations—A,extraarticular; B, partially articular; and C, completely articular. A more recent classification systemsuggested by Jupiter and Mehne is simpler: it describes only 25 types. This classification system is based on the “two-column” and “tie-arch” concepts of elbow stability. Mehne and Matta described complexbicolumnar distal humeral fractures according to the configuration formed by the fracture lines (Fig. 54-38):high or low T-fractures, Y-fractures, H-fractures, and medial and lateral l-fractures. We generally prefer to use the Jupiter classification system because it has been useful for preoperative planning.Fig. 54-38 A-F, Mehne and Matta classification of distal humeral fractures.(From Jupiter JB: Internal fixation for fracture about the elbow, Op Tech Orthop 4:34, 1994.)l i k u Www .d o c u -tr a c k .c mC c t ob yNO !w w .d o c u -t r a c k .c oThe goal of treatment is anatomical restoration of the joint surface with stable internal fixation that allows early motion. Lateral or medial column fractures (AO/OTA type B) (Fig. 54-39) usually can be reduced through a direct approach and fixed with simple buttress plating. Intraarticular fractures (AO/OTA type C)vary greatly. Generally, the lower the transverse component, the more difficult is attaining stable fixation.Likewise, the greater the comminution, the more difficult is attaining an anatomical reduction.A variety of approaches have been described for reduction and fixation of distal humeral fractures (Table 54-1). Most commonly, a posterior approach with an olecranon osteotomy has been used (see Technique 54-8), but concerns about healing and symptomatic implants have led to more frequent use of a triceps-reflecting (Bryan-Morrey [Fig. 54-40] or triceps-reflecting anconeus pedicle [Fig. 54-41]) approach, as advocated by Bryan and Morrey and O'Driscoll, or a triceps-splitting (Campbell [Fig. 54-42]) approach, as advocated by McKee et al. The best fracture exposure is provided by an olecranon osteotomy approach. As more familiarity is gained with fracture patterns and reduction techniques, a triceps-reflecting or triceps-splitting approach may be selected to reduce complications. With all posterior approaches, the ulnar nerve must be carefully dissected without excessive stripping and usually is transposed anterior to the medial epicondyle at the end of the procedure.Table 54-1 -- Surgical Approaches Used for Treatment of Fractures of the Distal HumerusFig. 54-39 A and B, Isolated lateral condylar fracture fixed with lag screw and minifragment buttress plate.SurgicalApproach Indications Contraindications Advantages Disadvantages Posterior Olecranon osteotomyORIF for fractures involving columns and articular surfaceTERGood access to posterior articular surfaces for reconstructionNonunion and failure of fixation of osteotomy Poor anterior access to capitellum Triceps-splittingORIF/TER for fractures involving columns and articular surfacePrevious olecranon osteotomy approach Patients atincreased risk forAvoidscomplications associated with olecranon osteotomyPoor access to articular surface for internal fixation Risk of tricepsww .d o c u -tr a c k .c w .d o c u -t r a c k .c ohealing problemsdetachment Triceps-reflectingFractures requiring TERORIFPrevious olecranon osteotomy approach Patients at risk for healing problemsAvoidscomplications associated with olecranon osteotomyRisk of triceps detachmentTriceps-detachingORIF/TER for fractures involving columns and articular surfacePrevious olecranon osteotomy approach Patients at risk for healing problemsAvoidscomplications associated with olecranon osteotomy Poor access to articular surfaces for internal fixation Risk of triceps detachment MedialMedialepicondylar fractures Lateral column inaccessibleMedial column fracturesKocherLateral column fractures Suspected more complex articular surface fractureRadial nerve protected Medial column inaccessibleLateralepicondylar fractures Capitellar fracturesLateral KoeberRisk of injury to radial nerve Medial column inaccessibleJupiterComplex articular surface fractures Significant involvement of the columns Medial column inaccessible AnteriorHenryVascular injuryRequirement for plate fixation of columns or articular surface reconstructionGood access to brachial arteryLimited access to columnsModified from Robinson CM: Fractures of the distal humerus. In Bucholz RW, Heckman JD, Court-Brown CM,eds: Rockwood and Green's fractures in adults, 6th ed. Philadelphia, 2006, Lippincott Williams & Wilkins.TECHNIQUE 54-8ORIF, open reduction and internal fixation; TER, total elbow replacement.Open Reduction and Internal Fixation of the Distal Humerus with Olecranon Osteotomy•P Aww .d o c u -tr a c k .c w .d o c u -t r a c k .c o•ParMthDPFig. 54-46Olecranon osteotomy approach (see text).A, Olecranon osteotomy is marked in shape of shallow V or chevron.B, Thin-blade oscillating saw is used to start osteotomy.C, Osteotomized proximal olecranon fragment is elevated proximally; ulnar nerve is isolated, mobilized, and protected.•LatriEPMthRprDUIfin).Fig. 54-47Open reduction and internal fixation of distal humerus through olecranon osteotomy approach (see text).A, Threaded Kirschner wires used as joysticks for fracture reduction.B, After plate application.C, After plate fixation of olecranon osteotomy.•PIfreRanUcoEERlaFig. 54-40 A and B, Plate application through triceps-reflecting approach.Fig. 54-41Triceps-reflecting anconeus pedicle approach.A, Modified Kocher lateral approach is combined with medial triceps-reflecting approach.B, Access to distal humerus is similar to that provided by olecranon osteotomy.(From Sanchez-Sotelo J, Torchia ME, O'Driscoll SW: Principle-based internal fixation of distal humerus fractures, Tech Hand Upper Extremity Surg 5:179, 2001.)The standard plating technique calls for plates to be placed at orthogonal angles (90-90 plating) (Fig. 54-43). Studies by Self et al. and Schemitsch et al. showed that direct medial and lateral plating isbiomechanically sound (Fig. 54-44). Sanchez-Sotelo et al. listed several principles for distal humeral fracture fixation that we have incorporated into our treatment protocol (Box 54-2). Small osteochondralfragments can be fixed with headless screws, countersunk minifragment screws, or absorbable screws (Fig.54-45).Fig. 54-42Triceps-splitting approach to distal humerus.A, Triceps split.B,Split extended to transcutaneous border of ulna.(From Frankle MA: Triceps split technique for total elbow arthroplasty, Tech Shoulder Elbow Surg 3:23, 2002.)Fig. 54-43 A, Supracondylar fracture with intraarticular extension.B, Fixation with 90-90 locked plates through olecranon osteotomy approach.C, After removal of symptomatic hardware.Fig. 54-44 A, Distal humeral fracture with intraarticular extension.B, After direct medial and lateral plate fixation.Box 54-2Technical Objectives for Fixation of Distal Humeral FracturesEvery screw should pass through a plate.Each screw should engage a fragment on the opposite side that is also fixed to a plate.As many screws as possible should be placed in the distal fragments.Each screw should be as long as possible.Each screw should engage as many articular fragments as possible.Plates should be applied such that compression is achieved at the supracondylar level for bothcolumns.Plates used must be strong enough and stiff enough to resist breaking or bending before unionoccurs at the supracondylar level.From Sanchez-Sotelo J, Torchia ME, O'Driscoll SW: Principle-based internal fixation of distal humerus fractures, Tech Hand Upper Extremity Surg 5:179, 2001.Fig. 54-45 A, Fixation of small osteochondral fragment with absorbable screw.B, Very distal intercondylar fracture fixed with headless screws and minifragment buttress plating through olecranon osteotomy approach.Reconstruction of the distal humerus can be done according to two strategies: (1) reduction and fixation of the articular surfaces followed by attachment to the humeral shaft or (2) reduction and fixation of the medial or lateral condyle to the shaft, then reconstruction of the articular surface (advantageous when the articular surface is comminuted), followed by reduction and fixation of the contralateral condyle. Care must be taken not to narrow the trochlea with a lag screw when there is bone loss because this would not allow the arm to sit properly. Because the area for screws is limited in the distal segment, provisional fixation can be used at the joint, with definitive fixation screws passing through the plate to ensure that the screws in the distal segment contribute to the overall stability of the construct (see Fig. 54-45). Newer plates that are precontoured or 3.5-mm compression plates are preferable to one-third tubular and 3.5-mm reconstruction plates because of fatigue failure in the latter group in fractures with metaphyseal comminution. For low-type fractures, additional minifragment plates may provide added fixation (see Fig. 54-45). Locking plates may provide added stability, but there are no clinical studies at this time to support this.If the goal of stable fixation that allows early motion is met, rehabilitation can begin within 3 days of surgery. Waddell et al. showed that disabling stiffness develops if the elbow is immobilized for more than 3 weeks. Supervised physical therapy sessions are scheduled three times a week, along with a daily home exercise program. Dynamic flexion and extension splinting is prescribed when early motion goals are not obtained. Union rates for distal humeral fractures have improved significantly over the years. The most frequent complication is stiffness, which often requires a second procedure. McKee et al. reported an average motion arc of 108 degrees, 74% strength compared with the opposite side, and a mean DASH (Disability of the Arm, Shoulder, and Hand) score of 20 (0 = perfect and 100 = complete disability) in 25 patients at an average 3 years after medial and lateral plate fixation of intraarticular distal humeral fractures. Other complications include ulnar neuropathy, posttraumatic arthritis, osteonecrosis, and symptomatic hardware (see Fig. 54-43). It has been estimated that one in eight patients with operative fixation of a distal humeral fracture eventually requires a second procedure. Many complications can be avoided by the appropriate choice of procedure and meticulous attention to technical details.AFTERTREATMENTThe elbow is splinted in extension. The drain is removed 2 days after surgery, and range of motion is begun3 days after surgery. No bracing is used.Posterior Fracture-Dislocations of the ElbowPosterior fracture-dislocations of the elbow in adults usually are treated surgically because most areunstable owing to the fracture and ligamentous components of the injury. Fracture of the coronoid process or radial head or both can render the elbow significantly unstable after reduction (Fig. 54-48). Untreated injury to the lateral collateral ligamentous complex and medial collateral ligament after repair of the osseous component of the injury can leave residual instability. Lengthy immobilization greatly increases stiffness,and open reduction and stable fixation should be done to allow early motion.These injuries usually result from a fall on the outstretched hand with a shearing component to the injury.Most dislocations are posterior in direction, and fracture of the radial head, radial neck, or coronoid process,or a combination of these, occurs as the proximal ulnar-radial complex is driven posteriorly. Valgus-directed stress can result in avulsion of the medial epicondyle, which is much more common in adolescents. The medial collateral ligament and lateral collateral ligamentous complex are invariably torn.Neurovascular InjuriesFig. 54-48Fracture-dislocation of elbow.A, Posterior fracture-dislocation with irreparable radial head and neck fractures. Type II coronoid fracture is not apparent. This patient's injuries were bilateral and almost identical.B, One elbow has redislocated in posterior splint at 90degrees of elbow flexion. Large radial head fragment and coronoid fracture are readily apparent. Coronoid fracture had to be repaired to provide stability before radial head could be excised.(From Crenshaw AH: Adult fractures and complex joint injuries of the elbow. In Stanley D, Kay NRM, eds: Surgery of the elbow: practical and scientific aspects, London, 1998, Arnold.)l i k u Www .d o c u -tr a c k .c mC c t ob yNO !w w .d o c u -t r a c k .c oInjury of the brachial artery in dislocation of the elbow is a rare but potentially disastrous complication.Arterial injury may range from an intimal tear with delayed occlusion from thrombosis to complete immediate transection. All of these vascular injuries involve stretching of the vessel as the mechanism of injury,especially in closed dislocations.Early recognition is crucial. If arterial flow is not reestablished after closed reduction, the vessel should be reconstructed immediately, using a saphenous vein graft. Arteriograms should be made in the operating room as the patient is being prepared and not in an angiography suite. If treatment has been delayed,forearm fasciotomies are necessary to reduce the chance of compartment syndrome. Howard et al.recommended immediate repair of the brachial artery or reconstruction with a saphenous vein graft for this vascular injury.Because intimal tears can cause delayed arterial thrombosis, all patients with dislocations of the elbowshould be observed closely. Severe swelling is common after reduction, and all patients should bemonitored closely for compartment syndrome.Dislocation of the elbow can damage the median, ulnar, or anterior interosseous nerves. Most such cases involve simple neurapraxia, which resolves quickly. If nerve deficit is present before and after reduction, it is best to wait and observe for signs of resolution. If resolution has not occurred at 3 months, exploration may be needed. Signs of nerve injury that appear after reduction of a dislocation warrant immediate nerveexploration.TreatmentA closed reduction should be performed as soon as possible. Radiographs often are necessary afterreduction to define the osseous injury completely. Three-dimensional CT may be necessary to identify all of the components of this injury. The elbow should be carefully placed through a flexion-extension arc ofmotion. Subluxation or impending dislocation at 30 degrees or more from full extension indicates instability,and surgical stabilization is required. If the elbow is stable, a long-arm posterior splint is applied with the elbow in 90 degrees of flexion. The patient is followed closely, and if subluxation or spontaneousredislocation occurs, the elbow is surgically stabilized. Patients with fracture-dislocations with nondisplaced and stable fracture components are started on early active exercises at 2 to 3 weeks.If surgical intervention is necessary, open reduction and internal fixation of the osseous components areperformed. Regan and Morrey divided fractures of the coronoid process into three types (Fig. 54-49). A type I fracture is a simple avulsion of the tip. A type II fracture involves less than 50% of the coronoid process,and a type III fracture involves more than 50%. Type III and some type II fractures render the elbowextremely unstable, especially if there is an associated fracture of the radial head. Type I and type IIcoronoid fractures are fixed with heavy suture woven into the brachialis and coronoid insertions, passed through two drill holes in the proximal ulna, and tied securely. Type III coronoid fractures are fixed with ascrew using interfragmentary techniques or a coronoid plate (Accumed, Hillsboro, Ore) (Fig. 54-50). Radial head and neck fractures are repaired as described later in the section on fractures of the radial head and fractures of the radial neck.ww .d o c u -t r a c k .c w .d o c u -t r a c k .c oTreatment of radial head and neck fractures associated with elbow dislocations is controversial. The radial head, similar to the coronoid process, is an important stabilizer of the elbow joint. Open reduction andinternal fixation of radial head fractures are preferable to excision if the radial head is salvageable.Josefsson et al. recommend preservation of the radial head, if possible, especially if there is an associated fracture of the coronoid process. If the radial head cannot be preserved, the medial collateral ligament and flexor-pronator mass should be repaired. The elbow should be immobilized in 90 degrees or more of flexion for 3 to 4 weeks and followed closely for redislocation. Broberg and Morrey recommend early, completeexcision of the radial head for type III fractures (see Technique 54-13) and immobilization for no longer than4 weeks. Use of a metallic radial head implant after excision of the radial head is controversial, but should Fig. 54-49Classification of fractures of coronoid process.(From Regan W, Morrey B: Fractures of the coronoid process of the ulna, J Bone Joint Surg 71A:1348, 1989.)Fig. 54-50Coronoid plate for fixation of type III fractures (Accumed, Hillsboro, Ore).ww .d o c u -t r a c k .c w .d o c u -t r a c k .c obe considered if instability is still present after the medial collateral ligament and flexor-pronator mass havebeen repaired. Harrington et al. followed 20 patients who had metallic radial head implants used for grossly unstable elbows. At a mean of more than 12 years, 80% had good-to-excellent results.TECHNIQUE 54-13If radial head excision is necessary, the head is reconstructed on the operative field to ensure that allfragments are removed. If the radial head is excised, the medial collateral ligament and flexor-pronatormass are repaired. If the elbow is still unstable to valgus stress, a radial head prosthesis is fitted as apermanent or temporary spacer. The goal of surgical intervention is a stable elbow, and, if necessary, all structures should be repaired to achieve this.Pugh et al. recommended the following operative treatment protocol, with repair of damaged structures proceeding from deep to superficial through a lateral approach (see Chapter 1): (1) repairing coronoidstability by open reduction and internal fixation of type II and type III fractures; (2) repairing the radial head fracture if possible or replacing with a metal prosthesis; (3) repairing the lateral collateral ligamentouscomplex and secondary constraints (common extensor origin and lateral capsule); and (4) if residualposterior instability remains, repairing the medial collateral ligament and applying a hinged external fixator.The elbow is immobilized in 90 degrees of flexion in a posterior splint. Active motion is started at 2 to 3weeks in a controlled motion brace that limits extension.ComplicationsExcision of the Radial HeadIf this procedure is performed early, relatively good function may be restored in most patients, and only a slight laxity of the lateral side of the elbow joint may remain. Regardless of how carefully the operation is done, the results may not be entirely satisfactory in many patients because rotation may be limited byexcess bone or scar tissue. If not enough bone is removed, or if the operation is delayed until new bone formation is well advanced, a poor result is more likely; motion in the elbow may be markedly limited, or synostosis may develop between the radius and the ulna.• Make an incision along the posterolateral aspect of the shaft of the radius beginning 5 cm distalto the head and extending proximally over the radial head and the lateral humeral condyle.• In the distal part of the incision, carry the dissection down between the extensor carpi ulnarisand the extensor digitorum communis muscles to the periosteum, then proximally over theremains of the radial head, and through the posterior capsule of the joint to the posterior surfaceof the lateral condyle.• An alternative and probably preferable approach to the radial head is through the intervalbetween the anconeus and extensor carpi ulnaris muscles (see Chapter 1).• Remove all loose particles of bone, and thoroughly irrigate the joint of cancellous bone debrisand blood clots.• Reflect the periosteum from the shaft down to the level of the bicipital tuberosity.• Just proximal to the tuberosity, divide the shaft transversely, and remove the head.• Resect the remains of the annular ligament, and excise every particle of periosteum withpainstaking care to limit new bone formation.• Reassemble the removed fragments of the radial head to ensure that none of the fragments hasbeen left behind.• If the articular surface of the radial head cannot be anatomically reassembled, anteroposteriorand lateral radiographs should be made, and a search for the remaining free fragments shouldbe done.• Suture the adjacent soft tissue over the raw end of the bone.• Removal of the annular ligament does not result in significant instability of the upper shaft of theradius. Attempts to leave a portion of the annular ligament intact may result in excision of toosmall a part of the radial head, with subsequent encroachment of the end of the radius on thecapitellum in certain positions of the elbow.l i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c oStiffness, recurrent instability, and posttraumatic arthritis are common complications of elbow fracture-dislocation. Anatomical reduction of intraarticular fractures is necessary to prevent arthritic changes. Loss of extension to some degree is expected.Ectopic calcification is common, including calcium deposition in the collateral ligaments and capsule. As Buxton pointed out, however, this condition rarely requires treatment.Heterotopic ossification can cause almost complete ankylosis of the elbow if severe enough (Fig. 54-51). It is common after fracture-dislocations and can be seen on radiographs 3 to 4 weeks after injury. Its severity seems to be associated with the magnitude of the injury and the length of immobilization. Also implicated as a cause is early passive elbow stretching. Rigid fracture fixation, thorough irrigation of soft tissues after fracture repair, and early motion also seem to reduce heterotopic ossification.Although radiation therapy is successful in controlling heterotopic ossification after total hip arthroplasty, as Coventry and Scanlon have shown, it is not suitable after fracture-dislocation of the elbow. The surgical incision cannot be easily isolated from the radiation ports, and wound healing may be compromised.Indomethacin has proved to be effective in reducing postoperative heterotopic ossification around the hip joint, as shown by Ritter and Gioe in total hip arthroplasty and by McLaren in repair of acetabular fractures.Although there are no prospective or retrospective studies related to the elbow, indomethacin can be used to reduce heterotopic ossification.Early resection of heterotopic bone (i.e., before it matures) can greatly increase stiffness because ofreformation. Resection of heterotopic bone to improve motion should be delayed until 12 months after injury.Fig. 54-51Extensive heterotopic ossification after fracture-dislocation of elbow and radial head excision.l i k u W ww .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c oOften a functional range of motion can be achieved by then, making resection unnecessary.Copyright © 2008 Elsevier Inc. All rights reserved. - likuWw w .d o c u -t r a c k .c mCct obyNO !w w .d o c u -t r a c k .c o。
中医药名词英文翻译18(中医骨伤科学)
18.001骨折fracture骨的完整性或连续性受到破坏所引起的，以疼痛、肿胀、青紫、功能障碍、畸形及骨擦音等为主要表现的疾病。
18.002损伤injury外界各种创伤因素作用于人体，引起皮肉、筋骨、脏腑等组织结构破坏，及其局部和全身反应疾病的统称。
18.003青枝骨折greenstick fracture仅有部分骨质和骨膜被拉长、皱褶或破裂，常有成角、弯曲畸形，如青嫩的树枝被折断状的一类骨折。
多见于儿童。
18.004裂缝骨折fissured fracture以骨折间隙呈裂缝或线状，骨折片无移位，形似瓷器上的裂纹为主要表现的一类骨折。
18.005锁骨骨折fracture of clavicle锁骨部发生的骨折。
18.006肩胛骨骨折fracture of scapula肩胛骨部发生的骨折。
18.007肱骨外科颈骨折fracture of surgicalneck of humerus以局部肿胀、疼痛、压痛和伤肢纵轴叩击痛，肩关节活动功能障碍，上臂上段可见瘀斑等为主要表现，发生在肱骨解剖颈下2～3cm处的骨折。
18.008肱骨大结节骨折fracture of greatertuberosity of humerus以局部疼痛、肿胀，肩关节活动障碍，尤以肩外展及外旋为甚，活动时疼痛加重，压痛明显，有移位骨折，可扪及异常活动及骨擦音等为主要表现，发生在肱骨大结节部的骨折。
18.009肱骨干骨折fracture of shaft ofhumerus 以患臂肿胀、疼痛、不能抬举，且有明显的压痛和纵轴叩击痛等为主要表现，发生在肱骨外科颈以下至内外髁上2cm处的骨折。
18.010肱骨髁上骨折supracondylar fractureof humerus 以肘部疼痛，肿胀明显甚至有张力水泡，肘部畸形，活动障碍为主要表现，发生在肱骨下端肱骨内、外上髁上方2cm以内的骨折。
18.011肱骨髁间骨折intercondylar fractureof humerus 以肘部肿胀、疼痛、畸形，肘关节呈半屈曲位，前臂旋前，肘部三角关系改变，稍用力掐捏肘部即有骨擦音为主要表现，发生在肱骨内、外髁之间及其邻近部位的骨折。
骨科特殊类型骨折汇总-考博真题
＞特殊类型骨折＞上肢【bankart骨折】指肩关节盂前下边缘骨折，伴或者不伴有肩前脱位。
【Hill-Sachs损伤】指肱骨头压缩性骨折，当肩关节前脱位时，关节盂前缘撞击导致肱骨头后外侧压缩骨折。
【Holstein —Lewis骨折】肱骨远端1/3骨折伴桡神经嵌压。
【Posadas骨折】经髁的肱骨骨折，伴有骨折碎块向前移位，以及因双髁骨折造成尺桡骨的脱位。
【Kocher骨折】肱骨小头骨折（分四型，I型为Hahn-steinthal骨折；n型为Kocher-lorenz 骨折；山型粉碎性骨折；W型软骨挫伤。
）【Hahn-steinthal骨折】全肱骨小头骨折，为一种少见的关节内骨折，多见于成年人。
【Hume骨折】译休姆【Monteggia骨折】孟氏骨折，指桡骨头脱位合并尺骨骨折。
孟氏骨折孟氏骨折Bado分类（1967）I型：尺骨干骨折向前成角，桡骨头向前脱位，约占60%，石膏固定于屈肘110°，前臂旋后II型：尺骨干骨折向后成角，桡骨头向后脱位，约占15%，石膏固定于屈肘70 °，前臂旋后III型：儿童尺骨近端干骺端骨折合并桡骨头前/外侧脱位，约占20% IV:型尺骨近端1/3骨折，桡骨头脱位。
约占5%。
【Galeazzi骨折】指桡骨干骨折伴下尺桡关节脱位脱位。
【双极骨折】即Monteggia骨折合并Galeazzi骨折.【肘关节恐怖三联征】特指伴有桡骨头和尺骨冠突骨折的肘关节后脱位，属于肘关节内复杂骨折脱位的一种类型。
这类损伤均同时伴有肘内外侧副韧带的撕裂，但不伴有尺骨鹰嘴骨折。
【Essex—Lopresti骨折】指桡骨颈骨折伴有远端尺桡关节分离。
【夜盗（杖）骨折】即尺骨干骨折【警棍骨折】（Night-stick fracture ）前臂单纯的尺骨骨折【Colles骨折】Colles骨折指桡骨远端骨折，伴有桡骨远端向背侧的移位，是关节外骨折，常常伴有尺骨茎突骨折。
【Smith骨折】桡骨远端屈曲型骨折，骨折远端向掌侧移位。
精品医学课件-肱骨近端骨折(英文)
Classification
• Neer (4 part)
– 2 part
• AN (anatomic neck) • SN (surgical neck)
– 3 part
• SN+GT, LT
– 4 part
• SN+GT+LT
• Young/Middle age
– nonreconstructable articular surface (severe head split) or extruded anatomic neck
• Elderly
– many 4 parts – some severe 3 parts – most 3,4 part fracture
Proximal Humerus Fractures/Dislocations
History/Demographics
• Bimodal: young-high energy, elderly-low energy(osteoporosis)
• 45% of all humerus fx. • elderly females 4:1
Radiographic Work Up
• Trauma Series
– true scapular AP – axillary (head defects,
displacement of tuberosities
– Y or transscapular
• Other
– modified axillary – AP in int. and ext.
• Displaced d or unstable surgical neck fx
坎贝尔第三卷(英文11版)-肱骨干骨折
Canale & Beaty: Campbell's Operative Orthopaedics,11th ed.Elsevier FRACTURES OF THE HUMERAL SHAFTFractures of the humeral shaft account for roughly 3% of all fractures; most can be treated nonoperatively. Charnley stated, “It is perhaps the easiest of the major long bones to treat by conservative methods.” The range of motion afforded by the shoulder and elbow joints, coupled with a tolerance for small amounts ofshortening, allow radiographic imperfections that cause minimal functional deficit and are well tolerated by the patient. Historically, methods of conservativetreatment have included skeletal traction, abduction casting and splinting, Velpeau dressing, and hanging arm cast, each with its own advantages anddisadvantages.Functional bracing has essentially replaced all other conservative methods and has become the “gold standard” for nonoperative treatment because of its ease of application, adjustability, allowance of shoulder and elbow motion, relatively low cost, and reproducible results. Initially popularized by Sarmiento in 1977, thefunctional brace works on the principles of the hydraulic effect of the brace, active contraction of the muscles, and beneficial effect of gravity. Union rates of 96% to 100% have been reported with this technique. We currently use a coaptation splint or hanging arm cast for the first 7 to 10 days to allow pain to subside and then convert to a prefabricated functional brace. The use of a sling is discouraged to avoid varus and internal rotation deformities. Pendulum exercises are started early,and use of the extremity is encouraged as tolerated, avoiding active shoulder abduction. The brace is worn until the patient is pain-free, and there is radiographic evidence of union. Skin maceration is a concern, so daily hygiene is stressed. Morbid obesity may increase the risk of varus deformities; however, these deformities are more of a cosmetic issue than a functional issue and often are not evident in an obese arm.Sarmiento et al. and Pehlivan reported high union rates with functional bracing of distal-third humeral shaft fractures. We reserve the use of a hanging arm cast for patients in whom compliance or finances preclude the use of a functional brace. Guidelines for acceptable reduction include less than 3 cm of shortening, angulation of less than 20 degrees, and rotation of less than 30 degrees.Operative TreatmentThe choice of operative treatment for a humeral shaft fracture depends on multiple factors. McKee divided the indications for operative treatment into threecategories: (1) fracture indications, (2) associated injuries, and (3) patient indications (Box 54-1). Some indications are more absolute than others. Failure ofconservative treatment, pathological fracture, displaced intraarticular extension, vascular injury, and brachial plexus injury almost always require surgery. Other conditions, such as minimally displaced segmental fractures and obesity, are only relative indications. Our most common indication for operative treatment is early mobilization of patients with polytrauma. Treatment decisions must take all factors into consideration, tailoring the treatment to the specific patient.Box 54-1The goal of operative treatment of humeral shaft fractures is to reestablish length, alignment, and rotation with stable fixation that allows early motion and ideally early weight bearing on the fractured extremity. Options for fixation include plate osteosynthesis, intramedullary nailing, and external fixation. External fixation generally is reserved for high-energy gunshot wounds, fractures with significant soft-tissue injuries, and fractures with massive contamination.Plate OsteosynthesisPlate osteosynthesis remains the “gold standard” of fixation for humeral shaft fractures. Plating can be used for fractures with proximal and distal extension and forIndications for Primary Operative Treatment of Humeral Shaft FracturesFracture IndicationsAssociated InjuriesPatient IndicationsFailure to obtain and maintain adequate closed reductionl i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c oopen fractures. It provides enough stability to allow early upper extremity weight bearing in polytrauma patients and produces minimal shoulder or elbow morbidity,as shown by Tingstad et al. Numerous reports in the literature cite high union rates, low complication rates, and rapid return to function after plate fixation of humeral shaft fractures. Five large series (Foster et al., McKee et al., Vander Griend et al., Bell et al., and Tingstad et al.) including 361 fractures had an average union rate of 96.7%.In a prospective, randomized comparison of plate fixation (23 patients) and intramedullary nail fixation (21 patients) of humeral shaft fractures, McCormack et al.found no significant differences in the function of the shoulder and elbow, but shoulder impingement occurred in six patients with intramedullary nailing and only one patient with plating, and a second surgical procedure was required in seven patients with intramedullary nails and only one patient with a plate. These authors concluded that intramedullary nailing may be indicated for specific situations, such as pathological or segmental fractures, but is technically more demanding and has a higher rate of complications than plating. A limitation of this study is that different nailing techniques were used. Flinkkilä et al. compared antegradeintramedullary nailing in 44 patients with plating in 29 and found that although patients had slightly more shoulder pain after intramedullary nailing than after plating,there was no difference in shoulder joint function except for flexion, which was better in patients with plating. Bhandari et al., in a meta-analysis of the literature,pooled data from three randomized trials that included 155 patients to compare intramedullary nailing with compression plating of humeral shaft fractures. They found that reoperation and shoulder impingement were significantly more common after intramedullary nailing.Implant ChoiceThe most commonly used plate for fixation of humeral shaft fractures is the broad, 4.5-mm, limited-contact dynamic compression plate (Fig. 54-28); occasionally, a narrow, 4.5-mm, limited-contact dynamic compression plate is used for smaller bones. The distal metaphyseal-diaphyseal transition zone may require dual 3.5-mm,limited-contact dynamic compression plates (Fig. 54-29) or newer plates designed specifically for the metaphysis. For spiral or oblique fractures, the ideal construct consists of a lag screw with a neutralization plate, whereas transverse fractures are ideally suited for a compression plating technique. In these fractures, attaining provisional reduction with a lag screw, Kirschner wire, or minifragment plate (Eglseder technique) allows direct observation of the reduction and a relatively simple plate application on the reduced humeral shaft (Fig. 54-30).Fig. 54-28Anterior plating of humeral shaft fracture with limited-contact dynamic compression plate.l i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c oComminuted fractures may require a bridge plating technique. Anatomical reduction of each fracture fragment is unnecessary. Attaining correct alignment, rotation,and length without disrupting the soft-tissue attachments to the comminuted fragments often leads to successful healing. Livani et al. reported 15 patients withbridge plating done through two small incisions proximal and distal to the fracture; all united within 12 weeks except for a grade III open fracture with an associated brachial plexus injury.In patients with poor bone quality, longer implants should be used to improve stability (Fig. 54-31). Locking plates and screw augmentation with methylmethacrylatehave been reported to add more stability to the construct. Generally, at least eight cortices (four screws) above and below the fracture are necessary to avoid screw pullout with longer implants; more screws may be needed for instability caused by poor bone quality or fracture comminution.Fig. 54-29Dual plating of distal metaphyseal-diaphyseal humeral shaft fracture.Fig. 54-30 A, Oblique humeral shaft fracture.B, After provisional reduction with lag screw and fixation with plate and screws.As minimally invasive plate osteosynthesis has become popular in other long bones, its use for humeral shaft fractures has been suggested; however, risk of injury to the radial nerve has been a concern. Apivatthakakul et al. determined in a cadaver study that with minimally invasive plate osteosynthesis, the plate was 2 to 4.9mm (average 3.2 mm) from the radial nerve. Pronation of the forearm moved the radial nerve closer to the plate by 3 mm. This technique has not been proved in any large series of patients, and we have no experience with it.ApproachNumerous approaches can be used for plate fixation of the humerus. Fractures of the middle or proximal third usually are best approached through an anterolateral approach (brachialis-splitting approach). A posterior approach (triceps-splitting or modified posterior approach) is best for fractures that are midshaft or extend into the distal third of the humerus (Fig. 54-32). Gerwin, Hotchkiss, and Weiland described a modified posterior approach in which the triceps is reflected medially off the lateral intermuscular septum (see Technique 54-6). This approach exposed an average 10 cm more of the humeral shaft than the standard posterior approach. Less frequently, a direct lateral or anteromedial approach may be appropriate.TECHNIQUE 54-6Fig. 54-31 A, Segmental shaft fracture with extension into proximal humerus.B and C,Long plate used to obtain secure fixation.Fig. 54-32 A, Fracture of distal third of humeral shaft.B, After plate fixation through posterior triceps-splitting approach.Open Reduction and Internal Fixation of the Humeral Shaft through a Modified Posterior Approach (Triceps-Reflecting)•PUMPostoperative Care Postoperatively, range of motion of the shoulder and elbow is begun within the first week, and weight bearing usually is allowed if fixation is stable.ComplicationsThe most frequently reported complication after plate fixation of humeral shaft fractures is radial nerve palsy. When using an anterolateral (brachialis-splitting)approach, it is essential to ensure that the nerve is not under the implant during plate application to avoid iatrogenic radial nerve injury. Posteriorly, soft-tissuetethers on the radial nerve can lead to iatrogenic injury. This can be remedied by adequate soft-tissue release off the radial nerve. Infection is reported to occur after 1% to 2% of closed humeral fractures and 5% of open fractures. Refractures occur in approximately 1% of patients. Nonunion of humeral shaft fractures isinfrequent. Treatment of nonunion is discussed in Chapter 56.Intramedullary FixationThe success of intramedullary nailing in the lower extremities led to an initial enthusiasm for intramedullary nailing of the humeral shaft, but without equal success.Although there are many reports in the literature of good results with nailing techniques, problems with insertion site morbidity and union rates have dampened the original enthusiasm for this mode of treatment. Shoulder pain has been reported after antegrade intramedullary nailing in 16% to 37% of patients in more recent studies, and Bhandari et al. found that reoperation and shoulder impingement were significantly more common after intramedullary nailing than after plate fixation.Confounding variables, such as flexible or rigid nails; antegrade or retrograde insertion; and lateral, anterolateral, or extraarticular portal for antegrade insertion,make conclusions difficult to interpret. A large well-controlled trial is needed.Early flexible nails, such as Rush and Enders, provided little axial or rotational stability and required additional forms of stabilization (cerclage wiring or prolonged immobilization) in comminuted or unstable fractures (Fig. 54-34). Even with additional stabilization, the resulting construct generally was not stable enough to allow early motion or weight bearing, especially in multiply-injured patients with concomitant lower extremity injuries. The development of locking nails improved stability and rotational control, but results still did not reach the successful outcomes obtained in lower extremity fractures. Because nail sizes were limited, reaming was required for insertion of most locked nails, and fracture distraction was a problem, especially in small medullary canals. Newer nails come in smaller sizes (7 mm, 8mm, or 9 mm) to fit smaller bones and can be inserted with or without reaming.).Fig. 54-33Open reduction and internal fixation of humeral shaft fracture through modified (triceps-reflecting) posterior approach (see text).A, Incision.B, Incision of fascia to expose intramuscular septum.C,cutaneous nerve.D, Mobilization of radial nerve.E, Bone clamp used to control fragments.F, After débridement, fixation with lag screw.G, After plate application.•CId33C). This usually is at Release the tourniquet.•IdDFrseptum for 3 cm to allow mobilization of the nerve•InPPsoft tissues with t •A transverse fractures where lag screw fixation is diffic technique can be used, or a minifragment plate (Eglseder technique) can be used for provisional fixation, followed by plate fixation.•PCPFig. 54-34Humeral shaft fracture treated by closed intramedullary nailing with multiple flexible intramedullary (Ender) nails.An antegrade approach is most commonly used for intramedullary nail fixation of humeral shaft fractures in adults. The specific portal placement is controversial, however. Traditionally, a midacromial lateral incision was used, which tends to place the nail through the posterior humeral head. In addition, the incision through the rotator cuff is not in line with the fibers of the tendon (see Fig. 54-22). An anterolateral starting portal is collinear with the humeral medullary canal, and the incision is in line with the fibers of the rotator cuff. Several authors have postulated that shoulder pain after antegrade nailing is caused by the transverse incision through the rotator cuff. Alternatives to antegrade humeral nailing (e.g., plate osteosynthesis) should be considered in patients who have preexisting shoulder pathology or who demand upper extremity weight bearing for ambulation (paraplegic or quadriplegic patients).Because of the frequency of shoulder pain after antegrade insertion, retrograde insertion has been advocated to avoid this complication; however, retrograde insertion has been associated with distal humeral fracture propagation. The traditional starting point for retrograde humeral nailing is in the midline, 2 cm above the olecranon fossa. More recently, insertion through the superior aspect of the olecranon fossa has been recommended. Proposed advantages of the olecranon fossa site include an increase in the effective working length of the distal fracture segment and straight alignment with the medullary canal; however, biomechanical studies have shown less resistance to torque and a reduction in load-to-failure with this approach compared with the more superior portal.Although flexible humeral nails have been successful in obtaining fracture union, insertion site morbidity and their suitability for only the most stable fracture patterns have limited their use. Albritton et al., in a cadaver study, found that the axillary nerve was at significant risk during insertion of the interlocking and tension screws of a titanium flexible humeral nail; they recommended blunt dissection through the deltoid, direct observation of the humeral cortex, and use of a soft-tissue sleeve during predrilling and placement of the screws.Newer self-locking expandable nails are reported to be easier to insert, while providing bending and torsional stiffness equal to that of locked nails. Few clinical studies are available to allow evaluation of these nails. Franck et al. described the use of an expandable nail (Fixion; Disc-o-Tech, Herzliya, Israel) for fixation of 25 unstable humeral shaft fractures in elderly patients with osteoporotic bone; all fractures healed without complications. Stannard et al. used a flexible locking nail (Synthes, Paoli, Penn) inserted through an extraarticular antegrade or retrograde portal for fixation of 42 humeral shaft fractures, with healing in 39; 86% had full range of motion, and 90% had no pain. Five complications occurred in four patients: two nonunions, two hardware failures, and one wound infection. All complications occurred in patients whose fractures were fixed with 7.5-mm nails, and the authors recommended that flexible nails should be used with caution in medullary canals with a diameter of 8 mm or less. The technique is technically demanding.Currently, we prefer rigid, locked nails inserted through an antegrade approach when intramedullary nailing is indicated, such as for segmental fractures (see Fig.54-16), for proximal–middle third junction fractures, for pathological fractures, for fractures with poor soft-tissue coverage, for fractures in obese patients, and forfractures in certain patients with polytrauma (Fig. 54-35A to C). We use an anterolateral incision with direct inspection and repair of the rotator cuff. Iatrogenic radialnerve injury has been reported, and care must be taken during fracture reduction, reaming, nail insertion, and locking screw placement. Intramedullary nailing is contraindicated in patients with very narrow medullary canals.TECHNIQUE 54-7Fractures of the Humeral Shaft with Radial Nerve PalsyThe radial nerve is the nerve most frequently injured with fractures of the humeral shaft because of its spiral course across the back of the midshaft of the bone and its relatively fixed position in the distal arm as it penetrates the lateral intermuscular septum anteriorly (Fig. 54-36). Usually the radial nerve injury is a neurapraxia,with recovery rates of 100% in low-energy injuries and 33% in high-energy injuries. Although it is possible for the nerve to be severed by the sharp edge of a bone fragment, this rarely occurs. We treat the fractured humeral shaft in the usual nonoperative manner, support the wrist and fingers with a dynamic splint, and reserve exploration of the nerve for instances when function has not returned in 3 to 4 months and the fracture has healed. Because the nerve usually is only bruised or stretched, function can be expected to return spontaneously. Routine exploration of the nerve would subject many patients to an unnecessary operation and mightincrease the frequency of complications. Early exploration and repair of a severed nerve have not been proved to produce any better results than repair at a laterdate.Fig. 54-35Intramedullary nailing of humeral shaft fracture (see text).A, Segmental shaft fracture in patient with multiple trauma.B and C, After fixation with intramedullary nail.D, Transverse shaft fracture.E and F, Reduction device is used to reduce fracture.G, Reaming is done to 1 to 1.5 mm larger than nail diameter.H, Outrigger device is used for insertion of proximal locking bolts.I, Reduction and screw placement confirmed with fluoroscopy.(D-I courtesy of Thomas A. Russell, MD, Memphis, Tenn.)•Carefully evaluate preoperative radiographs (Fig. 54-35D) to ensure that the diaphyseal diameter is adequate to accommodate the intramedullary nail; if the diameter is too small, plate fixation is indicated.• Position the patient on a radiolucent table with the thorax “bumped” 30 to 40 degrees. Place the image intensifer unit on the opposite side of the tablefrom the surgeon (see Fig. 54-21); rolling the unit back allows an adequate anteroposterior view, and rolling it forward allows an adequate lateral viewof the shoulder and humerus.• Make an incision diagonally from the anterolateral corner of the acromion, splitting the deltoid in line with its fibers in the raphe between the anteriorand middle thirds of the deltoid (see Fig. 54-22). To protect the axillary nerve, avoid splitting the deltoid more than 5 cm distal to the acromion.• Under direct observation, incise the rotator cuff in line with its fibers (see Fig. 54-22A). Use full-thickness sutures to protect the cuff from damageduring reaming of the humeral canal.• Place the initial guidewire posterior to the biceps tendon, and advance it under fluoroscopic guidance into the appropriate position as shown onanteroposterior and lateral views (see Fig. 54-21).• Carefully advance the proximal reamer, protecting the rotator cuff.• Use the reduction device to reduce the fracture and pass the bead-tipped guidewire (Fig. 54-35E and F). With sequentially larger reamers, ream thehumerus to the predetermined diameter, usually 1 to 1.5 mm larger than the nail diameter (Fig. 54-35G). With fractures of the middle third of theshaft, a small incision can be made at the fracture site to ensure manually that the radial nerve is not entrapped in the fracture before reduction andreaming.• When reaming is complete, pass the nail down the humeral canal, avoiding distraction of the fracture; ensure that the nail is below the articularsurface of the humeral head.• With the use of the outrigger device, insert the proximal locking bolts (Fig. 54-35H). Carefully spread the soft tissues to avoid injury to the axillarynerve.• Place the distal interlocking screws in an anterior-to-posterior direction to avoid the radial nerve. Make a 4- to 5-cm incision anteriorly to expose thebiceps musculature; bluntly split the muscle to avoid iatrogenic damage to the brachial artery.• Repair the rotator cuff with full-thickness sutures.•Confirm reduction and screw length on anteroposterior and lateral fluoroscopy images (Fig. 54-35I).• Begin an early rehabilitation program with active-assisted range-of-motion exercises.If radial nerve palsy occurs with an open fracture of the humeral shaft, the nerve should be explored at the time of the irrigation and débridement of the wound. If it is found intact, only watchful waiting is required while the fracture heals. Early exploration is required if evidence suggests that the radial nerve is impaled on a bone fragment or is caught between the fragments. Advances in ultrasonography have been useful in diagnosing entrapped and lacerated radial nerves. If this diagnostic tool proved to be reproducible in large numbers of patients, the indications for nerve exploration would be more specifically defined.In patients with radial nerve palsy for whom operative treatment of a humeral shaft fracture is indicated, the nerve should be explored at the time of fracture fixation.Shao et al. reviewed 21 scientific articles that included 4517 humeral shaft fractures and found an overall prevalence of radial nerve palsy of almost 12% (n = 532).Radial nerve palsy was most frequent with fractures of the middle and middle–distal humeral shaft and was more common with transverse and spiral fractures than with oblique or comminuted fractures. Overall, recovery occurred in 88%. Complete transection of the radial nerve usually occurs with open fractures of the humerus and requires nerve repair or grafting; most nerve palsies that occur with a closed fracture recover without treatment. Based on their review, Shao et al. developed an algorithm for the treatment of radial nerve palsy associated with humeral shaft fractures (Fig. 54-37).Periprosthetic Humeral Shaft Fractures Fig. 54-36Entrapment of radial nerve between fragments in spiral fracture of distal third of humerus.A, Nerve is least mobile as it passes through lateral intermuscular septum in distal third of arm.B, Oblique fracture is typically angulated laterally, and distal fragment is displaced proximally. Radial nerve, fixed to proximal fragment by lateral intermuscular septum, is trapped between fragments when closed reduction is attempted.(Redrawn from Holstein A, Lewis GB: Fractures of the humerus with radial-nerve paralysis, J Bone Joint Surg 45A:1382, 1963.)Fig. 54-37Treatment algorithm for radial nerve palsy associated with humeral shaft fracture. EMG, electromyogram; NAP, nerve axonal physiology; NCV, nerve conduction velocity.(From Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review, J Bone Joint Surg 87B:1647, 2005.)Periprosthetic humeral shaft fractures after shoulder or elbow arthroplasty are rare, but can be difficult to treat. Poor bone stock from osteoporosis, osteomalacia, or rheumatoid arthritis is the major contributing factor, and a variety of fracture patterns can result from low-energy direct blows, minor twisting injuries, “same level”falls, or intraoperative technical errors. Fractures around humeral arthroplasties may occur at the tuberosity level, metaphysis, upper diaphysis around the stem, or distal to the stem tip. Fractures around the humeral component of total elbow arthroplasties also can occur at any level from the medial or lateral column to proximal to the stem tip.Stable postoperative fractures without component loosening can be treated conservatively with immobilization. Stable fractures with component loosening require revision immediately or after fracture healing if still painful. Unstable fractures with or without component loosening require operative fixation with or withoutcomponent revision. If revision is necessary, the general principles of revision arthroplasty should be followed (see Chapters 8). Bone quality determines the need for supplemental allograft, strut grafts, methylmethacrylate cement, or autogenous bone grafts. Most patients requiring either hemiarthroplasty or total shoulder arthroplasty or elbow arthroplasty have age-related osteoporosis.When treating unstable periprosthetic humeral shaft fractures with well-fixed components, we have found the following guidelines helpful as outlined by Cameron and Iannotti: (1) displaced tuberosity fractures should be repaired with wire or heavy suture, and associated rotator cuff tears should be treated; (2) unstablediaphyseal fractures around or below the prosthesis require open reduction and internal fixation. Cerclage wire or limited screw fixation is unsatisfactory. A heavy plate with proximal cerclage wires and distal screws is preferred. At least four proximal cables and four distal screws, engaging eight cortices, are necessary. We recommend using 2-mm cables instead of the usual 1.6-mm cables. An anatomical reduction is necessary for union, and bone grafting the fracture site should be considered.When poor bone quality is present, fixation can be supplemented with methylmethacrylate cement. Cement should be kept out of the fracture site. If severeosteopenia is present, we recommend adding a full-thickness cortical allograft strut applied with additional cables 90 degrees to the plate-cable-screw construct.Autograft bone should be applied to the fracture site. We do not believe that a well-fixed, good functional shoulder or elbow arthroplasty should be revised to a long-stem implant just to repair a postoperative shaft fracture. Results with revision shoulder and elbow arthroplasty are not as satisfactory as primary arthroplasty.Instead we believe every effort should be made to achieve primary fracture union.Intraoperative fractures during shoulder arthroplasty can be avoided by careful attention to detail and respect for osteopenic bone. Intraoperative fractures should be repaired at the time of surgery by internal fixation or revision to a longer stem implant. The review by Cameron and Iannotti should be consulted for furtherinformation.The general treatment principles of periprosthetic humeral fractures around the humeral component of total elbow arthroplasties are as just outlined. Fractures of the medial or lateral column with a firmly seated implant can be treated with immobilization. Union of a column fracture is unnecessary for a good functional outcome.Copyright © 2008 Elsevier Inc. All rights reserved. - ww .d o c u -t r a c k .c w .d o c u -t r a c k .c o。
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
• Empiric antibiotic therapy
Fixation Methods: Group 1
• Lag screw fixation • Comminution is supported by small or mini-fragment buttress plate • Bone graft is considered for comminution and required for bone loss
• Hinged joint with single axis of rotation (trochlear axis) • Trochlea is center point with a lateral and medial column
distal humeral triangle
Functional Anatomy
Mechanism of Injury
• The fracture is related to the position of elbow flexion when the load is appPhysical exam
– Soft tissue envelope – Vascular status
Surgical Anatomy
• Medial and lateral columns diverge from humeral shaft at 45 degree angle • The columns are the important structures for support of the “distal humeral triangle”
– Distal humerus • Extra-articular • Intra-articular
Note: Fixation tactics & implants are based on groups
Treatment Principles
1. Anatomic articular reduction 2. Stable internal fixation of the articular surface 3. Restoration of articular axial alignment 4. Stable internal fixation of the articular segment to the metaphysis and diaphysis 5. Early range of motion of the elbow
– Definitive fixation at repeat evaluation
• Empiric antibiotic therapy • Repeat evaluation in OR until soft tissue closure (2-5 days)
Treatment: Closed Fracture
• Median nerve - rarely injured • Ulnar nerve
Evaluation
• Radiographic exam
– Anterior-posterior and lateral radiographs – Traction views are necessary to evaluate intraarticular extension and for pre-operative planning (“ligamentotaxis”) – Traction removes overlap – CT scan helpful in selected cases
Treatment: Open Fracture
• Emergent I&D • Definitive reduction and internal fixation • Temporary external fixation across elbow if definitive fixation not possible
• The distal humerus angles forward • Lateral positioning during ORIF facilitates reconstruction of this angle
Surgical Anatomy
• The trochlear axis compared to longitudinal axis is 94-98 degrees in valgus • The trochlear axis is 3-8 degrees externally rotated • The intramedullary canal ends 2-3 cm above the olecranon fossa
• Comminuted capitellum or trochlea
OTA Classification
• Follows AO Long Bone System • Humerus, distal segment given # 13 • 3 Main Types
• Extra-articular fracture (13-A) • Partial articular fracture (13-B) • Complete articular fracture (13-C)
• “Bag of bones” technique
– Rarely indicated if at all
• Cast or cast / brace
– Indicated for completely non-displaced, stable fractures
Literature: John, et al, 1994
Summary - Classifications
• Classifications are useful for research! • Classification data may not be reproducible between different surgeons! • Classification data may not be reproduced by the same surgeon at different times!
Literature: Cobb & Morrey, 1997
• 20 patients – (avg age 72 yrs) • TEA for distal humeral fracture • Conclusion
Summary - Classifications
• Meaningful patterns
– Extra-articular distal humerus
• Medial epicondyle • Lateral epicondyle • Distal metaphyseal humerus
– Partial articular distal humerus
• Capitellum • Trochlea
– Complete articular distal humerus
Simplicity
• Group 1
– – – – Lateral epicondyle Medial epicondyle Capitellum Trochlea
• Group 2
Other Potential Options
• Total elbow arthroplasty
– Comminuted intra-articular fracture in the elderly – Promotes immediate ROM – Usually limited by poor remaining bone stock
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Result very good good fair/poor
Literature: Pereles, et al, 1997
• 18 patients (> 60 yrs, avg age: 71 yrs) • SF-36 evaluation • All patients had a good or excellent clinical result • Their general health was comparable to published norms
• Radial and ulnar pulses
– Neurologic status
• Radial nerve - most commonly injured
– 14 cm proximal to the lateral epicondyle – 20 cm proximal to the medial epicondyle
• Definitive reduction and internal fixation
– Timing
• Within 24 hours or at 5-7 days – The inflammatory response peaks at 3 days post injury. ORIF during that peak may lead to excessive heterotopic ossification
• Each broad category further subdivided into 9 specific fracture types
OTA Classification
• Humerus, distal segment (13) – Types • Extra-articular fracture (13-A) • Partial articular fracture (13-B) • Complete articular fracture (13-C)