肱骨髁间骨折术后不愈合的原因分析及治疗

Objective To investigate the causes and treatment of postoperative nonunion of the intercondylar fracture of humerus. Methods Twenty-six patients suffering from postoperative nonunion of the intercondylar fracture of humerus, 14 males and 12 females, were analyzed in this study. Four cases underwent total elbow arthroplasty(TEA), and the other 22 received refixation and autografting, 4 of whom healed only after 2 operations. The causes of postoperative nonunion were analyzed. Results This group had 28 unstable fixations, 16 postoperative plaster external fixations and 21 significant bone defects. On average, they had a follow-up of 11.4 months (4 to 41 months). In the 4 TEA cases, the average flexion was 112° (90° to 130°) and the extension 18° (0 to 35°). Their average MEPS score was 85(80 to 90 points). The other 22 cases achieved bone union ultimately, with an average flexion of 97.7°± 10. 0° (70° to 110°),an average extension of 30. 9°± 12.8°(0 to 60°), and an average motion arc of 66. 8°± 10. 5° (50° to 90°).Their average MEPS score was 81.4 ± 11. 1 points (65 to 100 points). Conclusions Inadequate internal fixation, elbow stiffness due to plaster external fixation and significant bone defects are the main causes for postoperative nonunion of the intercondylar fracture of humerus. 90-90 plate fixation and parallel plate fixation, together with constructive bone grafting, can achieve bone union in most cases, though the motion arc of the elbow is still unsatisfactory.     

肱骨远端解剖型锁定接骨板的初步应用

Objective To investigate surgical techniques and effects of AO distal humeral plate used as a treatment alternative for distal humerus fractures. Methods From April 2008 to July 2009, 22 cases of distal humerus fracture were treated with open reduction and internal fixation with AO distal humeral plate (DHP). They were 10 males and 12 females. Their ages ranged from 14 to 65 years (average, 40 years). According to AO classification, one case was Type A, 6 were Type B and 15 were Type C. Their elbows were not immobilized postoperatively. The mean follow-up was 15 months. Functional results were evaluated according to the Mayo elbow performance score (MEPS). Results Fractures healed in all cases. There was no hardware failure or loss of reduction. No patient complained of pain. They had an average elbow flexion of 108° (range, 60° to 130°) and an average full extension to 25° (range 0 to 80°) . The average ulnohumeral motion was 79° (range, 10° to 130°). The average MEPS was 91 points (range, 60 to 100 points). Fifteen cases scored excellent, 5 good and 2 fair. Conclusions DHP has advantages of an anatomically preshaped locking plate which may enhance anchorage in fractures difficult to manage, such as metaphyseal comminuted supra-intercondylar fractures, lower fractures with relatively small distal fragments and osteoporotic fractures, and allow early postoperative rehabilitation. However, in order to achieve an optimal result,precise location and pre-bending of the plate should be ensured.     

肱骨远端解剖型锁定接骨板的初步应用

Objective To investigate surgical techniques and effects of AO distal humeral plate used as a treatment alternative for distal humerus fractures. Methods From April 2008 to July 2009, 22 cases of distal humerus fracture were treated with open reduction and internal fixation with AO distal humeral plate (DHP). They were 10 males and 12 females. Their ages ranged from 14 to 65 years (average, 40 years). According to AO classification, one case was Type A, 6 were Type B and 15 were Type C. Their elbows were not immobilized postoperatively. The mean follow-up was 15 months. Functional results were evaluated according to the Mayo elbow performance score (MEPS). Results Fractures healed in all cases. There was no hardware failure or loss of reduction. No patient complained of pain. They had an average elbow flexion of 108° (range, 60° to 130°) and an average full extension to 25° (range 0 to 80°) . The average ulnohumeral motion was 79° (range, 10° to 130°). The average MEPS was 91 points (range, 60 to 100 points). Fifteen cases scored excellent, 5 good and 2 fair. Conclusions DHP has advantages of an anatomically preshaped locking plate which may enhance anchorage in fractures difficult to manage, such as metaphyseal comminuted supra-intercondylar fractures, lower fractures with relatively small distal fragments and osteoporotic fractures, and allow early postoperative rehabilitation. However, in order to achieve an optimal result,precise location and pre-bending of the plate should be ensured.     

Treatment of open supracondylar fracture of humerus

Objective: To explore the injury mechanism and treatment principle of open supracondylar fracture of humerus. Methods: The data of 32 patients with open supracondylar fracture of humerus hospitalized in our department in the recent 20 years were analyzed retrospectively. On an average, they were followed up for 30 months. The relationship between the fracture type,situation of wounds, operating time, operating method and time for postoperative functional exercise and final function of elbow joint were evaluated with Flynn scoring standard. Results: Excellent therapeutic effect was found in 14 cases, good in 12 and bad in 6, with the percentage of fine therapeutic effect of 81.25 %. Conclusions:For the patients with open supracondylar fracture of humerus, debridement and internal fixation should be made as early as possible, for thorough debridement and correct internal fixation are the key points to improve the prognosis.     

平行双接骨板内固定治疗老年肱骨远端粉碎性骨折

Objective To summarize our experience of treating distal humeral fractures of AO/OTA type C with parallel-plate fixation in the aged. Methods From January 2007 to September 2008, we treated 22 cases of type C distal humeral fractures by parallel-plating. They were 6 males and 16 females, with a mean age of 70. 2 (range, 60 to 81 ) years, including 3 open fractures (Gustilo type Ⅰ) and 19 close fractures. According to AO classification, there were 5 cases of type C1, 10 cases of type C2 and 7 cases of type C3. The posterior midline approach was selected. After the articular surface of the distal humerus was exposed through the olecranon osteotomy or the liguliform flap of triceps brachii muscle, parallel-plate fixation was performed to fix fractures internally. All patients began functional exercise of the elbow joint from 3 days after operation. Results All patients were followed up for a mean of 18 (range, 13 to 35) months. All fractures achieved complete union. The mean degrees of the elbow movement were as follows: extension was 16°(range, 0 to 50°), flexion 125° (range, 95° to 140°), supination 65° (range, 40° to 90°) and pronation 67°(range, 40° to 90°). According to Mayo elbow performance score (MEPS), 11 cases were graded as excellent, 8 as good, 2 as fair and one as poor. 86. 4% of the patients had an excellent or good functional result. Two cases reported transient ulnar nerve paralysis, 2 heterotopic ossification, one delayed union and elbow stiffness,3 slight symptoms of traumatic arthritis, and 2 slight malformation of cubitus varus. Conclusions Parallel-plate fixation is a preferred treatment for AO type C distal humeral fractures in the aged because of satisfactory bone healing, early mobilization and recovery of joint function. However, more attention should be paid to the complexity of the fracture which may influence the therapeutic effects of the operation.     

平行双接骨板内固定治疗老年肱骨远端粉碎性骨折

Objective To summarize our experience of treating distal humeral fractures of AO/OTA type C with parallel-plate fixation in the aged. Methods From January 2007 to September 2008, we treated 22 cases of type C distal humeral fractures by parallel-plating. They were 6 males and 16 females, with a mean age of 70. 2 (range, 60 to 81 ) years, including 3 open fractures (Gustilo type Ⅰ) and 19 close fractures. According to AO classification, there were 5 cases of type C1, 10 cases of type C2 and 7 cases of type C3. The posterior midline approach was selected. After the articular surface of the distal humerus was exposed through the olecranon osteotomy or the liguliform flap of triceps brachii muscle, parallel-plate fixation was performed to fix fractures internally. All patients began functional exercise of the elbow joint from 3 days after operation. Results All patients were followed up for a mean of 18 (range, 13 to 35) months. All fractures achieved complete union. The mean degrees of the elbow movement were as follows: extension was 16°(range, 0 to 50°), flexion 125° (range, 95° to 140°), supination 65° (range, 40° to 90°) and pronation 67°(range, 40° to 90°). According to Mayo elbow performance score (MEPS), 11 cases were graded as excellent, 8 as good, 2 as fair and one as poor. 86. 4% of the patients had an excellent or good functional result. Two cases reported transient ulnar nerve paralysis, 2 heterotopic ossification, one delayed union and elbow stiffness,3 slight symptoms of traumatic arthritis, and 2 slight malformation of cubitus varus. Conclusions Parallel-plate fixation is a preferred treatment for AO type C distal humeral fractures in the aged because of satisfactory bone healing, early mobilization and recovery of joint function. However, more attention should be paid to the complexity of the fracture which may influence the therapeutic effects of the operation.     

尺骨鹰嘴骨折不同程度骨量丢失对肘关节稳定性的影响

Objective To investigate effects of different bone defects on stability of the elbow in the olecranon fracture. Methods Ten fresh cadavers with 20 upper extremities were used in the present study. Different models of bone defects in the middle olecranon were created by cutting the bone from 10 mm below the olecranon process. The 20 specimens were randomly made into intact, 3 mm defect, 6 mm defect and 9 mm defect groups. After osteotomy fixations were applied with the tension band wire. Changes in the range of motion of the elbow joint were measured. When the elbow was flexed at 30°, 60°, 90°, and 120°, a and the varus angulations in the varus test position, and observe the changes in relationship to the humeroulnar joint. Results Extension of the elbow was limited when the defect was 3 mm. X-ray showed that the extension of the elbow was obviously limited when the defect was 6 mm, with the humeroulnar joint moving resistantly, the olecranon process completely touching the surface of the trochlear and the interspace between the humeroulnar joint increasing. When the defect was up to 9 mm, the humeroulnar joint was subluxated obviously,with the trochlear notch nearly disappearing. Given the same degree of elbow flexion, the valgus angulation increased with the defect, especially when the defect was beyond6 mm (P ＜0.05). Conclusions When the bone defect at the middle olecranon reaches 6 mm, the trochlear notch radian will change, leading to an unstable elbow joint. Consequently, comminuted fractures of the middle olecranon can be treated with fixation if the defect is less than 6 mm: Otherwise bone grafting may be necessary to recover the trochlear notch radian and reduce the risk of traumatic osteoarthritis.     

尺骨鹰嘴骨折不同程度骨量丢失对肘关节稳定性的影响

Objective To investigate effects of different bone defects on stability of the elbow in the olecranon fracture. Methods Ten fresh cadavers with 20 upper extremities were used in the present study. Different models of bone defects in the middle olecranon were created by cutting the bone from 10 mm below the olecranon process. The 20 specimens were randomly made into intact, 3 mm defect, 6 mm defect and 9 mm defect groups. After osteotomy fixations were applied with the tension band wire. Changes in the range of motion of the elbow joint were measured. When the elbow was flexed at 30°, 60°, 90°, and 120°, a and the varus angulations in the varus test position, and observe the changes in relationship to the humeroulnar joint. Results Extension of the elbow was limited when the defect was 3 mm. X-ray showed that the extension of the elbow was obviously limited when the defect was 6 mm, with the humeroulnar joint moving resistantly, the olecranon process completely touching the surface of the trochlear and the interspace between the humeroulnar joint increasing. When the defect was up to 9 mm, the humeroulnar joint was subluxated obviously,with the trochlear notch nearly disappearing. Given the same degree of elbow flexion, the valgus angulation increased with the defect, especially when the defect was beyond6 mm (P ＜0.05). Conclusions When the bone defect at the middle olecranon reaches 6 mm, the trochlear notch radian will change, leading to an unstable elbow joint. Consequently, comminuted fractures of the middle olecranon can be treated with fixation if the defect is less than 6 mm: Otherwise bone grafting may be necessary to recover the trochlear notch radian and reduce the risk of traumatic osteoarthritis.     

两种手术入路在肘关节松解术中应用的比较

Objective To compare the posterior midline approach and the combined lateral and medial approach usually used in elbow arthrolysis. Methods From January to December in 2009, 41 cases of elbow stiffness were treated and fully followed up by the same team in our hospital. The posterior midline approach was used in 21 cases, 15 males and 6 females, with an average age of 35.8 years (16 to 70 years). In this group, the total flexion-extension arc was ＜ 30° in 12 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Eight cases had ulnar symptoms. The combined lateral and medial approach was applied in 20 cases, 8 males and 12 females, with an average age of 38. 8 years (16 to 51 years). In this group, the total flexion-extension arc was ＜ 30° in 11 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Five cases had ulnar symptoms. Results The 41 cases were followed up for 4 to 15 months (average, 7.9 months). In the posterior approach group, the mean preoperative flexion-extension ROM (27.6°± 25.7°) was improved to the postoperative 111.4°± 25.6°, the mean preoperative rotation ROM ( 152.9°± 46. 9°) to the postoperative 168.1°± 19. 1°, and the mean preoperative MEPS score (65.5 ± 11.5) to the postoperative 95.7 ±6.4. In the combined approach group, the mean flexion-extension ROM was improved from 35.5°± 25.0° preoperatively to 116. 5°± 19.1° postoperatively, the mean rotation ROM from 138.0°±55.7° preoperatively to 148.5°± 45.6° postoperatively, and the mean MEPS score from 66. 3 ± 13.0 preoperatively to 97.3 ± 7.0 postoperatively. The differences were statistically significant between preoperation and postoperation in both groups ( P ＜ 0. 05), but not statistically different between the 2 groups in the preoperative or postoperative values ( P ＞ 0. 05). In the posterior approach group, 5 patients had huge hematoma, 3 had wound dehiscence at the posterior elbow, and the others all had mild hematoma. But in the combined approach group, no wound complications were noted. Conclusion The combined lateral and medial approach should be used as far as possible in the elbow arthrolysis to avoid the likely complications when the posterior midline approach is used.     

两种手术入路在肘关节松解术中应用的比较

Objective To compare the posterior midline approach and the combined lateral and medial approach usually used in elbow arthrolysis. Methods From January to December in 2009, 41 cases of elbow stiffness were treated and fully followed up by the same team in our hospital. The posterior midline approach was used in 21 cases, 15 males and 6 females, with an average age of 35.8 years (16 to 70 years). In this group, the total flexion-extension arc was ＜ 30° in 12 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Eight cases had ulnar symptoms. The combined lateral and medial approach was applied in 20 cases, 8 males and 12 females, with an average age of 38. 8 years (16 to 51 years). In this group, the total flexion-extension arc was ＜ 30° in 11 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Five cases had ulnar symptoms. Results The 41 cases were followed up for 4 to 15 months (average, 7.9 months). In the posterior approach group, the mean preoperative flexion-extension ROM (27.6°± 25.7°) was improved to the postoperative 111.4°± 25.6°, the mean preoperative rotation ROM ( 152.9°± 46. 9°) to the postoperative 168.1°± 19. 1°, and the mean preoperative MEPS score (65.5 ± 11.5) to the postoperative 95.7 ±6.4. In the combined approach group, the mean flexion-extension ROM was improved from 35.5°± 25.0° preoperatively to 116. 5°± 19.1° postoperatively, the mean rotation ROM from 138.0°±55.7° preoperatively to 148.5°± 45.6° postoperatively, and the mean MEPS score from 66. 3 ± 13.0 preoperatively to 97.3 ± 7.0 postoperatively. The differences were statistically significant between preoperation and postoperation in both groups ( P ＜ 0. 05), but not statistically different between the 2 groups in the preoperative or postoperative values ( P ＞ 0. 05). In the posterior approach group, 5 patients had huge hematoma, 3 had wound dehiscence at the posterior elbow, and the others all had mild hematoma. But in the combined approach group, no wound complications were noted. Conclusion The combined lateral and medial approach should be used as far as possible in the elbow arthrolysis to avoid the likely complications when the posterior midline approach is used.     

胫骨干骨折的手术治疗对策

目的：明确不同固定器械在胫骨干不同骨折类型固定中的特点，以指导临床应用。方法：68例胫骨干骨折，行加压钢板螺钉、交锁髓内钉、单侧外固定架固定后，作临床疗效分析。结果：加压钢板固定组42例，感染5例，骨不连1例，平均愈合时间3．8个月；交锁髓内钉固定组13例，无感染及骨不连，平均愈合时间5．4个月；单侧外固定架组13例，骨不连1例，踝关节背伸受限3例，平均愈合时间4．5个月。结论：胫骨骨折交锁髓内钉固定并发症少，功能恢复好，适用范围广，但要注意及时进行动力加压。加压钢板及外固定架固定应选择各自的最佳适应证，以达到理想的疗效。