4种内固定方法治疗肱骨髁部粉碎性骨折的疗效比较

目的 比较4种内固定方法治疗肱骨髁部粉碎性骨折的疗效。方法 采用交叉克氏针＋石膏外固定、AO双钢板内固定、Y形钢板内固定和有限内固定＋绞链式肘关节外固定架固定等4种不同的内固定方法治疗肱骨髁上与髁间粉碎性骨折72例。结果 随访时间平均15个月,骨折愈合时间平均3．8个月。无骨不连、骨折畸形愈合、骨化性肌炎、迟发性尺神经炎等发生。按Aitken和Rorabeek标准进行肘关节功能评定,优良率：A组73．3％,B组89．5％,C组92．0％,D组92．3％。结论 绞链式肘关节外支架辅助内固定治疗肱骨髁部粉碎骨折能提高肘关节侧方稳定性,可早期功能锻炼。Y形钢板内固定具有固定牢靠、操作简单等优点。     

Open reduction and plate fixation of displaced AO type C3 fractures of the distal radius: restoration of articular congruity in eighteen cases.

OBJECTIVE: To determine the ability of open reduction and plate fixation to restore articular congruity in the treatment of fractures of the distal radius with intraarticular comminution and displacement. DESIGN: Prospectively followed series. METHODS: Eighteen consecutive fractures of the distal radius with intraarticular comminution and displacement were treated with open reduction and combined volar and dorsal plate fixation in thirteen, dorsal plate fixation in four, and volar plate fixation in one case. Kirschner wires were added in thirteen fractures and cancellous bone graft was used in four fractures. Articular congruity after a mean follow-up of twenty-three months was assessed using anteroposterior and lateral radiographs. RESULTS: Articular congruity without a two millimeter or more intraarticular stepoff was found at follow-up in fifteen of eighteen cases, without a two millimeter or more gap in nine cases and without a two millimeter or more stepoff or gap in only eight cases. One reason for not having obtained articular congruity in some of the fractures was insufficient intraoperative visualization of the joint surface. Three reduced fractures redisplaced. The reason for loss of intraarticular reduction was considered insufficient stabilization of the distal fragments. In two of the three cases, it was thought that insertion of bone graft would have prevented the loss of reduction. CONCLUSIONS: Articular incongruity after open reduction and plate fixation of comminuted fractures of the distal radius may occur more often than expected. The reduced fracture should be evaluated by intraoperative radiographs. If the reduced joint surface is not entirely visible on the radiographs because of implants or other reasons, oblique radiographs or fluoroscopy should be additionally used. Plate fixation alone does not always provide sufficient stability and cancellous bone graft should be added in cases of metaphyseal bone loss or for stabilization of multiple small articular fragments that cannot be fixed by screws or Kirschner wires.     

Treatment of proximal and middle one-third humeral fractures with lateral distal tibial helical plate

Objective

To evaluate the outcomes of treating patients with proximal and middle one-third humeral fractures treated with lateral distal tibial helical plate.

Materials and methods

From June 2004 to January 2009, 12 patients (8 men, 4 women: average age: 46.8?years, range: 25–63) with proximal and middle one-third humeral fractures were treated with open reduction and internal fixation using lateral distal tibial helical plate. Standard anterior–posterior and lateral radiographs were obtained and evaluated. Shoulder function was assessed according to the Constant–Murley score.

Results

At follow-up (average: 18?months), all fractures had healed (average: 15?weeks, range: 9–23). There were no cases of intraoperative complications, implant failures, infections, or iatrogenic intra- or post-operative nerve lesions. All patients achieved at least 100° of abduction by 3?months post-surgery and full range of movement by 12?months post-surgery, with the exception of one patient who had an impingement symptom with moderate loss of abduction and external rotation. The average Constant–Murley score was 88 points at 12-month follow-up. According to Constant–Murley score, 28% of patients had excellent functional outcome, 64% had good outcome, 8% had moderate outcome, and none had failure. According to self-reporting, all patients had returned to the pre-injury level of activity.

Conclusions

The lateral distal tibial helical plate promotes bone healing and minimizes the damage to the deltoid muscle insertion region, thereby facilitating rapid and good functional recovery. In addition, the helical plate design avoids affecting sliding of the biceps tendon and maintains good reduction position. The lateral distal tibial helical plate is an effective surgical option for proximal and middle one-third humeral fractures.     

Minimally invasive plate osteosynthesis of distal fractures of the tibia

Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures.     

Mid-term results of complex distal humeral fractures

The aim of this study was to assess outcomes following open reduction and internal fixation in complex fractures of the distal humerus. Between 2000 and 2006, 34 patients were operated for complex fractures of the distal humerus. Bone fixation was obtained with a reverse Y-shaped reconstruction plate in 13 cases and with double plating in 21 cases. At final follow-up, all the patients were assessed with the Mayo Elbow Performance Score. Satisfactory results were observed in 71% of the cases despite a high rate of complications. Age over 65 years is correlated with increased risk for an inferior postoperative result. Complex distal humeral fractures are difficult to treat and are associated with a high incidence of complications. It is therefore mandatory to obtain good anatomical reduction and a stable fixation of lateral and medial columns of the distal humerus. The results observed in older patients suggest that an alternative treatment for these patients may be joint replacement.     

Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years

BACKGROUND: The short-term results of open reduction and internal fixation of intra-articular distal humeral fractures are good to excellent in approximately 75% of patients, but the long-term results have been less well studied. This investigation addressed the long-term clinical and radiographic results of surgical treatment of intra-articular distal humeral fractures (AO Type C) as assessed with use of standardized outcome measures. METHODS: Thirty patients were evaluated at an average of nineteen years (range, twelve to thirty years) after open reduction and internal fixation of a fracture of the distal part of the humerus to assess the range of elbow motion and the functional outcome. Twenty patients had an olecranon osteotomy, and all had fixation with plates and/or screws and/or Kirschner wires. No ulnar nerve was transposed. RESULTS: Excluding one elbow salvaged with an arthrodesis and counted as a poor result, the average final flexion arc was 106 degrees and the average pronation-supination arc was 165 degrees. The average American Shoulder and Elbow Surgeons (ASES) score was 96 points, with an average satisfaction score of 8.8 points on a 0 to 10-point visual analog scale. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 7 points, and the average Mayo Elbow Performance Index (MEPI) score was 91 points. Including the patient with the arthrodesis, the final categorical ratings were nineteen excellent results, seven good results, one fair result, and three poor results. The presence of arthrosis did not appear to correlate with pain or predict disability or function. Subsequent procedures were performed in twelve patients (40%). CONCLUSIONS: The long-term results of open reduction and internal fixation of AO-Type-C fractures of the distal part of the humerus are similar to those reported in the short term, suggesting that the results are durable. Functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis.     

切开复位锁定钢板内固定治疗肱骨近端骨折

目的评价锁定钢板治疗肱骨近端骨折的临床效果及并发症。方法采用锁定钢板对骨折进行常规手术治疗。术后3、6、12个月对患者进行随访。随访内容包括疼痛、生活情况、力量及Constant评分,并与对侧肩关节进行对照。每次随访时,拍摄肩关节前后位片及"Y"位片,评价骨折愈合情况及可能存在的并发症。结果本组共106例肱骨近端骨折患者。其中,使用5孔钢板95例(90%),其余类型钢板11例(10%)。术后随访发现,患者受伤肩的活动度有明显的提高(P<0.05)。术后12个月,肩关节前伸可达(132°±35°),外展(122°±39°),外旋(45°±23°),内旋(77°±21°);患肩的Constant评分为(70.6±13.7),达到健侧(83.0±8.0)的(85.1%±14.0%),并随时间推移有明显提高(P<0.05)。在完成随访的93个患者中,25人(27%)出现了34例并发症,其中的18例(53%)并发症发生在术后3个月内,而22例(65%)并发症是因手术操作导致的。结论采用锁定钢板治疗不稳定性及老年性肱骨近端骨折有较好的临床效果。尽管也有并发症的发生,但大多是由手术操作造成的,是可以避免的。     

Internal fixation of proximal humeral fractures with locking proximal humeral plate (LPHP) in elderly patients with osteoporosis

Background  Different operative techniques used for treating displaced proximal humeral fractures could result in malunion, non-union, osteonecrosis of humeral head, loosening of screw and loss of reduction particularly in comminuted and osteoporotic fractures. Locking compression plate (LPHP) has been proposed for open reduction and internal fixation of these fractures and is associated with less complication rate. Materials and methods  We prospectively assessed the functional outcome and the complications after an average follow-up of 24.9 months in 25 patients of proximal humeral fractures with osteoporosis. Mean age was 62 years. Using AO classification, 48% were type A and 52% type B. Results  Mean constant score was 80 points. According to constant score, 28% had excellent outcome, 64% had good functional outcome, and 8% had moderate outcome. When the results were related to grades of osteoporosis, grade IV osteoporotic fractures had highest average Constant–Murley score (83 points, range 78–88 points), followed by grade III osteoporotic fractures (80 points, range 71–92 points), followed by grade II osteoporotic fractures (78 points, range 66–88 points). Varus malalignment and subacromial impingement were observed in 8% patients. Loosening of implant and loss of reduction were observed in 4% patients. Superficial infection was observed in 4% patients. Conclusions  Locking compression plate (LPHP) is an advantageous implant in proximal humeral fractures due to angular stability, particularly in comminuted fractures and in osteoporotic bones in elderly patients, thus allowing early mobilization.     

Trimed fixation system for displaced fractures of the distal radius

OBJECTIVE: To study the functional outcome of displaced distal radius fractures treated by open reduction and internal fixation with the use of fragment-specific fixation. METHODS: Fifteen consecutive displaced distal radius fractures (5 extra-articular and 10 intra-articular) were treated using the Trimed distal radius fixation system (Trimed, Valencia, CA). Radiographic assessment and range of motion of the affected wrist were evaluated postoperatively. Functional outcomes were evaluated with use of the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Gartland and Werley scoring system. RESULTS: The mean follow-up was 11 months. The patients initiated controlled passive and active motion exercises during the first week. The mean score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 16 points. The mean return to work was 12 weeks. The functional outcome was 80% excellent or good by the Gartland and Werley scoring system for intra-articular fractures and 80% excellent for extra-articular fractures. Range of active motion in intra-articular fractures was measured 60 degrees wrist extension, 64 degrees flexion, 65 degrees pronation, and 70 degrees supination, and for extra-articular fractures, 75 degrees extension, 70 degrees flexion, 80 degrees pronation, and 75 degrees supination. There was failure of fixation with loss of the reduction that was achieved at the time of operation in one patient. CONCLUSIONS: Fragment-specific fixation of unstable distal radius fractures using the Trimed system appears to be effective. Anatomic reduction, earlier range of motion, and improved functional results can be achieved using low-profile implants.     

Locking plates in distal humerus fractures： study of 43 patients

Objective:The treatment of multifragmentary,intraarticular fractures of the distal humerus is difficult,even in young patients with bone of good quality.Small distal fragment,diminished bone mineral qu...     

肱骨髁间骨折的内固定治疗

目的探讨切开复位双钢板内固定治疗肱骨髁间骨折的方法和临床疗效。方法回顾性分析采用双钢板内固定治疗肱骨髁间骨折44例。骨折按AO/OTA分型:C1型10例(22.7%),C2型18例(40.9%),C3型16例(36.4%)。术后随访时记录骨折愈合时间及Mayo肘关节功能评分。结果 44例中39例获得随访,平均随访21.6个月(13.0～31.0个月),平均骨折愈合时间为14.7周(12.0～21.0周)。术后12.0个月Mayo评分平均为82.4分(45.0～100.0分)。结论切开复位双钢板内固定能对骨折进行有效固定,保证早期功能锻炼,肘关节功能恢复满意。     

Biodegradable fixation of distal humeral physeal fractures.

Polyglycolic acid (PGA) has been used worldwide as a biodegradable suture material since 1970. Biodegradable polyglycolide implants were introduced in osteofixation of cancellous bone fractures in 1985. From September 1987 to September 1989, 19 consecutive children with physeal fractures of the distal humerus necessitating open reduction and internal fixation were treated by transphyseal biodegradable fixation using 1.5 x 60-mm2 self-reinforced polyglycolide (SR-PGA) pins. Included were nine displaced fractures of the lateral humeral condyle, five severe avulsions of the medial epicondyle of the humerus, four displaced fractures of the humeral capitellum, and one intraarticular fracture of the medial condyle of the humerus. After accurate reduction, two smooth Kirschner pins 1.5 mm in diameter were introduced across the growth plate for temporary fixation. The metallic pins then were removed one by one and subsequently replaced with the cylindrical SR-PGA pins 1.5 mm in diameter. After operation, a padded plaster splint was worn for four weeks. Neither secondary displacement nor signs of growth disturbance were seen during the 26-month follow-up time (mean, 17.2 months). Not only the reduction of the costs but also the psychological aspects should be considered when dealing with biodegradable fixation of physeal fractures in children. Transphyseal biodegradable fixation has established itself as a procedure of choice for handling simple physeal fractures.     

Supracondylar fractures of the femur above total knee arthroplasties with cortical allograft struts

Ten supracondylar fractures of the femur above a total knee arthroplasty were treated with open reduction and internal fixation using a metal plate and cortical allograft struts. Failure with nonunion of previous operative treatments was seen in 5 patients. The other 5 patients had either severe osteopenia or comminution of the fracture above the knee prosthesis. At an average of 38 months' follow-up, all the fractures healed with an average union time of 17.6 weeks. The postoperative knee alignment averaged 5.1 degrees valgus. Infection occurred in 1 patient, which resulted in a poor outcome. The remaining 9 patients were functioning well at the most recent follow-up examination. The use of cortical allograft struts combined with a compression plate provided satisfactory results for supracondylar fractures above knee prostheses with severe osteopenia or loss of bone stock after initial failure of internal fixation.     

Y形钢板治疗肱骨远端骨折疗效分析

目的 探讨Y形钢板内固定治疗肱骨远端骨折疗效.方法 对38例肱骨远端骨折患者应用Y形钢板内固定治疗,并对手术入路、内固定的应用、术后不良反应进行分析,对手术疗效进行评价.结果 38例均获随访,时间12～36个月,按照改良的Cassebaum评分系统评定术后肘关节功能:优22例,良11例,可5例,优良率为86.84%.出现桡神经挫伤1例,尺神经炎1例,肱肌异位骨化1例.结论 Y形钢板治疗肱骨远端骨折力求解剖复位,重建稳定;其具有固定牢固,术后可早期功能锻炼、并发症少等优点,疗效满意.     

Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates

PURPOSE: To determine whether volar fixed-angle plate fixation with a new plate system could be used to treat dorsally unstable distal radius fractures. We hypothesized that volar fixed-angle plate fixation with or without radial styloid fixed-angle plate fixation would provide sufficient rigidity to allow early active range of motion without compromising fracture reduction. The initiation of early active motion may improve functional outcomes. METHODS: A retrospective review was conducted of one institution's initial experience using a new volar fixed-angle plate system to treat dorsally displaced intra-articular and extra-articular distal radius fractures. Thirty-two fractures in 32 patients with dorsally displaced distal radius fractures were treated with a volar fixed-angle plate with or without a radial styloid fixed-angle plate. Fractures were classified using the AO classification. Radiographic parameters on preoperative, postoperative, and final follow-up radiographs were compared. The time to initiation of active range of motion was determined. Final follow-up ranges of motion and complications were reported. Finally, comparisons were made between the 23 fractures treated with a volar plate alone and the 9 fractures treated with a volar plate and a radial styloid plate. RESULTS: The average follow-up period was 13 months. Two thirds of the fractures were intra-articular. Average loss of reduction from initial postoperative to final follow-up radiographs was 0 degrees of volar tilt, 1 degrees of radial inclination, and 0 mm of radial length. Active wrist and forearm ranges of motion were initiated at an average of 11 days after surgery. The final follow-up flexion-extension and pronation-supination arcs averaged 112 degrees and 151 degrees , respectively. The 9 fractures treated with the combination of a fixed-angle volar plate with a fixed-angle radial styloid plate had greater initial displacement than did the 23 fractures treated with a volar plate alone. Otherwise, differences between the 2 groups were not significant. Only 1 radial styloid plate became symptomatic. CONCLUSIONS: Volar plate fixation using a new fixed-angle plate system successfully can stabilize dorsally unstable distal radius fractures. Early active range of motion was facilitated without compromising fracture reduction.     

Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C)

The aim of this study was to evaluate the functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO Type C) with a minimum follow-up of two years. A retrospective evaluation with prospective clinical review was carried out. Twenty-six consecutive patients with fractures of the distal humerus were treated over a 31-month period. Their mean age was 56 years (range, 18-82). Six patients were not available for final clinical review. Analysis of the results were based on the medical records, pre-operative and postoperative radiographs of all 26 patients and clinical review of 20 patients at a mean follow-up of 35 months (range, 24-48 months). Twenty-six fractures were fixed using the AO double column plating techniques. Radiographic evaluation of the quality of reduction was carried out using a grading system. Clinical outcome was assessed using the Broberg and Morrey functional rating index. Fourteen patients (70%) had an excellent or good outcome, five patients (25%) a fair outcome and one patient (5%) had a poor result. Three patients (15%) underwent a second procedure for hardware removal. The mean arc of flexion was 112 degrees (range, 85 to 122). Mean pronation was 75 degrees (range, 60-82) and supination was 76 degrees (range, 60-80). No patients had achieved normal grip strength; the mean grip strength was 82% (range, 46-90%) compared to the uninjured side. Fifteen patients (75%) were able to return to their pre-injury level of occupation and activity. Seventeen patients (85%) were satisfied with the final outcome. We conclude that internal fixation of intraarticular fractures of the distal humerus is an effective procedure with an excellent or good functional outcome in most patient age groups. Patients have a high level of satisfaction and the majority return to their previous level of activity.     

肱骨干骨折内固定的选择及应注意的问题

目的正确选择肱骨干骨折手术内固定.方法对107例肱骨干骨折分别进行交锁髓内钉(34例)、加压钢板(29例)、Y型钢板(38例)、螺钉(6例)等内固定,并随访比较分析. 结果所有病例均得到随访,平均随访6.3个月.交锁髓内钉、螺钉内固定组全部愈合;加压钢板内固定组愈合26例,伴桡神经损伤2例;Y型钢板内固定组全部愈合,伴肘关节僵硬2例. 结论根据肱骨干骨折的部位和类型选用适当的内固定方法,骨折愈合良好,可有效的减少并发症的发生.     

肱骨远端解剖型锁定接骨板的初步应用

目的 评价新型肱骨远端解剖型锁定接骨板(DHP)的治疗方法及疗效.方法 2008年7月至2009年4月使用DHP治疗且获得随访的肱骨远端骨折22例,男10例,女12例;年龄14～65岁,平均40.2岁;左侧13例,右侧9例.骨折按照AO分型:A型1例;B型6例;C1型2例,C2型1例,C3型12例.均采用切开复位DHP固定;术后无需外固定,第2天开始功能锻炼.所有患者按照Mayo肘关节功能评分(MEPS)及X线片评估疗效.结果 22例患者获得11～20个月(平均15个月)随访.骨折均获愈合,平均愈合时间16周,无内固定失效或骨折再移位.2例患者因肘关节僵硬接受肘关节松解手术,1例患者螺钉进入关节,但对肘关节功能无影响,2例患者内固定突起于皮下致轻微疼痛.22例患者中2例有轻微疼痛,前臂旋转功能同健侧一致,肘关节平均屈伸79°(10～130°),屈曲108°(60°～130°),伸直25°(0～80°).MEPS评分平均91分(60～100分),其中优15例,良5例,中2例,优良率91.0%.结论 DHP对于较高位的肱骨髁上部分粉碎骨折、低位的关节面粉碎骨折,以及合并骨质疏松的肱骨远端骨折均能够达到满意的稳定固定,允许早期功能锻炼.     

三叶草钢板治疗肱骨近端移位骨折

目的探讨肱骨近端移位骨折采用三叶草钢板治疗的临床价值。方法用三叶草钢板治疗肱骨近端骨折38例,按N eer分类,二部分骨折20例,三部分骨折13例,四部分骨折5例,其中骨折伴脱位3例。结果36例获得平均13个月(3~28个月)随访,2例失访。36例均骨性愈合,无畸形愈合,无肱骨头坏死。按N eer评分标准评分,优27例,良6例,可2例,差1例,总优良率91.6%。结论采用三叶草钢板内固定治疗肱骨近端移位骨折,固定牢靠,可早期功能训练,术后功能恢复满意,值得提倡。     

Open reduction and internal fixation of intra articular and unstable fractures of the distal radius using the AO distal radius plate

This study reports the results of open reduction and internal fixation of 25 dorsally displaced distal radial fractures using a specifically designed plate for the distal radius, the AO pi plate (Synthes Ltd, Paoli, USA). Twenty-one of these fractures were complex and intra-articular (AO Type 'C'). Measurement of range of motion of the affected wrist at an average follow-up of 16 months revealed a median return of 60 degrees of wrist extension, 40 degrees of wrist flexion, 90 degrees of pronation and 90 degrees of supination. Radiographic assessment revealed restoration of normal radial length, inclination and palmar tilt in all but six cases. The final outcome, as assessed by the Gartland and Werley scale, was excellent in four cases, good in 11, and fair in ten cases. Complications were seen in five patients.