3种手术入路在肱骨髁上、髁间粉碎性骨折手术治疗中的应用体会

目的分别采用肘关节后正中倒舌型瓣切开肱三头肌腱膜入路、肱三头肌内外侧联合入路、尺骨鹰嘴V形截骨入路,显露肱骨远端髁上、髁间骨折部位,探讨肱骨远端不同类型骨折的最佳手术入路。方法本组20例,根据术者习惯和手术入路的不断改进,采用肘后正中肱三头肌倒舌型瓣入路8例、肱三头肌内外侧联合入路6例、尺骨鹰嘴V形截骨入路6例,均安放内外侧锁定钢板固定骨折部位。结果 C1型骨折可采用肘后正中肱三头肌倒舌型瓣或肱三头肌内外侧联合入路;C2、C3型骨折应尽量采取尺骨鹰嘴V形截骨入路,可充分显露骨折部位及髁间关节面,复位精确,固定确切可靠,手术时间短,出血少,可早期功能锻炼,术后关节功能恢复良好,无术后肘关节不稳及半脱位发生。结论尺骨鹰嘴V形截骨入路是C2、C3型骨折的理想入路。     

两种手术入路治疗肱骨髁间骨折疗效分析

目的评价尺骨鹰嘴截骨入路与肱三头肌舌形瓣入路治疗肱骨髁间骨折手术疗效。方法手术治疗56例肱骨髁间骨折,行尺骨鹰嘴截骨入路32例,肱三头肌舌形瓣入路24例。结果对于AO/ASIF分型C1C2型肱骨髁间骨折,尺骨鹰嘴截骨入路比肱三头肌舌形瓣入路手术时间长,但骨折暴露充分。对于C3型骨折,两种入路手术时间相近,前者肘关节功能评分比后者显著较高。结论尺骨鹰嘴截骨入路治疗肱骨髁间骨折暴露充分,术后肘关节功能优于肱三头肌舌形瓣入路。     

尺骨鹰嘴截骨入路双钢板内固定治疗成人C型肱骨髁间骨折的效果

目的探讨尺骨鹰嘴截骨入路双钢板内固定治疗成人C型肱骨髁间骨折的效果。方法随机将76例成人C型肱骨髁间骨折患者分为2组,各38例。观察组采取尺骨鹰嘴截骨入路双钢板内固定,对照组采取肘后肱三头肌舌形瓣入路。比较2组疗效。结果观察组手术时间、X线暴露时间、骨折愈合时间均短于对照组,肘关节功能优良率高于对照组,差异均有统计学意义(P0.05)。结论在治疗成人C型肱骨髁间骨折证实施尺骨鹰嘴截骨入路双钢板内固定术,可缩短手术和骨折愈合时间,且肘关节功能恢复较好。     

三种肘后入路治疗肱骨髁间骨折

目的探讨三种肘后入路术式治疗肱骨髁间骨折的效果。方法2000年2月-2006年6月，我院对49例肱骨髁间骨折的患者，按AO分型属B型27例，C型22例，随机采用三种肘后入路术式（传统入路、尺骨鹰嘴截骨和经肱三头肌腱尺骨鹰嘴处入路）进行治疗。结果术后肘关节功能按JOA标准评定：优35例（35／49），占71．4％；良12例（12／49），占24．5％；一般2例（2／49），占4．1％。其中传统手术入路者术后功能的优良率明显低于其余2种手术入路。结论三种肘后入路对肱骨近端都能充分暴露，但采用传统入路术式者术后功能恢复欠佳，且产生医源性并发症的概率较高。尺骨鹰嘴入路是最佳手术入路，但对惧怕尺骨鹰嘴截骨者亦可采用经肱三头肌腱尺骨鹰嘴处入路，二者都能获得良好的疗效，且医源性并发症的发生率较低。     

经尺骨鹰嘴截骨入路解剖型锁定钢板固定治疗肱骨远端C型骨折

目的探讨经尺骨鹰嘴截骨入路内外侧解剖型锁定钢板固定治疗肱骨远端C型骨折的疗效。方法采用经尺骨鹰嘴截骨入路解剖型锁定钢板固定治疗32例肱骨远端C型骨折患者,术后24 h开始功能锻炼。末次随访时按照Mayo肘关节功能评分标准评价恢复情况。结果患者均获得随访,时间6～24个月。骨折均愈合,均解剖复位。合并神经损伤者均在6个月内恢复。末次随访时按照Mayo肘关节功能评分标准评价疗效:优19例,良10例,可3例,优良率90. 6%。结论经尺骨鹰嘴截骨入路可以充分显露肱骨远端,有利于关节面复位;内外侧解剖型锁定钢板固定符合生物力学固定原理,患者可早期进行功能锻炼,为肘关节功能恢复提供了保障。     

尺骨鹰嘴截骨入路手术治疗成人C型肱骨髁间骨折的疗效观察

目的探讨C型肱骨髁问骨折经尺骨鹰嘴截骨入路手术治疗的临床疗效。方法对16例肱骨髁间C型骨折,采用经尺骨鹰嘴截骨入路双钢板内固定。男9例,女6例;年龄18～72岁,平均36．9岁。结果对本组患者随访3—36个月,骨折及尺骨鹰嘴截骨均未发现不愈合。按照Mayo评分为0～100分,平均81．25分,优8例,良5例,可2例,差1例。结论经尺骨鹰嘴截骨入路切开复位内固定治疗肱骨髁间粉碎性骨折的疗效满意,截骨方法对术后功能无明显影响。坚强固定和早期功能锻炼有利于肢体功能恢复,是治疗肱骨髁间骨折的首选方法之一。     

尺骨鹰嘴截骨与肱三头肌舌形瓣入路固定治疗肱骨髁间C型骨折

目的比较不同手术入路(尺骨鹰嘴入路与肱三头肌舌形瓣入路)内固定治疗肱骨髁间C型骨折的临床效果。方法 42例成人肱骨髁间C型骨折患者,20例采用尺骨鹰嘴截骨入路,22例采用肘后肱三头肌形瓣入路,均采用重建钢板内固定。术后行功能锻炼。结果 42例均获随访,时间8～48(29±3.5)个月。根据改良的Cassebaum评分系统评定肘关节功能。尺骨鹰嘴截骨入路组:优14例,良4例,可1例,差1例,优良率90%(18/20);肘后肱三头肌舌形瓣入路组:优15例,良5例,可2例,优良率90.9%(20/22)。两组优良率比较差异无统计学意义(P>0.05)。结论尺骨鹰嘴入路与肱三头肌舌形瓣入路内固定治疗成人肱骨髁间粉碎性骨折配合早期主、被动功能锻炼,多数患者能获得良好的治疗效果。     

扩大后侧入路治疗成人肱骨远端C3型骨折

目的探讨采用扩大后侧入路治疗成人肱骨远端C3型骨折的疗效。方法回顾性分析21例行内固定的肱骨远端C3型骨折的临床资料,包括12例行扩大后侧入路,9例行尺骨鹰嘴截骨入路。结果 21例获得随访,平均38个月,扩大的肘后侧入路组手术时间、术中失血量更少,Mayo肘关节评分较高。结论对于成人肱骨远端C3型骨折的治疗,采用扩大的肘后侧入路手术疗效更佳。     

经尺骨鹰嘴截骨入路双锁定钢板垂直固定治疗肱骨髁间骨折疗效观察

目的探讨应用肱骨远端解剖型锁定钢板,经尺骨鹰嘴截骨入路垂直固定治疗肱骨髁间骨折的临床疗效。方法对36例肱骨髁间骨折采用经尺骨鹰嘴截骨入路双锁定钢板垂直固定。结果本组获随访13～27个月,肱骨骨折及尺骨截骨处均骨性愈合;肘关节功能按照Mayo评分:优16例,良15例,可4例,差1例,优良率86.1%。结论采用经尺骨鹰嘴截骨入路肱骨远端解剖型锁定钢板垂直固定治疗肱骨髁间骨折疗效满意,值得推广应用。     

肱骨髁“C”型骨折尺骨鹰嘴截骨入路与肱三头肌舌形瓣入路固定疗效分析

[目的]对尺骨鹰嘴入路与肱三头肌舌形瓣入路固定治疗肱骨髁间“C”型骨折的临床效果进行对比分析.[方法]51例肱骨髁间C型骨折患者,22例采用尺骨鹰嘴截骨入路,29例采用肘后肱三头肌舌形瓣入路,均采用重建钢板内固定.术后行功能锻炼.[结果]51例均获随访,时间8 ～ 42个月(18±3.4)个月.根据改良的Cassebaum评分系统评定肘关节功能.尺骨鹰嘴截骨入路组:优16例,良4例,可1例,差1例,优良率90.9％(20/22);肘后肱三头肌舌形瓣入路组:优15例,良5例,可2例,差1例,优良率89.7％ (26/29).两组优良率比较差异无统计学意义(P＞0.05).[结论]尺骨鹰嘴入路与肱三头肌舌形瓣入路内固定治疗肱骨髁间C型骨折,2种入路疗效相当,骨折类型是影响术后肘关节功能最重要因素,选择合适手术入路要依患者骨折类型而定.     

经尺骨鹰嘴截骨双钢板内固定治疗肱骨髁间严重粉碎性骨折

目的：探讨经尺骨鹰嘴截骨双钢板内固定治疗肱骨髁间严重粉碎性骨折的手术方法及疗效。方法：采用经尺骨鹰嘴截骨双钢板内固定治疗肱骨髁间严重粉碎性骨折30例,男19例,女11例;年龄21-62岁,平均42．3岁。按AO／ASIF分类：C2型17例,C3型13例。21例内外侧均采用重建钢板,9例外侧采用重建钢板,内侧采用1／3管形钢板。结果：术后随访6个月-3年,平均1．5年。骨折愈合时间3～6个月,平均4个月。无骨不连、骨化性肌炎、迟发性尺神经受压、内固定失效等并发症。按Aitken—Rorabeck标准评分系统对其肘关节功能评定,优16例,良10例,可2例,差2例。结论：手术解剖复位重建肘关节稳定,术后早期功能锻练,是肘关节功能恢复的重要因素,经尺骨鹰嘴截骨是治疗肱骨髁间严重粉碎性骨折较好入路。     

鹰嘴截骨入路双钢板固定治疗肱骨髁间骨折

目的：探讨尺骨鹰嘴截骨入路应用肱骨内、外髁双钢板治疗肱骨髁间骨折的方法和临床疗效。方法：2001年6月至2007年3月采用尺骨鹰嘴截骨入路结合肱骨内、外髁双钢板治疗肱骨髁间骨折38例,男24例,女14例;年龄19～48岁,平均37岁;全部病例均为闭合性骨折。根据A0肱骨髁间骨折分型：C1型12例,C2型20例,C3型6例。受伤至手术时间6h～14d,平均7d。结果：38例患者均获得随访,时间5个月～2年,平均12个月。1例切口愈合欠佳,经换药治疗后愈合。骨折均已愈合,无骨不连发生,无内固定松动及断裂。愈合时间12-22周,平均15周。根据改良的Cassebaum评价标准评价肘关节功能：优15例,良17例,可5例,差1例。结论：经尺骨鹰嘴截骨入路显露骨折充分,肱骨内、外髁双钢板固定肱骨髁间骨折牢固可靠,早期功能锻炼是提高疗效的关键因素。     

尺骨鹰嘴截骨与肱三头肌两侧入路内固定治疗肱骨髁间骨折的疗效比较

目的 比较尺骨鹰嘴截骨与肱三头肌两侧入路内固定治疗肱骨髁间骨折的疗效.方法 对1980年1月至2008年3月国内外发表的尺骨鹰嘴截骨与肱三头肌两侧入路内固定治疗肱骨髁间骨折的文献进行检索.采用Coehrane协作网提供的系统评价方法对纳入文献进行数据抽取、汇总及系统评价.结果 共检索到364篇原始文献,经筛选及评价,最后收集到已发表的33篇文献符合纳入标准.随访资料完整的患者876例,其中尺骨鹰嘴截骨入路509例,肱三头肌两侧入路367例.分析显示:肱骨髁间骨折C2及C3型患者尺骨鹰嘴截骨入路内固定的术后肘关节功能评分的优良率(82.32%与79.38%)均高于肱三头肌两侧入路术后肘关节功能评分的优良率(70.59%与64.71%);C1型患者两种人路的术后肘关节功能评分的优良率差异无统计学意义.14篇文献报道了术后并发症.尺骨鹰嘴截骨入路术后并发症的发生率为4.72%(95%可信区间4.70%～4.74%),肱三头肌两侧入路为8.17%(95%可信区间8.13%～8.21%).结论 尺骨鹰嘴截骨较肱三头肌两侧入路内固定治疗肱骨髁间骨折的疗效佳.     

经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨远端C型骨折

目的探讨经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨远端C型骨折的疗效。方法采用经尺骨鹰嘴截骨入路双钢板内固定治疗19例肱骨远端C型骨折患者。分析术后并发症、骨折愈合时间及肘关节功能等指标。结果19例均获得随访,时间13~24个月。骨折均愈合,时间12~23周。未发生手术并发症。末次随访时,按照Mayo肘关节功能评分标准评定疗效:优11例,良6例,可1例,差1例,优良率17/19;肘关节屈伸活动度为80°~140°(109.8°±12.2°),前臂旋转活动度为110°~180°(140.6°±22.6°)。结论经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨远端C型骨折显露充分,复位及内固定操作方便,双钢板固定牢固,术后并发症少,肘关节功能恢复好。     

经尺骨鹰嘴截骨入路与肱三头肌舌状瓣入路治疗肱骨髁间骨折的对比研究

目的对比经尺骨鹰嘴截骨入路与经肱三头肌舌状瓣入路治疗肱骨髁间骨折的临床效果。方法 2002年5月至2009年2月,手术切开复位内固定治疗62例肱骨髁间骨折患者。其中33例采用尺骨鹰嘴入路。按Riseborough-Radin分型,Ⅲ型18例,Ⅳ型15例。29例采用肱三头肌舌状瓣入路。左侧16例,右侧13例。按Riseborough-Radin分型,Ⅲ型18例,Ⅳ型11例。比较两组手术时间、出血量、术后并发症及愈合时间等,用Mayo评分来评价术后肘关节功能的改善程度。结果术后随访12～36个月,平均16.7个月。所有患者切口均Ⅰ期愈合。手术时间、出血量及愈合时间两组比较差异无统计学意义。术后尺骨鹰嘴截骨入路组肘部疼痛发生率低于肱三头肌舌状瓣入路组,肘关节活动度。采用尺骨鹰嘴入路组（优良率为87.88%）优于采用肱三头肌舌状瓣入路组（优良率为65.51%）。结论采用尺骨鹰嘴入路组的术后并发症的发生率少于采用肱三头肌舌状瓣入路组,术后肘关节活动度的满意率高于采用肱三头肌舌状瓣入路组采用肱三头肌舌状瓣入路组。     

鹰嘴截骨双钢板内固定治疗肱骨髁间C型骨折37例

目的探讨肱骨髁间C型骨折治疗的手术方法及临床疗效。方法37例肱骨髁间C型骨折采用尺骨鹰嘴V型截骨双钢板内固定术。结果所有患者随访4-24个月,平均随访15个月。骨折愈合时间2-5个月,平均愈合时间3个月。按照Aitken和Rorabeek标准评定,优25例,良8例,可4例,优良率为89%。结论经尺骨鹰嘴截骨入路双钢板内固定是治疗肱骨髁间骨折的理想手术方式。     

Surgical management of intercondylar fractures of the humerus using triceps reflecting anconeus pedicle (TRAP) approach

Background:

Operative fixation of intra-articular fractures of the distal humerus requires adequate exposure. The transolecranon approach is a commonly used approach. The olecranon osteotomy has potential complications related to prominence/migration of hardware, displacement/nonunion of osteotomy and triceps weakness. Triceps-reflecting anconeus pedicle (TRAP) approach avoids the olecranon osteotomy without compromising the operative exposure. We present outcome of fixation of displaced intra-articular distal humeral fractures with the use of TRAP approach.

Materials and Methods:

We reviewed the functional and radiological results of 40 consecutive patients with intercondylar fractures of the humerus treated by internal fixation through TRAP approach. There were 28 males and 12 females and the average age was 32 ± 4.5 years. The right elbow was involved in 27 patients and the left elbow in 13 patients. The mechanism of injury was a fall in 20 patients, a motor-vehicle accident in 16 patients and direct trauma in four patients.

Results:

At a minimum follow-up of 12 months (average 18 ± 4 months) 35 (87.5%) patients had good triceps strength. The average range of motion was 118.4 ± 7 degrees (range 80°-130°). The average time to union was 3.2 ± 1.6 months (range two to six months). No patient had triceps rupture, implant failure, neurovascular deficit or nonunion. Two patients needed removal of the implant because of subcutaneous prominence.

Conclusions:

The TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; and one can avoid iatrogenic fracture of the olecranon and its associated complications.     

Intercondylar fractures of the distal humerus treated with the triceps-reflecting anconeus pedicle approach

Introduction: Treatment choice for displaced, intercondylar fractures of the distal humerus is open reduction and internal fixation (ORIF) through a posterior approach. The triceps-reflecting anconeus pedicle (TRAP) approach, combination of modified Kocher and Bryan-Morrey has been described as a conservative surgical exposure for fixation of the complex intercondylar fractures. Materials and methods: Eleven patients with intercondylar fractures of the humerus operated with this approach were reviewed. The mean follow-up was 26 (14–40) months. The aetiology of injuries was mostly fall on the elbow. There were five females and six males and the average age of the patients was 58.3 years (range 16–70 years). Results: According to Müller et al.’s classification; five were Type C1, four were Type C2 and, two were Type C3. At the final follow-up; Type C1 and C2 fractures had a ROM of 116° (range 95°–140°) and, Type C3 fractures had a ROM of 85° which showed limitation of elbow motion. Average humerotrochlear angle is 93.4° (range 90°–98°). Two patients had transient n.ulnaris paraesthesia and one had heterotopic ossification. Conclusion: Our results demonstrate that TRAP approach is extensile enough in treating these complex fractures however both articular reconstruction and fixation can be easily managed without creating an olecranon fracture. No significant triceps weakness and dysfunction was observed after TRAP approach in the treatment of the intercondylar fractures of the humerus. Preliminary results of this study was presented at the 6th European Trauma Congress in Prague, Czech Republic on 16-19 May 2004. An erratum to this article can be found at     

肱骨髁间骨折内固定术后肘关节僵硬的危险因素探讨

目的：探讨肱骨髁间骨折内固定术后发生肘关节僵硬的危险因素。方法：自2015年3月至2019年2月采用切开固定术治疗120例肱骨髁间骨折患者,男59例,女61例,年龄25~77（53.5±3.2）岁。根据术后是否发生肘关节僵硬分为僵硬组37例和对照组83例,采用单因素分析发生肘关节僵硬的相关因素,Logistic回归分析肱骨髁间骨折内固定术后发生肘关节僵硬的危险因素。结果：所有患者至末次随访时发生肘关节僵硬37例（僵硬组）,未发生肘关节僵硬83例（对照组）,关节僵硬发生率为30.83%,僵硬组与对照组在年龄、损伤能量、合并其他部位骨折、骨折至手术时间、骨折AO分型、是否开放性损伤和术后过早或过度活动等方面比较,差异有统计学意义（P<0.05）。多因素Logistic回归分析显示年龄>50岁、高能量损伤、骨折AO分型、开放性骨折和术后过早或过度活动是肱骨髁间骨折内固定术后肘关节僵硬的危险因素。术后僵硬组术后活动度以及Mayo肘关节功能评分均低于术后非僵硬组,差异有统计学意义（P<0.05）。肱骨髁间骨折术后肘关节屈曲僵硬与旋转僵硬患者的术后活动度以及Mayo评分比较,差异均无统计学意义（P>0.05）。结论：针对肱骨髁间骨折内固定术后肘关节僵硬的危险因素,术前应制定合理的手术方案和康复策略,以最大程度降低肘关节僵硬的发生率。     

Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy

Background

Although open reduction and internal fixation (ORIF) is a standard fracture treatment method, the optimal way to expose a fracture prior to ORIF is debated. We compared the effects of two exposure methods, the triceps-sparing approach and olecranon osteotomy, on the functional outcomes of ORIF-treated type C distal humerus fractures in elderly people.

Methods

From January 2006 to January 2011, 75 elderly patients with type C distal humerus fractures were treated with ORIF, and we retrospectively reviewed their medical records, radiographs, and follow-up charts to identify any complications. Patients’ Mayo Elbow Performance Score (MEPS) and range of motion were determined at their final clinic visit.

Results

Sixty-seven patients (89 %) attended the final visit. Of these patients, 36 received olecranon osteotomy and 31 received the triceps-sparing approach. For patients with type C1 and C2 fractures, we observed reductions in procedure times, blood loss, complication rates, and MEPS outcomes (all P < 0.01) with the triceps-sparing approach compared with olecranon osteotomy. Except for MEPS outcomes, all of these approach-related improvements were also statistically significantly for type C3 fractures (all P < 0.01). Overall, we did not observe any cases of fracture nonunion, implantation breakage or loosening, or elbow stiffening in our series.

Conclusions

In our study, we found better functional outcomes for type C1 and C2 distal humerus fractures that were exposed using the triceps-sparing approach rather than olecranon osteotomy. Even for the most complex type of fracture, C3 fractures, similar recoveries in elbow function were achieved using either approach.

Level of evidence

Level III.