双钢板内固定治疗肱骨远端C型骨折

肱骨远端C型骨折属关节内骨折,传统的非手术治疗或有限的内固定手术治疗既不能恢复关节解剖形态和关节面平整,又因外固定时间较长,不利于关节功能的恢复,引起不同程度的肘关节功能障碍、骨不连或畸形愈合等并发症[1,2].     

Plate selection for fixation of extra-articular distal humerus fractures: A biomechanical comparison of three different implants

Operative fixation of extra-articular distal humerus using a single posterolateral column plate has been described but the biomechanical properties or limits of this technique is undefined. The purpose of this study was to evaluate the mechanical properties of distal humerus fracture fixation using three standard fixation constructs.Two equal groups were created from forty sawbones humeri. Osteotomies were created at 80 mm or 50 mm from the tip of the trochlea. In the proximal osteotomy group, sawbones were fixed with an 8-hole 3.5 mm LCP or with a 6-hole posterolateral plate. In the distal group, sawbones were fixed with 9-hole medial and lateral 3.5 mm distal humerus plates and ten sawbones were fixed with a 6-hole posterolateral plate. Biomechanical testing was performed using a servohydraulic testing machine. Testing in extension as well as internal and external rotation was performed. Destructive testing was also performed with failure being defined as hardware pullout, sawbone failure or cortical contact at the osteotomy.In the proximal osteotomy group, the average bending stiffness and torsional stiffness was significantly greater with the posterolateral plate than with the 3.5 mm LCP. In the distal osteotomy group, the average bending stiffness and torsional stiffness was significantly greater with the posterolateral plate than the 3.5 mm LCP. In extension testing, the yield strength was significantly greater with the posterolateral plate in the proximal osteotomy specimens, and the dual plating construct in the distal osteotomy specimens. The yield strength of specimens in axial torsion was significantly greater with the posterolateral plate in the proximal osteotomy specimens, and the dual plating construct in the distal osteotomy specimens.Limited biomechanical data to support the use of a pre-contoured posterolateral distal humerus LCP for fixation of extra-articular distal humerus exists. We have found that this implant provided significantly greater bending stiffness, torsional stiffness, and yield strength than a single 3.5 mm LCP plate for osteotomies created 80 mm from the trochlea. At the more distal osteotomy, dual plating was biomechanically superior. Our results suggest that single posterolateral column fixation of extra-articular humerus fractures is appropriate for more proximal fractures but that dual plate fixation is superior for more distal fractures.     

Treatment for type C fractures of the distal humerus with the LCP distal humerus system

Background

Although the locking compression plate-distal humerus system (LCP-DHS) is a biomechanically proven implant for fractures of the distal humerus, few have reported its clinical results.

Methods

Thirteen cases of type C intercondylar fractures of the distal humerus according to AO classification that were treated with the LCP-DHS followed for a minimum of 1?year were enrolled for this study. The mean age at the time of operation was 46.8?years (range, 26–80?years), and the mean follow-up period was 25.1?months (range, 13–39?months). The timing of bone union, implant failure, and loosening around screws were assessed on simple radiographs. For clinical evaluations, we analyzed range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS), and patient satisfaction.

Results

Bone union was achieved radiologically in all cases. The mean timing of bone union was 8.5?weeks (range, 5–18?weeks) after operation. At the last follow-up, the mean range of motion was 16 degrees (range, 0–40 degrees) in flexion and 131 degrees (range, 130–150 degrees) in extension deficit. The MEPS was 87.3 points (range, 45–100 points); the DASH score, 17.6 points (range, 0–86.7 points); and the VAS, 1.5 (range, 0–4). Complications included screw loosening and delayed union in 1 case, limited range of motion that led to adhesiolysis in 1 case, and transient ulnar nerve palsy in 1 case.

Conclusions

The internal fixation using the LCP-DHS for type C fractures of the distal humerus was stable, enabling early postoperative mobilization and good clinical results.     

Biomechanical comparison of three internal fixation configurations for low transcondylar fractures of the distal humerus

BackgroundWe aimed to evaluate the biomechanical stiffness and strength of different internal fixation configurations and find suitable treatment strategies for low transcondylar fractures of the distal humerus.Methods and materialsThirty 4^th generation composite humeri were used to create low transcondylar fracture models that were fixed by orthogonal and parallel double plates as well as posterolateral plate and medial screw (PPMS) configurations (n=10 in each group) using an anatomical locking compression plate-screw system and fully threaded medial cortical screws. Posterior bending (maximum 50 N), axial loading (maximum 200 N) and internal rotation (maximum 10 N·m) were tested, in that order, for each specimen. Stiffness under different biomechanical settings among different configurations were compared. Another 18 sets of fracture models were created using these three configurations (n=6 in each group) and the load to failure under axial loading among different configurations was compared.ResultsUnder posterior bending, the stiffness of parallel group was higher than orthogonal group (P<0.001), and orthogonal group was higher than PPMS group (P<0.001). Under axial loading, the stiffness of parallel group was higher than orthogonal group (P=0.001) and PPMS group (P<0.001); however, the difference between orthogonal and PPMS group was not statistically significant (P>0.05). Under internal rotation, the stiffness of parallel group was higher than orthogonal group (P=0.044), and orthogonal group was higher than PPMS group (P=0.029). In failure test under axial loading, the load to failure in the orthogonal group was lower than parallel group (P=0.009) and PPMS group (P=0.021), but the difference between parallel group and PPMS group was not statistically significant (P>0.05). All specimens in orthogonal group demonstrated “distal medial failure”; most specimens had “distal medial and trochlear failure” in the parallel group; most specimens exhibited “contact failure” in the PPMS group.ConclusionFor treating low transcondylar fractures, the overall stiffness and strength of the parallel configuration were superior to those of the orthogonal and PPMS configurations. Nevertheless, the PPMS configuration can provide adequate stability and stiffness comparable to double-plate configurations under axial loading. Therefore, the PPMS construct may have certain clinical value.     

Mechanical consequences of different scenarios for simulated bone atrophy and recovery in the distal radius

Metabolic bone diseases such as osteoporosis usually cause a decrease in bone mass and a deterioration of bone microarchitecture leading to a decline in bone strength. Methods to predict bone strength in patients are currently based on bone mass only. It has been suggested that an improved prediction of bone strength might be possible if structural changes are taken into account as well. In this study we evaluated which structural parameters (other than bone mass) are the best predictors for changes in bone mechanical properties of the human radius after different bone atrophy scenarios and whether the original strength of the affected bone can be recovered if bone loss is restored by thickening of the remaining structures. To answer these questions, a human radius was measured with a microcomputer tomography scanner to extract the full three-dimensional architecture of the distal radius at an isotropic resolution of 80 μm. Eight models with modified bone architecture were created and the mechanical variations due to these modifications were studied using microfinite element (micro-FE) simulations. In four models mass was lowered by 20%, either by reducing cortical thickness, trabecular thickness, or number of trabeculae or by overall thinning of structures. In the other four models bone mass was restored to the original value using a trabecular bone thickening procedure. The micro-FE analyses revealed that most load was carried by the cortical bone. For this reason, bone strength was affected most in the reduced cortical thickness model. For the same reason, the trabecular bone atrophy scenarios, all of which affected bone strength in a very similar way, resulted in less dramatic bone strength reduction. The restoration of bone mass did not recover the original bone strength. These findings demonstrate that the importance of different parameters for the prediction of bone strength also depends on the mechanical loading. This could explain why results of earlier studies on the importance of structural parameters can be inconsistent and site-dependent.     

三种内固定方法治疗肱骨髁间粉碎性骨折的疗效比较

目的比较二种内固定方法治疗肱骨髁间粉碎性骨折的疗效。方法2002年2月～2005年1月,采用单钢板螺钉(A组,21例)、“Y”形钢板(B组,33例)和双钢板(C组,19例)固定治疗73例肱骨髁间粉碎性骨折患者,根据Müller的AO分型标准均为C3型骨折。所有患者均取肘后正中切口,采用肱三头肌舌形瓣入路。对本组患者的内固定方式、肘关节功能及并发症等资料进行回顾性研究。结果所有患者获得12～36个月(平均22．3个月)随访。术后12个月,肘关节功能按Jupiter评定标准进行评定,A组优良率为57．1%,B组为81．8%,C组为89．5%。B、C组术后肘关节功能恢复明显较A组好,差异有显著性意义(P＜0．05)；根据Sodergard关于肱骨髁间骨折内固定失败的判断标准,A组失败率为33．3%,B组为15．2%,C组为5．3%,C组内固定失败率明显较A、B组低,B组明显较A组低,差异均有显著性意义(P＜0．05)。无一例出现切口皮肤坏死和深部感染。结论单钢板螺钉治疗肱骨髁间粉碎性骨折,术后肘关节功能恢复较差,内固定松动、断裂及肘内翻畸形发生率亦较高,临床应慎用此方法；“Y”形钢板和双钢板治疗肱骨髁间粉碎性骨折,符合肱骨远端生物力学特点,术后肘关节功能恢复良好者；但“Y”形钢板由于其自身的形态、结构特点,术后内固定松动发生率较高,因此对于肱骨内、外髁骨块较小者,不宜选用“Y”形钢板固定。     

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。     

不同术式治疗成人C型肱骨远端骨折

<正>2012年8月~2013年7月,我科采用不同术式治疗49例C型肱骨远端骨折患者,疗效满意,报道如下。1材料与方法1.1病例资料本组49例,男30例,女19例,年龄22~67(37±3.4)岁。左侧21例,右侧28例。均为新鲜闭合骨折,均无血管损伤及尺神经症状。手术时间为伤后5~11(6±1.7)d。按手术     

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。     

解剖型锁定接骨板治疗老年骨质疏松性肱骨远端骨折的初步疗效观察

目的：探讨肱骨远端解剖型锁定接骨板（distal humeral plate,DHP）治疗老年骨质疏松性肱骨远端骨折的方法与疗效。方法：2008年9月至2010年1月,手术治疗18例老年骨质疏松性肱骨远端骨折,男3例,女15例;年龄62～83岁,平均71.4岁。骨折按照AO分型：A2型1例,A3型3例,B1型2例,B2型2例,C1型3例,C2型4例,C3型3例。经肱三头肌两侧入路或尺骨鹰嘴＂V＂形截骨入路,均采用切开复位DHP内固定,术后早期积极进行功能锻炼。按照Mayo肘关节功能评分（MEPS）评估疗效。结果：所有患者术后获得随访,时间11～24个月,平均14.6个月。骨折均获愈合,无感染、内固定失效或骨折再移位。肘关节平均屈伸78°（10°～131°）,屈曲113°（65°～134°）,伸直25°（0～75°）。MEPS评分平均（92.2±9.6）分（65～100分）,其中疼痛（42.5±5.8）分（30～45分）,关节活动范围（19.2±1.9）分（15～20分）,稳定性（9.2±1.9）分（5～10分）,日常功能（21.4±2.9）分（15～25分）。本组患者优11例,良5例,可2例。结论：应用DHP治疗老年骨质疏松性肱骨远端骨折能获得坚强固定,有利于早期肘关节功能锻炼从而获得良好治疗效果。     

The use of pre-contoured plates in the treatment of C2–C3 fractures of the distal humerus: clinical experience

Open reduction and internal fixation is the treatment of choice in distal humerus fractures. The aims of the treatment are to obtain anatomic reconstruction and restoration of the elbow’s geometry followed by stable internal fixation that allows immediate rehabilitation. The plates are pre-contoured to fit the natural anatomy of the elbow and in the case of complex fractures they provide a guide for the anatomic restoration of the distal humerus. The two plates are placed parallel with the screws locked together by interdigitation creating a fixed angle in the distal fragments that provides stability to the entire distal humerus. Using this method we obtained good results according to the Mayo Elbow Performance Score (MEPS) and we are able to reduce the incidence of complications. Our experience shows also that it can be useful to obtain an anatomical reduction of distal humeral fractures using the pre-contoured plates in a parallel position recovering the anatomical antiversion of the articular surface.     

有限内固定结合外固定架治疗肱骨中远端C型骨折

我们自2002年3月～2005年9月采用有限内固定结合单臂外固定架方法急诊治疗肱骨干中远端C型骨折23例,取得满意效果。资料与方法一、一般资料本组23患,男15例,女8例;年龄17～68岁,平均32岁。致伤原因:交通伤20例,摔伤3例。X线片证实为肱骨远端粉碎性骨折。骨折根据AO／ASIF分型:C1型14例,C2型5例, C3型4例。闭合性骨折20例,开放性骨折3例(Gustilo分类均     

双钢板内固定与入工全肘关节置换术治疗老年肱骨髁间C型骨折的早期疗效比较

目的 比较老年肱骨髁间C型骨折应用双钢板内固定与人工全肘关节置换术的疗效.方法 2003年4月至2009年9月,采用双钢板内固定或人工全肘关节置换术治疗新鲜老年肱骨髁间骨折42例,骨折分型均为AO分型C型.对其中随访资料较完整的22例进行回顾性分析.双钢板内固定10例,男5例,女5例;年龄60～70岁,平均63.2岁;1例Gustilo Ⅰ型开放骨折,余9例均为闭合性骨折.人工全肘关节置换术12例,均为女性;年龄60～74岁,平均65.2岁;均为闭合性骨折.术后1、2、3、6个月、1年进行复查,之后每年复查1次.采用Mayo肘关节功能评分(Mayo elbow performance score,MEPS)进行评估,观察术后肘关节屈伸活动度、功能评分、优良率及并发症.结果 双钢板内固定组随访8～56个月,平均27.6个月;人工全肘关节置换组随访15～54个月,平均28.2个月.双钢板内固定组平均屈伸范围84.5°,人工全肘关节置换组平均屈伸范围107.5°,两组比较差异有统计学意义(P=0.007);双钢板内固定组MEPS评分平均75.5分,人工全肘关节置换组平均87.9分,两组比较差异有统计学意义(P=0.047);双钢板内固定组MEPS优良率60%,人工全肘关节置换组MEPS优良率83.3%,两组比较差异无统计学意义(P=0.348).双钢板内固定组术后并发症包括2例尺神经炎,2例异位骨化;人工全肘关节置换组术后并发症包括1例尺神经炎,1例肱三头肌肌力减弱,1例异位骨化.结论 对老年肱骨髁间C型骨折,一期行人工全肘关节置换术较双钢板内固定能获得更好的疗效.

Abstract：

Objective To compare the clinical outcomes of open reduction and internal fixation (ORIF) with total elbow arthroplasty (TEA) for type C inter-condylar fractures of the distal humerus in the elderly. Methods Twenty-two patients who were treated with ORIF or TEA from April 2003 to September 2009 were included in the study. All fractures were OTA classification 13C. Among them, 10 patients who were treated with ORIF were follow up for 8-56 months, while 12 patients who were treated with TEA were followed up for 15-54 months. The Mayo elbow performance score (MEPS) and the complications were compared. Results Using the MEPS, there were 2 in excellent, 4 in good, 4 in fair in the patients treated with ORIF. Complications included heterotopic ossifications (2 cases) and ulnar nerve dysfunction (2 cases).There were 6 in excellent, 4 in good, 2 in fair in the patients treated with TEA. Complications included 1heterotopic ossification (1 case), ulnar nerve dysfunction (1 case), the weakness of musculus triceps brachii (1 case). The patients treated with TEA had significantly better range of motion (107.5° vs 84.5°, P=0.007),also had better MEPS (87.9 vs 75.5, P=0.047) than those with ORIF had ones. Conclusion TEA is a liable option for type C inter-condylar fractures of the distal humerus in the elderly.     

Biomechanical stability of a fixed-angle volar plate versus fragment-specific fixation system: cyclic testing in a C2-type distal radius cadaver fracture model

PURPOSE: To compare the biomechanical stability of 2 recently introduced fixation systems in an intra-articular, dorsal comminution distal radius fracture model. METHODS: AO/ASIF type C2 fractures were simulated in 10 matched pairs of fresh-frozen cadaveric arms randomized between fixed-angle volar plate and fragment-specific fixation systems. Specimens were loaded in extension cyclically for 2,000 repetitions followed by a single cycle to failure. Initial, intermediate, and final stiffness values and failure load values were obtained and compared. RESULTS: Both systems were able to sustain physiologic cyclic loading. The fragment-specific system was significantly stiffer than the fixed-angle volar plate system for the ulnar segment in both the precycle and postcycle values. No other comparisons were significant with respect to stiffness. No significant difference in load to failure was found between the systems with respect to ulnar, radial, or overall fragment displacement. CONCLUSIONS: Both fixed-angle volar plate and fragment-specific fixation systems performed comparably in a simulated early postoperative motion protocol. Fragment-specific fixation had improved stiffness characteristics only with respect to the smaller ulnar-sided fragment.     

The use of pre-contoured plates in the treatment of C2-C3 fractures of the distal humerus: clinical experience

Open reduction and internal fixation is the treatment of choice in distal humerus fractures. The aims of the treatment are to obtain anatomic reconstruction and restoration of the elbow’s geometry followed by stable internal fixation that allows immediate rehabilitation. The plates are pre-contoured to fit the natural anatomy of the elbow and in the case of complex fractures they provide a guide for the anatomic restoration of the distal humerus. The two plates are placed parallel with the screws locked together by interdigitation creating a fixed angle in the distal fragments that provides stability to the entire distal humerus. Using this method we obtained good results according to the Mayo Elbow Performance Score (MEPS) and we are able to reduce the incidence of complications. Our experience shows also that it can be useful to obtain an anatomical reduction of distal humeral fractures using the pre-contoured plates in a parallel position recovering the anatomical antiversion of the articular surface.     

平行或垂直双钢板治疗中青年C型肱骨远端骨折的病例对照研究

目的 :比较使用垂直双钢板或平行双钢板内固定治疗C型肱骨远端骨折的临床疗效。方法 :自2009年3月至2013年3月采用双钢板内固定治疗40例C型肱骨远端骨折患者,按固定方式不同分为两组:垂直双钢板固定组(A组)和平行双钢板固定组(B组)。A组22例,男13例,女9例,年龄18~56岁,平均(37.56±9.24)岁;B组18例,男11例,女7例,年龄20~53岁,平均(41.35±9.03)岁;两组均为新鲜闭合性骨折,无血管及神经损伤。观察并比较两组患者的手术切口长度、手术时间、手术出血量、住院时间、影像学变化、肘关节活动范围、Mayo肘关节评分、肘关节屈伸肌肌肉力量以及并发症等情况。结果:全部病例术后切口愈合良好,两组术后各出现1例骨化性肌炎;A组2例、B组1例出现肘关节僵硬,术后骨折均获骨性愈合。A组随访20~36个月,平均(25.2±7.1)个月,B组随访18~35个月,平均(24.3±6.0)个月。两组手术出血量、手术时间比较差异有统计学意义;但手术切口、住院天数、肌肉力量、骨折愈合时间、肘关节活动范围等方面两组比较差异无统计学意义。A组Mayo肘关节评分为82.27±10.43,优6例,良12例,可3例,差1例;B组为81.94±12.02,优5例,良9例,可3例,差1例;两组比较差异无统计学意义。结论:垂直双钢板与平行双钢板对中青年C型肱骨远端骨折的临床疗效无明显差异,但具体术式的选择仍需要根据骨折的具体情况以及术者对术式的熟练程度。     

Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients

We reviewed the results of internal fixation in a series of 18 patients (mean age, 44.4 years; SD, 19.1 years; range, 16-81 years) with type C intraarticular fractures of the distal humerus after a mean follow-up of 24.7 months (range, 10-41 months; SD, 9.3 months). An excellent or good result was observed in 10 patients (56%), according to the rating system of the Orthopaedic Trauma Association. All patients younger than 40 years (n = 8) had an excellent or good result, whereas those rates were found in only 2 of 10 patients older than 50 years. Low range of elbow motion (extension-flexion) and, consequently, inferior postoperative score were also correlated to male sex, the triceps-splitting approach, and immobilization exceeding 3 weeks. When stability of the humeral columns is achieved and the articular platform is reconstructed, satisfactory results can be obtained, even in comminuted supracondylar fractures. However, age over 50 years, poor bone quality, and open fracture are correlated with increased risk for an inferior postoperative result. Early mobilization, when possible, and the use of an olecranon osteotomy are recommended.     

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.     

急诊交锁髓内钉内固定加锁钉开口处取骨植骨治疗胫骨中下段闭合性骨折

目的 探讨急诊切开复位交锁髓内钉内固定加锁钉开口处取骨植骨治疗胫骨下段闭合性骨折的疗效.方法 对26例胫骨下段闭合性骨折患者行切开复位交锁髓内钉内固定治疗,并行交锁髓内钉开口处取骨一期植骨.结果 患者均获随访,时间7～26(15±3.6)个月.切口均愈合良好,无感染,无皮肤坏死.24例骨折3～5(3.8±0.4)个月完全愈合,2例延迟愈合,未出现骨不连.按Tenny和Wiss评分系统评价疗效:优21例,良3例,可2例.结论 采用切开复位交锁髓内钉内固定加交锁髓内钉开口处取骨治疗胫骨下段闭合性骨折,能提高骨折一期愈合率,避免二期植骨手术和髂骨取骨的并发症.