两种手术入路治疗肱骨远端冠状面剪切骨折的临床效果

目的：比较前外侧入路及外侧入路切开复位内固定治疗肱骨远端冠状面剪切骨折的效果，探讨两种手术方法的利弊及适应证。方法： 回顾性分析北京积水潭医院2006年9月至2014年7月的10例肱骨远端冠状面剪切骨折的切开复位内固定病例，以Dubberley方法进行骨折的分型，采用前外侧入路为A组，外侧入路为B组，记录术后并发症发生情况，Mayo评分评价最终临床结果。结果： A组5例，术前分型ⅠA型1例，ⅡA型1例，ⅢA型1例，ⅢB型2例，均用自前向后埋头螺钉固定骨折块，对滑车桡侧骨折块也以螺钉单独固定，术后Mayo评分平均82分，4例需再次手术， 2例因螺钉刺激行内固定物取出，1例肘关节僵硬，1例内固定失效，1例发生一过性桡神经损伤；B组5例，术前分型ⅠA型和ⅠB型各1例，Ⅱ A型3例，术后Mayo评分平均91分，仅1例发生内固定失效，肘关节不稳定需再次手术。结论： 外侧入路较好，但对滑车部位骨折的处理略显不足，术中要注意外侧副韧带（lateral collateral ligament，LCL）的保护及修复。前外侧入路并发症发生较多，优点是对滑车部位的显露较直接，但因不脱位，肘关节显露范围较小，对于肱骨远端的压缩骨折显露及固定欠佳。

Analysis of anterolateral approach and lateral approach for the treatment of coronal shear fracture of the distal humeral

Objective：To treat the coronal shear fracture of the distal humeral during open reduction and internal fixation by anterolateral approach and lateral approach, and to analyze the advantage and disadvantage of each approach. Methods: From September 2006 to July 2014, 10 patients with coronal fracture of the distal humeral were analyzed, who were all treated with Open Reduction and Internal Fixation (ORIF), 5 with anterolateral approach (group A) and 5 with lateral approach (group B). For the anterior-lateral approach, the radial nerve and brachioradialis were retracted laterally and the brachialis was retracted medially, the capsule was incised and the fracture line was exposed, usually the capitellum and the lateral part of the trochlear could be exposed clearly but the exposure was limited. For the lateral approach, the brachioradialis was retracted anteriorly, the lateral collateral ligament (LCL) was protected or released from the starting point on the lateral condyle of the humeral, the elbow could be dislocated and the capitellum and part of the trochlear could be exposed. The fractures were classified with the system of Dubberley, the complications were analyzed and the ultimate results were evaluated according to the Mayo elbow performance index (MEPI). Results: For group A, 4 re-operations were performed, 2 for the irritation of the screws,1 for stiff elbow and 1 for failure of the internal fixation. One radial nerve injury happened but recovered later. The mean MEPI was 82 points. For group B, 1 failure of the internal fixation and instability of the elbow happened. The revision operation was performed for this patient. The mean MEPI was 91 points. Conclusions: Lateral approach is better，it gives more exposure for the joint and the radial nerve is safe, but the trochlear is difficult to be exposed, and the LCL must be protected or repaired during the operation. Anterolateral approach can be used to expose the capitellum and the radial side of the trochlear, but the radial nerve is dangerous and more complications may happen.