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低位肱骨远端骨折的手术策略与治疗效果

Operative effect and treatment strategies for the low distal humerus fracture

摘要:

目的:探讨低位肱骨远端骨折患者的手术策略与治疗效果。方法:回顾性分析2016年1月至2018年1月于同济大学附属同济医院骨科经手术治疗的16例新鲜肱骨鹰嘴窝以远骨折患者的临床资料。患者骨折形态呈肱骨头冠状面骨折、部分合并肱骨滑车及后髁骨折。按Dubberley分型,Ⅰ型9例、Ⅱ型3例、Ⅲ型4例。根据骨折类型及形态选择手术入路及内固定方式:单纯肱骨头冠状面骨折或合并滑车骨折的骨折面较稳定的患者采用外侧入路,行单枚或多枚埋头螺钉固定;肱骨头冠状面骨折合并滑车粉碎性骨折、骨折面移位明显者采用尺骨鹰嘴截骨入路,行后外侧锁定钢板及埋头螺钉复合内固定。术后2周观察创面、软组织恢复情况。术后3、6、12个月行影像学检查评估骨折复位愈合、内固定位置、骨关节炎等情况及肘关节活动范围,末次随访采用Mayo评分系统评估肘关节功能,对不同Dubberley分型患者功能恢复情况进行比较。计量资料组间比较采用Kruskal-Wallis H检验。 结果:16例患者均获得随访,随访时间(22.1±9.2)个月(范围:15~39个月)。术后2周患者切口愈合良好,无软组织感染、坏死及血管神经损伤等并发症。术后3个月影像学检查提示患者骨折均愈合,骨折复位无丢失,内固定无松动断裂。术后6个月1例患者出现异位骨化,经非甾体类抗炎药物治疗后缓解,1例术后出现尺神经炎症状,将长螺钉取出并松解尺神经后症状缓解。12个月随访时均未出现骨关节炎影像学表现,患者肘关节的最大屈曲角度为(120.4±11.2)°,最大背伸角度为(5.5±1.9)°。肘关节功能Mayo评分为(88.7±9.1)分,其中优11例、良4例、一般1例。DubberleyⅠ型患者Mayo评分为(90.1±3.7)分,Ⅱ型患者Mayo评分为(89.7±4.6)分,Ⅲ型患者Mayo评分为(84.5±5.8)分,三种分型患者的Mayo评分的差异无统计学意义( H=4.02, P>0.05)。 结论:根据低位肱骨远端骨折患者的骨折类型及形态采用合适手术入路、关节面解剖复位及个体化复合内固定是取得良好手术效果的关键。

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abstracts:

Objective:To explore the operative effect and treatment strategies for the low distal humerus fracture.Methods:A retrospective analysis was conducted on the clinical data of 16 patients with the low distal humerus fracture between January 2016 and January 2018 at Department of Orthopaedics, Shanghai Tongji Hospital Affiliated to Tongji University.All fractures were coronal fractures of humeral head, partly combined fractures of humeral trochlea or posterior part. Fractures were classified according to Dubberley classification as 9 cases in type Ⅰ, 3 cases in typeⅡ and 4 cases in type Ⅲ.Selection of the kind of operative approach and internal fixation was made according to the fracture type and shape. For simple coronal fractures of humeral head or combining humeral trochlea fractures, which were relatively stable, single or multiple countersunk screws fixation by the lateral approach were chosen.For humeral head coronal fractures, which combining obviously displaced comminuted humeral trochlea factures, posterolateral locking plates and countersunk screws internal fixation by the olecranon osteotomy approach were chosen. The incision and elbow soft tissues were observed within 2 weeks after operation.The radiographic evaluation of fracture reduction, bone healing, internal fixation, arthritis and elbow range of motion were made at 3, 6, 12 months after operation. The Mayo elbow functional scores were documented for analysis of elbow joint function, and compared between different surgery groups by Kruskal-Wallis H test. Results:The follow-up time was (22.1±9.2)months(range: 15 to 39 months). The incisions healed well in 2 weeks after operation without soft tissue infection, necrosis or vascular complications. There was no fracture reduction loss or internal fixation loosening according to radiographic evaluation 3 months after operation. One case of ectopic ossification was observed 6 months after operation and inhibited by the treatment of non steroidal anti-inflammatory drugs.One case of ulnar neuritis occurred after operation and released after removing the long screw and loosing the ulnar.Osteoarthritis images were observed at the end of follow-up.Arc of motion was (120.4±11.2) ° in flexion and (5.5±1.9) ° in extension. The Mayo score was 88.7±9.1, including 11 excellent, 4 good, and 1 fair.The Mayo score was 90.1±3.7 in Dubberley classification type Ⅰcases, 89.7±4.6 in type Ⅱ cases and 84.5±5.8 in type Ⅲ cases. There were no significant differences in Mayo scores between 3 types cases according to Kruskal-Wallis H test. Conclusion:Choosing the appropriate surgical approach and composite internal fixation according to the fracture types and shapes of low distal humerus fracture, anatomic reduction of the articular surface and early functional exercise are the keys to obtain ideal curative effect.

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作者: 樊健 [1] 季佳庆 [1] 张鑫 [1] 郭秀武 [1] 姚英 [1] 周家钤 [1] 李山珠 [1] 袁锋 [1] 俞光荣 [1] 程黎明 [1]
第一作者: 樊健
期刊: 《中华外科杂志》2020年58卷3期 213-219页 MEDLINEISTICPKUCSCD
栏目名称: 论著
DOI: 10.3760/cma.j.issn.0529-5815.2020.03.009
发布时间: 2021-09-26
基金项目:
上海市重中之重重点学科建设基金 Shanghai Key Clinical Discipline Program
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