成人中的肱骨远端骨折

Distal Humeral Fractures in Adults 成人中的肱骨远端骨折 Aaron Nauth, Michael D. McKee, Bill Ristevski, Jeremy Hall and Emil H. Schemitsch J Bone Joint Surg Am.2011;93:686-700. INCLUDEPICTURE "http://assets.dxycdn.com/third-party/ckeditor/plugins/smiley/images/qq/058.gif" Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases. Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90_ or 180_ to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus. Acute total elbow arthroplasty is the preferred treatment for elderly patients with a displaced, comminuted, intraarticular distal humeral fracture that is not amenable to stable internal fixation. Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach. 肱骨远端骨折在成人损伤中并不常见，大部分病例需要手术干预。 双钢板固定适用于所有肱骨远端涉及双柱的成人骨折，这一技术要求在每个柱上各置入一枚坚强的钢板，两枚钢板之间的方向为90度或180度。 在难复性移位粉碎的肱骨远端骨折中，内固定不能使骨折获得稳定时，对于老年患者可给予急症全肘关节置换治疗。 肱骨远端关节面的冠状面剪力移位骨折需要内固定手术治疗，多经外侧入路实施手术。 Distal humeral fractures in adults are complex and technically demanding injuries to manage. Operative intervention is indicated in most cases and is often complicated by difficult exposure, osteoporotic bone, and comminution in the metaphyseal and/or articular region. There is controversy regarding a number of issues pertaining to the management of distal humeral fractures, including the correct operative approach, fixation strategies, the role of total elbow arthroplasty, management of the ulnar nerve, and indications for prophylaxis against heterotopic ossification. This article provides an overview of these issues and others by reviewing the available evidence in the literature on distal humeral fractures and providing graded recommendations. 成人中的肱骨远端骨折的处理较为复杂，技术要求较高。大部分病例适于手术治疗，并发症的发生常由于手术暴露困难，骨质疏松以及干骺端或/和关节面粉碎等因素所致。肱骨远端骨折处理中的相关问题包括正确的选择手术入路，固定策略，全肘关节置换的意义，尺神经的处理以及实施异位骨化预防措施的指证等。本文通过回顾肱骨远端骨折的相关文献，对上述问题进行分析并提出分级治疗意见。 Epidemiology 流行病学 Distal humeral fractures have an estimated incidence in adults of 5.7 per 100,000 persons per year1. These injuries occur in a bimodal distribution, with an early peak in young males, twelve to nineteen years of age, as a result of high-energy trauma, and a second peak in elderly women, with osteoporotic bone, as a result of falls. In a recent study based on the Finnish National Health Registry, the authors reported a dramatic increase in the annual incidence of distal humeral fractures (from twelve per 100,000 to thirty-four per 100,000) in women sixty years of age or older during the period of 1970 to 19982. The actual number of lowenergy distal humeral fractures in this patient population increased even more dramatically, from forty-two fractures to 224 fractures, over the same time period. These dramatic increases were not sustained over the period from 1998 to 2007, during which the incidence and number of distal humeral fractures stabilized. These data indicate that, although fractures of the distal part of the humerus are rare in adults, there has been a substantial increase in their number and incidence. The dramatic increases reported in elderly women with potentially osteoporotic bone is of particular note, suggesting that fixation strategies for osteoporotic bone, possibly joint replacement techniques, as well as the management of osteoporosis itself will play important roles in the future management of these injuries. 肱骨远端骨折在成人中可估量的发病率为5.7/100,000/年【1】。这种损伤呈双峰分布，第一个高峰出现在12-19岁的青年男性患者中，为高能量损伤所致；第二个高峰存在骨质疏松的老年女性，多为跌落伤所致。 最近，在一项基于芬兰国民健康登记系统的研究中【2】，作者称1970年至1998年间60岁及其以上年龄的妇女其肱骨远端骨折的年发病率呈显著增加趋势（从12/100000增加到34/100000）。在这一病例人群中急性低能量性肱骨远端骨折的增加更为显著并超过同期水平，从42例增加到224例。这种显著增加趋势并不包括1998—2007年间的数据，在这一时期肱骨远端骨折的发病率及病人数量较为稳定。 这些数据结果明，尽管肱骨远端骨折在成人中较为少见，但其发病率及病人数量却不断增加，这在存在潜在骨质疏松的老年妇女人群中尤为突出，这表明，除了骨质疏松本身的处理，骨质疏松骨折的固定策略以及关节置换技术也在这类损伤未来的治疗中扮演重要角色。 Classification 骨折分类 Distal humeral fractures involve the supracondylar region of the humerus and/or the articular surface of the distal part of the humerus. They are most commonly classified according to the Orthopaedic Trauma Association/Arbeitsgemeinschaft f¨ur Osteosynthesefragen (OTA/AO) classification system (Fig. 1). In this classification system, ‘‘A’’ designates an extra-articular fracture, ‘‘B’’ designates a partial articular fracture, and ‘‘C’’ indicates an intra-articular fracture in which the articular surface is completely dissociated fromthe shaft of the humerus. These three types are subdivided with use of the numbers 1, 2, and 3 to indicate increasing degrees of comminution or to further define the location of the fracture. On the basis of epidemiological data from the United Kingdom, the distribution of these fractures has been reported to be 38.7% type A, 24.1% type B, and 37.2% type C1. 肱骨远端骨折包括肱骨髁上骨折和肱骨髁间骨折。应用最为普遍的分类方法为OTA/AO分类系统（图1）。在这一分类系统中，A型为关节外骨折，B型为关节内部分骨折，C型为关节内完全骨折，并伴有干骺端分离。这三种类型可进一步为三个亚型，分别以1、2、3表示骨折粉碎的程度，并可根据骨折的具体位置再做进一步细分。基于英国的流行病学调查数据，三种类型的分布情况为A型占38.7%，B型占24.1%，C型占37.2%。 Clinical Assessment and Radiography 临床及放射性评估 The clinical evaluation of a patient with a distal humeral fracture should include careful assessment of the ipsilateral shoulder and wrist, examination of the skin for open wounds, and a detailed neurovascular examination. A patient with an open distal humeral fracture most commonly has a posterior wound proximal to the elbow joint that was created by protrusion of the humeral shaft through the tricepsmuscle and posterior skin3.Neurological assessment should include examination of the median, radial, and ulnar nerves. The prevalence of preoperative ulnar nerve symptoms in patients with a type-C fracture of the distal part of the humerus has been reported to be 24.8%4. 肱骨远端骨折患者的临床评估应包括同侧肩、腕关节的细致查体，开放伤口皮肤的检查以及具体的神经血管检查。开放性肱骨远端骨折患者由于肱骨干骨折端经肱三头肌及后侧皮肤穿出，因此伤口多出现在背侧近肘关节处【3】。据报道【4】，在肱骨远端C型骨折患者中其手术前尺神经症状的发生率达24.8%。 Following clinical assessment, anteroposterior and lateral radiographs of the distal part of the humerus should be obtained (Fig. 2). In the setting of articular comminution, the use of computed tomography (CT) scanning with three-dimensional reconstructions can be helpful for classification and preoperative planning. Doornberg et al. compared the use of three dimensional CT reconstructions with the use of two-dimensional CT and radiographs for the classification of distal humeral fractures and treatment decision-making (Level-III evidence)5. The authors reported increased interobserver and intraobserver reliability for fracture classification as well as increased intraobserver reliability for treatment decisions with the use of three-dimensional CT. There have been several reports of Level-IV case series in which CT was used, primarily for the evaluation of coronal shear-type fractures of the distal part of the humerus (type B3)6-9 在进行临床评估之后，应进行肱骨远端正侧位X线片检查（图2）。对于关节内粉碎骨折，CT三维重建有助于骨折的分型和制定术前。Doornberg等【5】比较了三维CT重建与二维CT加X线片在肱骨远端骨折分型和制定治疗测量的作用（循证医学级别，III级）。作者报道称，应用CT三维重建技术在骨折分型中可增加观察者间和观察者内部的可靠性，并可在治疗决策上增加观察者内部的可靠性。另外，还有多项研究报道了肱骨远端冠状面剪力骨折（B3型）的原始评估中CT应用的意义，其研究的循证医学级别为IV级病例系列水平【6-9】。 4票票数 妙手书生！ ------Welcome to Visit DXY-Orthopeadics!zhanghaisen edited on 2011-06-03 23:41 举报 丁香猎头招聘大学附属医院 骨科学科带头人 【专题讲座】肱骨远端冠状面剪切骨折（另附经典讨论帖回顾）【0527】 【专题讲座】肱骨远端骨折 zhanghaisen 丁香园版主 医师认证骨科 735 积分 1028 得票 591 粉丝 加关注 2011-04-18 11:21消息 HYPERLINK "http://guke.dxy.cn/bbs/post/reply?bid=50&parent=19908023&done=/bbs/thread/19908013?keywords=Distal?humeral?fractures?in?adults"e=1"引用 HYPERLINK "javascript:void(0)"收藏分享分享到哪里？ 复制网址 新浪微博 豆瓣社区 腾讯微博 开心网 人人网 Nonoperative Treatment 非手术治疗 The outcomes of modern operative fixation of distal humeral fractures are such that operative intervention is indicated in most cases. Nonoperative management is reserved for completely undisplaced fractures, patients who are unable to tolerate anesthesia, and those with advanced dementia. This widely held view is supported by the available evidence, which suggests that operative management of distal humeral fractures is favored over nonoperative management with regard to several outcomes. Two Level-III studies, including one that was based exclusively on patients aged seventy-five years or older, compared functional outcomes between operatively and nonoperatively treated patients (n = 70)10,11. We performed a pooled analysis of those two studies, which demonstrated that patients treated nonoperatively are almost three times more likely to have an unacceptable result (RR [relative risk] = 2.8, 95% CI [confidence interval] = 1.78 to 4.4). Another retrospective study, by Robinson et al., compared the results in 273 operatively treated patients with those in forty-seven nonoperatively treated patients (Level-III evidence)1. The authors reported that nonoperatively treated patients were almost six times more likely to have a nonunion (RR = 5.8, 95% CI = 2.3 to 14.7) and four times more likely to have delayed union (RR = 4.4, 95% CI = 1.6 to 12.0). Numerous, recent Level-IV studies on modern techniques of fixation for distal humeral fractures have demonstrated high rates of satisfactory outcomes (47% to 93%), with acceptable rates of complications (19% to 53%)12-24. Overall, a Grade-B recommendation can be made for the operative management of all displaced fractures of the distal part of the humerus in patients able to tolerate anesthesia. In patients for whom anesthesia is deemed to pose too high a risk, conservative treatment with ‘‘early mobilization’’ is appropriate25. This typically involves immobilization of the elbow in 60_ of flexion for two to three weeks, followed by gentle range-of-motion exercises. 目前的肱骨远端骨折手术固定效果表明大部分病例适于手术干预。非手术保守治疗只适用于完全无移位骨折，不能耐受麻醉以及进展性老年痴呆症的患者。询证医学结果表明，目前普通接受的观点是肱骨远端骨折的手术治疗在多项临床效果方面均优于非手术治疗。两项基于75岁及其以上年龄组循证医学级III级的研究对手术与非手术治疗的功能效果进行了比较(n = 70)【10,11】。我们对这两项研究进行了会聚分析，结果表明非手术治疗的患者不满意率(RR [相关风险] = 2.8, 95% CI [可信区间] = 1.78 -4.4)较手术治疗组至少高出3倍。在另一项回顾研究中，Robinson等【1】将273例手术患者与47例非手术治疗患者进行了临床效果的比较（循证医学级别，III级）。其研究结果表明，在不愈合率方面，非手术治疗患者为手术治疗患者的大约6倍(RR = 5.8, 95% CI = 2.3 -14.7)，延迟愈合方面也达大约4倍(RR = 4.4, 95% CI = 1.6 - 12.0)。最近多项询证医学IV级的研究表明，肱骨骨折的现代固定技术满意率高(47%- 93%)，并发症的发生率(19%- 53%)也是可以接受地【12-24】。 总体来讲，对于能够耐受麻醉的肱骨远端移位骨折患者手术治疗制定的推荐意见为B级。存在麻醉高风险的患者适于可早期活动的保守治疗【25】。其一般措施包括屈肘制动60度3周，随后逐步增加活动训练的范围。 Operative Approach 手术治疗 Numerous operative approaches for the management of distal humeral fractures have been described. With the exception of approaches described for the fixation of coronal shear fractures (discussed later in this text), these all employ a posterior skin incision with various strategies of working through or around the triceps muscle. Described approaches include the paratricipital (Alonso-Llames)26,27, triceps-reflecting (Bryan-Morrey)28, triceps reflecting anconeus pedicle (TRAP)29, triceps-splitting30,31, and olecranon osteotomy techniques32,33 (Fig. 3). There is controversy regarding the optimal approach for the fixation of distal humeral fractures. Irrespective of the approach used, the ulnar nerve must always be isolated, mobilized, and protected throughout the procedure. The nerve is identified proximal to the elbow in the medial intermuscular septum and can be secured with a Penrose drain. The cubital tunnel, proximal fascia of the flexor carpi ulnaris, and articular branch of the ulnar nerve are released, thereby mobilizing the nerve to the level of the first motor branch to the flexor carpi ulnaris (Fig. 4).While there is general agreement about isolation and mobilization of the ulnar nerve, what to do with the nerve at the conclusion of the procedure is a subject of some debate and will be discussed later. 肱骨远端骨折可通过多种方式实施手术治疗。除了冠状面剪力骨折的手术固定方式有所不同外（将在本文的后半部分讨论），其他所有手术方式均后侧做皮肤切口，围绕肱三头肌实施不同的手术策略。具体手术入路（图3）包括肱三头肌两侧入路（Alonso-Llames入路），肱三头肌翻转入路（Bryan-Morrey入路）【28】，肱三头肌翻转-肘肌瓣入路(TRAP入路)【29】，肱三头肌劈开入路【30,31】以及尺骨鹰嘴截骨入路【32,33】。对于肱骨远端骨折的最佳入路选择目前尚有争议。 无论何种手术方式，手术操作中均应游离、移动及保护尺神经。于肘关节近侧内侧肌间隔找到尺神经，可应用一Penrose引流管对其进行牵开保护。对肘管、尺侧腕屈肌近侧筋膜以及 尺神经关节支进行松解，应将尺神经游离至尺侧腕屈肌的第一运动支水平（图4）。在尺神经的游离移动这一点上，各方的观点趋于一致，主要争论的焦点是尺神经的最后处理问题，这将稍后做进一步讨论。 The paratricipital approach avoids violation of the extensor mechanism of the elbow by utilizing medial and lateral windows on either side of the triceps, making it the favored approach for extra-articular fractures (Fig. 5). The major disadvantage of this approach is limited visualization of the articular surface, although visualization is generally adequate for extra-articular fractures and type-C1 and C2 intra-articular fractures26,27. In addition, this approach can be converted to an olecranon osteotomy approach for increased articular exposure and facilitates conversion to a total elbow arthroplasty. Satisfactory functional outcomes have been reported with the use of this approach for type-A and type-C1 and C2 fractures (Level-IV evidence)26,27, although we are not aware of any studies comparing this approach with others for distal humeral fractures. Similarly, case series of the triceps-reflecting28 and TRAP29 approaches have been reported (Level-IV evidence), but there is no comparative evidence in the literature on distal humeral fractures. 肱三头肌两侧入路通过在在肱三头肌的两侧开窗可避免肘关节伸肌装置的损害，这有更有利于关节外骨折的显露（图5）。尽管这一入路一般情况下能足够的显露关节外骨折及C1，C2型关节内骨折，但对关节面的显露比较局限，这是它的主要缺陷【26,27】。另外，为了实现关节更好的显露，这一入路可中转为鹰嘴截骨入路，也可方便的中转为全肘关节置换术。对于A型，C1，C2型骨折其应用的功能效果满意【26,27】（询证医学级别，IV级）。尽管笔者未见这一入路与其他入路用于肱骨远端骨折的比较研究。与之相类似，一些病例研究对肱三头肌翻转入路【28】及TRAP入路【29】进行报道（询证医学级别，IV级），但对于肱骨远端的入路选择，文献中无对照研究的证据。 The triceps-splitting approach involves a midline incision in the triceps fascia with sharp reflection of the triceps insertion off the olecranon, leaving the triceps tendon in continuity with the extensor/flexor fascia (Fig. 6)30. The proximal 1 cm of the olecranon tip is resected to improve visualization of the articular surface. At the conclusion of the procedure, the triceps tendon is repaired to the olecranon with use of transosseous, nonresorbable sutures. The olecranon osteotomy approach uses an apex distal, chevron-type osteotomy of the olecranon located 2.5 to 3 cm from the tip of the olecranon, oriented to exit in the so-called bare area of the trochlear groove (Fig. 7). The osteotomy is begun with an oscillating saw and completed with an osteotome. At the conclusion of the procedure, the osteotomy site is fixed with a tension band construct, an intramedullary screw, or a plate. 肱三头肌劈开入路通过在肱三头肌筋膜中间切开并将肱三头肌的尺骨鹰嘴附着点翻转，这可保留肱三头肌腱屈/伸筋膜的连续性(图6)【30】。近尺骨鹰嘴1cm处理切断肱三头肌肌腱以实现关节面的更好显露。手术最后经骨应用非可吸收缝线重新将肱三头肌腱固定与尺骨鹰嘴。 尺骨鹰嘴截骨入路是从鹰嘴尖端到顶点远端2.5 - 3 cm做鹰嘴的V字形截骨，从滑车沟的裸区穿出（图7）。开始时应用摆锯，之后应用骨凿完成截骨。最后，截骨部位通过张力带装置，髓内螺钉或钢板进行固定。 Anatomic studies have demonstrated that the olecranon osteotomy provides superior visualization of the articular surface34. However, retrospective studies comparing the triceps-splitting and olecranon osteotomy approaches have not shown any significant differences in terms of functional outcomes (Level- III evidence)31,35,36. A retrospective comparison of the two approaches, by McKee et al., showed equivalent outcomes with regard to the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores as well as objective muscle strength testing (n = 25 patients)31. However, the authors reported that three of eleven patients had a reoperation for removal of the olecranon implant in the osteotomy group (Level-III evidence). Other, Level-IV series of patients treated with olecranon osteotomy have had rates of implant removal ranging from 6% to 30% and rates of nonunion of the olecranon osteotomy site of 0% to 9%32,33,37,38. The triceps-splitting and olecranon osteotomy approaches for the treatment of open distal humeral fractures have also been compared retrospectively 3. In that study, of twenty-six patients, the triceps-splitting group had significantly better functional outcomes on the basis of the DASH (p = 0.05) and Mayo Elbow Performance Scores (MEPS) (p = 0.05) as well as a trend toward an improved range of motion (Level-III evidence). The authors hypothesized that this effect was due to the fact that open fractures typically were associated with a large tear in the triceps muscle and this tear was easily incorporated into the triceps-splitting approach. This seemed to offer an advantage over sectioning of the extensor mechanism at an adjacent site with an olecranon osteotomy. This study also provided Level-IV evidence that acute plate fixation of open distal humeral fractures was safe and reliable after adequate irrigation and debridement, with only one deep infection developing in the series. 解剖学研究表明，鹰嘴截骨入路对关节面的显露视野更佳【34】。然而，多项回顾性对照研究显示肱三头肌劈开入路与鹰嘴截骨入路在功能效果方面无显著差异（循证医学级别，III级）【31,35,36】。在一项对两种入路的回顾性对照研究中，McKee等指出无论是主观肌肉力量测试还是在臂-肩-手残障功能评分(DASH)，SF-36评分等方面，二者得出的结果相同(n = 25例)【31】。但作者同时指出，鹰嘴截骨入路组的11例患者中有3例实施了鹰嘴部内固定物的取出手术（循证医学级别，III级）。其它一些循证医学级别IV级的病例研究显示，鹰嘴截骨入路手术的内固定取出率为6% - 30%，鹰嘴截骨处的不愈合率为0%- 9%【32,33,37,38】。一项回顾性研究还比较了肱三头肌劈开入路与鹰嘴截骨入路用于开放性肱骨远端骨折的治疗情况【3】。该研究显示在DASH (p = 0.05)，Mayo肘关节功能评分(MEPS) (p = 0.05)以及关节活动度改善情况等方面，肱三头肌劈开入路组（26例患者）的功能效果更佳（循证医学级别，III级）。作者推测出现这一结果的原因是由于开放骨折往往存在肱三头肌的广泛撕裂，肌肉的撕裂对于实施肱三头肌劈裂入路更为有利，这似乎较鹰嘴截骨临近部位的伸肌装置切开更具优势。该研究中只有1例患者出现深部感染，这表明在经过充分的清创、冲洗之后，开放性肱骨远端骨折的急症钢板固定是安全可靠地，其循证医学级别为IV级水平。 On the basis of the available evidence, a Grade-C recommendation can be made for the use of the paratricipital approach for extra-articular or simple intra-articular fractures. There is fair evidence to suggest that the use of a tricepssplitting approach leads to functional outcomes equivalent to those provided by an olecranon osteotomy while potentially avoiding the complications associated with the olecranon osteotomy, rendering this a Grade-B recommendation. In addition, there is fair evidence to suggest that the use of a tricepssplitting approach leads to improved functional outcomes compared with those following the use of an olecranon osteotomy for the treatment of open distal humeral fractures, rendering this a Grade-B recommendation in that setting. 基于询证医学证据，对于关节外骨折或简单的关节内骨折推荐应用肱三头肌双侧入路治疗，其推荐意见等级为C级。应用肱三头肌劈开入路获得的功能效果与鹰嘴截骨入路相同，但却可能避免出现鹰嘴截骨入路相关并发症，这些观点均有充分的证据支持。另外，也有充分的证据表明，对于肱骨远端的开放性骨折，肱三头肌劈开入路在功能效果的改善方面较之鹰嘴截骨入路更佳，其推荐意见级别为B级。 Plate Fixation 钢板固定 Since the introduction of AO techniques involving dual column plates for the fixation of distal humeral fractures in the 1970s, substantial improvements in surgical outcomes have been observed. The principles of treatment include anatomic articular reduction and rigid fixation with two strong plates. Strong plates generally refers to those that are highly rigid and 3.5 mm at a minimum, with the use of one-third tubular plates not recommended. The sequence of fracture reduction typically involves anatomic reduction and fixation of the articular surface followed by rigid plate fixation of the articular surface to the diaphysis39. In cases of severe comminution of the metaphysis or substantial bone loss in that region, some shortening at the fracture site with maintenance of appropriate alignment of the articular surface is acceptable and can substantially enhance the stability of the fracture, particularly in the setting of osteoporotic bone40. Care must be taken to adequately recreate the olecranon fossa or resect a portion of the olecranon tip in order to allow full extension when shortening is carried out. Bone-grafting of the articular surface may be necessary to restore the geometry of a severely comminuted articular surface and usually involves grafting of the trochlea to restore trochlear width when bone loss is present. Otherwise, bone loss is generally associated with open fractures, and bone-grafting is best performed on a delayed basis. 自从20世纪80年代AO双钢板技术引入肱骨远端骨折端固定手术中，手术治疗的效果得以明显改善。其治疗原则包括解剖复位及双钢板坚强固定。用于手术的钢板一般为至少3.5mm的高刚度钢板，不建议应三分之一管型钢板。骨折的手术顺序一般为解剖复位骨折，关节面及骨干的钢板坚强固定【39】。对于干骺端严重粉碎或骨折部位存在大块骨缺损的病例，在维持关节面对线的情况下对骨折处实施适当的短缩是可以接受地，且可增加骨折固定的稳定性，特别是存在骨质疏松的情况下【40】。在实施短缩手术时，应对鹰嘴窝进行适当重建或切除部分鹰嘴尖一般实现完全伸直功能。在关节面严重粉碎的情况下，需要通过植骨以重建关节面的几何学，通常需对滑车的骨缺损部位进行植骨以重建其宽度。