解剖锁定接骨板治疗C型肱骨远端骨折的疗效分析

朱前拯 段亚景 杨雨润 杨欢 陈星佐 王立强陈瀛 杨连发 林朋 刘成刚



·论著·

解剖锁定接骨板治疗C型肱骨远端骨折的疗效分析

朱前拯1段亚景2杨雨润1杨欢1陈星佐1王立强1陈瀛1杨连发1林朋1刘成刚1

目的 观察解剖锁定接骨板治疗C型肱骨远端骨折以及术后规范化康复的疗效。方法 2009年12月至2013年6月使用解剖锁定接骨板治疗17例C型肱骨远端骨折患者，其中男性6例，女性11例；年龄24～84岁，平均51.2岁。损伤原因：低能量损伤9例(低能量组)；高能量损伤8例(高能量组)。受伤至手术时间为1～30 d，平均8.4 d。术后患者开始规范化肘关节功能康复治疗。末次随访时记录患侧肘关节活动范围并采用Mayo肘关节功能评分。结果 所有患者术后获9～48个月(平均18.59个月)随访，所有骨折均愈合，1例合并尺骨鹰嘴截骨处延迟愈合。末次随访时，肘关节伸直15.0°±10.2°，屈曲103.2°±16.3°，活动范围88.2°±22.8°。MEPS评分(83.9±19.2)分，优良率76.5%(13/17)。高能量组与低能量组MEPS评分分别为(71.9±22.5)分和(94.6±4.9)分，差异有统计学意义(P=0.025)。结论 AO解剖锁定接骨板治疗C型肱骨远端骨折的疗效肯定，高能量损伤患者的预后较差，初始损伤因素影响患者肘关节功能恢复，规范化的康复治疗有助于肘关节功能恢复。

肱骨骨折，远端；锁定接骨板；治疗

AO分型中C型肱骨远端骨折是一类非常复杂的关节内骨折，其肱骨远端干骺端及关节面常粉碎严重，治疗难度大，易合并骨缺损、软组织损伤、神经损伤及骨质疏松等，难以获得稳定固定，对预后产生不利影响[1-2]。AO肱骨远端锁定接骨板，使用双钢板垂直内固定，在设计上解剖预塑型，远端使用2.7 mm锁定螺钉，手术中使用时更为灵活、方便，可有效预防复位丢失，尤其适合于复杂类型骨折及骨质疏松的患者。通过对我院2009年12月至2013年6月使用AO肱骨远端解剖锁定接骨板治疗的17例C型肱骨远端骨折患者资料进行回顾性研究，旨在对肘关节功能及术后康复训练的疗效进行观察和分析。

资 料 与 方 法

一、一般资料

本组17例，其中男性6例，女性11例；年龄24～84岁，平均51.2岁；左侧8例，右侧9例；闭合性骨折16例，开放性骨折1例。损伤原因：低能量损伤(摔倒)9例(低能量组)；高能量损伤8例(高能量组)，包括交通伤3例，高处坠落伤4例，皮带绞伤1例。骨折AO分型：C1型2例，C2型5例，C3型10例。合并损伤：尺神经断裂1例，同侧尺骨鹰嘴骨折1例，同侧肱三头肌断裂1例，同侧肱骨近端骨折1例，颅脑损伤蛛网膜下腔出血1例，同时合并骨盆骨折、髋臼骨折、股骨颈骨折、疟疾1例。受伤至手术时间为1～30 d，平均8.4 d，其中7 d内手术11例，7～14 d手术3例，>14 d手术3例，最长者因合并疟疾延迟手术治疗时间。高能量组与低能量组患者在年龄、性别、伤侧、受伤至手术时间、屈肘角度、伸肘角度、活动范围方面差异均无统计学意义(P>0.05，表1)，具有可比性。

二、手术及康复方法

术前30 min预防应用抗生素，采用全身麻醉，患者侧卧位，患肢上气囊止血带，取肘后正中切口，显露并保护尺神经，经尺骨鹰嘴截骨入路，显露肱骨远端及关节面[3]。在截骨时需要注意在尺骨鹰嘴关节面的“裸区”内截骨，大约在尺骨鹰嘴尖下方约2 cm处。术中可以首先显露鹰嘴内、外侧面，选择鹰嘴滑车的中点处的“裸区”进行截骨，截骨时首先用薄锯片截断背侧皮质骨直到软骨下骨，最后的关节面用薄骨刀截断。肱骨远端骨折的固定原则是首先恢复关节面的平整，可用1.0 mm克氏针经关节软骨下方穿入临时或永久固定[4]，复位肱骨远端内、外侧柱，使用克氏针及复位钳临时固定。使用AO肱骨内、外侧解剖锁定接骨板(辛迪斯强生，美国)固定，桡侧板放置于外侧柱的桡背侧，尺侧板与内侧柱的内侧骨嵴贴附。所有患者均行尺神经前置术，对合并尺神经断裂患者予手术缝合，需要注意尺神经不能与内固定金属接触。在关闭伤口前充分屈、伸肘关节，观察是否存在尺神经卡压的情况并及时纠正。

表1 高能量组与低能量组患者术前一般资料和末次随访时MEPS评分的比较

注：MEPS为Mayo肘关节功能评分

术毕放置引流管，术后24 h拔除引流管，并指导患者肘关节功能锻炼，每天进行肘关节屈伸活动，以主动活动为主。患者口服吲哚美辛至术后6周。患者采用经尺骨纵轴垂直平面截骨5例，尖端在远端的"V"形截骨12例。截骨固定方法：克氏针张力带固定4例，张力带钢板固定2例，钢缆捆绑系统固定11例。

术后开始规范化肘关节康复程序：患者术后根据具体骨折固定稳定程度及软组织损伤情况决定是否使用石膏或者支具外固定保护，保护时间为1～3周。对于损伤较轻，骨折固定坚强的患者，术后次日开始主动功能锻炼。康复内容包括:(1)肘关节主动屈伸运动。(2)肩关节主动活动，要求患者伤后进行肩关节主动上举、外展、外旋及内旋活动。(3)手的功能锻炼，包括握拳、分指、并指、拇指及各指的对指运动。(4)前臂的旋转运动，要求进行旋后及旋前运动。(5)以上运动每天3次，每次10～15次。根据肘关节肿胀情况逐渐增加次数，若肘关节疼痛及肿胀加重。减少训练次数及时间。术后6周根据X线片复查骨折愈合情况逐渐开始肘关节力量训练。(6)物理治疗：患者进行上肢主动训练前对治疗部位进行热敷5～10 min，训练后进行冷敷5～10 min。若患者存在明显肿胀，进行该部位磁疗，20 min，每天一次。

三、功能评价

末次随访时记录患侧肘关节活动范围并采用Mayo肘关节功能(mayo elbow performance score，MEPS)评分从疼痛、活动度、稳定性及生活能力4个方面进行功能评价，满分为100分：90～100分为优，75～89分为良，60～74分为可，<60分为差。

四、统计学处理

采用SPSS 16.0统计学软件，高能量损伤与低能量损伤两组患者的年龄、受伤至手术间隔、伸肘角度、屈肘角度、活动范围及MEPS评分采用独立样本t检验，两组间性别及伤侧对比采用Fisher检验。P<0.05为差异有统计学意义。

结 果

所有患者术后获9～48个月(平均18.59个月)随访，所有骨折均愈合，无内固定失效表现。末次随访患侧时，肘关节伸直15.0°±10.2°，屈曲103.2°±16.3°，活动范围88.2°±22.8°；MEPS评分(83.9±19.2)分；优11例，良2例，可2例，差2例，优良率76.5%；高能量损伤组与低能量损伤组MEPS评分分别为(71.9±22.5)分和(94.6±4.9)分，差异有统计学意义(P=0.025，表1)，典型病例见图1。术后并发症包括：尺骨鹰嘴截骨延迟愈合1例、尺神经麻痹2例，均得以自主康复。

讨 论

肱骨远端骨折大约占成人骨折的7%，占肘关节骨折的30%。除了合并严重骨质疏松、不能耐受手术、合并肢体神经功能障碍、软组织缺损或感染的患者，切开复位坚强内固定是肱骨远端骨折的首选治疗方式[2]。

C型肱骨远端骨折类型复杂，骨折粉碎程度严重，需要仔细的术前计划了解骨折类型，以制定完善的手术方案[5]。我们建议术前行牵引位的肘关节正、侧位X线检查，可以更清晰地观察骨折情况。随着CT应用的日趋广泛，如具备条件也可以行CT三维重建。术中要首先搞清楚各个骨折块间的位置关系，特别是较小的骨折块，在克氏针固定时尽量一次成功，避免重复操作。

图1 女性患者，47岁，术前左侧肘关节正、侧位X线片示肱骨远端骨折骨折(AO分型为C2型)(A,B);术后即刻肘关节正、侧位X线片(C,D)，术后1年肘关节正、侧位X线片示肱骨远端及尺骨鹰嘴截骨均愈合(E,F)，术后1年伸肘、屈肘功能相(G，H)，MEPS评分95分

影响肱骨远端骨折预后的因素有很多，包括创伤的严重程度、创伤至手术的间隔时间、合并损伤、骨质量、关节面重建的程度、手术技术、使用的内固定物、固定的稳定性、制动时间、感染和患者的合作程度等[6]。本研究结果显示高能量组与低能量组在术后功能MEPS评分上的差异有统计学意义(P=0.025)，分析原因如下：首先，本组高能量损伤患者多合并其他部位损伤，如臂丛神经损伤、颅脑损伤蛛网膜下腔出血、骨盆骨折、髋臼骨折、右侧股骨颈骨折；其次，高能量损伤组的患者受伤至手术的时间间隔较长，虽然差异无统计学意义，但间隔时间超过1周的患者以高能量损伤为主；另外，高能量损伤患者的局部软组织损伤较重，部分合并有开放性骨折，影响肘关节功能康复；本研究中高能量损伤的患者，术后进行短期石膏外固定保护，开始功能锻炼的时间较晚，对晚期屈伸肘产生了影响。

术后肘关节规范化康复训练是影响关节功能的重要因素之一[7]，通过临床实践总结以下几点：(1)尽可能早期进行肘关节活动，需要结合骨折及手术固定情况，对于C3型骨折病例，术后早期可以辅助石膏固定，但时间不能超过3周。(2)以肘关节的屈伸功能恢复为优先，屈肘功能对患者日常生活动作影响较大，而伸肘滞缺主要影响美观、提物的力量和穿衣等功能，相对而言，屈肘更为重要。(3)主动训练为主，避免暴力牵拉损伤肌肉及软组织，过度力量的被动活动往往造成肌肉的拉伤、增加软组织水肿，力量较大的被动活动容易促进异位骨化的形成，造成僵硬。主动活动时的肌肉收缩，产生泵性作用，利于体液的回流，可以避免肿胀。(4)活动的次数和强度根据骨折稳定性和愈合情况逐渐增加。(5)重视物理治疗在肘关节康复中的作用，包括冷疗和磁疗，通过冷疗可以减轻肘关节训练后渗出，减轻肿胀。磁疗可以促进肢体血液循环，改善血管通透性，从而减轻肿胀。

本组患者有1例采用垂直尺骨长轴的横行截骨，术后出现截骨面分离，截骨处延迟愈合。在此之后手术改进为“V”字形截骨，尖端指向远端[8]，使用钢缆捆绑系统[9]或张力带钢板固定，均未出现截骨面分离移位的情况。文献[10-11]报道常规行尺神经前置会引起神经损伤，本组患者术中均显露尺神经，术中尺神经走形位置被内固定物占据，均行尺神经前置术，有2例患者术后出现尺神经麻痹，末次随访时神经麻痹恢复。

本组患者均采用双钢板垂直固定法[12]，目前对于双钢板放置在90°还是180°位置仍存在争议[13]，平行钢板技术是借助建筑学“拱门”原理来重建肱骨远端解剖结构，通过钢板螺钉与骨质的整体咬合来维持稳定性[14-15]。AO肱骨远端解剖锁定接骨板在垂直方向固定，其设计不仅具有锁定功能，并且远端螺钉更小(2.7 mm)，应对骨质疏松及关节面粉碎的骨折更为方便。

C型肱骨远端骨折是一类复杂的肘关节骨折，我们经过随访发现，使用AO解剖锁定接骨板治疗C型肱骨远端骨折的疗效肯定，高能量损伤患者的预后较差，初始损伤因素影响患者肘关节功能恢复，规范化的肘关节康复训练有利于关节功能的恢复。本研究的不足在于入组的病例较少，随访时间较短，今后需继续观察，为临床工作提供更有效的研究证据。

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(本文编辑：李静)

朱前拯，段亚景，杨雨润，等.解剖锁定接骨板治疗C型肱骨远端骨折的疗效分析[J/CD].中华肩肘外科电子杂志,2015,3(2):89-94.

Analysis of the Outcomes of Anatomical Lock Plate for C Type Distal Humerus Fracture

ZhuQianzheng，DuanYajing，YangYurun，YangHuan，ChenXingzuo，WangLiqiang，ChenYing，YangLianfa，LinPeng，LiuChenggang.

1DepartmentofTraumaandOrthopedics,2DepartmentofRehabilitationMedicine,China-JapanFriendshipHospital,Beijing100029,China

LiuChenggang，Email：zqzpku@sina.com

Background Among AO types, C type distal humerus fracture is a very complicated intra-articular fracture. The distal humerus metaphysis and the articular surface are easy to get severe smash, which add more difficulties to the treatment. C type distal humerus fracture is complicated with bone defects, soft tissue injury, nerve injury, osteoporosis and other symptoms, which add to the unsteady fixation and can lead to adverse impacts to prognosis. AO distal humerus lock plates are paralleled plates that vertically fix the internal fracture. It designs to be anatomical plastotype and the distal point is fixed with the 2.7mm screws. It is more flexible and convenient to use in the operation, and can effectively prevent the restoration from loosing. It′s especially suitable for those patients with complicated fractures and osteoporosis. Through a retrospective study on the 17 cases of C type distal humerus fracture treated by AO distal humerus lock plate in our hospital from December 2009 to June 2013, we observed and analyzed the curative effects on the elbow joints functions and the prognosis rehabilitation training.Methods General data: 17 patients, 6 males and 11 females aging from 24-84 years old with the average age 51.2 years old were selected to be the study subjects. 8 of them injured the left side and 9 of them injured the right side. 16 cases were closed fracture and 1 case was open fracture. Injury reasons: 9 cases were due to low energy injury (low energy group) who fell over, and 8 cases were due to high energy injury (high energy group) including 3 cases of traffic accident injuries, 4 cases of high falling accident injuries and 1 case of belts wrapping injuries. AO types of the fracture: 2 cases were of C1 type, 5 cases were of C2 type, 10 cases were of C3 type. Complicated injuries: 1 case had ulnar nerve rupture, 1 case had ipsilateral olecranal fracture, 1 case had ipsilateral triceps brachii rupture, 1 case had ipsilateral proximal humerus fracture, 1 case had craniocerebral injury subarachnoid hemorrhage, 1 case had complications of perlvic fracture, acetabular fracture, femoral neck fracture and malaria. The injury time was 1-30 days before the operation time, with an average time of 8.4 days. There were 11 cases with operation done within 7 days, 3 cases with operation done from the 7th to the 14th day, 3 cases with operation done after the 14th day. The operation time of the patient who was complicated with malaria was delayed.Operation time and the rehabilitation methods: 30 minutes before the operation, the patients were given antibiotics as prophylaxis. The patients had general anesthesia and lay down in lateral position. The fracture limb was wrapped with pneumatic tourniquet and the incision was from the postmiddle side of the elbow. The ulnar nerve was revealed and protected, and the operation was started from the olecroanon resected surface, the distal humerus and the joint surface were revealed. The operators should be cautious of the osteotomy inside the olecroanon joint surface apterium, and the osteotomy location was 2cm below the olecroanon point. In the operation, firstly both the inner side and lateral side of olecranon should be exposed and then performed osteotomy to the midpoint apterium between elecranon and trochlear. When performing the osteotomy, the operators firstly used the thin saw blade to cut off from the dorsal cortical bone to the subchondral bone, and then cut off the final joint surface by osteotome. The principles of fixing the distal humerus fracture were firstly recovering the evenness of the joint surface, and then using 10mm kirschner pins temporally or permanently to fix beneath the articular cartilage. the distal humerus inner side and lateral side column were restored, and then they were temporally fixed with kirschner pins. The fixation couldbe achieved by using the AO humerus inner side and lateral side anatomical lock plates. The radial side plate was placed to the radial dorsal side of lateral column, the ulnar plate was placed next to the inner side of bone crest. Anterior transposition of ulnar nerve was performed in all patients, and those patients who were complicated with ulnar nerve rapture were given suture. It should be noted that the ulnar nerve should be out of touch of the internal fixation metals. Before closing the wound, the patients should stretch their elbow joints and observed whether they ulnar nerve entrapment so as to rectify in time. Drainage tubes were placed after operation, and the drainage tubes should be taken away 24 hours after operation. Meanwhile, the patients should be guided to have elbow joint functional exercise, and keep doing the elbow joint flexion and extension movements, mainly active movements. The patients should take indometacin from the beginning of operation to 6 weeks after the operation. Among all the study subjects, 5 cases adopted the tran-ulnar osteotomy vertically, 12 cases adopted osteotomy from the V-shape distal point. Osteotomy fixation methods: 4 cases fixed with kirschner tension bands, 2 cases fixed with tension bands with plated, 11 cases fixed with wirerope bounding system. The normalized elbow rehabilitation process began after the operation: the patients will decide whether to use gypsum or external fixation for protection depending on their fracture fixation stability condition and the soft tissue injury conditions. And the protection period was 1-3 weeks. For those patients who had mild injury and strong fixation, they could start the active movements the next day after operation. The rehabilitation contents included:(1) elbow joint active flexion and extension movements.(2) shoulder joint active movements which include active lifting, outstretch, edxtorsion and internal rotation.(3) the hands functional exercise including clenching fists, separating fingers, closing fingers, fingers movements.(4) Rotation movement of the forearms. Rear rotation and forward rotation were requested.(5) the above-mentioned movements should be done for 3 times per day, and 10-15 rounds each time. When the swelling condition of the elbow joints was improved, the times of movements could be added accordingly. But if the joint pain and the swelling became more severe, the times and the time of movements should be reduced. 6 weeks after operation, the patients should start the joint strength training gradually when the fracture union condition indicated in the X-ray film became better. 6) Physiotherapy: the patients should have hot compress on the fraction for 5-10 minutes before doing the upper limb active movements training, and then cold compress on the same part for 5-10 minutes after training. If the fracture of the patient were swollen, this part should be performed magnet therapy for 20 minutes each day.Functional evaluation: At the last follow-up visit, the visitors recorded the lateral elbow joint movement ranges and adopted the Mayo elbow joint functions evaluation systems, namely, mayo elbow performance score and MEPS. The functions were evaluated from 4 aspects: the pain degree, movements degree, stability and living ability. The full scores are 100 points: 90-100 points is excellent, 75-89 points is good, 60-74 is ok, less than 60 points is poor.Statistical treatment: SPSS 16.0 statistical software was utilized. The ages of high energy injury and low energy injury, the period from being injured and performed operation, the elbow stretch angles, the elbow bending angles, the movement range and the MEPS evaluation were all adopted independent-samples t test. TFisher test was adopted for the genders of both groups and the injury inner side and lateral side comparison. AndP<0.05 is set as t statistically significance.Results All patients were followed up for 9-48 months and the average was 18.59 months. All the fractures became union and no failure of internal fixation was found. In the last follow-up visit, the results were: the elbow joints extension 15.0°±10.2°, flexion 103.2°±16.3°, movement range 88.2°±22.8°, MEPS evaluation (83.9±19.2) points. 11 cases were excellent, 2 cases were good, 2 cases were ok, and 2 cases were poor, the excellent and good rate was 76.5%. The MEPS evaluation of high energy injury was (71.9±22.5) points and the low energy injury was (94.6±4.9) points, the differences had statistically significance (P=0.025).The prognosis complications include: 1 case had delayed union in olecroanon osteotomy, 2 cases had ulnar nerve paralysis, but all of them were recovered in the end.Conclusion The curative effects of C type distal humerus fracture treated with AO anatomical lock plate deserves to be approved. The prognosis of high energy injury patients is poor. The initial injury factors can affect the patients′ elbow joints functional recovery. Normalized rehabilitation treatment helps the elbow joints functional recovery.

Humerus fracture,distal;Anatomical lock plate;Treatment

10.3877/cma.j.issn.2095-5790.2015.02.005

骨科常见疾病术后康复模式和临床路径研究(D131100004913005)

100029 北京，中日友好医院创伤骨科1，康复医学科2

刘成刚,Email：zqzpku@sina.com

2014-09-26)