肱骨小頭與滑車骨折的手術(shù)療效

劉洋 王東 蔣協(xié)遠 公茂琪 周君琳

·論著·

肱骨小頭與滑車骨折的手術(shù)療效

劉洋1王東1蔣協(xié)遠2公茂琪2周君琳1

目的 觀察手術(shù)治療肱骨小頭與滑車骨折的療效。方法 2009年6月至2012年8月首都醫(yī)科大學(xué)附屬北京朝陽醫(yī)院聯(lián)合北京積水潭醫(yī)院、北京友誼醫(yī)院及北京宣武醫(yī)院共納入橈骨小頭及滑車而不累及內(nèi)外側(cè)柱骨折患者23例，其中男6例,女17例;年齡27～81歲,平均49.5歲。致傷原因:低能量摔傷13例，騎自行車摔傷5例(其中電動自行車摔傷4例)，交通事故傷4例，高處墜落傷1例。所有患者均為閉合性骨折,無血管、神經(jīng)損傷。受傷至手術(shù)時間為0～11d，平均4.2d。術(shù)后3d開始肘關(guān)節(jié)被動功能練習(xí)。術(shù)后1周行肘關(guān)節(jié)主動屈伸鍛煉。記錄患者肘關(guān)節(jié)疼痛評分、活動度、Mayo評分。結(jié)果 所有患者均獲隨訪，平均隨訪時間27.2個月(24～55個月)，骨折全部愈合。2年隨訪時，肘關(guān)節(jié)無疼痛6例，輕度疼痛14例，中度疼痛3例，重度疼痛0例。肘關(guān)節(jié)屈伸活動度平均93° (30°～150°), 屈肘平均116°(110°～150°)，伸肘平均31°(0°～80°)，前臂旋前平均74.2°(55°～80°)，前臂旋后平均82.2°(70°～90°)。所有患者無肘關(guān)節(jié)不穩(wěn)，無缺血壞死，無內(nèi)固定松動。Mayo評分平均73.7分(43～98分)，其中優(yōu)5例，良14例，中3例，差1例。結(jié)論 肱骨遠端肱骨小頭骨折及滑車骨折主要影響肘關(guān)節(jié)屈伸活動范圍，而對于前臂旋轉(zhuǎn)影響有限。肘關(guān)節(jié)屈伸活動度與骨折損傷嚴重性存在正相關(guān)性。堅強內(nèi)固定和術(shù)后早期、正規(guī)的功能鍛煉對于肘關(guān)節(jié)功能恢復(fù)至關(guān)重要。

肱骨小頭骨折；滑車骨折；手術(shù)治療；療效觀察

臨床上單純肱骨小頭骨折較少見到，肱骨小頭骨折同時合并肱骨滑車骨折也是近些年才被關(guān)注[1-2]。因其發(fā)生率低，骨折程度復(fù)雜，治療難度大，且其受傷機制為摔傷或高能量交通傷常常伴有嚴重軟組織的損傷及肘部皮膚挫傷，因此對骨科臨床工作者提出了巨大的挑戰(zhàn)[2-4]。此類骨折臨床發(fā)生率少[5-7]，單一醫(yī)院病例數(shù)較少，大多數(shù)骨科醫(yī)師對于此類骨折的診斷及處理經(jīng)驗有限，因此本院聯(lián)合北京積水潭醫(yī)院、北京友誼醫(yī)院及北京宣武醫(yī)院共收集自2009年6月至2012年8月采用手術(shù)治療肱骨小頭骨折及滑車骨折并完整隨訪2年及以上的23例患者的臨床資料，對療效及預(yù)后結(jié)果進行系統(tǒng)的回顧性分析，希望能給廣大的骨科醫(yī)務(wù)工作者提供幫助。

資 料 與 方 法

一、一般資料

自2009年6月至2012年8月收集肱骨遠端骨折患者共721例，通過X線及CT評估，共發(fā)現(xiàn)骨折僅累及橈骨小頭和滑車而不累及內(nèi)外側(cè)柱骨折患者資料共23例，其中男6例,女17例;年齡27～81歲,平均49.5歲;右側(cè)14例(右利手13例，左利手1例)，左側(cè)9例(全部為右利手)。受傷至手術(shù)時間為0～11 d,平均4.2 d。致傷原因:低能量摔傷13例，騎自行車摔傷5例(其中電動自行車摔傷4例)，交通事故傷4例，高處墜落傷1例。所有患者均為閉合性骨折,無血管、神經(jīng)損傷。 合并傷:同側(cè)橈骨小頭骨折3例，尺骨鷹嘴骨折1例。

二、納入標(biāo)準

(1) 患者均為肱骨小頭骨折及滑車骨折，骨折不累及肱骨遠端內(nèi)外側(cè)柱； (2) 所有患者受傷肘關(guān)節(jié)均為首次手術(shù)；(3)無血管、神經(jīng)損傷。

三、排除標(biāo)準

(1)開放性骨折的患者；(2)病理性骨折的患者；(3)合并神經(jīng)、血管損傷；(4)受傷肘關(guān)節(jié)不是首次手術(shù)；(5)其他不符合納入標(biāo)準的患者。

四、骨折分型

(一)Dubberley分型[8]

Dubberley分型是根據(jù)肱骨髁損傷程度以及肱骨小頭和滑車是否為一整體骨折塊,將肱骨小頭骨折分為三種類型,Ⅰ型:肱骨小頭骨折,可以包含滑車外側(cè)緣;Ⅱ型:骨折累及肱骨小頭和滑車,兩者連接形成完整骨塊;Ⅲ型：骨折累及肱骨小頭和滑車,兩者分開形成各自單獨骨塊。根據(jù)是否并存肱骨遠端后髁部粉碎骨折,又將Ⅰ～Ⅲ型分為 A(不并存肱骨后髁粉碎骨折)、B(并存肱骨后髁粉碎骨折)兩個亞型(圖1)。依據(jù) Dubberley分型ⅠA型8例(合并橈骨小頭骨折3例 )，IB型5例(橈骨小頭骨折1例)，ⅡA型3例，ⅡB型1例，ⅢA型4例，ⅢB型2例(合并尺骨鷹嘴骨折1例)。

(二)Ring分型[9]

依據(jù)Ring分型分為五種類型(圖2),Ⅰ型為肱骨小頭和滑車外側(cè)關(guān)節(jié)面3例, Ⅱ型為包括I型在內(nèi)的外上髁骨折6例(合并橈骨小頭3例), Ⅲ型為Ⅱ型合并肱骨小頭后方干骺端嵌插骨折5例(合并橈骨小頭骨折1例), Ⅳ型為Ⅲ型合并滑車后部骨折3例,Ⅴ型為Ⅳ型加內(nèi)上髁骨折6例(合并尺骨鷹嘴骨折1例)。

五、治療方法

臂叢麻醉或全身麻醉下,患肢驅(qū)血后上止血帶加壓至220～250 mmHg(1 mmHg=0.133 kPa)。根據(jù)術(shù)前X線及CT檢查確定Dubberley分型并選擇手術(shù)入路,3例Dubberley分型ⅠA型(RingⅠ型 3例)患者，未合并橈骨小頭骨折及內(nèi)外側(cè)韌帶損傷患者選擇肘關(guān)節(jié)前外側(cè)入路，患者切口起自肘關(guān)節(jié)屈側(cè)橫紋上7 cm，近端沿肱二頭肌外側(cè)緣，遠端沿肱橈肌內(nèi)側(cè)緣S型切口，長約10 cm。切開皮膚、皮下，顯露頭靜脈及肌皮神經(jīng)予以保護，經(jīng)肱肌及肱橈肌間隙進入，切開肘關(guān)節(jié)前關(guān)節(jié)囊，顯露肱骨小頭及滑車前側(cè)骨折。Dubberley分型ⅠA型5例(合并橈骨小頭骨折3例 ),IB型5例(橈骨小頭骨折1例),ⅡA型3例,ⅡB型1例,共14例患者選擇外側(cè)切口及其延長切口，切口起自肱三頭肌外側(cè)頭外側(cè)緣向遠端跨越肘關(guān)節(jié)沿橈骨縱軸方向延伸,經(jīng)Kocher入路(尺側(cè)腕伸肌及肘肌)，剝離部分外上髁起點處的橈側(cè)腕伸肌和前臂伸肌起點,并將其牽開,合并外側(cè)副韌帶或外上髁撕脫骨折,將附帶韌帶的骨折塊其向近端牽開，并內(nèi)翻肘關(guān)節(jié)，以進一步增加顯露范圍。若暴露足夠充分,沿肱骨遠端和橈骨近端肱三頭肌外側(cè)緣剝離,可充分顯露肱骨遠端前方及后方的關(guān)節(jié)面,打開關(guān)節(jié)囊,去除淤血,暴露骨折端。3例合并橈骨小頭骨折經(jīng)此入路同時固定橈骨小頭，合并外側(cè)副韌帶損傷4例予以肱骨外側(cè)髁打孔并應(yīng)用愛惜康2號線固定。

6例患者DubberleyⅢA型4例,ⅢB型2例切口選擇后正中切口，探查尺神經(jīng)，經(jīng)尺骨鷹嘴截骨 (其中1例ⅢB型原發(fā)存在尺骨鷹嘴骨折，見圖3)，充分暴露肱骨小頭及滑車骨折端。直視下復(fù)位骨折塊克氏針臨時固定，根據(jù)骨折類型、骨塊大小、復(fù)位后的穩(wěn)定性及伴隨損傷選擇固定方式,醫(yī)師可選擇鋼板、螺釘、空心釘及可吸收螺釘混合應(yīng)用。合并的尺骨鷹嘴骨折或鷹嘴截骨的患者尺骨鷹嘴采用鋼板螺釘或者Cable-pin(Zimmer 3.5 mm)固定。2例外側(cè)副韌帶損傷及1例同時合并內(nèi)側(cè)副韌帶損傷于術(shù)中于肱骨遠端髁上打孔應(yīng)用愛惜康2號線固定。

圖1 Dubberley分型：根據(jù)骨折波及的范圍以及骨折移位程度分為3種類型(6種亞型)。圖AⅠ型；圖BⅠ型A；圖CⅠ型B；圖DⅡ型；圖EⅡ型A；圖FⅡ型B；圖GⅢ型；圖HⅢ型A；圖IⅢ型B

六、術(shù)后處理與隨訪

術(shù)后常規(guī)留置切口引流管,抗生素預(yù)防感染,術(shù)后24～48 h拔出引流管,口服吲哚美辛4周,100 mg/d,預(yù)防異位骨化,患者術(shù)后3 d行肘關(guān)節(jié)被動功能練習(xí)。術(shù)后1周行肘關(guān)節(jié)主動屈伸鍛煉。術(shù)后2周拆線，第1、3、6、12、18、24個月常規(guī)隨訪，行肘關(guān)節(jié)正側(cè)位X線，于術(shù)后1年及2年記錄肘關(guān)節(jié)屈伸活動度及旋轉(zhuǎn)活動度，按Mayo肘關(guān)節(jié)功能評分標(biāo)準評定肘關(guān)節(jié)功能，肘關(guān)節(jié)炎影像學(xué)的評估依據(jù)Broberg和Morrey系統(tǒng)[10]進行分級評定。

結(jié) 果

所有患者均獲隨訪，平均隨訪時間為27.2個月(24～55個月)，骨折全部愈合。2年隨訪時，肘關(guān)節(jié)無疼痛6例， 輕度疼痛14例， 中度疼痛3例， 重度疼痛0例。測量肘關(guān)節(jié)屈伸活動度平均93° (30°～150°), 屈肘平均116°(110°～150°)，伸肘平均31°(0°～80°)，前臂旋前平均74.2°(55°～80°)，前臂旋后平均82.2°(70°～90°)。所有患者無肘關(guān)節(jié)不穩(wěn)，無缺血壞死，無內(nèi)固定松動。Mayo評分平均73.7分(43～98分)，優(yōu)5例， 良14例， 中3例， 差1例。2例患者術(shù)后出現(xiàn)輕度尺神經(jīng)癥狀，3個月后均有所緩解，術(shù)后6個月5例患者出現(xiàn)肘關(guān)節(jié)外側(cè)少量異位骨化，肘關(guān)節(jié)屈伸活動度良好。1例患者術(shù)后1個月出現(xiàn)肘關(guān)節(jié)肘位異位骨化，術(shù)后6個月肘關(guān)節(jié)周圍大量移位骨化，術(shù)后2年肘關(guān)節(jié)屈伸活動度30°(肘關(guān)節(jié)屈曲110°，伸直80°)，較健側(cè)明顯受限。

圖2 Ring分型：根據(jù)骨折波及范圍分為5種類型。圖A示意圖；圖BⅠ型；圖CⅡ型；圖DⅢ型；圖EⅣ型；圖FⅤ型

圖3 肱骨小頭合并滑車骨折患者術(shù)前、術(shù)后影像學(xué)檢查和術(shù)中肱骨骨折情況。圖A術(shù)前側(cè)位片；圖B術(shù)前正位片；圖C術(shù)中取出的骨塊；圖D術(shù)后側(cè)位片；圖E術(shù)后正位片;圖F拼湊術(shù)中取出的骨塊

圖4 肱骨遠端骨折雙弧征。圖A側(cè)位片可見雙弧征；圖B正位片可見關(guān)節(jié)對位關(guān)系

討 論

單純的肱骨小頭及肱骨滑車骨折臨床發(fā)生率較低，由于是關(guān)節(jié)內(nèi)復(fù)雜骨折，預(yù)后相對差[3-5，7]。單純的肱骨小頭及肱骨滑車骨折通常由低能量損傷所致。當(dāng)肘關(guān)節(jié)處于伸肘位或半屈肘位時，外力經(jīng)橈骨小頭傳遞至肱骨關(guān)節(jié)面所致，可合并橈骨小頭脫位及尺骨鷹嘴骨折。也可由于摔傷時肘關(guān)節(jié)向后外側(cè)脫位，橈骨小頭自行復(fù)位時對肱骨遠端關(guān)節(jié)面的前切力所致。在統(tǒng)計的病歷資料中，女性患者數(shù)量遠遠多于男性患者，占73.9%，與早期相關(guān)文獻一致，可能與女性絕經(jīng)后骨質(zhì)疏松等因素相關(guān)。本研究病歷合并同側(cè)橈骨小頭骨折3例，占14.2%,尺骨鷹嘴骨折僅1例。綜合本研究，患者平均年齡較高且致傷因素以自行車、低能量損傷為主，低能量損傷占82.6%，比例高于國外相關(guān)文獻報道。因此，本研究多為老年患者且以生活傷為主，與國外相關(guān)文獻報道存在一定差異[11-16]。

肱骨小頭及滑車骨折在查體及臨床表現(xiàn)上無明顯特異性，均需通過影像學(xué)檢查明確。單純肘關(guān)節(jié)正側(cè)位X線檢查存在一定的局限性，正位片可能僅僅表現(xiàn)為肱骨遠端不規(guī)則低密度區(qū)，不易發(fā)現(xiàn)。肘關(guān)節(jié)標(biāo)準側(cè)位片可出現(xiàn)分離移位的肱骨小頭和部分滑車與內(nèi)髁形成的雙弧征[17]從而診斷(圖4)。但由于肱骨遠端骨折患者因疼痛和急診照相條件等不利因素限制不能很好的拍攝標(biāo)準側(cè)位時，則導(dǎo)致雙弧征顯示不清，骨折則難以發(fā)現(xiàn)。故肘關(guān)節(jié)CT檢查至關(guān)重要，其不僅可以明確骨折，且可以明確骨折分型并指導(dǎo)治療，因此CT檢查對肱骨小頭及滑車骨折患者有至關(guān)重要的指導(dǎo)意義。

目前可應(yīng)用于肱骨小頭及滑車骨折的分型有AO分型、Dubberley分型、Ring分型、Bryan-Morrey分型和McKee分型等，但目前較多采用的分型為Dubberley分型。AO分型中長骨干骺端發(fā)生于冠狀面的部分關(guān)節(jié)內(nèi)骨折屬于B3型，完全關(guān)節(jié)面碎裂為C 3型，而沒有進一步把肱骨小頭及滑車骨折情況做進一步描述及分析。Bryan-Morrey僅僅直觀地描述了肱骨小頭骨折塊的形態(tài)，而沒有涉及關(guān)于滑車骨折，McKee進一步完善其分型，McKee 在 Bryan-Morrey 對孤立肱骨小頭分型的基礎(chǔ)上提出了肱骨小頭累及滑車大部的Ⅳ型骨折,以此區(qū)分孤立的肱骨小頭骨折, 首次稱之為肱骨遠端冠狀面剪切骨折。但沒有對單純的滑車骨折及肱骨小頭與滑車骨折且不為一整體等情況作進一步闡述。 Ring 分型是根據(jù)肱骨遠端冠狀面波及范圍提出的分型方式。 Dubberley 根據(jù)后髁是否粉碎,肱骨小頭和滑車是否為一整體骨折塊,將肱骨小頭骨折分為 6 型，此分型清晰明確，且易于操作，對治療方案、手術(shù)入路及預(yù)后均有指導(dǎo)意義。因此在肱骨小頭及滑車骨折治療上，應(yīng)緊密結(jié)合病史、體格及影像學(xué)檢查，應(yīng)用Dubberley分型、Bryan-Morrey 聯(lián)合 Mckee 分型、AO 分型、Ring分型綜合分析，明確骨折類型，充分評估軟組織情況、韌帶損傷及影響肘關(guān)節(jié)穩(wěn)定性因素，對臨床治療有至關(guān)重要的指導(dǎo)意義。

肱骨遠端肱骨小頭及滑車的骨折屬于完全關(guān)節(jié)內(nèi)骨折，關(guān)節(jié)面解剖復(fù)位，堅強固定，恢復(fù)肘關(guān)節(jié)穩(wěn)定及早期功能鍛煉對患者功能恢復(fù)至關(guān)重要。對于單純肱骨小頭冠狀面骨折的患者且不存在橈骨小頭及韌帶損傷的患者，肘關(guān)節(jié)前外側(cè)入路能夠減少對肘關(guān)節(jié)外側(cè)韌帶的人為損傷，最大可能保護維持肘關(guān)節(jié)穩(wěn)定性結(jié)構(gòu)免遭手術(shù)破壞。但肘關(guān)節(jié)前外側(cè)入路顯露范圍有限，對于合并肱骨遠端滑車骨折、后側(cè)面骨折及合并橈骨小頭等患者不能得到很好顯露。肘關(guān)節(jié)外側(cè)入路及擴大的外側(cè)入路能很好的顯露肱骨遠端肱骨小頭及滑車外側(cè)面，并可同時進行肘關(guān)節(jié)外側(cè)韌帶及橈骨小頭的復(fù)位固定，應(yīng)用最為廣泛。但此手術(shù)入路不能良好的顯露肱骨滑車的內(nèi)側(cè)遠端及關(guān)節(jié)后側(cè)，常常剝離外上髁伸肌止點及外側(cè)副韌帶起點，以進一步增加顯露范圍，同時醫(yī)源性破壞了肱骨小頭的血運及維持肘關(guān)節(jié)穩(wěn)定性的結(jié)構(gòu)，修補肘關(guān)節(jié)外側(cè)穩(wěn)定結(jié)構(gòu)增加了手術(shù)難度和肱骨小頭缺血壞死的幾率，因此，術(shù)中應(yīng)盡少剝離外側(cè)副韌帶。肱骨遠端骨折合并外側(cè)韌帶完全斷裂時或肘關(guān)節(jié)外側(cè)韌帶的外上髁存在撕脫骨折時，可以將近端肱骨遠端外髁連同外側(cè)韌帶向遠端打開，內(nèi)翻肘關(guān)節(jié)，以內(nèi)側(cè)韌帶為軸心，合葉式顯露肘關(guān)節(jié)內(nèi)側(cè)關(guān)節(jié)面，待骨折復(fù)位后，可將帶有外側(cè)副韌帶的肱骨遠端外髁撕脫骨折加以固定。此種方法大大增加了顯露范圍，降低外側(cè)副韌帶的損傷，臨床上值得大力推廣。肘關(guān)節(jié)后側(cè)入路聯(lián)合尺骨鷹嘴截骨可以完整顯露肱骨遠端關(guān)節(jié)面，有利于關(guān)節(jié)面的復(fù)位，同時可以處理橈骨小頭骨折、內(nèi)外側(cè)副韌帶損傷的修補，尤其適用于合并尺骨鷹嘴骨折的患者。對于年齡>75歲、肱骨遠端關(guān)節(jié)面碎裂嚴重、同時不伴有尺骨鷹嘴骨折的患者，肘關(guān)節(jié)置換也是一種具有可行性的選擇，術(shù)后功能恢復(fù)滿意。本研究認為，相對簡單的肱骨小頭骨折及外髁骨折可以通過外側(cè)入路的方法復(fù)位骨折，重建外側(cè)韌帶，對于較嚴重的骨折，難以通過良好的復(fù)位確定正確的旋轉(zhuǎn)中心，故應(yīng)用外固定架來替代修補韌帶維持肘關(guān)節(jié)的穩(wěn)定性的方法值得商榷。

本研究患者出現(xiàn)5例肘關(guān)節(jié)外側(cè)韌帶處異位骨化發(fā)生，肘關(guān)節(jié)活動度良好，1例患者由于骨折粉碎程度嚴重，屬于DubberleyⅢ B型且同時合并尺骨鷹嘴骨折，術(shù)后功能鍛煉欠佳。術(shù)后1個月出現(xiàn)肘關(guān)節(jié)肘位異位骨化，術(shù)后6個月肘關(guān)節(jié)周圍大量異位骨化，術(shù)后2年肘關(guān)節(jié)屈伸活動度30°，伸肘80°，屈肘110°，較健側(cè)明顯受限。本研究認為堅強內(nèi)固定和術(shù)后早期、正規(guī)的功能鍛煉對于肘關(guān)節(jié)功能恢復(fù)至關(guān)重要。2例DubberleyⅢ A型患者采用后側(cè)入路，出現(xiàn)尺神經(jīng)癥狀，與后側(cè)入路顯露與牽拉尺神經(jīng)存在一定關(guān)系，術(shù)中應(yīng)輕柔操作至關(guān)重要。肱骨小頭骨折塊無軟組織附著,理論上有缺血壞死發(fā)生的風(fēng)險,本研究患者未出現(xiàn)。但應(yīng)盡量減少軟組織韌帶的剝離、保護肱骨小頭和滑車的血供,避免肱骨小頭缺血壞死和骨折不愈合的發(fā)生。

本研究為回顧性病歷研究，且樣本量有限，隨訪時間短，對于創(chuàng)傷性關(guān)節(jié)炎、遲發(fā)性尺神經(jīng)炎及肘關(guān)節(jié)置換長時間隨訪數(shù)據(jù)不足，期待進一步研究。

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(本文編輯：胡桂英)

劉洋,王東,蔣協(xié)遠，等.肱骨小頭與滑車骨折的手術(shù)療效[J/CD]. 中華肩肘外科電子雜志,2016,4(4):221-229.

·讀者·作者·編者·

本刊對來稿中統(tǒng)計學(xué)處理的有關(guān)要求

1. 統(tǒng)計研究設(shè)計：應(yīng)交代統(tǒng)計研究設(shè)計的名稱和主要做法。如調(diào)查設(shè)計(分為前瞻性、回顧性還是橫斷面調(diào)查研究)，實驗設(shè)計(應(yīng)交代具體的設(shè)計類型，如自身配對設(shè)計、成組設(shè)計、交叉設(shè)計、析因設(shè)計、正交設(shè)計等)，臨床試驗設(shè)計(應(yīng)交代屬于第幾期臨床試驗，采用了何種盲法措施等)；主要做法應(yīng)圍繞4個基本原則(重復(fù)、隨機、對照、均衡)概要說明，尤其要交代如何控制重要非試驗因素的干擾和影響。

3. 統(tǒng)計分析方法的選擇：對于定量資料，應(yīng)根據(jù)所采用的設(shè)計類型、資料所具備的條件和分析目的，選用合適的統(tǒng)計分析方法，不應(yīng)盲目套用t檢驗和單因素方差分析；對于定性資料，應(yīng)根據(jù)所采用的設(shè)計類型、定性變量的性質(zhì)和頻數(shù)所具備的條件以及分析目的，選用合適的統(tǒng)計分析方法，不應(yīng)盲目套用χ2檢驗。對于回歸分析，應(yīng)結(jié)合專業(yè)知識和散布圖，選用合適的回歸類型，不應(yīng)盲目套用簡單直線回歸分析，對具有重復(fù)實驗數(shù)據(jù)的回歸分析資料，不應(yīng)簡單化處理；對于多因素、多指標(biāo)資料，要在一元分析的基礎(chǔ)上，盡可能運用多元統(tǒng)計分析方法，以便對因素之間的交互作用和多指標(biāo)之間的內(nèi)在聯(lián)系作出全面、合理的解釋和評價。

4. 統(tǒng)計結(jié)果的解釋和表達：當(dāng)P<0.05(或P<0.01)時，應(yīng)說對比組之間的差異有統(tǒng)計學(xué)意義，而不應(yīng)說對比組之間具有顯著性(或非常顯著性)的差別；應(yīng)寫明所用統(tǒng)計分析方法的具體名稱(如：成組設(shè)計資料的t檢驗、兩因素析因設(shè)計資料的方差分析、多個均數(shù)之間兩兩比較的q檢驗等)，統(tǒng)計量的具體值(如：t=3.45，χ2=4.68，F(xiàn)=6.79等)，應(yīng)盡可能給出具體的P值(如：P=0.0238)；當(dāng)涉及到總體參數(shù)(如總體均數(shù)、總體率等)時，在給出顯著性檢驗結(jié)果的同時，再給出95%置信區(qū)間。

(本刊編輯部)

Operativeoutcomesofhumerocapitular-trochlearfracture

LiuYang1,WangDong1,JiangXieyuan2,GongMaoqi2,ZhouJunlin1.

1DepartmentofOrthopaedics,BeijingChao-YangHospital,Beijing100020,China;2DepartmentofTraumaticOrthopedics,BeijingJishuitanHospital,Beijing100035,China

ZhouJunlin,Email:zhoujunlin@medmail.com.cn

Background The single fracture of humeral capitellum is rare clinically, but the humeral capitellum fracture combined with humeral trochlea fracture has been concerned in recent years. As the fracture has low incident rate and increased complexity and difficulty of treatment, and the mechanism of injury is fall or high-energy traffic injury often combined with severe soft tissue damage and skin contusion of elbow, a great challenge has been brought to the clinicians in the department of orthopedics. The diagnostic and therapeutic experience for such fracture was limited in most of the orthopedic physicians due to the few cases. Hence, 23 cases of surgically treated humerocapitular-trochlear fractures with 2 years complete follow-ups were collected in 4 hospitals from June 2009 to August 2012, and the therapeutic effect and the prognosis were systematically and retrospectively explored and analyzed, hoping to provide assistance to the general orthopedic clinicians.Methods (1) General materials. A total of 721 patients with distal humeral fractures were collected from June 2009 to August 2012 and 23 cases of humerocapitular-trochlear fractures without involving lateral and medial columns were discovered by X-ray and CT evaluation, including 6 male cases and 17 female cases; aged 27 to 81 years, with an average of 49.5 years; 14 right side cases (13 cases of right handness and 1 case of left handness) and 9 left side cases (right handness). The time from injury to operation were 0-11 days with an average of 4.2 days. Mechanism of injuries: 13 cases of low-energy falls, 5 cases of bicycle falls (4 cases of electric bicycle falls), 4 cases of traffic accident and 1 case of high fall. Combined injuries: 3 cases of ipsilateral radial head fractures and 1 cases of olecranon fracture. (2) Inclusive criteria: ①Patients with articular surface fractures of humeral capitellum and/or with humeral trochlea fractures, without involving the lateral and the medial columns of distal humerus; ②First-time elbow surgeries after injury; ③No neurovascular injuries. (3)Exclusive criteria: ①Patients with open fractures; ②Patients with pathological fractures; ③Combined with neurovascular injuries; ④Not the first-time surgeries after injury; ⑤ Other patients who do not meet the inclusive criteria. (4)Fracture classification: ①Dubberley classification: 8 cases of type ⅠA (3 cases combined with radial head fractures), 5 cases of type ⅠB (including 1 case combined with radial head fracture), 3 cases of type Ⅱ A, 1 cases of type ⅡB, 4 cases of type ⅢA and 2 cases of type IIIB (including 1 cases combined with olecranon fracture). ②Ring classification: 3 cases of type I fractures, 6 cases of typeⅡ fractures (combined with 3 cases of radial head fractures), 5 cases of type Ⅲ fractures (combined with 1 case of radial head fracture), 3 cases of type Ⅳ fractures and 6 cases of type Ⅴ fractures (combined with 1 case of olecranon fracture). (5)Treatment methods.Under successful brachial plexus block or general anesthesia, the pressure of tourniquet was increased to 220-250 mmHg (1 mmHg=0.133 kPa) after the blood of the affected limb was driven. The determination of Dubberley classification and the selection of surgical approach was based on the preoperative X-ray and CT examination. The anterolateral approach was selected in the 3 patients of type IA (3 cases of type I fracture in Ring classification) without radial head fracture or medial and lateral ligament injury. An "S" shaped incision of about 10 cm was made from 7 cm above the flexor side of elbow joint with its proximal part along the lateral margin of biceps and distal part along the medial margin of brachioradialis. The skin and subcutaneous tissue were cut open to expose and protect the cephalic vein and the musculocutaneous nerve. The incision on the anterior joint capsule of elbow was made to expose the fractures of humeral capitellum and trochlea. The lateral incision and its extended incision were applied in 14 patients (5 cases of type ⅠA fracture including 3 cases combined with radial head fractures, 5 cases of type ⅠB fracture including 1 case combined with radial head fracture, 3 cases of type ⅡA fracture and 1 case of type ⅡB fracture). The incision was made from the lateral margin of ectotriceps distally across the elbow and extended along the longitudinal direction of radius. The extensor carpi radialis at the starting point of condylus lateralis humeri and the starting point of the forearm extensor muscles were stripped partially and retracted through Kocher approach (extensor carpiulnaris and anconeus). Combined with lateral collateral ligament injury or lateral epicondyle avulsion fracture, the fracture fragment with ligament was retracted proximally and the elbow joint was inverted to further increase the exposure range; if the exposure range was sufficient enough, the anterior and posterior articular surface of distal humerus was visible after stripping along the triceps lateral margin of distal humerus and proximal radius. The joint capsule was cut open to remove blood clots and expose fracture ends. This approach was adopted in 3 patients combined with radial head fractures which was fixed at the same time.Four cases with lateral collateral ligament injuries were treated by drilling of condylus lateralis humeri and fixation with No. 2 suture lines of Ethicon. The posterior median incision was applied in 6 patients (4 cases of type IIIA and 2 cases of type ⅢB) for exploration of ulnar nerve. The fracture ends of humeral capitellum and trochlea were exposed via olecranon osteotomy. The fracture fragments were reduced and fixed with Kirschner wires temporarily. The fixation methods were selected according to fracture type, fragment size, stability after reduction and combined injuries. Plates, screws, hollow screws and absorbable screws were available for single use or mixed application. Plate and screw fixation or Cable-pin (Zimmer 3.5 mm) fixation was applied for patients combined with olecranon fracture or olecranon osteotomy. Drilling of condylus lateralis humeri and fixation of No. 2 suture lines of Ethicon were adopted for 2 cases combined with lateral collateral ligament and 1 case combined with medial collateral ligament. (6)Post-operative management and follow-ups: The drainage tube was indwelled routinely and the antibiotics was given to prevent infection after operation. The drainage tube was withdrawn in the postoperative 24-48 hours. Oral indomethacin with 100 mg/d for 4 weeks was advised for the prevention of heterotopic ossification. The passive functional exercise of elbow joint was conducted on the 3rd postoperative day and the active flexion and extension exercise began 1 week after operation. The stiches were taken out after 2 weeks. The postoperative routine follow-ups were conducted in the 1st, 3rd, 6th, 12th, 18th, and 24th month with X-ray films of elbow joint taken each time. The range of motion of flexion, extension and rotation were recorded in the postoperative 1st and 2nd year. The function of elbow joint was assessed according to Mayo elbow performance score (MEPS) and the radiographic evaluation of elbow arthritis was assessed according to Broberg and Morrey system.Results All the patients were followed up for 27.2 months on average (24 to 55 months) and

fractures healing. During the 2nd year follow-ups, there were 6 patients with no pain, 14 cases with mild pain, 3 cases with moderate pain, and no cases with severe pain. The range of motion of elbow flexion and extension was 93° on average (30° to 150°) with elbow flexion of 116° on average (110° to 150°), elbow extension of 31° on average (0° to 80°), forearm pronation of 74.2° on average (55° to 80°) and forearm supination of 82.2° on average (70° to 90°). All patients had no elbow instability, ischemic necrosis or internal fixation loosening. The mean MEPS score was 73.7 points (43 to 98 points) with 5 excellent cases,14 good cases, 3 middling cases and 1 poor case.Two patients had mild symptoms of ulnar nerve after surgery and got partial remission 3 months later.Five patients had heterotopic ossifications in the lateral side of elbow joint 6 months after surgery with good flexion and extension activities.One patient had heterotopic ossification of elbow joint 1 month after surgery and got worse around the elbow in the postoperative 6th month. The range of motion of elbow flexion and extension was 30° (110° of elbow flexion and 80° of elbow extension) 2 years postoperatively and the function was remarkably limited compared with the contralateral elbow.Conclusions This study suggests the relatively simple fractures of humeral capitellum and condyle can be reduced through lateral approach with lateral ligament reconstruction. As to severe fractures, it is difficult to determine the right rotational center via good reduction. Therefore, the application of external fixator for elbow joint stability instead of the repair of ligaments is worth of discussion. This study also suggests rigid fixation with early and regular postoperative functional exercises is essential in the recovery of elbow function and the prevention of heterotopic ossification. The presence of ulnar nerve symptoms has certain relationship with the exposure of posterior approach and the traction of ulnar nerve. Thus, the operation should be gentle and soft. The humeral capitellum may have a risk of ischemic necrosis in theory as the fracture fragments have no attachment of soft tissue, but it did not occur in patients of this study. The soft tissue stripping should be minimized as much as possible to protect the blood supply of humeral capitellum and condyles and thus avoid the necrosis of humeral capitellum and the nonunion of fractures. This research is retrospective with limited samples and short-time follow-ups, and the data of long term follow-ups is insufficient for traumatic arthritis, delayed ulnar neuritis and elbow arthroplasty, which requires further studies.

Humeral capitellum fracture;Trochlear fracture;Surgical treatment;Curative effect observation

10.3877/cma.j.issn.2095-5790.2016.04.006

北京市醫(yī)管局揚帆計劃臨床技術(shù)創(chuàng)新項目(XMLX201307)

100020首都醫(yī)科大學(xué)附屬北京朝陽醫(yī)院骨科1；100035北京積水潭醫(yī)院創(chuàng)傷骨科2

周君琳,Email：zhoujunlin@medmail.com.cn

2016-03-10)