肘关节外侧脱位入路临床研究及应用

Clinical study and application of lateral elbow dislocation approach

目的探讨肘关节外侧脱位入路复位固定法治疗肱骨远端冠状面骨折的方法及临床疗效。方法2019年1月至2021年10月本院通过外侧切口脱位入路复位及内固定法治疗肱骨远端冠状面骨折患者12例,男4例、女8例,年龄23~80岁,平均年龄(51.67±4.90)岁。受伤原因为:摔伤6例、交通伤1例、运动损伤2例、高处坠落伤3例。根据Dubberley分型,2A型2例、2B型3例、3A型3例、3B型4例。合并外髁骨折10例。术中直视下进行关节面骨块复位,无头钉内固定,必要时附加后侧解剖钢板或铰链外架固定。术前、术后各应用抗生素1次,术后3 d开始主动功能锻炼,外固定支架固定6周门诊去除。观察术中显露范围、记录术后三维CT检查骨折复位、关节面平整性(分离或台阶<2 mm为优)、肱尺关节匹配情况、螺钉是否切割、术后3个月Mayo肘关节功能指数评分(Mayo elbow performance score,MEPS)及优良率、异位骨化及关节退变情况。结果术后随访3~16个月,平均7.9个月,术中所有病例均可完全显露肱骨远端关节面。术后三维CT证实所有患者关节面复位良好,分离或台阶<2 mm。无螺钉切割。1例术后出现尺神经牵拉症状,3周后恢复,所有患者无血管损伤等严重并发症。末次随访骨折愈合,未发现肱骨小头坏死,2例出现关节退变,无异位骨化。MEPS评分为(90.0±1.38)分,其中优9例、良3例,优良率100%。结论肘关节外侧脱位入路可以完全显露肱骨远端关节面,直视下解剖复位、精准固定,不影响肘关节稳定性,预后良好,值得推广。

Background The elbow anatomy is complex,and the peripheral nerve,blood vessel and ligament components are dense,which makes the surgical exposure of complex elbow injuries technically demanding.At present,there are mainly posterior approaches(i.e.,olecranon osteotomy,triceps cleft,triceps flap flip,para-triceps approach),medial and lateral approaches,lateral or anterolateral approaches,etc.These approaches have specific applications and advantages,but for the distal humerus surrounded by olecranon,In particular,Dubberley classification type 2A and 3A fracture lines of the distal humerus coronal fractures extend to the posterior coronal process and Dubberley type B fractures.The distal fracture is usually at the lowest point or even posterior of the articular surface,completely covered by the olecranon of the ulna.It is difficult to expose the distal fracture lines of the articular surface through the lateral or anterolateral approach.The posterior approach does not fully expose the anterior aspect,such as the radial head fossa or coronal fossa,making intraoperative fracture reduction and fixation very difficult.Hoyt et al.conducted cadaver studies and found that 95.9%of the anterior surface and 100%of the small head could be exposed by the lateral approach of elbow dislocation and reduction.Objective To investigate the method and clinical effect of reduction and fixation of lateral elbow dislocation in the treatment of coronal fracture of distal humerus.Methods From January 2019 to October 2021,12 patients with distal humerus coronal fracture were treated by lateral incision dislocation approach reduction and internal fixation in our hospital.There were 4 males and 8 females,aged 23-80 years,with an average age of(51.67±4.90)years.The causes of injury included 6 cases of falling,1 case of traffic injury,2 cases of sports injury,and 3 cases of falling from height.According to Dubberley classification,there were 2 cases of type 2A,3 cases of type 2B,3 cases of type 3A,and 4 cases of type 3B.There were 10 cases with lateral condyle fracture.During the operation,the articular surface bone mass was reduced under direct vision,and the internal fixation was performed without head nails.If necessary,the posterior anatomical plate or hinge outer frame was attached.Antibiotics were used once before and after operation.Active functional exercise was started 3 days after operation,and the external fixator was removed after 6 weeks.The extent of intraoperative exposure,fracture reduction,articular surface smoothness(separation or step<2 mm is better),brachial-ulnar joint matching,screw cutting,and Mayo elbow performance score(MEPS)at 3 months after operation were recorded as well as the excellent and good rate,heterotopic ossification and joint degeneration.Reuslts The average follow-up time was 7.9 months(ranging from 3 to 16 months).The distal humeral articular surface was completely exposed in all cases.Postoperative three-dimensional CT confirmed that all patients had good articular surface reduction,separation or step<2 mm.Cut without screws.One patient developed ulnar nerve traction symptom after operation and recovered after 3 weeks.No serious complications such as vascular injury occurred in all patients.At the last follow-up,no necrosis of the humeral head was found,and 2 cases had joint degeneration and heterotopic ossification.The MEPS score was(90.0±1.38)points,of which 9 cases were excellent,3 cases were good,and the excellent and good rate was 100%.Conclusion Lateral elbow dislocation approach can fully expose the articular surface of the distal humerus,anatomical reduction and accurate fixation under direct vision,without affecting the stability of the elbow joint,and has a good prognosis,which is worthy of promotion.