朱前拯 段亞景 楊雨潤(rùn) 楊歡 陳星佐 王立強(qiáng)陳瀛 楊連發(fā) 林朋 劉成剛

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·論著·

解剖鎖定接骨板治療C型肱骨遠(yuǎn)端骨折的療效分析

朱前拯1段亞景2楊雨潤(rùn)1楊歡1陳星佐1王立強(qiáng)1陳瀛1楊連發(fā)1林朋1劉成剛1

目的 觀察解剖鎖定接骨板治療C型肱骨遠(yuǎn)端骨折以及術(shù)后規(guī)范化康復(fù)的療效。方法 2009年12月至2013年6月使用解剖鎖定接骨板治療17例C型肱骨遠(yuǎn)端骨折患者，其中男性6例，女性11例；年齡24～84歲，平均51.2歲。損傷原因：低能量損傷9例(低能量組)；高能量損傷8例(高能量組)。受傷至手術(shù)時(shí)間為1～30 d，平均8.4 d。術(shù)后患者開(kāi)始規(guī)范化肘關(guān)節(jié)功能康復(fù)治療。末次隨訪時(shí)記錄患側(cè)肘關(guān)節(jié)活動(dòng)范圍并采用Mayo肘關(guān)節(jié)功能評(píng)分。結(jié)果 所有患者術(shù)后獲9～48個(gè)月(平均18.59個(gè)月)隨訪，所有骨折均愈合，1例合并尺骨鷹嘴截骨處延遲愈合。末次隨訪時(shí)，肘關(guān)節(jié)伸直15.0°±10.2°，屈曲103.2°±16.3°，活動(dòng)范圍88.2°±22.8°。MEPS評(píng)分(83.9±19.2)分，優(yōu)良率76.5%(13/17)。高能量組與低能量組MEPS評(píng)分分別為(71.9±22.5)分和(94.6±4.9)分，差異有統(tǒng)計(jì)學(xué)意義(P=0.025)。結(jié)論 AO解剖鎖定接骨板治療C型肱骨遠(yuǎn)端骨折的療效肯定，高能量損傷患者的預(yù)后較差，初始損傷因素影響患者肘關(guān)節(jié)功能恢復(fù)，規(guī)范化的康復(fù)治療有助于肘關(guān)節(jié)功能恢復(fù)。

肱骨骨折，遠(yuǎn)端；鎖定接骨板；治療

AO分型中C型肱骨遠(yuǎn)端骨折是一類(lèi)非常復(fù)雜的關(guān)節(jié)內(nèi)骨折，其肱骨遠(yuǎn)端干骺端及關(guān)節(jié)面常粉碎嚴(yán)重，治療難度大，易合并骨缺損、軟組織損傷、神經(jīng)損傷及骨質(zhì)疏松等，難以獲得穩(wěn)定固定，對(duì)預(yù)后產(chǎn)生不利影響[1-2]。AO肱骨遠(yuǎn)端鎖定接骨板，使用雙鋼板垂直內(nèi)固定，在設(shè)計(jì)上解剖預(yù)塑型，遠(yuǎn)端使用2.7 mm鎖定螺釘，手術(shù)中使用時(shí)更為靈活、方便，可有效預(yù)防復(fù)位丟失，尤其適合于復(fù)雜類(lèi)型骨折及骨質(zhì)疏松的患者。通過(guò)對(duì)我院2009年12月至2013年6月使用AO肱骨遠(yuǎn)端解剖鎖定接骨板治療的17例C型肱骨遠(yuǎn)端骨折患者資料進(jìn)行回顧性研究，旨在對(duì)肘關(guān)節(jié)功能及術(shù)后康復(fù)訓(xùn)練的療效進(jìn)行觀察和分析。

資 料 與 方 法

一、一般資料

本組17例，其中男性6例，女性11例；年齡24～84歲，平均51.2歲；左側(cè)8例，右側(cè)9例；閉合性骨折16例，開(kāi)放性骨折1例。損傷原因：低能量損傷(摔倒)9例(低能量組)；高能量損傷8例(高能量組)，包括交通傷3例，高處墜落傷4例，皮帶絞傷1例。骨折AO分型：C1型2例，C2型5例，C3型10例。合并損傷：尺神經(jīng)斷裂1例，同側(cè)尺骨鷹嘴骨折1例，同側(cè)肱三頭肌斷裂1例，同側(cè)肱骨近端骨折1例，顱腦損傷蛛網(wǎng)膜下腔出血1例，同時(shí)合并骨盆骨折、髖臼骨折、股骨頸骨折、瘧疾1例。受傷至手術(shù)時(shí)間為1～30 d，平均8.4 d，其中7 d內(nèi)手術(shù)11例，7～14 d手術(shù)3例，>14 d手術(shù)3例，最長(zhǎng)者因合并瘧疾延遲手術(shù)治療時(shí)間。高能量組與低能量組患者在年齡、性別、傷側(cè)、受傷至手術(shù)時(shí)間、屈肘角度、伸肘角度、活動(dòng)范圍方面差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，表1)，具有可比性。

二、手術(shù)及康復(fù)方法

術(shù)前30 min預(yù)防應(yīng)用抗生素，采用全身麻醉，患者側(cè)臥位，患肢上氣囊止血帶，取肘后正中切口，顯露并保護(hù)尺神經(jīng)，經(jīng)尺骨鷹嘴截骨入路，顯露肱骨遠(yuǎn)端及關(guān)節(jié)面[3]。在截骨時(shí)需要注意在尺骨鷹嘴關(guān)節(jié)面的“裸區(qū)”內(nèi)截骨，大約在尺骨鷹嘴尖下方約2 cm處。術(shù)中可以首先顯露鷹嘴內(nèi)、外側(cè)面，選擇鷹嘴滑車(chē)的中點(diǎn)處的“裸區(qū)”進(jìn)行截骨，截骨時(shí)首先用薄鋸片截?cái)啾硞?cè)皮質(zhì)骨直到軟骨下骨，最后的關(guān)節(jié)面用薄骨刀截?cái)唷ｋ殴沁h(yuǎn)端骨折的固定原則是首先恢復(fù)關(guān)節(jié)面的平整，可用1.0 mm克氏針經(jīng)關(guān)節(jié)軟骨下方穿入臨時(shí)或永久固定[4]，復(fù)位肱骨遠(yuǎn)端內(nèi)、外側(cè)柱，使用克氏針及復(fù)位鉗臨時(shí)固定。使用AO肱骨內(nèi)、外側(cè)解剖鎖定接骨板(辛迪斯強(qiáng)生，美國(guó))固定，橈側(cè)板放置于外側(cè)柱的橈背側(cè)，尺側(cè)板與內(nèi)側(cè)柱的內(nèi)側(cè)骨嵴貼附。所有患者均行尺神經(jīng)前置術(shù)，對(duì)合并尺神經(jīng)斷裂患者予手術(shù)縫合，需要注意尺神經(jīng)不能與內(nèi)固定金屬接觸。在關(guān)閉傷口前充分屈、伸肘關(guān)節(jié)，觀察是否存在尺神經(jīng)卡壓的情況并及時(shí)糾正。

表1 高能量組與低能量組患者術(shù)前一般資料和末次隨訪時(shí)MEPS評(píng)分的比較

注：MEPS為Mayo肘關(guān)節(jié)功能評(píng)分

術(shù)畢放置引流管，術(shù)后24 h拔除引流管，并指導(dǎo)患者肘關(guān)節(jié)功能鍛煉，每天進(jìn)行肘關(guān)節(jié)屈伸活動(dòng)，以主動(dòng)活動(dòng)為主?；颊呖诜胚崦佬林列g(shù)后6周?；颊卟捎媒?jīng)尺骨縱軸垂直平面截骨5例，尖端在遠(yuǎn)端的"V"形截骨12例。截骨固定方法：克氏針張力帶固定4例，張力帶鋼板固定2例，鋼纜捆綁系統(tǒng)固定11例。

術(shù)后開(kāi)始規(guī)范化肘關(guān)節(jié)康復(fù)程序：患者術(shù)后根據(jù)具體骨折固定穩(wěn)定程度及軟組織損傷情況決定是否使用石膏或者支具外固定保護(hù)，保護(hù)時(shí)間為1～3周。對(duì)于損傷較輕，骨折固定堅(jiān)強(qiáng)的患者，術(shù)后次日開(kāi)始主動(dòng)功能鍛煉?？祻?fù)內(nèi)容包括:(1)肘關(guān)節(jié)主動(dòng)屈伸運(yùn)動(dòng)。(2)肩關(guān)節(jié)主動(dòng)活動(dòng)，要求患者傷后進(jìn)行肩關(guān)節(jié)主動(dòng)上舉、外展、外旋及內(nèi)旋活動(dòng)。(3)手的功能鍛煉，包括握拳、分指、并指、拇指及各指的對(duì)指運(yùn)動(dòng)。(4)前臂的旋轉(zhuǎn)運(yùn)動(dòng)，要求進(jìn)行旋后及旋前運(yùn)動(dòng)。(5)以上運(yùn)動(dòng)每天3次，每次10～15次。根據(jù)肘關(guān)節(jié)腫脹情況逐漸增加次數(shù)，若肘關(guān)節(jié)疼痛及腫脹加重。減少訓(xùn)練次數(shù)及時(shí)間。術(shù)后6周根據(jù)X線片復(fù)查骨折愈合情況逐漸開(kāi)始肘關(guān)節(jié)力量訓(xùn)練。(6)物理治療：患者進(jìn)行上肢主動(dòng)訓(xùn)練前對(duì)治療部位進(jìn)行熱敷5～10 min，訓(xùn)練后進(jìn)行冷敷5～10 min。若患者存在明顯腫脹，進(jìn)行該部位磁療，20 min，每天一次。

三、功能評(píng)價(jià)

末次隨訪時(shí)記錄患側(cè)肘關(guān)節(jié)活動(dòng)范圍并采用Mayo肘關(guān)節(jié)功能(mayo elbow performance score，MEPS)評(píng)分從疼痛、活動(dòng)度、穩(wěn)定性及生活能力4個(gè)方面進(jìn)行功能評(píng)價(jià)，滿(mǎn)分為100分：90～100分為優(yōu)，75～89分為良，60～74分為可，<60分為差。

四、統(tǒng)計(jì)學(xué)處理

采用SPSS 16.0統(tǒng)計(jì)學(xué)軟件，高能量損傷與低能量損傷兩組患者的年齡、受傷至手術(shù)間隔、伸肘角度、屈肘角度、活動(dòng)范圍及MEPS評(píng)分采用獨(dú)立樣本t檢驗(yàn)，兩組間性別及傷側(cè)對(duì)比采用Fisher檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

所有患者術(shù)后獲9～48個(gè)月(平均18.59個(gè)月)隨訪，所有骨折均愈合，無(wú)內(nèi)固定失效表現(xiàn)。末次隨訪患側(cè)時(shí)，肘關(guān)節(jié)伸直15.0°±10.2°，屈曲103.2°±16.3°，活動(dòng)范圍88.2°±22.8°；MEPS評(píng)分(83.9±19.2)分；優(yōu)11例，良2例，可2例，差2例，優(yōu)良率76.5%；高能量損傷組與低能量損傷組MEPS評(píng)分分別為(71.9±22.5)分和(94.6±4.9)分，差異有統(tǒng)計(jì)學(xué)意義(P=0.025，表1)，典型病例見(jiàn)圖1。術(shù)后并發(fā)癥包括：尺骨鷹嘴截骨延遲愈合1例、尺神經(jīng)麻痹2例，均得以自主康復(fù)。

討 論

肱骨遠(yuǎn)端骨折大約占成人骨折的7%，占肘關(guān)節(jié)骨折的30%。除了合并嚴(yán)重骨質(zhì)疏松、不能耐受手術(shù)、合并肢體神經(jīng)功能障礙、軟組織缺損或感染的患者，切開(kāi)復(fù)位堅(jiān)強(qiáng)內(nèi)固定是肱骨遠(yuǎn)端骨折的首選治療方式[2]。

C型肱骨遠(yuǎn)端骨折類(lèi)型復(fù)雜，骨折粉碎程度嚴(yán)重，需要仔細(xì)的術(shù)前計(jì)劃了解骨折類(lèi)型，以制定完善的手術(shù)方案[5]。我們建議術(shù)前行牽引位的肘關(guān)節(jié)正、側(cè)位X線檢查，可以更清晰地觀察骨折情況。隨著CT應(yīng)用的日趨廣泛，如具備條件也可以行CT三維重建。術(shù)中要首先搞清楚各個(gè)骨折塊間的位置關(guān)系，特別是較小的骨折塊，在克氏針固定時(shí)盡量一次成功，避免重復(fù)操作。

圖1 女性患者，47歲，術(shù)前左側(cè)肘關(guān)節(jié)正、側(cè)位X線片示肱骨遠(yuǎn)端骨折骨折(AO分型為C2型)(A,B);術(shù)后即刻肘關(guān)節(jié)正、側(cè)位X線片(C,D)，術(shù)后1年肘關(guān)節(jié)正、側(cè)位X線片示肱骨遠(yuǎn)端及尺骨鷹嘴截骨均愈合(E,F)，術(shù)后1年伸肘、屈肘功能相(G，H)，MEPS評(píng)分95分

影響肱骨遠(yuǎn)端骨折預(yù)后的因素有很多，包括創(chuàng)傷的嚴(yán)重程度、創(chuàng)傷至手術(shù)的間隔時(shí)間、合并損傷、骨質(zhì)量、關(guān)節(jié)面重建的程度、手術(shù)技術(shù)、使用的內(nèi)固定物、固定的穩(wěn)定性、制動(dòng)時(shí)間、感染和患者的合作程度等[6]。本研究結(jié)果顯示高能量組與低能量組在術(shù)后功能MEPS評(píng)分上的差異有統(tǒng)計(jì)學(xué)意義(P=0.025)，分析原因如下：首先，本組高能量損傷患者多合并其他部位損傷，如臂叢神經(jīng)損傷、顱腦損傷蛛網(wǎng)膜下腔出血、骨盆骨折、髖臼骨折、右側(cè)股骨頸骨折；其次，高能量損傷組的患者受傷至手術(shù)的時(shí)間間隔較長(zhǎng)，雖然差異無(wú)統(tǒng)計(jì)學(xué)意義，但間隔時(shí)間超過(guò)1周的患者以高能量損傷為主；另外，高能量損傷患者的局部軟組織損傷較重，部分合并有開(kāi)放性骨折，影響肘關(guān)節(jié)功能康復(fù)；本研究中高能量損傷的患者，術(shù)后進(jìn)行短期石膏外固定保護(hù)，開(kāi)始功能鍛煉的時(shí)間較晚，對(duì)晚期屈伸肘產(chǎn)生了影響。

術(shù)后肘關(guān)節(jié)規(guī)范化康復(fù)訓(xùn)練是影響關(guān)節(jié)功能的重要因素之一[7]，通過(guò)臨床實(shí)踐總結(jié)以下幾點(diǎn)：(1)盡可能早期進(jìn)行肘關(guān)節(jié)活動(dòng)，需要結(jié)合骨折及手術(shù)固定情況，對(duì)于C3型骨折病例，術(shù)后早期可以輔助石膏固定，但時(shí)間不能超過(guò)3周。(2)以肘關(guān)節(jié)的屈伸功能恢復(fù)為優(yōu)先，屈肘功能對(duì)患者日常生活動(dòng)作影響較大，而伸肘滯缺主要影響美觀、提物的力量和穿衣等功能，相對(duì)而言，屈肘更為重要。(3)主動(dòng)訓(xùn)練為主，避免暴力牽拉損傷肌肉及軟組織，過(guò)度力量的被動(dòng)活動(dòng)往往造成肌肉的拉傷、增加軟組織水腫，力量較大的被動(dòng)活動(dòng)容易促進(jìn)異位骨化的形成，造成僵硬。主動(dòng)活動(dòng)時(shí)的肌肉收縮，產(chǎn)生泵性作用，利于體液的回流，可以避免腫脹。(4)活動(dòng)的次數(shù)和強(qiáng)度根據(jù)骨折穩(wěn)定性和愈合情況逐漸增加。(5)重視物理治療在肘關(guān)節(jié)康復(fù)中的作用，包括冷療和磁療，通過(guò)冷療可以減輕肘關(guān)節(jié)訓(xùn)練后滲出，減輕腫脹。磁療可以促進(jìn)肢體血液循環(huán)，改善血管通透性，從而減輕腫脹。

本組患者有1例采用垂直尺骨長(zhǎng)軸的橫行截骨，術(shù)后出現(xiàn)截骨面分離，截骨處延遲愈合。在此之后手術(shù)改進(jìn)為“V”字形截骨，尖端指向遠(yuǎn)端[8]，使用鋼纜捆綁系統(tǒng)[9]或張力帶鋼板固定，均未出現(xiàn)截骨面分離移位的情況。文獻(xiàn)[10-11]報(bào)道常規(guī)行尺神經(jīng)前置會(huì)引起神經(jīng)損傷，本組患者術(shù)中均顯露尺神經(jīng)，術(shù)中尺神經(jīng)走形位置被內(nèi)固定物占據(jù)，均行尺神經(jīng)前置術(shù)，有2例患者術(shù)后出現(xiàn)尺神經(jīng)麻痹，末次隨訪時(shí)神經(jīng)麻痹恢復(fù)。

本組患者均采用雙鋼板垂直固定法[12]，目前對(duì)于雙鋼板放置在90°還是180°位置仍存在爭(zhēng)議[13]，平行鋼板技術(shù)是借助建筑學(xué)“拱門(mén)”原理來(lái)重建肱骨遠(yuǎn)端解剖結(jié)構(gòu)，通過(guò)鋼板螺釘與骨質(zhì)的整體咬合來(lái)維持穩(wěn)定性[14-15]。AO肱骨遠(yuǎn)端解剖鎖定接骨板在垂直方向固定，其設(shè)計(jì)不僅具有鎖定功能，并且遠(yuǎn)端螺釘更小(2.7 mm)，應(yīng)對(duì)骨質(zhì)疏松及關(guān)節(jié)面粉碎的骨折更為方便。

C型肱骨遠(yuǎn)端骨折是一類(lèi)復(fù)雜的肘關(guān)節(jié)骨折，我們經(jīng)過(guò)隨訪發(fā)現(xiàn)，使用AO解剖鎖定接骨板治療C型肱骨遠(yuǎn)端骨折的療效肯定，高能量損傷患者的預(yù)后較差，初始損傷因素影響患者肘關(guān)節(jié)功能恢復(fù)，規(guī)范化的肘關(guān)節(jié)康復(fù)訓(xùn)練有利于關(guān)節(jié)功能的恢復(fù)。本研究的不足在于入組的病例較少，隨訪時(shí)間較短，今后需繼續(xù)觀察，為臨床工作提供更有效的研究證據(jù)。

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[5] O′driscoll SW,Jupiter JB,Cohen MS,et al.Difficult elbow fractures:pearls and pitfalls[J].Instr Course Lect,2003,52:113-134.

[6] Frattini M,Soncini G,Corradi M,et al.Mid-term results of complex distal humeral fractures[J].Musculoskelet Surg,2011,95(3):205-213.

[7] Helfet DL,Schmeling GJ.Bicondylar intraarticular fractures of the distal humerus in adults[J].Clin Orthop Relat Res,1993(292):26-36.

[8] 劉林濤，馬寶通.尺骨鷹嘴截骨入路切開(kāi)復(fù)位內(nèi)固定治療肱骨髁間骨折的中長(zhǎng)期療效觀察[J].中華骨科雜志，2009，29(11)：1015-1018.

[9] 林朋，朱前拯，陳瀛，等.Cable-pin系統(tǒng)與克氏針張力帶治療MayoⅡa型尺骨鷹嘴骨折的近期療效比較[J].中日友好醫(yī)院學(xué)報(bào),2011，5(4):201-203.

[10] Chen RC,Harris DJ,Leduc S,et al.Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures?[J].J Orthop Trauma,2010,24(7):391-394.

[11] Ruan HJ,Liu JJ,Fan CY,et al.Incidence,management,and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus[J].J Trauma,2009,67(6):1397-1401.

[12] 蔣協(xié)遠(yuǎn)，公茂琪，查曄軍，等.肱骨髁間骨折術(shù)后不愈合的原因分析及治療[J].中華創(chuàng)傷骨科雜志,2010，12(6):534-537.

[13] Zalavras CG,Vercillo MT,Jun BJ,et al.Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures[J].J Shoulder Elbow Surg,2011,20(1):12-20.

[14] Penzkofer R,Hungerer S,Wipf F,et al.Anatomical plate configuration affects mechanical performance in distal humerus fractures[J].Clin Biomech (Bristol,Avon),2010,25(10):972-978.

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(本文編輯：李靜)

朱前拯，段亞景，楊雨潤(rùn)，等.解剖鎖定接骨板治療C型肱骨遠(yuǎn)端骨折的療效分析[J/CD].中華肩肘外科電子雜志,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

骨科常見(jiàn)疾病術(shù)后康復(fù)模式和臨床路徑研究(D131100004913005)

100029 北京，中日友好醫(yī)院創(chuàng)傷骨科1，康復(fù)醫(yī)學(xué)科2

劉成剛,Email：zqzpku@sina.com

2014-09-26)