Morrey Mark E, Morrey Bernard F, Sanchez-Sotelo Joaquin, Barlow Jonathon D, O'Driscoll Shawn
Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
J Clin Orthop Trauma. 2021 Jun 12;20:101477. doi: 10.1016/j.jcot.2021.101477. eCollection 2021 Sep.
Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.
成人肱骨远端骨折是具有挑战性的损伤。它们通常需要通过内固定或全肘关节置换术的形式进行手术干预，全肘关节置换术在患有粉碎性骨折的生理上较为年长的患者中越来越多地被使用。仔细的术前评估，包括骨折类型、骨质质量、既往病症和功能需求，有助于确定最佳治疗方案。在手术治疗的合理规划中，包括二维和三维重建的CT扫描几乎是必不可少的。在大多数生理上年轻且健康的患者中，切开复位内固定术（ORIF）是首选治疗方法。生物力学研究表明，平行钢板比90/90钢板在更大程度上抵抗旋转畸形，从而允许髁上愈合。关节面碎片的精确复位和髁上区域的加压是内固定成功的关键。固定失败的主要原因是髁上区域的不愈合或畸形愈合。奥德里斯科尔等人描述的原则允许对远端关节面碎片进行牢固固定，并在髁上水平进行加压，这对愈合以及预防内固定物失败和不愈合至关重要。鹰嘴截骨术可改善肱骨远端关节面的暴露，但也有其自身的问题，应尽可能避免。尺神经激惹是一种常见并发症，因此应将其分离，全程保持可视，如果必要，可向前移位。髁上骨折的不愈合或畸形愈合可通过翻修切开复位内固定术或全肘关节置换术（TEA）治疗。髁上缩短、植骨和挛缩松解是不愈合治疗的重要环节。在无法进行切开复位内固定的不可重建的肱骨远端骨折中，由于碎片尺寸小、严重粉碎和/或骨质质量差，全肘关节置换术是首选治疗方法。肱三头肌可以保持完整，因为切除骨折碎片通常能提供足够的操作空间。有时，只有在暴露骨折后才决定进行全肘关节置换术，因此如果无法进行切开复位内固定术，外科医生应熟练掌握全肘关节置换术；并且应备有必要的器械和植入物。尽管结果令人满意，但全肘关节置换术后的总体并发症发生率仍然很高，这使得手术效率和技术能力至关重要。
