手术-肱骨干骨折桥接钢板内固定术

1、1.1、原则 桥接钢板Bridge plating uses the plate as an extramedullary splint, fixed to the two main fragments, while the intermediate fracture zone is left untouched. Anatomical reduction of the shaft fragments is not necessary. Furthermore, direct manipulation risks disturbing their blood supply. If the so

2、ft tissue attachments are preserved, and the fragments are relatively well aligned, healing is predictable.桥接钢板把钢板作为髓外夹板，固定两个主要骨折端，而骨折区域不予干预，肱骨干骨折不必解剖复位，并且，直接操作复位有干扰骨折端血供的风险，如果保留软组织的连续，骨折愈合可能性增加。Alignment of the main shaft fragments can usually be achieved indirectly utilizing traction and soft tiss

3、ue tension.主要骨折块的对位对线可以通过间接使用牵开器和软组织附着性来完成。Mechanical stability, provided by the bridging plate, is adequate for indirect healing (callus formation). Occasionally, a larger wedge fragment might be approximated to the main fragments with a lag screw. Lag screws should be avoided when there are multip

4、le fragments桥接钢板提供稳定性，对于骨折二期愈合（骨痂愈合）是充足的，个别情况下，一个大的楔形骨折需要用拉力螺钉固定到主要骨折块，在多段骨折情况下避免使用拉力螺钉。1.2 桥接钢板的置入Bridge plate insertionBridge plates can be inserted either with an open exposure, or through a minimally invasive (MIO) approach, which leaves soft tissues intact over the fracture site. The latter req

5、uires fluoroscopic monitoring. With open bridge plating, it is important to preserve soft-tissue attachments to the fracture fragments. To do this, stable provisional reduction (with external fixation, large distractor, or maintained manual traction), and minimal exposure and manipulation of the fra

6、cture zone are important. The bridge plate is applied through an incision just wide enough for the plate.桥接钢板可以通过切开显露，或通过微创显露置入，在MIO情况下可以保留骨折区域软组织完整性，但其要求术中透视帮助。桥接钢板技术，保留骨折断端软组织连续性是很重要的，为了做到这个，稳定的临时复位（通过外固定架，大的牵开器，持骨器），最小程度显露和操作骨折区域是很重要的，桥接钢板需要手术切口可以置入钢板即可。1.3 复位ReductionIt is important to restore a

7、xial alignment and rotation. A little shortening of 1 or 2 cm can be accepted in the humerus, and in complex multifragmentary fractures may improve bone contact.Exceptionally, a large fragment has been separated from the fracture with a sharp end impaled in the adjacent muscle. This may need to be r

8、epositioned directly with protection of soft-tissue attachments.复位骨折轴向序列和旋转移位是重要的，短缩1-2cm是可以接受的，在复杂多段骨折可以提供骨的接触。另外一些情况，大骨折块从骨折断端分离插入临近的肌肉组织，此中情况需要直接复位骨折，同时注意保护软组织连续性。2.1 钢板的位置 Plate locationThe humerus has an anterolateral, a posterior, and a medial surface to each of which a plate can be applied. T

9、he location of the fracture will determine where the surgeon chooses to apply a plate to the humerus. The position of the plate is selected according to fracture location, and the length of proximal and distal main segments.肱骨有前外侧面，后面，内侧面，三面都可以应用钢板。钢板的位置通过骨折位置以及位置。The location should allow sufficien

10、t plate length on both proximal and distal segments, with a minimum of 4 holes for each.钢板在骨折的主要骨折端最少需要4孔长度An anterolateral plate fits well from very proximally to the distal fifth of the humerus.肱骨前外侧可以适合从肱骨最近端到远端1/5的区域。The posterior surface is difficult to access proximally and is best suited for

11、middle and distal third fractures. Once a location for the plate has been selected, the surgical approach is determined by that location. For proximal fractures, an anterolateral plate location and anterolateral surgical exposure are usual. For distal fractures, a posterior plate location is preferr

12、ed. This area can be accessed with either a posterolateral, or a posterior, approach. In the central portion of the humerus, the plate can be applied to the anterolateral, lateral, or posterior surfaces, with the approach dependent on the preferred plate location.肱骨后面显露近端较困难，更适合中段和远1/3骨折，当内置物选择完成后，手

13、术切口由骨折位置决定，对于近端骨折，可以前外侧显露和前外侧置入钢板。对于远端骨折，后侧钢板置入更合适，此区域可以通过后外侧或后侧切口进入。在肱骨干中段，钢板可以放置在前外侧或外侧，或后侧，切口根据钢板放置位置决定。The medial surface is generally reserved for complex reconstructive procedures.内侧面通常为复杂骨折重建应用。2.2 外侧置入Lateral platingAn anterolateral approach is chosen for proximal and middle third fractures,

14、 and allows supine patient positioning.The lateral approach can also be used, particularly if the most proximal part of the humerus need not be exposed.Distally, the plate may lie deep to the radial nerve.前外侧切口可以用来显露肱骨近端和中1/3骨折，病人仰卧位，如果肱骨近端不需要显露，外侧切口也可以。在肱骨远端，肱骨位于桡神经深面。2.3 后方置入Posterior platingA pos

15、terior approach will generally be chosen for more distal fractures.It is important to protect the radial nerve and its accompanying vessels in the spiral groove. Typically, a posterior plate must be placed underneath the radial nerve, to gain proximal bone anchorage.后方入路通常用于肱骨远端骨折。要注意保护桡神经及其伴行的血管束，一

16、般情况下，后方内置物需要放置桡神经下方，以获得近端肱骨把持。注意Note(a) It is possible to extend an anterolateral approach to access the posterior surface of the distal humerus.(b) It is mandatory to record accurately in the operation record the exact relationship of the radial nerve to the plate - either by a precise drawing, or

17、by recording the plate hole numbers (counted from proximal to distal) where the nerve lies. This will reduce the risk of accidental nerve damage if the plate should ever need to be removed.（a）可以延伸前外侧入路至肱骨远端后面。（b）必须记录准确的桡神经和内置物关系，可以通过精确画图或记录钢板孔数（从近向远数）来记录神经位置。这样钢板需要取出的时候可以降低神经损伤的风险。3.1 手法复位Manual red

18、uctionReduction should begin with limb realignment. This manipulative reduction takes advantage of soft tissue tension. Traction on the distal humerus restores bone length and tension in the soft tissues, and realigns the axis. Rotation must also be corrected.复位首先整复肢体轴线，此操作通过软组织张力来实现，牵引肱骨远端以恢复骨的长度和轴

19、线，并需要矫正旋转。Interposed soft tissue may interfere with bone contact. If so, this will need to be cleared by direct exposure, preserving as much soft-tissue attachment as possible.嵌顿软组织可能影响骨接触，如果这样，则需要清除骨折断端，尽量保持软组织的连续性。3.2 外固定架或牵开器复位Reduction by external fixator or distractorParticularly with comminute

20、d fractures, use of an external fixator or distractor can provide alignment and stability for bridge plating without disturbing the soft tissues at the fracture site.Proximal and distal pins should be inserted outside the planned plate location, through small open wounds to protect nerves and vessel

21、s. For this intraoperative purpose, careful positioning of the pins outside the safe zones is acceptable.Complete reduction may require additional correction of angulation or rotation.Folded linen bolsters under the fracture often help.在粉碎骨折，使用外固定架或牵开器可以提供较好稳定性，并且不干扰骨折处软组织。近端和远端斯式针应位于钢板的两侧，小切口以保护神经和

22、血管，注意选择置入针安全区域。完全复位需要另外矫正成角畸形和旋转畸形。3.3 粉碎骨折Comminuted fragmentsRemember that alignment of comminuted fragments need not be anatomical, and that efforts to manipulate them often injure their blood supply.Generally, soft tissue attachments will bring these fragments into appropriate positions as the p

23、roximal and distal portions of the humerus are brought into correct alignment and fixed.Occasionally, a lag screw through a plate or major humeral segment can be used to improve fracture fragment approximation.粉碎骨折的骨折块不需解剖复位，复位它们常损伤其血供。一般来讲，软组织附着可以使这些骨折块在骨折远近端复位后获得恰当位置。偶尔，通过钢板或主要骨折块的拉力螺钉可以提高骨折块间接近程度

24、。4.1 选择内置物 Choice of implantAs bridge plating spans a long section of the bone, the length of the implant has to be chosen accordingly. Usually a narrow large fragment plate is selected.If the cortex of the humerus is thin, screw fixation is compromised. Particularly with osteoporosis, it is safer t

25、o fill all the screw holes. Multiple screws add torsional stability and decrease the risk of failure.An angular stable plate is a good option in osteoporotic bone. Also, with short proximal segments, consideration should be given to angular stable plating with a long blade plate or locking compressi

26、on plate, with screws in the humeral head.In the past, the broad plate has been advised to allow staggered screw holes. This is not necessary, but the screws may be inserted divergently to achieve this effect on the far cortex.桥接钢板跨越粉碎骨折区域，内置物需要根据此确定。如果骨皮质较薄，可以增加螺钉来增加稳定。特别是骨质疏松患者，增加螺钉数量以增加安全。角稳定钢板对于

27、骨质疏松患者是一个很好的选择。对于肱骨近端骨折，最好应用角稳定钢板。过去，使用宽内置物来达到螺钉交叉的目的，这不是必须的，但可以通过螺钉的分散置入来完成此作用。4.2 钢板塑型Contouring the plateDepending upon the planned plate location, some contouring of the plate may be necessary. This is true distally on the posterior surface, and also centrally on the anterolateral surface.Someti

28、mes, twisting the plate around the shaft of the humerus provides better fit and allows for a longer plate.To match the orientation of the anterolateral surface of the distal humerus, the distal end of the plate will need to be twisted internally.Contouring is aided by first achieving a provisional r

29、eduction using the large distractor or an external fixator. A malleable template is helpful for matching contours of proximal and distal segments.钢板塑形依据设计钢板位置，一些塑形是必须的，如在肱骨远端后面，又如前外侧面中央。有时，沿肱骨干扭转钢板（如下图）可以提供更好的贴服，并允许更长的内置物。为匹配肱骨远端前外侧面，内置物的远端需要向内侧扭转。可以用一个塑形模版来帮助钢板塑形（如下图）4.3 注意：避免软组织损伤Pitfall: Avoid so

30、ft tissue damageDuring contouring and application of the bridge plate, the soft tissues attached to the fracture fragments must be preserved. Provisional fracture stabilization and minimal handling of the fracture site are the keys to this.在塑形和应用内置物时，必须注意保护骨折块上的软组织附着，临时固定和最小化处理骨折区域很重要。4.4 内置物应用 Plat

31、e applicationApply the properly contoured plate to the proximal fragment, so that it is correctly aligned with the humeral axis. When the plate fits satisfactorily against the proximal segment, it can be attached provisionally with a single bicortical screw. While the plate is held manually against

32、the bone, the screw is inserted.使用恰当塑形的内置物在肱骨近端，以便其与肱骨轴线一致，当内置物与骨干近端完全贴服时，可以先用1枚皮质骨螺钉固定，钢板用手压住，拧入螺钉。Sometimes it is helpful to clamp the plate to the proximal fragment of the humerus with a bone forceps.有时，可以用持骨器来把持肱骨近端。Applying the plate to the distal fragment will correct rotation and axial alignm

33、ent.In the lateral view the plate must be parallel to the longitudinal axis of the humerus. If alignment is satisfactory, apply a second screw to secure the plate proximally in this correct position.在肱骨远端，内置物要与肱骨的旋转及轴线一致。在侧位上，内置物必须与肱骨的长轴平行，如果轴线满意，在肱骨近端拧入第2个螺钉。4.5 对线并固定肱骨远端Alignment and fixation of the distal fragmentOnce the plate is satisfactorily fixed proximally, the distal fragment is brought into alignment against the plate.Often t