肱骨远端复杂骨折cdr.ppt

1、,Complex Distal Humeral Fractures:Internal Fixation with a Principle-BasedParallel-Plate,By Joaquin Sanchez-Sotelo, MD, PhD, Michael E. Torchia, MD, and Shawn W. ODriscoll, PhD, MD,2,J. Bone Joint Surg. Am., May 2007; 89: 961 969 By Joaquin Sanchez-Sotelo, MD, PhD, Mi-chael E. Torchia, MD, and Shawn

2、 W. OD- riscoll, PhD, MD,3,BACKGROUND,Severe comminution, bone loss, and osteopenia at the site of a distal hum- eral fracture increase the riskof an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the out- come of treating these fractures wi

3、th a principle-based technique that max- imizes fixation in the articular fragm- ents andstability at the supracondylar level.,4,METHODS,fixed with two parallel plates applied (medially and laterally) in approxim- ately the sagittal plane two principles: (1) fixation in the distal fragments should b

4、e maximized (2) screw fixation in the distal segment should contribute to stability at the supracondylar level,5,CONCLUSIONS,Stable fixation and a high rate of un- ion of complex distal humeral fractu- res can be achieved when a principle-based surgical technique that max- imizes fixation in the dis

5、tal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilit-ation to restore elbow motion.,6,INTRODUCTION,Poor outcomes include contracture, seco- ndary to prolonged immobilization thought to be necessary to protect

6、the fixation, and nonunion improved fixation technique: enhance fixation in the distal fragments provide compression at the supracondylar level The key to the stability - locking the two columns of the distal part of the humerus together.,7,EXPOSURE,The TRAP (triceps-anconeus reflecting pedicle) How

7、ever,we believe that anolecranon osteotomy provides even greater ex- posure and it is recommended in the setting of intra-articular comminution,8,PARALLEL PLATING,parallel plating eight technical objectives Six of these objectives concern the screws in the distal fragments, and two concern the plate

8、s,9,PARALLEL PLATING,TABLE Technical Objectives Checklist Objectives concerning screws in the distal fragments Objective 1: each screw should pass through a plate Objective 2: Each screw should engage a fragment on the opposite side that is also fixed to a plate Objective 3: An adequate number of sc

9、rews should be placed in the distal fragments Objective 4: Each screw should be as long as possible Objective 5: Each screw should engage as many articular fragments as possible Objective 6: The screws should lock together by interdigita- tion, thereby creating a fixed-angle structure and linking th

10、e columns together Objectives concerning the plates used for fixation Objective 7: Plates should be applied such that compression is achieved at the supracondylar level for both columns Objective 8: Plates used must be strong enough and stiff enough to resist breaking or bending before union occursa

11、t the supracondylar level.,10,PARALLEL PLATING,The medial plate is placed on the medial aspect of the medial column, and the lateral plate is placed laterally, rather than posteriorly, on the lateral column the angle between them is often in the range of 150 to 160 Permit: at least four long screws

12、com- pletely through the distal fragments from one side to the other increasing stability of the construct enhance the locking together of the two columns,11,PARALLEL PLATING,12,SURGICAL TECHNIQUE Step 1,Articular Surface Reduction The articular fragments are provisionally fixed with smooth Kirschne

13、r wires absent bone-two important principles First, the anterior aspect of the distal part of the humerus is the critical region that needs to be restored in order to have a functional joint Second,the medial half of the trochlea is essential for obtaining a stable and well-aligned,13,SURGICAL TECHN

14、IQUE Step 1,14,SURGICAL TECHNIQUE Step 2,Plate Placement and Provisional Fixation contour plates to fit the reassembled humerus medially and laterally or to choose precontoured plates The length of the plates is selected so that at least three screws can be placed in the prox- imal part of the humer

15、al shaft The plates should end at different levels proximally to avoid the creation of a stress-riser,15,SURGICAL TECHNIQUE Step 2,16,SURGICAL TECHNIQUE Step 3,Articular Fixation medial and lateral screws are introduced distally to provide stable fixation of the intra-articular fragments and rigid a

16、nchorage to the plates the screws should be as long as possible, should pass through as many fragments as possible, and should engage in the opposite column a large bone clamp is used to compress the intra-articular fracture lines,17,SURGICAL TECHNIQUE Step 3,18,SURGICAL TECHNIQUE Step 4,Supracondyl

17、ar Compression a large bone clamp is applied and a proximal screw is inserted through the plate in compr-ession mode the same steps are followed on the opposite side diaphyseal screws are then introduced, providing additional compression as a result of the undercontoured plates being pulled down to

18、the underlying bone,19,SURGICAL TECHNIQUE Step 4,20,SURGICAL TECHNIQUE Step 4,21,SURGICAL TECHNIQUE Step 5,Final Fixation The smooth Steinmann pins are removed the remainder of the screws are inserted The intraoperative elbow motion should be full unless substantial swelling has already developed,22

19、,SURGICAL TECHNIQUE Step 5,23,SURGICAL TECHNIQUE,Dealing with Metaphyseal Bone Loss Adequate osseous contact with interfragmen- tary compression in the supracondylar region is necessary to ensure the stability of the construct and eventual fracture union Metaphyseal bone loss, the humerus can be shortened at the metaphysealdiaphyseal fracture site, provided that the overall align- ment and geometry of the distal part of the humerus is correct as much as 2 cm of shortening can be tole- rated without serious disturbance of elbow biomechanics,24,SURGICAL TECHNIQUE,25,SURGICAL