微钢板重建肱骨外侧髁治疗Bryan-MorreyⅢ型肱骨小头骨折

doi:10.3877/cma.j.issn.2095-5790.2024.02.005

目的

探索微钢板重建肱骨远端外侧髁治疗Bryan-MorreyⅢ型肱骨小头骨折的效果。

方法

回顾性分析2016年11月至2022年4月20例Bryan-MorreyⅢ型肱骨小头骨折患者使用微钢板经肘关节外侧入路治疗肱骨小头骨折手术治疗的效果。

结果

所有20例患者均经过平均周期14个月的长时间随访。术后影像学评估均获得肱骨远端关节面满意复位。末次随访所有患者均获得骨性愈合，无肱骨小头坏死表现。根据Mayo功能评分评估，17例（85.0%）获得优秀、2例（10.0%）良好、1例（5.0%）中等。所有病例均无肘关节不稳或脱位，2例（10.0%）出现有症状异位骨化，所有患者均无神经功能障碍或感染表现。

结论

微钢板重建外侧髁治疗Bryan-MorreyⅢ型肱骨小头骨折尤其对于Dubberley B型是有效可行的。

关键词: 微钢板, Bryan-MorreyⅢ型肱骨小头骨折, 肘关节外侧入路, 疗效分析

Background

Capitulum humeral fractures are rare elbow injuries, accounting for less than 1% of elbow fractures and 6% of distal humerus fractures. Due to the frequent underestimation of capitulum humeral fractures on X-rays, non-displaced or osteochondral fractures may go undetected, making them easily missed or misdiagnosed. Open reduction and internal fixation effectively restore articular surface fractures and allow early functional rehabilitation, thereby preventing elbow stiffness and secondary degenerative arthritis. Among internal fixation methods, K-wires may not provide sufficient stability for early functional recovery and may damage the articular cartilage. Buried screws may cause joint pain and exacerbate joint degeneration when exposed, particularly in patients with avascular necrosis or chondrolysis. Plates can provide sufficient stability and be removed after fracture healing to avoid similar problems. However, for Bryan-Morrey Type III capitulum humeral fractures, in which there is the posterior condylar fracture of the capitellum, the loss of anterior screw fixation in the anterior capitellar articular surface poses a challenge for fixation using only a lateral plate. In this regard, the authors use mini plates placed on the posterior and lateral aspects of the distal humerus to achieve adequate fixation of the anterior capitellar articular surface with screws inserted along the coronal fracture line and to address the issue of ineffective fixation of Dubberley Type B posterior capitulum humeral fracture.

Objective

To explore the effect of micro-plate reconstruction of humeral lateral condyle for treatment of Bryan-Morrey Ⅲ capitellum humeral fractures.

Methods

A retrospective analysis was performed on 20 patients with Bryan-Morrey typeⅢ capitellum humeral fractures treated with micro-plate through lateral elbow approach from November 2016 to April 2022.

Results

All 20 patients were followed for a long time with a mean period of 14 months. Satisfactory reduction of the distal articular surface of the humerus was obtained by postoperative imaging evaluation. Bone healing was achieved in all patients at the last follow-up, and there was no sign of necrosis of the humeral capitellum. According to the Mayo functional score assessment, 17 cases (85.0%) were excellent, 2 cases (10.0%) were good, and 1 case (5.0%) was moderate. All the patients had no instability or dislocation of the elbow joint, 2 patients (10.0%) had symptomatic ectopic ossification, and none had neurological dysfunction or infection.

Conclusion

Lateral condylar reconstruction with micro-plate is practical and feasible for Bryan-Morrey type Ⅲ capitellum humeral fractures, especially for Dubberley type B fractures.

Key words: Micro-plate, Bryan-Morrey typeⅢ capitellum humeral fracture, Kocher approach, Efficacy analysis

图1 患侧肘关节受伤急诊影像学检查，X线片示：肱骨远端外侧髁骨折（图A）,肱骨远端前侧双弧征（图B）；三维CT示：患侧肱骨远端外侧髁骨折，关节面冠状位骨折累及滑车（图C），关节面冠状位骨折块向前上移位（图D），肱骨外侧髁后柱粉碎骨折（图E）

图2 术中操作流程外像　图A：肱骨小头冠状位骨折，肱骨外侧髁后柱骨折移位明显；图B：延外侧切口剥离前方软组织显露肱骨远端前侧滑车部分，确保关节面冠状位骨折解剖复位；图C：解剖复位关节面骨折，克氏针临时固定；图D：肱骨远端外侧、后外侧放置钢板，拔除临时固定克氏针

图3 术中验证影像　图A-B：克氏针临时固定后术中透视明确关节面解剖复位；图C-D：术中透视明确是否有螺钉穿出关节面

图4 术后X线影像　图A：肘关节正位；图B：肘关节侧位示肱骨远端冠状位骨折解剖复位，内固定物位置满意

图5 术后1年随访功能评估：患侧肘关节功能伸10°（图A）、曲120°（图B）、旋前85°（图C）、旋后90°（图D）、及手术切口

表1 患者肘关节损伤情况及术后随访结果

序号	部位	分型	合并损伤	伸直（°）	屈曲（°）	旋前（°）	旋后（°）	MEPS（分）	异位骨化	随访周期（月）
1	R	ⅢB		10	120	85	90	100		12
2	L	ⅢA		5	125	90	95	100		12
3	L	ⅢB	MCL、桡骨头骨折	30	95	90	80	85	后侧	14
4	R	ⅢA	MCL	5	110	90	85	95		12
5	L	ⅢB	MCL	5	110	85	80	95		12
6	L	ⅢA		5	130	75	80	100		12
7	L	ⅢA		0	140	90	90	100		9
8	L	ⅢB	MCL	10	120	90	90	100		12
9	R	ⅢB	MCL	20	120	80	90	95		12
10	L	ⅢA		0	140	90	90	100		12
11	R	ⅢB	MCL	60	100	90	90	75	后侧	12
12	R	ⅢB	MCL	0	130	90	90	100		18
13	L	ⅢA		10	130	90	90	100		12
14	R	ⅢA		10	110	80	90	90		14
15	L	ⅢA		0	135	90	90	100		16
16	R	ⅢB	MCL	0	110	90	90	95		12
17	L	ⅢB		10	120	80	85	100		14
18	L	ⅢA		5	120	90	90	100		17
19	L	ⅢB	桡骨头骨折	0	125	90	90	100		14
20	L	ⅢA		10	120	85	90	100		12

表1 患者肘关节损伤情况及术后随访结果

序号	部位	分型	合并损伤	伸直（°）	屈曲（°）	旋前（°）	旋后（°）	MEPS（分）	异位骨化	随访周期（月）
1	R	ⅢB		10	120	85	90	100		12
2	L	ⅢA		5	125	90	95	100		12
3	L	ⅢB	MCL、桡骨头骨折	30	95	90	80	85	后侧	14
4	R	ⅢA	MCL	5	110	90	85	95		12
5	L	ⅢB	MCL	5	110	85	80	95		12
6	L	ⅢA		5	130	75	80	100		12
7	L	ⅢA		0	140	90	90	100		9
8	L	ⅢB	MCL	10	120	90	90	100		12
9	R	ⅢB	MCL	20	120	80	90	95		12
10	L	ⅢA		0	140	90	90	100		12
11	R	ⅢB	MCL	60	100	90	90	75	后侧	12
12	R	ⅢB	MCL	0	130	90	90	100		18
13	L	ⅢA		10	130	90	90	100		12
14	R	ⅢA		10	110	80	90	90		14
15	L	ⅢA		0	135	90	90	100		16
16	R	ⅢB	MCL	0	110	90	90	95		12
17	L	ⅢB		10	120	80	85	100		14
18	L	ⅢA		5	120	90	90	100		17
19	L	ⅢB	桡骨头骨折	0	125	90	90	100		14
20	L	ⅢA		10	120	85	90	100		12

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Micro-plate reconstruction of humeral lateral condyle for Bryan-MorreyⅢ capitellum humeral fractures

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Micro-plate reconstruction of humeral lateral condyle for Bryan-MorreyⅢ capitellum humeral fractures