克氏针张力带内固定治疗肱骨远端骨折生物力学研究及临床应用
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摘要
目的肱骨远端骨折是一种严重的肘部损伤,传统治疗方法从保守治疗到手术治疗效果不佳,近年随着内固定技术发展及对生物力学研究不断深入认识,比较广泛采用切开复位内固定手术治疗,但对于肱骨远端骨折如何固定一直存在争议,肱骨远端骨折对骨科医师是一极大的挑战。本研究采用克氏针张力带固定肱骨远端骨折,通过生物力学研究及临床应用,探讨其生物力学规律,为克氏针张力带固定治疗肱骨远端骨折应用提供理论依据及临床指导。
方法
(一)生物力学研究
新鲜成人尸体肱骨标本6例,X线排除骨骼病理异常,去除周围软组织,距肱骨远端关节面2cm处用板锯横行截骨,制成骨折模型。随机编号分为三组,每组分别以单枚克氏针张力带、双枚克氏针张力带及双钢板固定,测定后再依次更换为另一种固定方式,即每个标本先后采用三种不同的固定方式进行测定,每种固定方式可测定6次。采用CSS—44000电子万能试验机进行力学测试。因肱骨远端骨块较小,不易固定,本实验采用自行设计的多针夹具系统进行固定以确保受力分布均匀并达到可靠的固定。近段在距关节面7cm处侧方加载,模拟肘关节伸、屈、内、外翻状态,设定速度为3mm/min。为了防止标本破坏,将载荷最大值设为40N,首先测定载荷与变形关系,最后测定极限载荷。微机进行数据的记录处理,绘出载荷与变形曲线,用斜率(刚度)表示固定的稳定性。
(二)临床应用共30例,男11例,女19例；年龄16～67岁,平均41岁。左侧13例,右侧17例。开放骨折9例,Gustilo I度5例,Ⅱ度4例。闭合骨折21例。受伤原因：摔伤21例,交通伤7例,其它原因2例。按照AO/ASIF分类：C1型4例,C2型14例,C3型12例。合并其它部位损伤4例,其中桡骨远端骨折2例,肋骨骨折1例,肱骨外科颈骨折1例。合并有内科疾病3例,合并尺神经损伤2例。受伤至手术时间0—17天,平均7天。手术在臂丛神经阻滞麻醉下进行,采用肘关节后正中切口暴露骨折端后,采用双钢板17例,克氏针张力带内固定13例。
结果在三种固定方式中,双钢板组在后侧加载下固定强度(肘关节屈曲)最大为9.71±3.53 N/mm (p<0.05),而双枚克氏针张力带固定组在前侧加载下(肘关节伸直)最大5.36±2.17 N/mm (p<0.05),单枚克氏针张力带组在前后方向均明显小于双枚克氏针张力带组及双钢板进行固定组(p<0.05)。内外侧刚度各组间无明显区别(p>0.05)。双枚克氏针张力带组及双钢板进行固定组各方向极限载荷值明显大于单枚克氏针张力带固定组。临床结果显示克氏针张力带固定组手术时间短、出血量少(p<0.05),肘关节功能相同(p>0.05)。
结论对于肱骨远端骨折,复位固定后整体稳定性受到内固定及骨骼质量双重因素的影响。张力带系统在肱骨远端骨折固定符合生物力学要求,应用张力带固定时,应进行双针加强固定。在临床应用上适应证广泛,操作简单,可与双钢板内固定取得相同效果。
Object:Fractures of distal humerus is a severe injury in the elbow, treatment can be done by traditional conservatives to open reduction and internal fixation, but the outcome is unacceptable. With the evaluation of biomechanical study and clinical experience, open reduction and internal fixation is optimal for this injury, but how to get stable fixation is controversial, however it is a challenge for the orthopedic surgeons. This study, biomechanical study and clinical experience of k-wire tension band to distal humerus fractures, intend to investigate the characteristic of fixation and provide clinical guide for distal humerus fractures.
Method:1. Biomechanical study:6 fresh cadaver humerus species, excluded pathology by x-ray, were removed soft tissue and apply osteoectomy proximal 2 cm to articular surface. Every two species were fixed with single k-wire tension band, double k-wire and tension band, double plates and then change another style. CSS—44000 electronic multipurpose biomechanical apparatus were used to determine the stable features. Distal part were fixed with a multiple screw set clamp and four direction loading were given on humerus shaft 7 cm to articular surface to imitate the elbow extension, flexion, adduction and abduction. We set up velocity for 3mm/min and maximum loading for 40N to prevent the species damage. Measure the loading and deformity relationship then the maximum loading, all the data input computer and output loading deformity line, the slop rigidity represent stability.2. Clinical application:There were 30 case distal humerus in this study, male 11 case, female 19case, age from 16 to 67, average 41, left 13 and right 17. open fracture 9 case, with GustiloⅠ5 case,Ⅱ4case, close fracture 21 case, cause of fracture falling 21 case, motor vehicle accident 7 case, according to AO/ASIF classification:C14 case, C2 14 case, C3 12 case. All the patients undergone operation 0 to 17day after injury, brachial plexus block anesthesia, with a posterior midline incision exposure the fracture, double plate 17 case, double tension band 13 case.
Result Double plate group with highest rigidity for 9.71±3.53 N/mm (p<0.05) in posterior direction, while double tension band group with highest rigidity 5.36±2.17 N/mm (p<0.05) in anterior direction. There is no difference between medial and lateral direction. Clinical study show double tension band group with less time and less blood lose, but with the same elbow function.
Conclusion Stability for distal humerus fracture was determined by character of bone and style of internal fixation, double tension band conform to biomechanical character but double k-wire is better to strengthen the rigidity. Double tension band has more indication, easy and can achieve the same result with double plate.
方法
(一)生物力学研究
新鲜成人尸体肱骨标本6例,X线排除骨骼病理异常,去除周围软组织,距肱骨远端关节面2cm处用板锯横行截骨,制成骨折模型。随机编号分为三组,每组分别以单枚克氏针张力带、双枚克氏针张力带及双钢板固定,测定后再依次更换为另一种固定方式,即每个标本先后采用三种不同的固定方式进行测定,每种固定方式可测定6次。采用CSS—44000电子万能试验机进行力学测试。因肱骨远端骨块较小,不易固定,本实验采用自行设计的多针夹具系统进行固定以确保受力分布均匀并达到可靠的固定。近段在距关节面7cm处侧方加载,模拟肘关节伸、屈、内、外翻状态,设定速度为3mm/min。为了防止标本破坏,将载荷最大值设为40N,首先测定载荷与变形关系,最后测定极限载荷。微机进行数据的记录处理,绘出载荷与变形曲线,用斜率(刚度)表示固定的稳定性。
(二)临床应用共30例,男11例,女19例；年龄16～67岁,平均41岁。左侧13例,右侧17例。开放骨折9例,Gustilo I度5例,Ⅱ度4例。闭合骨折21例。受伤原因：摔伤21例,交通伤7例,其它原因2例。按照AO/ASIF分类：C1型4例,C2型14例,C3型12例。合并其它部位损伤4例,其中桡骨远端骨折2例,肋骨骨折1例,肱骨外科颈骨折1例。合并有内科疾病3例,合并尺神经损伤2例。受伤至手术时间0—17天,平均7天。手术在臂丛神经阻滞麻醉下进行,采用肘关节后正中切口暴露骨折端后,采用双钢板17例,克氏针张力带内固定13例。
结果在三种固定方式中,双钢板组在后侧加载下固定强度(肘关节屈曲)最大为9.71±3.53 N/mm (p<0.05),而双枚克氏针张力带固定组在前侧加载下(肘关节伸直)最大5.36±2.17 N/mm (p<0.05),单枚克氏针张力带组在前后方向均明显小于双枚克氏针张力带组及双钢板进行固定组(p<0.05)。内外侧刚度各组间无明显区别(p>0.05)。双枚克氏针张力带组及双钢板进行固定组各方向极限载荷值明显大于单枚克氏针张力带固定组。临床结果显示克氏针张力带固定组手术时间短、出血量少(p<0.05),肘关节功能相同(p>0.05)。
结论对于肱骨远端骨折,复位固定后整体稳定性受到内固定及骨骼质量双重因素的影响。张力带系统在肱骨远端骨折固定符合生物力学要求,应用张力带固定时,应进行双针加强固定。在临床应用上适应证广泛,操作简单,可与双钢板内固定取得相同效果。
Object:Fractures of distal humerus is a severe injury in the elbow, treatment can be done by traditional conservatives to open reduction and internal fixation, but the outcome is unacceptable. With the evaluation of biomechanical study and clinical experience, open reduction and internal fixation is optimal for this injury, but how to get stable fixation is controversial, however it is a challenge for the orthopedic surgeons. This study, biomechanical study and clinical experience of k-wire tension band to distal humerus fractures, intend to investigate the characteristic of fixation and provide clinical guide for distal humerus fractures.
Method:1. Biomechanical study:6 fresh cadaver humerus species, excluded pathology by x-ray, were removed soft tissue and apply osteoectomy proximal 2 cm to articular surface. Every two species were fixed with single k-wire tension band, double k-wire and tension band, double plates and then change another style. CSS—44000 electronic multipurpose biomechanical apparatus were used to determine the stable features. Distal part were fixed with a multiple screw set clamp and four direction loading were given on humerus shaft 7 cm to articular surface to imitate the elbow extension, flexion, adduction and abduction. We set up velocity for 3mm/min and maximum loading for 40N to prevent the species damage. Measure the loading and deformity relationship then the maximum loading, all the data input computer and output loading deformity line, the slop rigidity represent stability.2. Clinical application:There were 30 case distal humerus in this study, male 11 case, female 19case, age from 16 to 67, average 41, left 13 and right 17. open fracture 9 case, with GustiloⅠ5 case,Ⅱ4case, close fracture 21 case, cause of fracture falling 21 case, motor vehicle accident 7 case, according to AO/ASIF classification:C14 case, C2 14 case, C3 12 case. All the patients undergone operation 0 to 17day after injury, brachial plexus block anesthesia, with a posterior midline incision exposure the fracture, double plate 17 case, double tension band 13 case.
Result Double plate group with highest rigidity for 9.71±3.53 N/mm (p<0.05) in posterior direction, while double tension band group with highest rigidity 5.36±2.17 N/mm (p<0.05) in anterior direction. There is no difference between medial and lateral direction. Clinical study show double tension band group with less time and less blood lose, but with the same elbow function.
Conclusion Stability for distal humerus fracture was determined by character of bone and style of internal fixation, double tension band conform to biomechanical character but double k-wire is better to strengthen the rigidity. Double tension band has more indication, easy and can achieve the same result with double plate.
引文
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