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1、Distal Humeral Fractures in Adults成人中的肱骨远端骨折Aaron Nauth, Michael D. McKee, Bill Ristevski, Jeremy Hall and Emil H. SchemitschJ Bone Joint Surg Am. 2011;93:686-700.Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases.Dual pla
2、te fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90_ or 180_ to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus.Acute total elbow arthroplasty is the preferred treatment for elderly
3、 patients with a displaced, comminuted, intraarticular distal humeral fracture that is not amenable to stable internal fixation.Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach. 肱骨远端骨折在成人损伤中并不常见，大部分病例需要手术干预。双钢
4、板固定适用于所有肱骨远端涉及双柱的成人骨折，这一技术要求在每个柱上各置入一枚坚强的钢板，两枚钢板之间的方向为 90 度或 180 度。在难复性移位粉碎的肱骨远端骨折中，内固定不能使骨折获得稳定时，对于老年患者可给予急症全肘关节置换治疗。肱骨远端关节面的冠状面剪力移位骨折需要内固定手术治疗，多经外侧入路实施手术。 Distal humeral fractures in adults are complex and technically demanding injuries to manage. Operative intervention is indicated in most cases
5、and is often complicated by difficult exposure, osteoporotic bone, and comminution in the metaphyseal and/or articular region. There is controversy regarding a number of issues pertaining to the management of distal humeral fractures, including the correct operative approach, fixation strategies, th
6、e role of total elbow arthroplasty, management of the ulnar nerve, and indications for prophylaxis against heterotopic ossification. This article provides an overview of these issues and others by reviewing the available evidence in the literature on distal humeral fractures and providing graded rec
7、ommendations. 成人中的肱骨远端骨折的处理较为复杂，技术要求较高。大部分病例适于手术治疗，并发症的发生常由于手术暴露困难，骨质疏松以及干骺端或/和关节面粉碎等因素所致。肱骨远端骨折处理中的相关问题包括正确的选择手术入路，固定策略，全肘关节置换的意义，尺神经的处理以及实施异位骨化预防措施的指证等。本文通过回顾肱骨远端骨折的相关文献，对上述问题进行分析总结并提出分级治疗意见。Epidemiology流行病学Distal humeral fractures have an estimated incidence in adults of 5.7 per 100,000 persons p
8、er year1. These injuries occur in a bimodal distribution, with an early peak in young males, twelve to nineteen years of age, as a result of high-energy trauma, and a second peak in elderly women, with osteoporotic bone, as a result of falls. In a recent study based on the Finnish National Health Re
9、gistry, the authors reported a dramatic increase in the annual incidence of distal humeral fractures (from twelve per 100,000 to thirty-four per 100,000) in women sixty years of age or older during the period of 1970 to 19982. The actual number of lowenergy distal humeral fractures in this patient p
10、opulation increased even more dramatically, from forty-two fractures to 224 fractures, over the same time period. These dramatic increases were not sustained over the period from 1998 to 2007, during which the incidence and number of distal humeral fractures stabilized.These data indicate that, alth
11、ough fractures of the distal part of the humerus are rare in adults, there has been a substantial increase in their number and incidence. The dramatic increases reported in elderly women with potentially osteoporotic bone is of particular note, suggesting that fixation strategies for osteoporotic bo
12、ne, possibly joint replacement techniques, as well as the management of osteoporosis itself will play important roles in the future management of these injuries. 肱骨远端骨折在成人中可估量的发病率为 5.7/100,000/年【1】。这种损伤呈双峰分布，第一个高峰出现在 12-19 岁的青年男性患者中，为高能量损伤所致；第二个高峰存在骨质疏松的老年女性，多为跌落伤所致。最近，在一项基于芬兰国民健康登记系统的研究报告中【2】，作者称 1
13、970 年至 1998 年间 60 岁及其以上年龄的妇女其肱骨远端骨折的年发病率呈显著增加趋势（从 12/100000 增加到 34/100000）。在这一病例人群中急性低能量性肱骨远端骨折的增加更为显著并超过同期水平，从 42 例增加到 224 例。这种显著增加趋势并不包括 19982007 年间的数据，在这一时期肱骨远端骨折的发病率及病人数量较为稳定。这些数据结果表明，尽管肱骨远端骨折在成人中较为少见，但其发病率及病人数量却不断增加，这在存在潜在骨质疏松的老年妇女人群中尤为突出，这表明，除了骨质疏松本身的处理，骨质疏松骨折的固定策略以及关节置换技术也在这类损伤未来的治疗中扮演重要角色。Cl
14、assification骨折分类Distal humeral fractures involve the supracondylar region of the humerus and/or the articular surface of the distal part of the humerus. They are most commonly classified according to the Orthopaedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classificati
15、on system (Fig. 1). In this classification system, A designates an extra-articular fracture, B designates a partial articular fracture, and C indicates an intra-articular fracture in which the articular surface is completely dissociated fromthe shaft of the humerus. These three types are subdivided
16、with use of the numbers 1, 2, and 3 to indicate increasing degrees of comminution or to further define the location of the fracture. On the basis of epidemiological data from the United Kingdom, the distribution of these fractures has been reported to be 38.7% type A, 24.1% type B, and 37.2% type C1. 肱骨远端骨折包括肱骨髁上骨折和肱骨髁间骨折。应用最为普遍的分类方法为 OTA/AO 分类系统（图 1）。在这一分类系统中，A 型为关节外骨折，B 型为关节内部分骨折，C 型为关节内完全骨折，并伴有干骺端分离。这三种类型可进一步为三个亚型，分别以 1、2 、3 表示骨折粉碎的程度，并可根据骨折的具体位置再做进一步细分。基于英国的流行病学调
