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시간 : 2022-06-25 조회수 : 21

Fractures of the proximal end of the ulna

I. 개요

1. Younger patients are more likely to suffer from high-energy trauma and older patients from falls.

2. There are two main basic types of proximal ulnar fractures, most of which require surgical treatment. Hawk's-eye fractures, which account for about 10% of elbow injuries; and coronoid fractures, which account for 10%-15% of elbow injuries and are often indicative of elbow instability when combined with injuries to other sites.

The goal of treatment for proximal ulnar fractures is to restore the articular surface of the semicircular notch of the proximal ulna, restore the length of the semicircular notch, provide strong internal fixation, and allow early functional exercise after surgery.

II. 부상의 메커니즘

1. Direct violence: dislocation of the hawkbone fracture caused by an external force acting directly on the elbow.

a. The elbow lands on the ground and receives direct violence. The different positions of the elbow joint at the time of the violent injury can result in different types of fractures of the hawk's beak, as well as combined injuries such as coronoid process and radial head fractures.

b. A simple fracture of the hawk's beak caused by the distal humeral carriage striking the body of the hawk's beak during direct violence to the elbow in the flexed position is seen with the forearm translating palmarly. The injury mostly involves the humeral ulnar joint and less frequently the radial structures, including the upper ulnar radial joint, radial head and radial collateral ligament.

c. The distal humeral carriage impacts directly on the intersection of the hawkbone and the base of the coronoid process during direct violence to the elbow in the extended position, resulting in a double fracture of the hawkbone and coronoid process. A fracture of the radial head may also result from the small head of the humerus striking the radial head. Due to the specific direction of the violence, this often leads to fracture collapse of the articular surface. It is difficult to fix the fracture of the hawk's beak, coronoid process or radial head and to restore the collapsed articular surface, with a poor prognosis.

d. Some ulnar hawkbone fractures extending into the ulnar trunk, and comminuted fractures of the proximal ulna, require special solutions such as plate fixation.

2. Indirect violence.

a. Indirect injury caused by a fall in which the hand lands on the ground and the violence does not act directly on the elbow joint but is transmitted through the forearm to the elbow joint. At the moment of injury, the different anatomical parts of the elbow joint are subjected to different degrees and nature of mechanical loads due to the anterior and posterior rotation of the forearm, the flexion or extension of the elbow joint and the angle of flexion of the elbow joint, resulting in various types of injuries and dislocations of the elbow joint, such as: coronal fractures, radial head fractures, posterior lateral rotational injuries and posterior medial rotational injuries.

b. When the elbow joint is flexed <20° with the hand on the ground, the axial load is transmitted to the elbow joint via the forearm and the coronoid process carries a greater stress and can therefore result in a simple coronoid fracture. When the elbow is flexed >30° with the hand on the ground, the brachioradialis joint is subjected to a greater load, resulting in a fracture of the radial head.

c. Postero-lateral rotational injuries can result in dislocation of the elbow joint and surrounding soft tissue injuries. Stress on the elbow joint in the valgus position can result in radial head fractures and coronoid fractures, creating postero-lateral rotational instability.

III. 평가

1. Typical presentation: The affected elbow is most often in a flexed position, with the healthy hand often supporting the affected elbow. There is swelling around the elbow joint, often more pronounced behind the elbow. Signs such as subcutaneous bleeding or bruising are seen in the affected area.

2. Examine the elbow joint. A hollow feeling, paradoxical movement and dysfunction of elbow flexion and extension are indicative of a fracture or dislocation.

3. Check the stability of the elbow joint: if the X-ray shows no fracture, an internal or external stress test of the elbow joint should be performed. If there are signs of pain and instability, this is suggestive of soft tissue damage such as ligaments.

4. Patients with concomitant forearm and wrist pain should be further examined for pressure pain between the ulnar and radial bones and instability of the inferior ulnar radial joint to prevent missed diagnosis of combined injuries such as ulnar intertrochanteric membrane and inferior ulnar radial joint.

5. Nerve function: check the sensory and motor function of the ulnar innervation zone for early detection of ulnar nerve injury.

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