今日の臨床サポート

肘頭骨折

著者: 今谷潤也 岡山済生会総合病院

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/03/03
患者向け説明資料

概要・推奨   

  1. 受傷機転、術前の臨床所見、画像所見などから発生病態を正しく把握する
  1. 大多数の症例で早期リハビリテーション・早期社会復帰を目的として手術的治療が行われる
  1. 手術は正確な肘関節の適合性十分な安定性骨折部の強固な初期固定性の獲得原則となる。
  1. 直達外力による肘頭骨折と上腕三頭筋の牽引力によって起こる肘頭剝離骨折がある。
    前者に対しては観血整復内固定術が行われることが多く、tension band wiring、intramedullary screw fixation、肘頭用アナトミカルロッキングプレートによるプレート骨接合術などの選択肢がある。
    また後者に対する内固定法としては、骨片摘出+上腕三頭筋腱前進+その付着部の再縫着術が行われることが多い。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
今谷潤也 : 特に申告事項無し[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、単純な肘頭骨折から腕尺関節や近位橈尺関節の破綻を伴う肘頭脱臼骨折までの治療戦略について、系統立てて詳述した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 肘頭骨折は肘関節周辺骨折の中でも比較的頻度の高い関節内骨折である。肘関節周辺骨折の約10%を占め、1万人に対して年間推定1.08人の頻度で発生するとの報告がある[1]
  1. 発生機序としては直達外力、介達外力のいずれでも発生する。
  1. 前者は肘頭部を直接打撲することによって起こり、頻度も高い。
  1. 後者は肘屈曲位で肘頭を中心に幅広く停止する上腕三頭筋の牽引力によって発生する。
  1. いずれの場合でも近位骨片には上腕三頭筋腱が停止しており、骨折部を離開・転位させようとする力がかかるため、大多数は不安定型骨折となる。
  1. 単純な肘頭骨折である場合、骨折部に粉砕を伴う場合(<図表>)、そしてさまざまな合併損傷(肘関節靱帯損傷、尺骨骨幹端~骨幹部骨折、鉤状突起骨折など)を伴う複合損傷の形態をとる場合(<図表>)がある。
 
肘関節側面像

骨折部の粉砕および関節面の陥没を伴う症例

出典

img1:  著者提供
 
 
 
肘関節側面像

尺骨骨幹端部骨折および鉤状突起骨折を伴う複合損傷の形態を呈する症例

出典

img1:  著者提供
 
 
 
  1. 本骨折の分類法としてよく用いられるColton分類[2]とMayo分類[3]を示す。またColton分類 Type 3およびMayo分類 Type IIIである肘頭脱臼骨折の細分類である森谷・今谷分類を示す[4]
 
Colton分類

Type 1:剝離骨折で骨折線は横走する、転位2mm以内で肘関節90°屈曲にても転位がなく、重力に抗して肘伸展可能なもの。
Type 2:滑車切痕より背側に向かう斜骨折で転位・粉砕の程度によって4つの亜分類がある。stage a:単純な斜骨折、転位の有無は問わない、stage b:stage aに第三骨片を伴い、転位が2mm未満の無転位骨折、stage c:stage bに転位があるもの、stage d:stage cの第三骨片が粉砕したもの。
Type 3:脱臼骨折。
Type 4:分類不能型、骨折部の粉砕が著明で、前腕近位骨幹部や上腕骨遠位部の骨折を合併することが多い。

出典

Mayo分類

Type I:転位のないもの、Type II:転位はあるが腕尺関節は安定しているもの、Type III:腕尺関節は不安定で、脱臼もしくは亜脱臼位となるものであり、通常、内側側副靱帯損傷を伴う。各Typeを非粉砕型(a)と粉砕型(b)に分類。

出典

 
肘頭脱臼骨折の森谷・今谷分類

腕尺・腕頭関節の脱臼の方向と近位橈尺関節の損傷の有無により4つの型に分類する

 
  1. 肘頭部分は皮膚および軟部組織が薄いため開放骨折となりやすい。
  1. 高齢者における骨粗鬆症合併例や、高エネルギー外傷による高度粉砕例、関節面陥没例、鉤状突起骨折合併例などでは十分な初期固定性を得ることが困難なことがあるので注意を要する。また頻度は低いが関節リウマチや転移性腫瘍によって起こる病的骨折もある。
問診・診察のポイント  
問診:
  1. 患者から受傷時の肢位、受傷機転、外力の種類や方向を聞き取る。これらを十分に問診することは正確な診断、治療方針にきわめて重要である。

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文献 

著者: Magnus K Karlsson, Ralph Hasserius, Caroline Karlsson, Jack Besjakov, Per-Olof Josefsson
雑誌名: Clin Orthop Relat Res. 2002 Oct;(403):205-12.
Abstract/Text The incidence of olecranon fractures in adults and the long-term outcome of closed olecranon fractures in 45 women and 28 men (mean age, 54 and 36 years at the time of fracture, respectively), were examined at a mean of 19 years after the fracture. The uninjured elbows served as controls. Thirteen percent of the original fractures were displaced less than 2 mm, 65% more than 2 mm, and 22% were multifragmental. Primary treatment consisted of mobilization in 4%, application of a plaster cast in 12%, and open reduction and internal fixation in 84% of the elbows. The incidence of an isolated fracture of the olecranon in individuals older than 16 years was 1.15 per 10,000 person-years. Eighty-four percent of the 73 patients had no complaints at followup, 12% had occasional pain, and 4% had daily pain. Ninety-six percent had an excellent or good outcome. Elbow flexion and extension were reduced but most patients had no or only occasional subjective complaints. Radiographic signs of degenerative changes were found in more than 50% of the formerly fractured elbows, which was more than in the uninjured (11%). Radiographic signs of osteoarthritis were found in 6% of the formerly fractured elbows versus zero percent in the uninjured, of which only two patients had a poor outcome. Isolated, closed fractures of the olecranon in adults have a favorable, long-term outcome.

PMID 12360028  Clin Orthop Relat Res. 2002 Oct;(403):205-12.
著者: C L Colton
雑誌名: Injury. 1973 Nov;5(2):121-9.
Abstract/Text
PMID 4774763  Injury. 1973 Nov;5(2):121-9.
著者: A D Duckworth, N D Clement, J E McEachan, T O White, C M Court-Brown, M M McQueen
雑誌名: Bone Joint J. 2017 Jul;99-B(7):964-972. doi: 10.1302/0301-620X.99B7.BJJ-2016-1112.R2.
Abstract/Text AIMS: The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.
PATIENTS AND METHODS: Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year.
RESULTS: A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05).
CONCLUSION: These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964-72.

©2017 The British Editorial Society of Bone & Joint Surgery.
PMID 28663405  Bone Joint J. 2017 Jul;99-B(7):964-972. doi: 10.1302/03・・・
著者: G M Gartsman, T P Sculco, J C Otis
雑誌名: J Bone Joint Surg Am. 1981 Jun;63(5):718-21.
Abstract/Text We reviewed the cases of 107 patients who underwent surgical treatment of an isolated fracture of the olecranon. Fifty-three patients were treated by primary excision and fifty-four, by open reduction and internal fixation by various methods. Static and dynamic strength measurements were obtained from the elbow extensors of twenty-nine patients from these two groups. In the over-all series, the ratings for pain, function, range of motion, elbow stability, and incidence of degenerative joint changes were similar for each group. However, thirteen local complications occurred in the fifty-four patients who had open reduction and two, in the fifty-three who had primary excision. Need for removal of the fixation device led to an additional thirteen procedures in the fixation group. Biomechanical testing demonstrated no significant difference in elbow extensor performance for the two groups.

PMID 7240294  J Bone Joint Surg Am. 1981 Jun;63(5):718-21.
著者: Tom H Carter, Samuel G Molyneux, Jeffrey T Reid, Timothy O White, Andrew D Duckworth
雑誌名: JBJS Essent Surg Tech. 2018 Sep 28;8(3):e22. doi: 10.2106/JBJS.ST.17.00071. Epub 2018 Aug 8.
Abstract/Text Olecranon fractures account for approximately 20% of fractures of the proximal part of the forearm1. Clinicians may consider nonoperative management for elderly low-demand patients2, whereas operative fixation is recommended for active patients with a displaced fracture. Tension-band wire (TBW) fixation is commonly employed for simple isolated stable displaced fractures of the olecranon (type IIA according to the Mayo classification)3-5. In contrast, plate fixation is thought to provide superior outcomes for unstable comminuted olecranon fractures. Biomechanical principles of the TBW construct are based on the hypotheses of absolute fracture stability, exploiting functional limb movement, and converting tensile forces into compression through the actions of the triceps and brachialis. The surgical goals are to restore articular congruity, provide stable reliable fixation, and allow early mobilization to minimize joint stiffness. In a recent prospective randomized trial comparing plate fixation with TBW in 67 active adult patients, we found no difference between groups with respect to either patient or surgeon-reported outcome measures6. The overall complication rate was higher following TBW fixation, with implant removal required for 1 in 2 patients. However, it may still be the preferable procedure given that the more serious issues of infection and revision surgery occurred exclusively following plate fixation. The key steps of the procedure are (1) preoperative planning with careful assessment of radiographs; (2) positioning the patient supine and gaining exposure with a posterior longitudinal direct midline incision, raising lateral and medial fasciocutaneous flaps, and developing subperiosteal dissection in the interval between the flexor carpi ulnaris and extensor carpi ulnaris to visualize the fracture; (3) visual reduction maintained with a pointed reduction clamp, with joint congruity confirmed with an image intensifier if needed; (4) creation of the TBW construct with 2 parallel 1.6-mm Kirschner wires passed longitudinally from the proximal fragment into the distal part of the ulna, engaging the anterior cortex with care, and a 1.2-mm flexible cerclage wire placed through a transverse tunnel 3 to 4 cm distal to the fracture, passed posterior to the 2 Kirschner wires, and secured in a figure-of-8 configuration; (5) appropriate tensioning of the construct followed by trimming and burial of the wire ends; (6) layered wound closure according to surgeon preference; and (7) a postoperative protocol consisting of application of an above-the-elbow synthetic bandage, which is worn for 10 to 14 days, and gentle active mobilization under physiotherapy supervision. We advise against heavy lifting for at least 6 to 8 weeks and do not routinely remove implants unless they are symptomatic.

PMID 30588367  JBJS Essent Surg Tech. 2018 Sep 28;8(3):e22. doi: 10.21・・・
著者: Nicolai Baecher, Scott Edwards
雑誌名: J Hand Surg Am. 2013 Mar;38(3):593-604. doi: 10.1016/j.jhsa.2012.12.036.
Abstract/Text Olecranon fractures are common injuries of the upper extremity; majority are treated surgically. A variety of fixation techniques are available to surgeons in modern practice, but there is little comparative clinical research to guide one's decision. Nonetheless, good results over all are to be expected after surgical management. This article presents a review of the current understanding and available evidence in the treatment of olecranon fractures, their relevant anatomy, fracture patterns, fixation options, and outcomes.

Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
PMID 23428192  J Hand Surg Am. 2013 Mar;38(3):593-604. doi: 10.1016/j.・・・
著者: S Siebenlist, T Torsiglieri, T Kraus, R D Burghardt, U Stöckle, M Lucke
雑誌名: Injury. 2010 Dec;41(12):1306-11. doi: 10.1016/j.injury.2010.08.008. Epub 2010 Sep 9.
Abstract/Text INTRODUCTION: The purpose of this investigation was to review the preliminary results and patients outcome following treatment with an anatomically preshaped LCP in patients with comminuted fractures of the proximal ulna. We hypothesized that this fixation system provides equal or superior results in fracture care when compared with other available plating devices, but results in better patient's comfort due to its low-profile design.
PATIENTS AND METHODS: Between 2007 and 2009, 15 patients with comminuted fractures of the proximal ulna including three posterior Monteggia fractures were managed with the preshaped LCP olecranon plate. The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the shortened Disability of the Arm, Shoulder and Hand (Quick-DASH) score, postoperative range of motion, objective muscle-strengths testing and patient's satisfaction were evaluated. All patients had follow-up radiographs.
RESULTS: Fourteen patients were available for evaluation. The mean arc of elbow motion was 129°. The mean MEPI was 97 with good results in two patients and excellent results in 12 patients. The mean Quick-DASH was 13. Thirteen of fourteen patients documented satisfaction with their elbow outcome. There was one patient with symptomatic hardware and one patient complained about deficit of motion. In four patients the hardware was removed including two patients with elective removal. Fourteen fractures healed with ulnohumeral congruity after a mean time to union of 11 weeks. One fracture non-union occurred without mechanical failure or loss of reduction.
CONCLUSION: Anatomically preshaped LCP olecranon plating is an effective fixation method for comminuted fractures of the proximal ulna allowing reliable stability for early elbow motion. The functional results are comparable with formerly described plating systems. A low rate of symptomatic hardware removal suggests better patient's compatibility.

Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID 20828689  Injury. 2010 Dec;41(12):1306-11. doi: 10.1016/j.injury.・・・
著者: Ramazan Erden Erturer, Cem Sever, Mehmet Mesut Sonmez, Ismail Bulent Ozcelik, Senol Akman, Irfan Ozturk
雑誌名: J Shoulder Elbow Surg. 2011 Apr;20(3):449-54. doi: 10.1016/j.jse.2010.11.023.
Abstract/Text HYPOTHESIS: Using radiologic and clinical results, we studied the outcome of patients who underwent open reduction and plate osteosynthesis for comminuted olecranon fractures.
MATERIALS AND METHODS: We retrospectively studied 18 patients (5 women [27.8%] and 13 men [72.2%]; mean age, 41 years [range, 19-67 years]) with comminuted fractures of the olecranon who underwent locking-plate osteosynthesis after open reduction between March 2005 and August 2009. According to the Mayo classification, 11 cases were classified as type IIB (61.11%) and 7 cases were classified as type IIIB (38.88%). In 7 cases, additional injuries were present in the olecranon area. We evaluated results with respect to clinical and radiologic findings. The mean follow-up duration was 22.6 months (range, 7-42 months).
RESULTS: Complete union was achieved in all cases. Mean union time was 4.4 months (range, 4-6 months). According to the Morrey scale, 4 cases were considered very good; 8, good; 5, fair; and 1, poor. The mean QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score was 17 (range, 0-75). There were no statistically significant differences between the Mayo type IIB and type IIIB cases in terms of elbow range of motion, QuickDASH score, and Morrey score. On long-term follow-up, elbow stiffness developed in 1 patient, who underwent surgical release with simultaneous removal of the hardware. The cases with fair and poor scores were cases with open fractures and additional elbow injuries.
CONCLUSIONS: Locking-plate osteosynthesis is an effective and safe treatment option for comminuted olecranon fractures, allowing early joint motion and yielding satisfactory radiologic and clinical results. In cases with concomitant injuries, the risk of limited elbow motion is high.

Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
PMID 21397794  J Shoulder Elbow Surg. 2011 Apr;20(3):449-54. doi: 10.1・・・
著者: L Niglis, F Bonnomet, B Schenck, D Brinkert, A Di Marco, P Adam, M Ehlinger
雑誌名: Orthop Traumatol Surg Res. 2015 Apr;101(2):201-7. doi: 10.1016/j.otsr.2014.09.025. Epub 2015 Feb 24.
Abstract/Text BACKGROUND: Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes.
HYPOTHESIS: Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances.
MATERIALS AND METHODS: From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis.
RESULTS: Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified.
DISCUSSION-CONCLUSION: Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation.
LEVEL OF EVIDENCE: Level IV, retrospective study.

Copyright © 2015 Elsevier Masson SAS. All rights reserved.
PMID 25736196  Orthop Traumatol Surg Res. 2015 Apr;101(2):201-7. doi: ・・・

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