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橈骨頭骨折、橈骨頚部骨折

著者: 南野光彦 日本医科大学 整形外科

監修: 竹下克志 自治医科大学整形外科

著者校正/監修レビュー済:2022/02/16
患者向け説明資料

概要・推奨   

  1. 橈骨頭骨折,橈骨頸部骨折の解剖学的特徴を把握する。
  1. 橈骨頭骨折,橈骨頸部骨折は上腕骨小頭と橈骨頭が衝突して生じる。
  1. 成人では橈骨頭に加え橈骨頚部も骨折しやすいが、小児では多くが橈骨頚部骨折である。
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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。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※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、実際の保険適応の査定において保険適応及び保険適応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応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:
南野光彦 : 未申告[2022年]
監修:竹下克志 : 講演料(第一三共,イーライリリー,ファイザー,エーザイ,塩野義)[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 橈骨頭は円形の関節面を有し、上腕骨と腕橈関節(車軸関節)を形成している。橈骨頭のすぐ遠位が橈骨頚部で、橈骨頭とともに橈骨近位端といわれている。
  1. 転倒あるいは高所からの転落で、肘関節伸展位で手をついた際に、軸圧力が肘関節への外反ストレスに変わり、上腕骨小頭と橈骨頭が衝突して生じる[1][2][3][4]
 
受傷機序

橈骨頭、橈骨頚部骨折の受傷機序

 
  1. 橈骨頭骨折と橈骨頚部骨折の発生頻度は、全骨折の1.7~5.4%、肘関節周辺骨折の10~30%といわれている[1][2][3][4][5]。橈骨近位端骨折(橈骨頭骨折と橈骨頚部骨折)の15~20%が橈骨頚部骨折といわれている[1]
  1. 成人では橈骨頭に加え橈骨頚部も骨折しやすいが、小児では多くが橈骨頚部骨折である[1][4]。橈骨近位端骨折の約85%が20~60歳に発生し、平均年齢は30~40歳といわれているが、近年高齢化の傾向がある。男女比は約1:2といわれている[1]
  1. 受傷時の外反ストレスが強い場合は、肘関節内側側副靱帯損傷、上腕骨内上顆剝離骨折、肘頭骨折などを合併しやすく、特に小児例では約60~70%に合併するといわれている[4]
  1. 橈骨頭骨折と橈骨頚部骨折は、肘関節脱臼、尺骨鉤状突起骨折、尺骨肘頭骨折、上腕骨内上顆骨折、上腕骨外顆骨折などの肘関節周辺の骨折や肘関節内側および外側側副靱帯損傷を合併することが多い。特に肘関節脱臼の合併率は約10%といわれている[4]
問診・診察のポイント  
問診:
  1. 受傷機転を確認する。利き手と職業を確認する。

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文献 

W Regan, B Morrey
Fractures of the coronoid process of the ulna.
J Bone Joint Surg Am. 1989 Oct;71(9):1348-54.
Abstract/Text A review of thirty-five patients who had a fracture of the coronoid process of the ulna revealed three types of fracture: Type I--avulsion of the tip of the process; Type II--a fragment involving 50 per cent of the process, or less; and Type III--a fragment involving more than 50 per cent of the process. A concurrent dislocation or associated fracture was present in 14, 56, and 80 per cent of these patients, respectively. The outcome correlated well with the type of fracture. According to an objective elbow-performance index used to assess the results for the thirty-two patients who had at least one year of follow-up (mean, fifty months), 92 per cent of the patients who had a Type-I fracture, 73 per cent who had a Type-II fracture, and 20 per cent who had a Type-III fracture had a satisfactory result. Residual stiffness of the joint was most often present in patients who had a Type-III fracture. We recommend early motion within three weeks after injury for patients who have a Type-I or Type-II fracture. Reduction and fixation, followed by early motion when possible, may be the preferred treatment for patients who have a Type-III fracture.

PMID 2793888
T K TAYLOR, B T O'CONNOR
THE EFFECT UPON THE INFERIOR RADIO-ULNAR JOINT OF EXCISION OF THE HEAD OF THE RADIUS IN ADULTS.
J Bone Joint Surg Br. 1964 Feb;46:83-8.
Abstract/Text
PMID 14126240
P ESSEX-LOPRESTI
Fractures of the radial head with distal radio-ulnar dislocation; report of two cases.
J Bone Joint Surg Br. 1951 May;33B(2):244-7.
Abstract/Text
PMID 14832324
Jeffrey M Pike, George S Athwal, Kenneth J Faber, Graham J W King
Radial head fractures--an update.
J Hand Surg Am. 2009 Mar;34(3):557-65. doi: 10.1016/j.jhsa.2008.12.024.
Abstract/Text Radial head fractures are the most common fractures occurring around the elbow. Although radial head fractures can occur in isolation, associated fractures and ligament injuries are common. Assembling the clinical presentation, physical examination, and imaging into an effective treatment plan can be challenging. The characteristics of the radial head fracture influence the technique used to optimize the outcome. Fragment number, displacement, impaction, and bone quality are considered when deciding between early motion, fragment excision, and radial head excision, repair, or replacement. Isolated, minimally displaced fractures without evidence of mechanical block can be treated nonsurgically with early active range of motion (ROM). Partial, displaced radial head fractures without evidence of mechanical block can be treated either nonsurgically or with open reduction internal fixation (ORIF), as current evidence does not prove superiority of either strategy. For displaced fractures with greater than 3 fragments, radial head replacement is recommended. Radial head arthroplasty may be preferred over tenuous fracture fixation in the setting of associated ligament injuries when maintenance of joint stability could be compromised by ineffective fracture fixation.

PMID 19258159
T Judet, C Garreau de Loubresse, P Piriou, G Charnley
A floating prosthesis for radial-head fractures.
J Bone Joint Surg Br. 1996 Mar;78(2):244-9.
Abstract/Text We report our experience over seven years with a floating radial-head prosthesis for acute fractures of the radial head and the complications which may result from such injury. The prosthesis has an integrated articulation which allows change of position during movement of the elbow. We present the results in 12 patients with a minimum follow-up of two years. Five prostheses had been implanted shortly after injury with an average follow-up of 49 months and seven for the treatment of sequelae with an average follow-up of 43 months. All prostheses have performed well with an improved functional score (modified from Broberg and Morrey 1986). We have not experienced any of the complications previously reported with silicone radial-head replacement. Our initial results suggest that the prosthesis may be suitable for the early or delayed treatment of Mason type-III fractures and more complex injuries involving the radial head.

PMID 8666635
I J Harrington, A Sekyi-Otu, T W Barrington, D C Evans, V Tuli
The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review.
J Trauma. 2001 Jan;50(1):46-52.
Abstract/Text BACKGROUND: A long-term review of metal prosthetic radial head replacement in patients with radial head fractures associated with gross instability of the elbow has been performed.
METHOD: Twenty patients were reviewed using a modified Mayo Clinic functional rating index system. The mean follow-up was 12.1 years, with a range from 6 to 29 years.
RESULTS: Results were excellent in 12 patients, good in 4 patients, fair in 2 patients, and poor in 2 patients. A metal radial head replacement restored elbow stability when fracture of the radial head occurred in combination with dislocation of the elbow, rupture of the medial collateral ligament, fracture of the proximal ulna, and/or fracture of the coronoid process.
CONCLUSION: We conclude that a metal radial head prosthesis has select indications. We advocate its use when the radial head cannot be reconstructed in the setting of a clinically unstable elbow. Results suggest that it functions well on a long-term basis.

PMID 11231669
N Popovic, P Gillet, A Rodriguez, R Lemaire
Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis.
J Orthop Trauma. 2000 Mar-Apr;14(3):171-7.
Abstract/Text OBJECTIVES: To assess elbow function, complications, and problems of radial head fractures associated with elbow dislocation receiving surgical treatment with a floating prosthesis.
DESIGN: Prospective clinical study.
SETTING: University Hospital, Orthopaedic Department, Sart Tilman, Liège, Belgium.
PATIENTS: Eleven consecutive adult patients were treated with a floating prosthesis for acute radial head fractures associated with elbow dislocation from January 1994 to September 1996.
INTERVENTION: The floating radial head prosthesis (Tornier SA, Saint-Ismier, France) was used in all our patients. The implant is in two parts: a radial head made of high-density polyethylene enclosed in a cobalt-chrome cup, which articulates in a semiconstrained manner with the spherical end of a cemented intramedullary stem. The implants were inserted within the first week following the injury (range 2 to 7 days). Three cases also required internal fixation of the coronoid process of the ulna; in one case plate fixation of an olecranon fracture was also performed.
MAIN OUTCOME MEASUREMENTS: Patients were assessed by physical examination, a functional rating index (Morrey et al.), and radiographs. The parameters evaluated were motion, stability, pain, and grip strength. Potential complications such as infection, prosthetic failure, or dislocation were investigated.
RESULTS: The minimum follow-up time was two years (mean 32 months, range 24 to 56 months). Four patients were considered to have excellent results, four patients were considered to have good results, two patients had fair results, and one patient had a poor result. There were no cases of infection, prosthetic failure, or dislocation. No patient required prosthetic revision.
CONCLUSION: The basic principle of maintaining anatomic and physiologic relationships applies when deciding on treatment for radial head fractures with associated elbow dislocation. The loss of lateral osseous support will render the elbow grossly unstable. We believe that a floating prosthesis may be indicated in Mason Type III radial head fractures associated with elbow dislocation, especially in the presence of associated destabilizing fractures. Well-controlled comparative randomized studies will be needed to delineate the optimal treatment for a given situation.

PMID 10791667
Nebojsa Popovic, Roger Lemaire, Pierre Georis, Philippe Gillet
Midterm results with a bipolar radial head prosthesis: radiographic evidence of loosening at the bone-cement interface.
J Bone Joint Surg Am. 2007 Nov;89(11):2469-76. doi: 10.2106/JBJS.F.00723.
Abstract/Text BACKGROUND: Metal prostheses are useful for restoring elbow and forearm stability when the radial head cannot be fixed after a fracture. Because the anatomy of the radial head is difficult to reproduce with a prosthesis, two different options have been proposed: a bipolar prosthesis with a fixed stem and a mobile head, and a monoblock prosthesis with a smooth stem that is intentionally fixed loosely in the neck of the radius. One concern with a fixed-stem implant with a mobile head has been the risk of osteolysis. The purpose of this study was to evaluate radiographic changes reflecting or suggesting progressive osteolysis in patients with a bipolar radial head prosthesis.
METHODS: The functional and radiographic outcomes following treatment of fifty-one comminuted fractures of the radial head with a bipolar radial head prosthesis in fifty-one consecutive patients were evaluated at a mean of 8.4 years postoperatively. There were eleven isolated comminuted fractures involving the entire radial head. Thirty-four fractures were associated with a posterior elbow dislocation, and six patients had a posterior Monteggia lesion.
RESULTS: According to the Mayo Elbow Performance Index, fourteen elbows were graded as excellent; twenty-five, as good; nine, as fair; and three, as poor. Radiographic changes reflecting or suggesting progressive osteolysis were present in thirty-seven patients. Complications occurred in ten patients, but only one underwent surgical treatment, for an ulnar neuropathy.
CONCLUSIONS: Although satisfactory midterm functional results were achieved in thirty-nine of the fifty-one patients, the high prevalence of adverse radiographic changes suggesting periprosthetic osteolysis should alert clinicians to this possible drawback of the use of bipolar radial head prostheses, especially in young and/or active patients.

PMID 17974891
P I O'Brien
Injuries involving the proximal radial epiphysis.
Clin Orthop Relat Res. 1965 Jul-Aug;41:51-8.
Abstract/Text
PMID 5832738
J P Metaizeau, P Lascombes, J L Lemelle, D Finlayson, J Prevot
Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning.
J Pediatr Orthop. 1993 May-Jun;13(3):355-60.
Abstract/Text Radial neck fractures in children are serious injuries with frequent sequelae when the tilt exceeds 60 degrees. Conservative treatment is often inadequate in such cases and open reduction may produce iatrogenic complications. We report our experience with an original technique. An intramedullary wire introduced from below and projected upward allows reduction of the displacement and maintenance of the correction without infringing the joint. The operative technique is described. This method was used in 31 fractures with between 30 degrees and 80 degrees of tilt and in 16 fractures with > 80 degrees of tilt. Excellent and good functional results were obtained in 30 cases in the first group and in 11 cases in the second group.

PMID 8496371
G R Smith, R N Hotchkiss
Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation.
J Shoulder Elbow Surg. 1996 Mar-Apr;5(2 Pt 1):113-7.
Abstract/Text A cadaveric study of the radial head and neck was performed to determine the anterior and posterior limits for safe placement of internal fixation on the surface of the radial head or neck. A "safe zone" of approximately 110 degrees of radial head surface was first identified by cross-sectional anatomic dissections. This "safe zone" was then reproducibly confirmed relative to forearm position when viewed from a standard lateral approach. Because the proximal radioulnar joint cannot be directly visualized through the standard lateral approach, the zone was indirectly identified by making reference marks along the radial head and neck. To determine the position of the "safe zone" reference marks are first made along radial head and neck so as to bisect the bone's anteroposterior distance. Three such marks are made with the forearm in neutral rotation, full supination, and full pronation. Next, the posterior limit of the zone is determined by bisecting the reference marks made with the forearm in neutral rotation and full pronation. The anterior limit is determined by going nearly two thirds of the distance from the neutral mark to that mark made in full supination.

PMID 8742874
R L Linscheid, D K Wheeler
Elbow dislocations.
JAMA. 1965 Dec 13;194(11):1171-6.
Abstract/Text
PMID 4284719

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