The significance of double screw fixation of the lower end of the humerus in the treatment of complex ankle joint injury

The topic of orthopedics. The significance of double-screw fixation of the lower end of the humerus fracture in the treatment of complex ankle joint injuries ZHANG Shi-quan, ZHANG Hong, Nong Shao-you, Xiang Xiang-cheng, Li Mei-cai, Ding Qiang (Shenzhen Red Cross Hospital, Shenzhen, Guangdong 518029, China) I丨R6847丨B丨 Article number 丨100

The topic of orthopedics.

The significance of double-screw fixation of the lower end of the humerus fracture in the treatment of complex ankle joint injuries ZHANG Shi-quan, ZHANG Hong, Nong Shao-you, Xiang Xiang-cheng, Li Mei-cai, Ding Qiang (Shenzhen Red Cross Hospital, Shenzhen, Guangdong 518029, China) I丨R6847丨B丨 article number 丨1001*9421(2002)02*0108* Ankle fracture and dislocation is more common clinically. According to Danis' distal radius fracture, lower ankle joint separation and talus dislocation, it is a complex ankle injury. If the treatment is not appropriate, it can lead to the occurrence of traumatic arthritis. In severe cases, ankle arthrodesis should be performed. Since 1999, the hospital has used double-screw fixation of the lower end of the humerus fracture to treat 19 cases of C-type fracture, and achieved satisfactory results.

1 Clinical data 1.1 General information The group of 19 patients, 15 males and 4 females. The average age is 29 (18~46) years old. Causes of injury: 10 cases of traffic accidents, 5 cases of work injuries, 4 cases of falls. There were 16 cases of closed injury and 3 cases of open injury.

There were 1 case of mild craniocerebral injury, 2 cases of clavicular fracture, and 4 cases of other parts of the extremities.

1.2 Treatment methods Open fractures were performed within 2 hours after injury within 4 to 13 days after the injury. Antibiotics were used to prevent infection before and after surgery. Use epidural anesthesia, balloon tourniquet on the thigh. The arcus incision was made along the internal malleolus, the internal malleolus was fixed with a screw, and a longitudinal incision of about 4 cm was made along the lower end of the humerus. The lower end of the humerus fracture with overlapping displacement was reset under appropriate traction, and the ankle joint was placed in the neutral position. Use two large towel clamps to fix the proximal and distal ends of the humerus to the humerus. At this time, the separation of the lower ankle joint and the dislocation of the talus have generally been reset, and the passive active ankle joint has returned to normal. Then drill and tap the center of the medial aspect of the humerus at about 1~2cm near and at the distal side of the humeral fracture line. Twist and screw the appropriate length of the screw through the humerus. Be careful not to make the nail tip protrude from the medial edge of the humerus. After stimulating the inner skin of the calf, it causes pain. Postoperatively, the ankle joint was fixed with a short leg plaster for 3 to 4 weeks, and the ankle joint flexion and extension was gradually performed. After 8 to 12 weeks, the weight was gradually carried.

2 Results ~ 16 months, all fractures healed 4 to 13 months after surgery, no pain in the ankle joint, good stability, normal range of flexion and extension. According to the AOFAS (American Foot Surgery Association) division, master's degree, mainly engaged in orthopedic clinical work.

The scoring criteria, 19 patients scored 97 to 100 points, with an average of 99 points.

3 Discussion The ankle joint is the largest saddle-shaped weight joint in the whole body. After the ankle joint injury, it is a recognized treatment principle to restore the integrity of the axillary point and the normal position of the talus as soon as possible, and strive to achieve anatomical reduction. 11. Weber divides the ankle fracture into A, B, C according to the position of the tibiofibular fracture. type. C-type fractures are high-energy injuries. Huge violence not only causes severe displacement of the internal or external iliac crest or fracture of the lower end of the humerus, but also easily causes tearing of the inferior tibiofibular ligament and joint capsule, causing separation of the lower ankle joint and dislocation of the talus. In the past, the anatomical reduction of the internal and external ankle fractures was emphasized for the A and B fractures, but the C type was only satisfied with the reduction of the medial malleolus fracture and the lower ankle joint, and the treatment of the lower end of the humerus fracture was neglected. Most of the lower humeral fractures have different degrees of shortening or rotational displacement. This displacement can cause changes in the position and direction of the external ankle joint surface that are difficult to find on the X-ray film, and the normal stress distribution of the axillary joint surface is damaged. Since the longitudinal axis of the tibia and the longitudinal axis of the iliac crest form an outward 15* angle, if the external malleolus is displaced upward, the axillary cavity will be wide, and the talus will be unstable in the acupoint, eventually leading to the occurrence of traumatic arthritis. Lambert's biomechanical study proves that the tibia is not only an important structure that constitutes acupoints, but also bears the weight-bearing function together with the tibia, accounting for about 17% of the lower limbs' weight; the humerus defect, shortening or malunion healing, the stress on the humerus side Exceeding the normal physiological range is one of the important causes of traumatic arthritis. Fan Yongxiang et al. 2丨 Through long-term follow-up of patients with ankle fractures, it was found that when the lower end of the humerus was unsatisfactory or the fixation was not fixed, traumatic arthritis occurred, and ankle pain occurred and could not participate in manual labor. This group of patients paid attention to the good reduction and fixation of the lower end of the humerus fracture during operation, corrected the overlap and rotation deformity, no traumatic arthritis occurred after operation, and the ankle joint function recovered well.

As for the fixation of the lower end of the humerus, because the lower end of the lower end of the humerus is subcutaneous, lacking rich soft tissue coverage, the high-energy injury factors of the fracture often cause contusion or even necrosis of the skin and soft tissue of the ankle, which is not conducive to the placement of the steel plate; Although the fixation can better fix the fracture of the tibia, it often affects the separation of the ankle joint after the insertion of the screw. This group used double screws to fix the two fracture ends of the tibia fracture laterally on the humerus, so that the two sides of the humerus and the humerus, the upper and lower iliac crest of the forearm of the medical forearm dorsal artery in the reversed island flap. Tang Juyu, Li Kanghua (Central South College Xiangya Hospital, Changsha, Hunan Province, China 410008, China) The bone and tendon are exposed when the soft tissue defect of the back of the hand is exposed; after the soft tissue defect of the tiger's mouth or the contraction of the tiger's mouth, the wound often needs to be repaired with a flap. From June 1997 to August 2001, the author applied the retrograde island flap of the dorsal interosseous artery to repair the soft tissue defect of the back of the hand and the tiger's mouth and 11 cases of the tiger's mouth contracture. The results are satisfactory.

1 Clinical data 1.1 General conditions The group of 10 males and 1 female; mean age 27 ~ 42) years old. There were 7 cases of crush injury, 2 cases of blast injury, 1 case of traffic accident and 1 case of electric burn. There were 6 cases of soft tissue defect of the back of the hand and bone or tendon exposure, 3 cases of tiger's mouth contracture, and 2 cases of soft tissue defect of tiger's mouth.

1.2 Applied anatomy The dorsal interosseous artery originates from the superior interosseous artery in the upper part of the forearm, the superior margin of the forearm interosseous membrane to the dorsal side of the forearm, between the supinator and the long abductor muscle, and the deep extensor muscles in the forearm Downstream. The dorsal interosseous artery sends out 5 to 13 skins on the dorsal side of the forearm in the forearm, and travels to the dorsal cutaneous branch of the ulnar ulnar artery at 2. 5~3cm. The anatomical basis of the retrograde island flap of the dorsal interosseous artery.

1.3 Surgical method 1 flap design: the rotation point of 2.5 ~ 3cm on the ulnar styloid process, the line connecting the lateral iliac crest to the lateral edge of the ulna small iliac crest is the axis of the flap, according to the point of rotation to the near and far of the wound surface The distance between the points determines the near point and the far point of the flap. The flap is designed according to the size and shape of the wound. The flap is enlarged by about 1 cm from the wound surface. 2 flap removal: first cut the pedicle skin, subcutaneous tissue and forearm fascia along the axis of the flap to separate the dorsal vascular bundle between the ulnar wrist muscle and the extensor digitorum of the small finger, retain 1.5 division, in-service master's degree, Mainly engaged in clinical work in hand surgery.

~2cm wide fascia pedicle, clear the vascular wall, cut the two sides of the flap, sharp separation of the sarcolemma, to avoid damage to the cutaneous branch and the dorsal nerve.

The maximal area of ​​the flap was 13cm×8cm, and the smallest was 8cm×4cm.3 flap transfer: 11 cases in this group, 3 cases were transferred by subcutaneous tunnel, the vascular pedicle area was completely free, completely hemostasis, ensuring no tension of the vascular pedicle, preventing vascular pedicle compression, wrist The suture was sutured in the dorsal extension position, and the suture of the flap was directly sutured when the width of the wound was less than 4 cm. The thicker skin graft was cut on the inner side of the upper arm. 4 postoperative treatment: close observation of flap blood supply, application of anti-infection and improvement of microcirculation drugs, postoperative routine plaster fixation in the functional position 2 to 3 weeks.

1.4 Results 9 cases of flaps survived completely. In 3 cases of tunnel metastasis, 2 cases of flaps were swollen after operation, and the margins were partially necrotic. After the dressing change, the flaps were all survived. After 1 month to 3 years follow-up, 11 cases of skin flaps were normal in color, blood supply was abundant, the shape was not bloated, and the flaps recovered. According to the Seddom standard S38 case, S23 case. The tiger's mouth was opened from the original 20*~30* to 60*~70°, and the hand function was restored.

2 Discussion 2.1 The choice of flap donor area to repair the back of the hand, soft tissue defect of the tiger's mouth, fun contracture, the forearm flap pedicled by the radial artery or ulnar artery has been reported in the past. The biggest disadvantage of these flaps is the sacrifice of one main blood supply artery of the forearm. There are complications of skin flap adhesion and tendon exposure. The skin of the back of the foot is the closest to the skin of the back of the hand. After repairing, the shape of the hand is the best, but the flap of the anastomosis should be transplanted. The risk is high and the main blood supply artery of the hand and foot is sacrificed, and the skin of the foot is necrotic. The incidence of exposure is high. The forearm interosseous dorsal artery flap is rich in blood supply, the anatomy is relatively constant, the vascular pedicle is long, and the rotation range is large. The elasticity, skin color and thickness are similar to the back of the hand. The shape of the hand after repair is good. The biggest advantage is that the forearm is not sacrificed. Mainly supplying blood arteries, and conforming to the two stable rectangular mechanical structures formed by Ning Jinshao joint, the distal screw also fixed the lower ankle joint at the same time. This method is simple and practical, and does not need to widely peel the periosteum. There are only two screw heads. It stays under the skin, the incision is small, the fixation is reliable, and it has important clinical practical significance for those with poor skin conditions.

*Neurature Industry 415 Hospital Hand Surgery Work (Hengyang 421002)

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