肱骨近端嚴(yán)重骨折半肩關(guān)節(jié)置換術(shù)后護(hù)理與康復(fù)治療

孔祥燕

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肱骨近端嚴(yán)重骨折半肩關(guān)節(jié)置換術(shù)后護(hù)理與康復(fù)治療

孔祥燕

目的 探討肱骨近端骨折行半肩關(guān)節(jié)置換術(shù)后的護(hù)理與康復(fù)效果。方法 將67例行半肩關(guān)節(jié)假體置換術(shù)的肱骨近端粉碎性骨折患者，術(shù)后康復(fù)鍛煉分為早期、中期和晚期3個(gè)階段，并對(duì)患者的功能康復(fù)鍛煉進(jìn)行指導(dǎo)。對(duì)67例患者進(jìn)行了平均9個(gè)月的隨訪和功能鍛煉指導(dǎo)，按照Neer評(píng)分標(biāo)準(zhǔn)進(jìn)行評(píng)價(jià)。結(jié)果 67例患者中優(yōu)38例，良18例，可11例，差0例，優(yōu)良率達(dá)83.58%。結(jié)論 對(duì)肱骨近端粉碎骨折肩關(guān)節(jié)置換術(shù)患者，進(jìn)行精心的護(hù)理和規(guī)范化的康復(fù)指導(dǎo)，是取得患者肩關(guān)節(jié)良好功能恢復(fù)的重要因素之一。

肱骨骨折，近端；肩關(guān)節(jié)置換；康復(fù)；護(hù)理

肱骨近端骨折是指包括肱骨外科頸在內(nèi)及其以上部位的骨折，約占全身骨折的4%～5%，且大多為復(fù)雜、移位和不穩(wěn)定的骨折[1-2]，在老年人群中較多見。目前，在大部分醫(yī)院多采用石膏外固定或切開復(fù)位內(nèi)固定治療，但大多數(shù)學(xué)者認(rèn)為老年患者肱骨近端4部分骨折，尤其是伴有肱骨頭粉碎性骨折或關(guān)節(jié)脫位時(shí)，肱骨頭血供已受到不可逆損傷，如一期內(nèi)固定后失敗，二期再行關(guān)節(jié)置換手術(shù)將會(huì)影響手術(shù)效果和肩關(guān)節(jié)功能的恢復(fù)[3-4]。對(duì)于一些高齡患者，尤其是骨質(zhì)疏松的患者，骨折為Neer分型中的3部分或4部分骨折[5]，雖然經(jīng)過了內(nèi)、外固定治療，但肩關(guān)節(jié)功能卻難以取得滿意的效果。對(duì)于這種情況，肩關(guān)節(jié)置換術(shù)無疑是一種有效的更有優(yōu)勢(shì)的治療方式[3]。肩關(guān)節(jié)置換術(shù)按照置換范圍大小分為半肩關(guān)節(jié)人工肱骨頭置換和全肩關(guān)節(jié)置換。肩關(guān)節(jié)置換術(shù)后的精心護(hù)理與規(guī)范化康復(fù)治療越來越受到人們的重視[6]，肩關(guān)節(jié)置換術(shù)后規(guī)范化、持續(xù)的康復(fù)治療是能否最大限度地恢復(fù)肩關(guān)節(jié)功能的重要因素之一。我科于2004年1月至2013年6月對(duì)67例具備肩關(guān)節(jié)置換適應(yīng)證的患者施行半肩關(guān)節(jié)假體置換術(shù)，經(jīng)過圍手術(shù)期的精心護(hù)理，無一例發(fā)生并發(fā)癥，并在患者出院后進(jìn)行平均9個(gè)月的隨訪與功能鍛煉康復(fù)指導(dǎo)，每次隨訪參照Neer評(píng)分標(biāo)準(zhǔn)進(jìn)行效果評(píng)定，67例患者肩關(guān)節(jié)功能恢復(fù)良好，現(xiàn)將護(hù)理與康復(fù)治療體會(huì)介紹如下。

資 料 與 方 法

一、一般資料

67例臨床診斷均為閉合性肱骨近端粉碎性骨折行半肩關(guān)節(jié)置換術(shù)的患者，其中男性19例，女性48例。年齡52～90歲，平均73.06歲。Neer分型：3部分骨折29例，3部分骨折-脫位9例，4部分骨折23例，4部分骨折-脫位6例。67例患者傷前肢體功能基本正常，生活可自理，可勝任日常工作。

二、護(hù)理

(一)術(shù)前心理護(hù)理

術(shù)前向患者介紹積極的康復(fù)鍛煉對(duì)肩關(guān)節(jié)功能恢復(fù)的重要性，同時(shí)也要給患者及家屬強(qiáng)調(diào)肩關(guān)節(jié)康復(fù)鍛練的艱苦性與長期性，一般需要6～12個(gè)月的康復(fù)鍛煉才能獲得顯著效果，這樣可以使患者做好充分的思想準(zhǔn)備，建立康復(fù)的信心。

(二)一般護(hù)理

術(shù)后行常規(guī)護(hù)理，患者取平臥或低坡臥位，患肢用前臂懸吊巾固定在外展40°～50°，內(nèi)旋30°。即患肢前臂斜放在患側(cè)胸壁旁的軟墊上，以抬高患肢，促進(jìn)水腫消退。嚴(yán)密觀察患者生命體征，注意患肢皮溫、色澤以及傷口情況，警惕有無手指及患肢皮膚麻木、青紫、腫脹等神經(jīng)血管損傷的表現(xiàn)，發(fā)現(xiàn)異常及時(shí)報(bào)告醫(yī)生處理。

(三)引流管護(hù)理

術(shù)后引流通暢是手術(shù)成功的關(guān)鍵之一，應(yīng)妥善固定傷口引流管并保持通暢，防止引流管受壓、曲折、阻塞、脫落等，注意觀察引流液的顏色、流量、性質(zhì)并準(zhǔn)確記錄。若短時(shí)間內(nèi)持續(xù)引出大量血液，應(yīng)引起高度重視是否存在活動(dòng)性出血。

三、康復(fù)鍛煉

根據(jù)Brown等[7]的肩關(guān)節(jié)康復(fù)治療程序，結(jié)合患者的具體情況及手術(shù)特點(diǎn)，制定半肩關(guān)節(jié)置換術(shù)后康復(fù)治療方案。將患者術(shù)后康復(fù)鍛煉分為3個(gè)階段，分別為早期、中期和晚期，全程對(duì)患者的功能康復(fù)鍛煉進(jìn)行指導(dǎo)。

(一)第一階段(術(shù)后1 d～6周)

術(shù)后根據(jù)患者骨折類型及固定情況，麻醉消失后即可進(jìn)行肘關(guān)節(jié)以遠(yuǎn)肢體的主動(dòng)活動(dòng)[8]，肩關(guān)節(jié)以被動(dòng)活動(dòng)為主，除訓(xùn)練時(shí)間外，均需配帶肩關(guān)節(jié)專用吊帶。該階段具體可分為5個(gè)步驟[9]：(1)麻醉消失后，開始進(jìn)行手指、腕關(guān)節(jié)及肘關(guān)節(jié)的主動(dòng)鍛煉和肩關(guān)節(jié)的被動(dòng)活動(dòng)，術(shù)后7 d增加鐘擺練習(xí)；(2)術(shù)后2周,患肩關(guān)節(jié)及鄰近關(guān)節(jié)無負(fù)重下行后伸及內(nèi)外旋轉(zhuǎn)運(yùn)動(dòng)；(3)術(shù)后3周健手保護(hù)患側(cè)低負(fù)重雙肩關(guān)節(jié)后伸及擴(kuò)胸練習(xí)；(4)術(shù)后4周進(jìn)行重力輔助下的鐘擺練習(xí)及前屈練習(xí),肩外展、外旋、上舉功能鍛煉；(5)術(shù)后6周X線檢查確定肩袖及大小結(jié)節(jié)愈合后，開始進(jìn)行主動(dòng)功能鍛煉，增加岡上肌、三角肌功能鍛煉及爬墻練習(xí)。該階段應(yīng)重點(diǎn)關(guān)注關(guān)節(jié)活動(dòng)度及肌力的訓(xùn)練。

1.關(guān)節(jié)活動(dòng)度訓(xùn)練：(1)鐘擺練習(xí)[10]：患者彎腰使軀干與地面平行，患側(cè)上肢放松、懸垂，與軀干成90°，用健側(cè)手托住患側(cè)前臂做順時(shí)針或逆時(shí)針畫圈運(yùn)動(dòng)， 10圈為1組，上、下午各練習(xí)1組。(2)肩關(guān)節(jié)被動(dòng)前屈上舉練習(xí)：患者去枕仰臥，患側(cè)臂屈肘90°放于體側(cè)(休息位)。治療師一手托住患側(cè)上臂，一手握住患側(cè)前臂，在肩胛骨平面 (冠狀平面之前30°～45°) 做肩關(guān)節(jié)被動(dòng)前屈上舉，當(dāng)前屈到一定角度出現(xiàn)疼痛或遇到阻力時(shí)停留5 s，然后逐漸回到休息位，重復(fù)4 次為1組，上、下午各練習(xí)1組。(3) 被動(dòng)外旋練習(xí)：患者仰臥位，去枕，上臂外展30°保持肢體在肩胛骨平面，肘關(guān)節(jié)屈曲。治療師一手托住患側(cè)上臂，一手握住患側(cè)腕部向遠(yuǎn)離身體中線的方向做肩關(guān)節(jié)被動(dòng)外旋。重復(fù)4次為1組，上、下午各練習(xí)1組。(4)被動(dòng)外展、內(nèi)收和內(nèi)旋練習(xí)(從術(shù)后第5周開始) ：患者仰臥位，治療師幫助患者行肩關(guān)節(jié)被動(dòng)外展、內(nèi)收、內(nèi)旋(外展90°內(nèi)旋) 訓(xùn)練，重復(fù)4 次為1組，上、下午各練習(xí)1組。

2.肌力訓(xùn)練：肩帶肌等長收縮訓(xùn)練從術(shù)后第3周開始，術(shù)后第6周開始行內(nèi)、外旋肌群等長收縮訓(xùn)練。(1)肩關(guān)節(jié)前屈肌群訓(xùn)練：患者立位，面對(duì)門或墻，患側(cè)屈肘90°放于體側(cè)，然后用健側(cè)手托住患側(cè)手，手握拳向前用力推，試圖做肩關(guān)節(jié)前屈的動(dòng)作，但不產(chǎn)生關(guān)節(jié)運(yùn)動(dòng)。(2)外展肌群訓(xùn)練：患者立位，患側(cè)屈肘90°放于體側(cè)，用健側(cè)手托住患側(cè)手，患側(cè)上臂外側(cè)完全接觸門或墻，肘部用力向外推，做外展動(dòng)作。(3)肩關(guān)節(jié)伸肌群訓(xùn)練：患者立位，患側(cè)屈肘90°放于體側(cè)，然后用健側(cè)手托住患側(cè)手，患側(cè)上臂背側(cè)完全接觸門或墻，肘部用力向后推門或墻做后伸動(dòng)作。(4) 提肩胛骨肌群訓(xùn)練：患者立位，患側(cè)屈肘90°放于體側(cè)，然后用健側(cè)手托住患側(cè)手，雙側(cè)同時(shí)用力做聳肩動(dòng)作。(5)內(nèi)收肩胛骨肌群訓(xùn)練：患者立位，患側(cè)屈肘90°放于體側(cè)，然后用健側(cè)手托住患側(cè)手，雙側(cè)同時(shí)用力做內(nèi)收肩胛骨動(dòng)作。(6)內(nèi)旋肌群訓(xùn)練：患者站立位，患側(cè)屈肘90°放于體側(cè)，健側(cè)手握住患側(cè)前臂，患側(cè)肩關(guān)節(jié)試圖做內(nèi)旋動(dòng)作，健側(cè)手阻礙肩關(guān)節(jié)產(chǎn)生運(yùn)動(dòng)。(7)外旋肌群訓(xùn)練：保持內(nèi)旋肌訓(xùn)練的姿勢(shì)，患側(cè)肩關(guān)節(jié)試圖做體側(cè)的外旋動(dòng)作。每次每個(gè)動(dòng)作持續(xù)用力5 s，重復(fù)10次為1組，上、下午各練習(xí)1組。

(二)第2階段(術(shù)后7～12周)

能否去掉吊帶需根據(jù)患者大小結(jié)節(jié)愈合程度決定。此階段訓(xùn)練以肩關(guān)節(jié)主動(dòng)活動(dòng)為主，除關(guān)節(jié)活動(dòng)度和肌力訓(xùn)練外，增加了耐力訓(xùn)練。

1.活動(dòng)度訓(xùn)練：繼續(xù)肩關(guān)節(jié)各方向的牽拉訓(xùn)練，可開始進(jìn)行滑輪牽拉訓(xùn)練和爬墻梯/爬墻等閉鏈訓(xùn)練。

2.肌力訓(xùn)練：繼續(xù)上一階段的等長收縮訓(xùn)練，開始行肩帶肌等張收縮及肱二頭肌、肱三頭肌等張收縮。

3.耐力訓(xùn)練：逐漸增加運(yùn)動(dòng)量(20次為1組) 和運(yùn)動(dòng)持續(xù)時(shí)間(每個(gè)動(dòng)作持續(xù)10 s) 。

(三)第3階段(術(shù)后12周)

此階段開始進(jìn)行肌肉抗阻力的強(qiáng)化訓(xùn)練, 以抗阻訓(xùn)練為主，包括肩關(guān)節(jié)牽拉訓(xùn)練、抗阻力訓(xùn)練、肩胛的旋轉(zhuǎn)和三角肌強(qiáng)化練習(xí)。此階段除關(guān)節(jié)活動(dòng)度、肌力及耐力訓(xùn)練外，增加了運(yùn)動(dòng)能力訓(xùn)練。

1.活動(dòng)度訓(xùn)練：繼續(xù)肩關(guān)節(jié)各個(gè)方向的牽拉訓(xùn)練(強(qiáng)度可增加)，如借助門框牽拉。

2.肌力訓(xùn)練：以抗阻訓(xùn)練為主。每個(gè)動(dòng)作達(dá)最大限度時(shí)停留5 s，重復(fù)10次為1組，上、下午各練習(xí)1組。(1)抗阻前屈和外展：患者站立位，取一根長1 m的彈力帶，一端踩在腳下，一端握在手里進(jìn)行前屈上舉和外展上舉練習(xí)。(2)抗阻后伸：患者站立位，患側(cè)臂伸直面對(duì)彈力帶，彈力帶一端固定在相當(dāng)于腕關(guān)節(jié)的高度，肩前屈約60°使彈力帶具有一定張力，注意張力不要過高，患者牽拉彈力帶，放下手臂做后伸動(dòng)作。(3)抗阻內(nèi)旋和外旋：患者站立位，將一根彈力帶系在約肘關(guān)節(jié)高度的門或家具上。內(nèi)旋時(shí)，患側(cè)靠近彈力帶，上臂內(nèi)收于體側(cè)，屈肘90°，以肘關(guān)節(jié)為軸，前臂和手做超過身體中線的動(dòng)作，盡量拉長彈力帶。外旋動(dòng)作與內(nèi)旋方向相反。當(dāng)肌力增強(qiáng)后，可改用墻壁拉力器進(jìn)行抗阻訓(xùn)練。

3. 耐力訓(xùn)練：此期可增加運(yùn)動(dòng)量(每個(gè)動(dòng)作重復(fù)30次為1組，上、下午各2組)和運(yùn)動(dòng)持續(xù)時(shí)間(每個(gè)動(dòng)作保持15 s)。

4. 運(yùn)動(dòng)能力訓(xùn)練：參加體育運(yùn)動(dòng)，包括本體感覺訓(xùn)練。在患者舒適度以內(nèi)，可進(jìn)行任何活動(dòng)，但應(yīng)避免接觸性運(yùn)動(dòng)，最佳運(yùn)動(dòng)有游泳、打乒乓球等。

四、Neer評(píng)分

術(shù)后67例患者平均獲得9個(gè)月的隨訪，根據(jù)Neer評(píng)分標(biāo)準(zhǔn)評(píng)估患者的患側(cè)肩關(guān)節(jié)功能，其中疼痛占35分，日常生活功能占30分，術(shù)后肩關(guān)節(jié)活動(dòng)范圍占25分，術(shù)后解剖位置占10分。90～100分為優(yōu)，80～89分為良，70～79分為可，<70分為差。

結(jié) 果

本組67例患者經(jīng)過以上規(guī)范、系統(tǒng)地術(shù)后護(hù)理和康復(fù)鍛煉并進(jìn)行術(shù)后平均9個(gè)月的隨訪。根據(jù)Neer評(píng)分標(biāo)準(zhǔn)評(píng)估患者的患側(cè)肩關(guān)節(jié)功能，結(jié)果顯示，67例患者中優(yōu)38例，良18例，可11例，差0例，優(yōu)良率達(dá)到83.58%。無一例并發(fā)癥，經(jīng)康復(fù)鍛煉后患者生活完全能夠自理，康復(fù)效果滿意。

討 論

肱骨近端骨折在肩部骨折中較為常見，治療效果與患者的肩關(guān)節(jié)功能、日?；顒?dòng)及生活質(zhì)量直接相關(guān)。目前肩關(guān)節(jié)置換術(shù)的適應(yīng)證范圍尚未完全明確，傳統(tǒng)上認(rèn)為包括老齡骨質(zhì)疏松性骨折、骨折/脫位、頭劈裂性骨折及累及關(guān)節(jié)面>40%的壓縮骨折可選用半肩關(guān)節(jié)置換術(shù)[11]。雖然嫻熟的手術(shù)技巧對(duì)治療的成功起著重要作用，但術(shù)后的護(hù)理和康復(fù)鍛煉也同樣不可忽視，過于保守的康復(fù)訓(xùn)練會(huì)導(dǎo)致關(guān)節(jié)僵硬，肌肉過度萎縮，影響肩關(guān)節(jié)的活動(dòng)范圍及功能，而過量的康復(fù)訓(xùn)練又會(huì)使愈合的關(guān)節(jié)囊、大小結(jié)節(jié)受到二次損害，影響肩關(guān)節(jié)的穩(wěn)定性和功能。與其他關(guān)節(jié)置換術(shù)后的護(hù)理和康復(fù)截然不同的是，肩關(guān)節(jié)的康復(fù)所需的時(shí)間更長，可達(dá)12個(gè)月之久。因此，制定一套完整的能讓患者接受的護(hù)理和規(guī)范的功能鍛煉方法是至關(guān)重要的，這對(duì)于肱骨近端內(nèi)固定術(shù)后患者和肩關(guān)節(jié)置換患者同樣適用。有研究表明，術(shù)后配合積極的康復(fù)鍛煉，不僅可以控制術(shù)后感染的發(fā)生，還能夠促進(jìn)傷口愈合，安全有效地避免術(shù)后骨不愈合和骨髓炎等并發(fā)癥的發(fā)生[11-12]。

人工肩關(guān)節(jié)置換術(shù)與人工髖、膝關(guān)節(jié)置換術(shù)幾乎是同時(shí)代的手術(shù)技術(shù)，但是人工肩關(guān)節(jié)置換術(shù)的實(shí)施數(shù)量及長期效果目前仍達(dá)不到人工髖、膝關(guān)節(jié)置換術(shù)那樣令人滿意的效果，之所以產(chǎn)生這樣差異，主要是由于肩關(guān)節(jié)的特殊功能要求和解剖特點(diǎn)決定的[13]。肩關(guān)節(jié)是人體各關(guān)節(jié)中活動(dòng)度最大的關(guān)節(jié)，占整個(gè)上肢功能的60%，對(duì)關(guān)節(jié)的靈活性要求較高。另外，肩周肌肉豐富，肱骨幾乎是由肩周軟組織懸吊于肩胛上，因此肩周軟組織功能的恢復(fù)程度對(duì)術(shù)后肩關(guān)節(jié)的功能就顯得極其重要。

在骨質(zhì)疏松的肱骨近端的Neer 4部分骨折或3部分骨折伴脫位患者中，肩關(guān)節(jié)置換術(shù)較為常用，因?yàn)榇祟愋凸钦鄢３Ｆ茐牧思绮孔钪匾膭?dòng)力穩(wěn)定結(jié)構(gòu)——肩袖的止點(diǎn)處的大、小結(jié)節(jié)。精確復(fù)位大、小結(jié)節(jié)于假體頭下是肩關(guān)節(jié)置換術(shù)最重要的步驟之一，并在術(shù)后一段時(shí)間達(dá)到大、小結(jié)節(jié)之間以及大、小結(jié)節(jié)和肱骨干之間的骨性愈合[14]，在大、小結(jié)節(jié)沒有達(dá)到骨性愈合之前，功能鍛煉中應(yīng)避免肩袖肌肉主動(dòng)收縮，以免造成結(jié)節(jié)骨折移位，影響術(shù)后效果?；贾谋Ｗo(hù)在早期康復(fù)鍛煉中更為重要，因?yàn)榇藭r(shí)骨折尚未愈合，錯(cuò)誤的鍛煉方式會(huì)造成二次損傷，影響預(yù)后，在早期康復(fù)鍛煉過程中應(yīng)強(qiáng)調(diào)進(jìn)行正確的被動(dòng)鍛煉，6周后骨折初步愈合后才可進(jìn)行主動(dòng)鍛煉。由此可見，肱骨近端骨折患者行肩關(guān)節(jié)置換術(shù)的最終效果，不單純是手術(shù)技術(shù)所決定的，其術(shù)后規(guī)范化的康復(fù)訓(xùn)練治療也是一個(gè)不可或缺的因素。

肩關(guān)節(jié)置換術(shù)后早期康復(fù)治療是存在一定的風(fēng)險(xiǎn)的，大、小結(jié)節(jié)骨折塊移位等問題在某些時(shí)候是無法完全避免的。因此，我們需要與臨床醫(yī)師及康復(fù)醫(yī)師進(jìn)行溝通，并制定個(gè)性化的康復(fù)方案，這樣才能更好的針對(duì)每位患者進(jìn)行康復(fù)指導(dǎo)。第一階段行肩關(guān)節(jié)被動(dòng)活動(dòng)時(shí)，向手術(shù)醫(yī)師了解術(shù)中情況，對(duì)于被動(dòng)活動(dòng)的角度應(yīng)參考術(shù)中記錄的安全活動(dòng)范圍，并根據(jù)患者的傷情、術(shù)式及其全身情況制定康復(fù)方案。第二階段行肩關(guān)節(jié)主動(dòng)活動(dòng)的時(shí)間應(yīng)在X線片顯示有骨折愈合征象證據(jù)之后并根據(jù)隨訪查體情況進(jìn)行。本研究復(fù)雜肱骨近端骨折的患者均施行半肩關(guān)節(jié)置換術(shù)，與全肩關(guān)節(jié)置換術(shù)不同，大、小結(jié)節(jié)重建的問題需要重視，若過早進(jìn)行主動(dòng)活動(dòng)，則增加結(jié)節(jié)移位的風(fēng)險(xiǎn)，如大結(jié)節(jié)在岡上肌、岡下肌、小圓肌的牽拉下向后上方移動(dòng)，則可能繼發(fā)肩峰下撞擊等。肩關(guān)節(jié)不穩(wěn)定是肩關(guān)節(jié)置換術(shù)后常見并發(fā)癥之一。使肩關(guān)節(jié)盡快恢復(fù)功能的方法之一就是肌力訓(xùn)練，這種方法還可減少不穩(wěn)定的發(fā)生率。肩關(guān)節(jié)置換患者康復(fù)的全過程均需要肌力訓(xùn)練，只是不同階段需要不同的訓(xùn)練內(nèi)容。如第一階段以肩帶肌等長收縮為主，第二階段以肩帶肌等張收縮為主，第三階段以抗阻肌力訓(xùn)練為主。通過肩帶肌的系統(tǒng)訓(xùn)練，可增強(qiáng)肩關(guān)節(jié)的穩(wěn)定性，預(yù)防肌源性肩關(guān)節(jié)不穩(wěn)定的發(fā)生[15]。對(duì)于肱骨近端粉碎性骨折肩關(guān)節(jié)置換術(shù)的患者，進(jìn)行詳盡細(xì)致的護(hù)理和規(guī)范的康復(fù)指導(dǎo)治療，是取得患者肩關(guān)節(jié)良好功能恢復(fù)的重要因素。經(jīng)過上述細(xì)致的護(hù)理及系統(tǒng)的康復(fù)治療，患者在術(shù)后6～12個(gè)月一般都能恢復(fù)滿意的肩關(guān)節(jié)功能，但要提醒患者6個(gè)月后應(yīng)繼續(xù)鞏固訓(xùn)練并定期復(fù)查。

結(jié)論：對(duì)肱骨近端粉碎性骨折肩關(guān)節(jié)置換術(shù)患者進(jìn)行精心的護(hù)理和規(guī)范化的康復(fù)指導(dǎo)治療，是取得患者肩關(guān)節(jié)良好功能恢復(fù)的重要因素之一。

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(本文編輯：胡桂英)

孔祥燕.肱骨近端嚴(yán)重骨折半肩關(guān)節(jié)置換術(shù)后護(hù)理與康復(fù)治療[J/CD]. 中華肩肘外科電子雜志,2015,3(3):167-174.

Nursing and rehabilitation after shoulder hemi-arthroplasty for severe proximal humeral fracture

KongXiangyan.

DepartmentofTraumaandOrthopaedics,PekingUniversityPeople′sHospital,PekingUniversityTrafficMedicineCenter,Beijing100044,China

KongXiangyan,Email:kxy1766@163.com

Background Proximal humeral fracture refers to the fractures within surgical neck of humerus and at the positions above it, and such fracture cases accounts for 4%-5% of all fracture cases; Most of proximal humeral fractures are complicated and unstable fractures with displacements and mainly occur among the elder population. At present, plaster external fixation or open reduction and internal fixation (ORIF) therapy is mainly adopted in most of hospitals. However, majority of scholars believe that, when an elderly patient suffers from 4 parts of proximal humeral fractures, in particular when such fracture is accompanied with comminuted humeral head fracture or dearticulation, blood supply to humeral head has suffered non-reversible injury; In case of failure after Phase I internal fixation, performance of joint replacement at Phase I will affect the operation effect and the recovery of shoulder joint functions. For some aged patients, in particular some patients with osteoporosis, their fractures are 3 parts or 4 parts fractures in Neer typing. Although they have

internal/external fixation therapy, it is difficult to obtain satisfactory results in the recovery of shoulder joint functions. For such cases, shoulder arthroplasty is no doubt a effective therapy with more advantage. In terms of range of joint replacement, shoulder arthroplasty is divided into humeral head hemi-arthroplasty and total shoulder arthroplasty. The careful nursing and normalized rehabilitation after shoulder arthroplasty has been paid more and more attention. The postoperative standardized and continuous rehabilitation is one of the significant factors that may determine whether the shoulder joint functions can be recovered to the maximum extent. During the period from January 2004 to June 2013, our department performed half shoulder joint prosthesis replacement for 67 cases with shoulder replacement indications. Through careful peri-operative nursing, no case had complication; In addition, after the patients have been discharged from hospital, our department performed follow-up and instruction for functional exercise and rehabilitation with duration of 9 months on average. At each time of follow-up, our department made effect evaluation with reference to Neer scoring criterion, and 67 cases had recovered their shoulder joint functions with good effect. Now, our experiences in nursing and rehabilitation are introduced as follows.Method I.General materials:According to clinical diagnosis, 67 cases with closed comminuted proximal humeral fractures received shoulder hemi-arthroplasty, including 19 male cases and 48 female cases, aged at 52-90 years, with an average age of 73.06 years. Neer typing: 29 cases with 3-part fracture, 9 cases with 3-part fracture dislocation, 23 cases with 4-part fractures and 6 cases with 4-part fracture dislocation. 67 patients had basically normal pre-injury extremity functions and self-care ability of daily life, and were competent for routine work. II. Nursing:(1)Preoperative psychological nursing:Prior to operation, we introduced to the patients the importance of active rehabilitation exercise to the recovery of shoulder joint functions, and also emphasized the arduous and long-term course of rehabilitation training on shoulder joint. In general, rehabilitation exercise for 6-12 months is necessary to achieve obvious effect. In this way, we can help the patients to make sufficient mental preparation and establish the confidence in rehabilitation. (2) General nursing:After operation, we performed conventional nursing. Allow the patient to take horizontal position or low-scope lying position, use forearm suspension bandage to fix the affect limb at abduction 40°-50° and internal rotation 30°, namely, obliquely place the forearm of affected limb cushion nearby the affected side breast wall, so as to raise the affected limb and promote extinction of edema. It is necessary to keep close observation on the vital signs of the patients, paying attention to the skin temperature and color of affected limb as well as wound condition, and being alert on symptom expressions of neurovascular injury such as finger and affected limb skin numbness, cyanosis and swelling. Upon finding any abnormal circumstance, timely report the physician for treatment. (3) Nursing of the drainage tube: Unobstructed post-operative drainage is one of the keys to successful operation. It is necessary to properly fix the wound drainage tube and keep it unobstructed, prevent the drainage tube from compression, bending, blocking and falling, keep close observation on the color, flow and property of drainage liquid and accurately record the results. If a log of blood is continuously drained in short time, it is necessary to pay high attention to the existence of active hemorrhage or not. III. Rehabilitation exercise:According to the shoulder joint rehabilitation procedures established by Brown et al, in combination with the physical circumstances of the patients as well as the surgical characteristics, we established the post-operative rehabilitation protocol after shoulder hemi-arthroplasty. The post-operative rehabilitation exercise is divided into 3 stages, which are early stage, intermediate stage and late stage. We provided the instructions for the functional rehabilitation exercise in the whole process. First stage (1d-6 weeks post operation):After operation, according to the fracture type and fracture fixation condition of the patients, upon disappearance of anaesthesia, allow the elbow joint and distal limbs to perform active motion, mainly allow the shoulder joint to perform passive motion; Except for the training time, it is necessary to wear special sling for shoulder joint. This stage can be divided into 5 procedures: (1) After disappearance of anaesthesia, start the active exercise on fingers, wrist joint and elbow joint, the passive motion of shoulder joint, and on the postoperative 7d, increase pendulum exercise; (2) In the 2nd week post operation, the affected shoulder joint and adjacent joint perform rear traction without load as well as internal and external rotation motion; (3) In the 3rd week post operation, use healthy hand to protect the affected side to perform low load rear traction of both shoulder joints as well as chest extension exercise; (4) Iin the 4th week post operation, perform gravity-assisted pendulum exercise and anteflexion exercise, shoulder abduction, external rotation and uplifting function exercise; (5) In the 6th week post operation, after the healing of rotator cuff and big/small tubercles has been verified through X-ray examination, start active function exercise and increase functional training on supraspinous muscle and musculus deltoideus as well as wall-climbing exercise. At this stage, it is necessary to pay special attention to the training on the range of joint motion and muscle strength. Training on range of joint motion: (1) Pendulum exercise: Allow the patient to bend down, so that trunk is parallel with ground, relax and hang the affected side upper limb, allow the upper limb and the trunk to present an angle of 90°, use heath side hand to support the affected side forearm to make clockwise or counterclockwise circle moment; with 10 circles as 1 group, respectively exercise for 1 group in the morning and at afternoon respectively. (2) Passive anteflexion and uplifting exercise on shoulder joint: Remove pillow, allow the patient to lie on his/her back, allow the affected side arm to flex elbow by 90° and put arm on body side(rest position); The therapist use one hand to hold up the affected side upper arm and use another hand to hold the affected side forearm, make passive anteflexion and uplifting of shoulder joint in scapula plane (30 °-45 ° in front of coronal plane); If pain occurs or resistance is met when flexion motion has proceeded to a certain angle, stop movement for 5s, the gradually return to rest position; with repetition for 4 times as 1 group, respectively exercise for 1 group in the morning and at afternoon respectively. (3) Passive external rotation exercise: Allow the patient to take dorsal position, remove the pillow, perform abduction of upper limb by 30 °, keep the limbs in the scapula plane, and perform elbow joint flexion. The therapist uses one hand to hold up the affected side upper arm and uses another hand to hold the affected side wrist to make passive external rotation of shoulder joint in the direction away from the centre line of body. With repetition for 4 times as 1 group, respectively exercise 1 group in the morning and at afternoon. (4) Passive abduction, adduction and internal rotation exercise (Start from the 5th week post operation): Allow the patient to take dorsal position, the therapist help the patient to perform passive abduction, adduction and internal rotation (Abduction by 90°, internal rotation) training on shoulder joint; With repetition for 4 times as 1 group, respectively exercise 1 group in the morning and at afternoon. Muscle strength training: The training of isometric contraction of shoulder girdle is started from the 3rd week post operation. From the 6th week post operation, start isometric contraction training on shoulder internal and external rotation muscle groups. (1) Training on the shoulder joint anteflexion muscle group: Allow the patient to take standing position, face towards door or wall, allow the affected side elbow to flex by 90° and put the elbow on body side, use heath side hand to hold up the affected side hand, make a fist to push forward, try to make the motion of shoulder joint anteflexion, without generation of joint movement, however. (2) Training on abductor muscle group: Allow the patient to take standing position, allow the affected side elbow to flex by 90° and put the elbow on body side, use heath side hand to hold up the affected side hand, allow the outside of affected side upper arm to completely contact door or wall, allow elbow to push outward and perform shoulder adbution. (3) Training on shoulder joint extensor muscle group: Allow the patient to take standing position, allow the affected side elbow to flex by 90° and put the elbow on body side, use heath side hand to hold up the affected side hand, allow the back side of affected side upper arm to completely contact the door or wall, use elbow to push the door or wall backwards and perform rear protraction motion. (4) Training on muscle group lifting the shoulder blades: Allow the patient to take standing position, allow the affected side elbow to flex by 90° and put the elbow on body side, use heath side hand to hold up the affected side hand, and allow both sides to make shoulder shrugging motion at the same time. (5) Training on muscle group adducting the shoulder blade: Allow the patient to take standing position, allow the affected side elbow to flex by 90° and put the elbow on body side, use heath side hand to hold up the affected side hand, allow the affected side shoulder joint to try to perform internal rotation motion, and use health side hand to hinder the shoulder joint to generate motion. (7) Training on the extortor group: Keep the posture for training on intorters, allow the affected side shoulder joint to try to perform body side external rotation motion. At each time, continue effort in performing each motion for 5 s; with repetition for 10 times as 1 group, respectively exercise 1 group in the morning and at afternoon.Second stage (7-12 weeks post operation): Whether the suspender can be removed shall be determined according to the healing degree of greater/lesser tubercles. At this stage, training is mainly of active motion of shoulder joint. In addition to the training on the range of joint motion and the muscle strength, endurance training is increased. (1)ROM training: Continue the traction training on shoulder joint in various directions, and start the closed chain trainings such as pulley traction training and wall/ladder climbing. (2)Muscle strength training: Continue the isometric contraction training of previous stage, and start isotonic contraction of muscles of shoulder girdle as well as isotonic contraction of musculus biceps brachii and musculus triceps brachii. (3)Endurance training: Gradually increase the amount of exercise (with 20 times as 1 group) and exercise duration (each action continues for 10 s). Third stage (12 weeks post operation):At this stage, start intensive training on muscle strength aginst resistance, and mainly perform exercises aginst resistance, including shoulder joint traction training and resistive exercise as well as the rotation of scapula and the intensified exercise on musculus deltoideus. At this stage, in addition to ROM training, muscle strength training and endurance training, athletic ability training is increased. ROM training: Continue the traction training on shoulder joint in various directions (can increase strength), such as traction with the help of doorframe. Muscle strength training: Mainly perform exercise against resistance. When each motion reaches the maximum extent, stay for 5 s; with repetition for 10 times as 1 group, respectively exercise 2 groups in the morning and at afternoon. (1) Anteflexion and abduction aginst resistance: Allow the patient to take standing position, take a elastic strap in length of 1m, allow the patient to trample on one end of strap and hold another hand in hand to perform anteflexion uplifting and abduction uplifting exercise. (2) Rear traction aginst resistance: Allow the patient to take standing position, straighten the affected side arm and face towards the elastic strap; one end of the elastic strap is fixed at the height equivalent to wrist joint; allow the shoulder to flex forward by 60°, so that the elastic strap has certain tension (It is noted that the tension may not be too high). Allow the patient to pull the elastic strap, and let down the arm to make rear traction motion. (3) Internal rotation and external rotation aginst resistance: Allow the patient to take standing position, tie an elastic strap on a door or furniture at the height of elbow joint. In the process of internal rotation, the affected side approaches the elastic strap, the upper limit adducts on body side, perform elbow flexion by 90°; with elbow joint as axis, allow the forearm and hand to perform the motion of exceeding centre line of body, and make every effort to stretch the elastic force. The external rotation motion is made in the opposite direction of internal rotation. When the muscle strength has been enhanced, use wall pulley to perform exercise against resistance. Endurance training: At this stage, it is allowed to increase the amount of exercise (with repetition of each motion for 30 times as 1 group, respectively exercise 2 groups in the morning and at afternoon) and the movement duration (keep each movement for 15 s). Athletic ability training: Allow the patient to take part in sports, including proprioceptive sense training. Within the comfort degree of the patients, the patient is allowed to perform any motion, but contact sports shall be avoided. The optimal sports items include swimming and table tennis. IV. Neer scoring:After operation, 67 cases obtained 9-month follow-up on average; According to Neer scoring criterion, we evaluated the function of affected side shoulder joint of the patients, where pain accounts for 35 points, daily life function accounts for 30 points, positive-operative range of joint motion accounts for 25 points and post-operative anatomical position accounts for 10 points. Excellent: 90-100 points; Good: 80-89 points; Acceptable: 70-79 points; and poor: <70 points.Results After the said normalized and systemic postoperative nursing and rehabilitation exercise, 67 patients in this group obtained post-operative follow-up for 9 on average. According to Neer scoring criterion, we evaluated the affected side shoulder joint functions of the patients, and the results displayed that, among 67 cases, there were 38 cases with excellent score, 18 cases with good score, 11 cases with acceptable score and 0 case with poor score, with good rate up to 83.58%. There is no case with complication. After rehabilitation exercise, each patient can completely realize self-care in daily life and achieve satisfactory rehabilitation effect.Conclusion Careful nursing and normalized rehabilitation instruction for the patient with comminuted fractures of proximal humerus after shoulder joint arthroplasty is one of significant factors for achieving satisfactory functional rehabilitation of shoulder joint.

Humeral fracture,proximal;Shoulder joint arthroplasty;Rehabilitation;Nursing

10.3877/cma.j.issn.2095-5790.2015.03.009

衛(wèi)生部衛(wèi)生公益性行業(yè)科研專項(xiàng)基金(201002014)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心(Email：kxy1766@163.com)

2015-02-06)