肱骨髓內(nèi)釘治療肱骨近端骨折的療效與體會(huì)

王艷華 張曉萌 付中國(guó) 陳建海 黨育 楊明 張殿英

·論著·

肱骨髓內(nèi)釘治療肱骨近端骨折的療效與體會(huì)

王艷華 張曉萌 付中國(guó) 陳建海 黨育 楊明 張殿英

目的探討肱骨近端髓內(nèi)釘治療有移位肱骨近端骨折（Neer分型二部分、三部分骨折）的療效。方法回顧性分析2012年10月至2014年12月北京大學(xué)人民醫(yī)院創(chuàng)傷骨科采用髓內(nèi)釘治療且獲得完整隨訪的21例肱骨近端骨折患者，其中Neer分型二部分骨折12例，三部分骨折9例。分別記錄患者手術(shù)時(shí)間、術(shù)中出血量和手術(shù)并發(fā)癥，采用Constant評(píng)分評(píng)價(jià)肩關(guān)節(jié)功能。結(jié)果隨訪時(shí)間最短7個(gè)月，最長(zhǎng)37個(gè)月，平均隨訪時(shí)間為17.45個(gè)月。所有患者骨折均愈合。平均手術(shù)時(shí)間為71.67 min，術(shù)中平均出血量為70.48 ml。末次隨訪平均肩關(guān)節(jié)疼痛評(píng)分0.52分。骨折平均愈合時(shí)間為4.24個(gè)月，肩關(guān)節(jié)活動(dòng)平均活動(dòng)范圍:前屈135.24°，外展130.24°，內(nèi)旋33.33°，外旋50.71°。術(shù)后平均肩關(guān)節(jié)Constant-Murley評(píng)分為82.48分，其中優(yōu)2例、良15例、可3例、差1例，優(yōu)良率為80.95%。1例延遲愈合、1例術(shù)后肩痛、1例傷口滲液不愈合。結(jié)論采用髓內(nèi)釘治療肱骨近端二部分和三部分骨折創(chuàng)傷小、固定牢固、可允許術(shù)后早期進(jìn)行功能鍛煉，關(guān)節(jié)功能恢復(fù)好，是治療肱骨近端骨折的有效手段之一。

骨折； 肱骨近端； 髓內(nèi)釘； 手術(shù)

肱骨近端是指包括肱骨外科頸在內(nèi)及以上部位的骨折，是臨床常見(jiàn)的上肢骨折。無(wú)移位的肱骨近端骨折常采取保守治療，對(duì)于有移位的Neer分型二部分、三部分骨折和部分四部分肱骨近端骨折，目前臨床上多采用鎖定鋼板進(jìn)行固定。但由于鎖定鋼板固定為偏心、髓外固定，在治療骨質(zhì)疏松性骨折以及移位較大的肱骨近端骨折時(shí)常出現(xiàn)骨折復(fù)位丟失、螺釘切割穿出、肱骨頭缺血壞死等并發(fā)癥[1-2］。同時(shí)國(guó)內(nèi)外多篇文獻(xiàn)報(bào)道髓內(nèi)釘在治療肱骨近端骨折時(shí)有其自身優(yōu)勢(shì)：創(chuàng)傷小、對(duì)骨折局部血供影響小、固定牢靠。自2012年，本科嘗試采用肱骨近端髓內(nèi)釘治療有移位的Neer分型二部分、三部分肱骨近端骨折，療效滿意。本文就髓內(nèi)釘治療肱骨近端骨折的療效和體會(huì)總結(jié)如下。

資料與方法

一、一般資料

自2012年10月至2014年12月，本科采用肱骨近端髓內(nèi)釘治療肱骨近端骨折患者23例，獲完整隨訪21例，男10例，女11例；年齡41～78歲，平均年齡56歲。術(shù)前行X線及三維CT掃描及重建評(píng)估傷情。按Neer分類(lèi)法分類(lèi)：二部分骨折12例，三部分骨折9例。其中伴肩關(guān)節(jié)脫位1例，肩袖撕裂2例。

二、手術(shù)方法

患者全麻后取沙灘椅位，常規(guī)碘酒、酒精消毒術(shù)區(qū)并鋪巾，充分暴露患側(cè)肩部，于肩峰前角行長(zhǎng)3～4 cm切口，沿肩峰前角經(jīng)三角肌前中部間隙乏血管區(qū)縱向分離三角肌，分離肩峰及三角肌下滑囊顯露肩袖，同時(shí)切開(kāi)胸鎖筋膜，沿肌纖維走行方向劈開(kāi)肩袖。顯露肱二頭肌肌腱后方的肱骨近端，術(shù)中注意保護(hù)肱二頭肌腱及腋神經(jīng)。術(shù)中使用Synthes公司的Multiloc肱骨近端髓內(nèi)釘和Smith&Nephew公司的Trigen髓內(nèi)釘對(duì)骨折進(jìn)行固定。在透視引導(dǎo)下行手法及克氏針撬撥復(fù)位，Trigen髓內(nèi)釘選擇結(jié)節(jié)間溝后方肱骨頭和大結(jié)節(jié)交界處為進(jìn)針點(diǎn)，Multiloc髓內(nèi)釘進(jìn)針點(diǎn)選擇在肱二頭肌腱（結(jié)節(jié)間溝）后方、岡上肌腱附著點(diǎn)近側(cè)1～1.5 cm處的肱骨頭頂點(diǎn)，置入定位針后須在透視下確定位于肱骨干正側(cè)位片的解剖軸線上，如果位置不良，必需進(jìn)行調(diào)整。確認(rèn)進(jìn)針點(diǎn)后開(kāi)髓并置入合適髓內(nèi)釘，盡量使主釘尾端沒(méi)入骨質(zhì)內(nèi)，經(jīng)瞄準(zhǔn)器進(jìn)行近端和遠(yuǎn)端鎖定,近端3～4枚,遠(yuǎn)端2枚。取出打拔器及瞄準(zhǔn)器,安裝尾帽，仔細(xì)縫合肩袖和三角肌，縫合包扎傷口。

三、術(shù)后處理

術(shù)前0.5 h開(kāi)始應(yīng)用抗生素至術(shù)后24 h。術(shù)后前臂吊帶固定保護(hù)患肢，術(shù)后2～3 d進(jìn)行患肩鐘擺樣運(yùn)動(dòng)，7～10 d視患者情況進(jìn)行患肩被動(dòng)活動(dòng)，包括被動(dòng)屈伸、外展、內(nèi)外旋轉(zhuǎn)活動(dòng)。術(shù)后8周復(fù)查X線片見(jiàn)骨痂愈合后進(jìn)行屈伸、旋轉(zhuǎn)、外展上舉等主動(dòng)活動(dòng)鍛煉。術(shù)后12～16周復(fù)查見(jiàn)骨折愈合后開(kāi)始行肩部力量鍛煉。

四、觀察指標(biāo)

觀察指標(biāo)包括手術(shù)時(shí)間、術(shù)中出血量。定期對(duì)所有患者進(jìn)行隨訪，隨訪內(nèi)容包括肩關(guān)節(jié)視覺(jué)模擬評(píng)分（visual analog scale，VAS）、骨折愈合時(shí)間、肩關(guān)節(jié)活動(dòng)范圍、術(shù)后并發(fā)癥。優(yōu)良率采用Constant-Murley肩關(guān)節(jié)功能評(píng)分，總分為100分，疼痛15分，日常生活能力20分，活動(dòng)度40分，三角肌力量25分，90～100分為優(yōu)秀，80～89分為良，70～79分為可，70分以下為差。內(nèi)翻畸形愈合標(biāo)準(zhǔn)為頸干角 ＜120°。

結(jié) 果

21例患者獲得完整隨訪，隨訪時(shí)間最短7個(gè)月，最長(zhǎng)37個(gè)月，平均隨訪時(shí)間為17.45個(gè)月。所有患者骨折均愈合，平均手術(shù)時(shí)間為71.67 min（50～132 min），術(shù)中平均出血量為70.48 ml（40～150 ml）。末次隨訪平均肩關(guān)節(jié)VAS評(píng)分0.52分（0～5）分、肩關(guān)節(jié)活動(dòng)平均活動(dòng)范圍:前屈135.24°（70～180°），外展 130.24°（90～170°），內(nèi)旋 33.33°（15～60°），外旋 50.71°（30～75°）。骨折平均愈合時(shí)間為 4.24個(gè)月（3～7個(gè)月），按照Constant-Murley肩關(guān)節(jié)功能評(píng)分標(biāo)準(zhǔn)，優(yōu)2例、良15例、可3例、差1例，優(yōu)良率為80.95%，術(shù)后平均肩關(guān)節(jié)Constant-Murley評(píng)分為82.48分（62～91）分。無(wú)骨折不愈合，無(wú)腋神經(jīng)和橈神經(jīng)損傷，隨訪中未發(fā)現(xiàn)肱骨頭壞死，無(wú)退釘和螺釘松動(dòng)。

1例患者發(fā)生皮下感染，傷口不愈合，予以反復(fù)換藥傷口不愈合，術(shù)后3個(gè)月復(fù)查見(jiàn)骨折愈合后，行內(nèi)固定去除加清創(chuàng)術(shù)，術(shù)后3周傷口愈合。1例患者術(shù)后5個(gè)月出現(xiàn)髓內(nèi)釘大結(jié)節(jié)區(qū)骨質(zhì)吸收，螺釘尾部外露，致肩袖損傷肩關(guān)節(jié)疼痛，予以抗炎止痛、熱敷理療等保守治療3個(gè)月，肩痛癥狀緩解不明顯，復(fù)查X線片見(jiàn)骨折愈合于術(shù)后11個(gè)月將髓內(nèi)釘取出，肩痛癥狀消失。1例二部分骨折患者出現(xiàn)延遲愈合，經(jīng)過(guò)吊帶固定后于術(shù)后7個(gè)月愈合。

討 論

肱骨近端骨折多由于暴力所致，常見(jiàn)于骨質(zhì)疏松的老年人和暴力損傷后的年輕人。有移位的肱骨近端骨折手術(shù)治療的目的是爭(zhēng)取骨折理想復(fù)位，保護(hù)血運(yùn)，堅(jiān)強(qiáng)固定，早期進(jìn)行功能鍛煉。最常用的手術(shù)方法是鋼板螺釘固定和髓內(nèi)釘固定。但到底采用哪種治療方式效果最佳，目前尚無(wú)共識(shí)。在本研究中發(fā)現(xiàn)，采用新型髓內(nèi)釘治療有移位的Neer分型肱骨近端骨折手術(shù)切口小、術(shù)中出血少、固定牢靠、術(shù)后Constant-Murley評(píng)分82.48分，優(yōu)良率為80.95%，療效確切。

肱骨近端骨折治療的關(guān)鍵是骨折理想復(fù)位，尤其是大、小結(jié)節(jié)及肱骨頭下內(nèi)側(cè)皮質(zhì)骨折的復(fù)位和固定。對(duì)于移位型肱骨近端骨折，只有對(duì)骨折進(jìn)行解剖復(fù)位和堅(jiān)強(qiáng)固定，才可以使骨折患者早期開(kāi)展功能鍛煉，從而獲得最佳的功能恢復(fù)。本研究中，患者術(shù)后最后一次隨訪X線片發(fā)現(xiàn)大、小結(jié)節(jié)骨性愈合，術(shù)后頸干角125～135°，未發(fā)現(xiàn)復(fù)位丟失。這提示髓內(nèi)釘治療肱骨近端骨折復(fù)位滿意，固定牢固。關(guān)于復(fù)位，Stefaan等[3］認(rèn)為肱骨近端“解剖”復(fù)位的標(biāo)準(zhǔn)包括：①關(guān)節(jié)內(nèi)的骨折移位完全糾正；②肱骨頭既不內(nèi)翻也不外翻；③肱骨頭相對(duì)肱骨干的前傾角或后傾角小于20°；④任何方向上大、小結(jié)節(jié)骨折塊的移位均 ＜3 mm；⑤肱骨頭和肱骨干之間的移位 ＜5 mm。如果大結(jié)節(jié)因復(fù)位不良而畸形愈合，將導(dǎo)致術(shù)后肩峰撞擊和肩袖撕裂。而如果大結(jié)節(jié)骨折愈合良好，即使術(shù)后發(fā)生肱骨頭壞死。患者仍能保留一定的肩關(guān)節(jié)活動(dòng)范圍。因此應(yīng)重視骨折尤其是大結(jié)節(jié)的解剖復(fù)位與固定。本文21例髓內(nèi)釘固定患者大結(jié)節(jié)無(wú)畸形愈合。這與新型髓內(nèi)釘重視大結(jié)節(jié)骨折固定的設(shè)計(jì)有關(guān)，Trigen髓內(nèi)釘近端螺釘4枚：3枚螺釘分別由后向前和由外向內(nèi)固定大結(jié)節(jié)骨折塊，1枚由前向后固定小結(jié)節(jié)骨折塊，四個(gè)層面的固定增加了固定的穩(wěn)固性。而Multiloc肱骨近端髓內(nèi)釘?shù)慕寺葆旑A(yù)留有縫線孔，便于術(shù)中根據(jù)需要利用縫線固定大結(jié)節(jié)，以減少肩袖的張力、增加固定的穩(wěn)定性[4］。此外在復(fù)位過(guò)程中應(yīng)重視肱骨頭下內(nèi)側(cè)皮質(zhì)的復(fù)位與重建，肱骨頭下內(nèi)側(cè)皮質(zhì)在維持骨折復(fù)位中具有重要意義[5］,尤其是對(duì)于骨質(zhì)疏松患者，如果術(shù)中內(nèi)側(cè)皮質(zhì)復(fù)位不良，將導(dǎo)致肱骨頭關(guān)節(jié)受到軸向壓力時(shí)塌陷及螺釘切割穿出關(guān)節(jié)面、肱骨頭高度丟失及內(nèi)翻畸形。因此如果內(nèi)側(cè)皮質(zhì)缺損嚴(yán)重，應(yīng)考慮植骨重建。在對(duì)肱骨頸下內(nèi)側(cè)皮質(zhì)固定支撐方面，Multiloc較Trigen有優(yōu)勢(shì)，該釘設(shè)計(jì)有斜向內(nèi)上方的骨矩螺釘，該螺釘對(duì)肱骨骨矩的固定可明顯增加髓內(nèi)釘?shù)妮S向穩(wěn)定性，為防止肱骨頭術(shù)后發(fā)生內(nèi)翻移位，還增加了“釘中釘”設(shè)計(jì)，進(jìn)一步固定頭部骨折塊并防止螺釘?shù)耐酸敽痛┏鯷3,6］。

肩袖損傷是髓內(nèi)釘廣為詬病的缺點(diǎn)之一。由于髓內(nèi)釘進(jìn)釘點(diǎn)多位于肱骨頭和大結(jié)節(jié)的交界處，此處進(jìn)釘可造成肩袖損傷及足印區(qū)骨缺損或大結(jié)節(jié)骨折塊的分離，一旦損傷后很難再修復(fù)，從而殘留術(shù)后肩關(guān)節(jié)疼痛和外展上舉困難。但隨著新一代髓內(nèi)釘?shù)某霈F(xiàn)，髓內(nèi)釘?shù)耐庑斡汕妥優(yōu)橹毙?。直型髓?nèi)釘?shù)倪M(jìn)針點(diǎn)內(nèi)移到肱骨頭的最高點(diǎn)。通過(guò)沿肌纖維劈開(kāi)岡上肌肌腱可有效避免入釘點(diǎn)損傷足印區(qū)腱骨結(jié)合部，從而減少對(duì)肩袖的損傷。但從應(yīng)用的經(jīng)驗(yàn)來(lái)看，不論4°外展曲度的Trigen髓內(nèi)釘，還是直釘Multiloc，只要術(shù)中謹(jǐn)慎剝離并及時(shí)縫合修復(fù)，二者術(shù)后功能并無(wú)太大差異。本文21例患者通過(guò)閉合復(fù)位或有限切開(kāi)對(duì)骨折進(jìn)行復(fù)位，避免了損壞肩袖及肱骨頭的血供，尤其是避免了術(shù)中損傷旋肱后動(dòng)脈，而旋肱后動(dòng)脈提供肱骨頭64%的血供，旋肱前動(dòng)脈提供其余36%的血供[7］。

近端螺釘松動(dòng)退釘也是髓內(nèi)釘治療肱骨近端骨折常見(jiàn)并發(fā)癥，固定大結(jié)節(jié)的螺釘由于退釘可導(dǎo)致肩峰撞擊、大結(jié)節(jié)骨折固定失效或畸形愈合，進(jìn)而引起術(shù)后肩關(guān)節(jié)疼痛僵硬和骨折不愈合。本組病例有1例出現(xiàn)近端螺釘撞擊肩峰而導(dǎo)致肩關(guān)節(jié)疼痛伴功能受限。考慮原因?yàn)楣潭ù蠼Y(jié)節(jié)的螺釘擰入過(guò)淺所致。為了避免上述情況發(fā)生，在固定大結(jié)節(jié)時(shí)盡量將螺釘擰入皮質(zhì)下，避免外留釘尾，術(shù)中應(yīng)仔細(xì)活動(dòng)肩關(guān)節(jié)，確認(rèn)無(wú)撞擊后方可關(guān)閉創(chuàng)口。選用的新一代髓內(nèi)釘設(shè)計(jì)更合理，Trigen近端鎖定孔襯有帶螺紋的聚乙烯內(nèi)襯，可實(shí)現(xiàn)螺釘和髓內(nèi)釘之間的鎖定，有效地防止退釘情況的出現(xiàn)，而髓內(nèi)釘近端幾何形態(tài)增強(qiáng)了其在髓腔內(nèi)的旋轉(zhuǎn)穩(wěn)定性。Multiloc則是螺釘和髓內(nèi)釘之間實(shí)現(xiàn)雙皮質(zhì)鎖定。

有文獻(xiàn)報(bào)道髓內(nèi)釘治療肱骨近端骨折術(shù)后可導(dǎo)致肩關(guān)節(jié)功能障礙。這主要由于長(zhǎng)期的固定以及釘尾對(duì)肩峰下組織的撞擊導(dǎo)致肩峰下滑囊分泌液體增多,引起組織纖維化,使肩袖的肌腱群、關(guān)節(jié)囊、韌帶相互粘連,從而發(fā)生肩關(guān)節(jié)功能障礙[8-9］。因此在髓內(nèi)釘置入時(shí)，應(yīng)盡可能將主釘釘尾埋入關(guān)節(jié)面以下，避免影響肩峰下間隙。同時(shí)應(yīng)重視肩關(guān)節(jié)術(shù)后的功能康復(fù)鍛煉。此外，本文中有1例患者出現(xiàn)傷口感染，二次清創(chuàng)將局部組織送檢未檢出細(xì)菌，徹底清創(chuàng)并將固定大結(jié)節(jié)的縫線拆除后傷口愈合。考慮可能是機(jī)體對(duì)縫線的排異反應(yīng)所致。

采用肱骨近端髓內(nèi)釘治療有移位的、不穩(wěn)定的肱骨近端骨折，多位學(xué)者報(bào)道療效滿意[10-12］。認(rèn)為髓內(nèi)釘可提供足夠的穩(wěn)定性以允許患者早期活動(dòng)，即使較復(fù)雜的骨折也可以應(yīng)用髓內(nèi)釘治療。Hessmann等[13］認(rèn)為，肱骨近端髓內(nèi)釘?shù)倪m應(yīng)證是：Neer分型的二、三和四部分骨折；肱骨近端骨折合并肱骨干的節(jié)段性骨折；延伸到干部的肱骨近端骨折。禁忌證為肱骨頭劈裂骨折合并肱骨近端外科頸骨折的肱骨近端骨折。Kloub等[14］報(bào)道髓內(nèi)釘治療四部分骨折肱骨頭壞死率高。俞銀賢等[15］認(rèn)為對(duì)于四部分骨折，盡量不采用髓內(nèi)釘治療，因?yàn)樗牟糠止钦蹚?fù)位困難，難以做到閉合復(fù)位，如果擴(kuò)大切口，對(duì)軟組織損傷和肱骨近端血供的破壞較大，可能失去了髓內(nèi)釘微創(chuàng)治療的意義，而且由于內(nèi)、外側(cè)支撐均破壞，很容易造成術(shù)后的復(fù)位丟失。作者比較認(rèn)同Cuny等[16］的觀點(diǎn)，即對(duì)于Neer分型的二、三部分骨折和外翻崁插四部分骨折可嘗試采用髓內(nèi)釘進(jìn)行固定，但對(duì)于有移位的關(guān)節(jié)內(nèi)骨折盡量避免使用髓內(nèi)釘。此外髓內(nèi)釘治療肱骨近端骨折需要一定的學(xué)習(xí)曲線，因此在早期開(kāi)展這項(xiàng)技術(shù)時(shí)，應(yīng)盡量選擇肱骨近端二部分骨折，當(dāng)逐漸熟練掌握了該項(xiàng)技術(shù)時(shí)，可以擴(kuò)大到部分三部分骨折[15］。因?yàn)?，?duì)于二部分骨折，若髓內(nèi)釘進(jìn)針點(diǎn)選擇合適，一般閉合復(fù)位都較容易[17］?？傊畯谋疚?1例患者的應(yīng)用體會(huì)來(lái)看，對(duì)于Neer分型二、三部分骨折，肱骨近端髓內(nèi)釘創(chuàng)傷小、固定牢固、可允許術(shù)后早期進(jìn)行功能鍛煉、療效確切，是肱骨近端骨折的有效治療手段之一。

[1]Schliemann B, Siemoneit J, Theisen Ch, et al. Complex fractures of the proximal humerus in the elderly--outcome and complications after locking plate fixation[J］. MusculoskeletSurg, 2012, 96（Suppl 1）: S3-S11.

[2]Clavert P, Adam P, Bevort A, et al. Pitfalls and complications with locking plate for proximal humerus fracture[J］. J Shoulder Elbow Surg, 2010, 19（4）: 489-494.

[3]Stefaan JB, Mark M, Manin HH. Pmximal humerus fractures:intramedullary nailing [J］. Tech 0rthop, 2013, 28（4）: 319-323.

[4]吳曉明, 吳劍宏, 王秋根. 肱骨近端骨折髓內(nèi)釘治療的老概念與新方法——第三代肱骨近端髓內(nèi)釘?shù)脑O(shè)計(jì)理念和臨床實(shí)踐[J/CD］. 中華創(chuàng)傷骨科雜志, 2015, 17（10）：915-920．

[5]Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures[J］. J Orthop Trauma, 2007, 21（3）: 185-191.

[6]周君琳. 肱骨近端骨折的交鎖髓內(nèi)釘治療[J/CD］. 中華肩肘外科電子雜志, 2015, 3（2）:51-56.

[7]Hettrich CM, Boraiah S, Dyke JP, et al. Quantitative assessment of the vascularity of the proximal part of the humerulls [J］. J Bone Joint Surg Am, 2010, 92（4）:943-948．

[8]Flinkkil? T, Hyv?nen P, Siira P, et al. Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation[J］. Arch Orthop Trauma Surg, 2004, 124（8）: 537-541.

[9]張麒云, 范存義, 曾炳芳. 肱骨髓內(nèi)釘影響肩關(guān)節(jié)功能的研究進(jìn)展[J］. 上海醫(yī)學(xué) , 2008, 31（2）：144-146．

[10]Zhu Y, Lu Y, Shen J, et al. Locking intramedullary nails and locking plates in the treatment of two-part proximal humeral surgical neck fractures: a prospective randomized trial with a minimum of three years of follow-up[J］. J Bone Joint Surg Am, 2011, 93（2）: 159-168.

[11]Young AA, Hughes JS. Locked intramedullary nailing for treatment of displaced proximal humerus fractures[J］.Orthop Clin North Am, 2008, 39（4）: 417-428.

[12]任世祥, 林源, 曲鐵兵, 等. 交鎖髓內(nèi)釘與鎖定鋼板治療肱骨近端骨折的療效研究[J］. 中華創(chuàng)傷骨科雜志, 2011, 13（10）：937-939．

[13]Hessmann MH, Nijs S, Mittlmeier T, et al. Internal fixation of fractures of the proximal humerus with the MultiLoc nail[J］.Oper Orthop Traumatol, 2012, 24（4-5）: 418-431.

[14]Kloub M, Holub K, Polakova S. Nailing of three-and four-part fractures of the humeral head--Long-term results[J］. Injury,2014, 45（1）: S29-S37.

[15]俞銀賢, 吳曉明, 王秋根. 交鎖髓內(nèi)釘治療肱骨近端骨折[J］.中華創(chuàng)傷骨科雜志, 2012, 14（12）：1092-1094.

[16]Cuny C, Goetzmann T, Dedome D, et al. Antegrade nailing evolution for proximal humeral fractures, the Telegraph IV（?）:a study of 67 patients[J］. Eur J Orthop Surg Traumatol,2015, 25（2）: 287-295.

[17]Konrad G, Audigé L, Lambert S, et al. Similar outcomes for nail versus plate fixation of three-part proximal humeral fractures[J］. Clin Orthop Relat Res, 2012, 470（2）: 602-609.

Curative effect observation and application experience of intramedullary nailing for displaced proximal humeral fractures

Wang Yanhua, Zhang Xiaomeng, Fu Zhongguo, Chen Jianhai, Dang Yu,Yang Ming, Zhang Dianying. Department of Trauma and Orthopeadics, Peking University People's Hospital, Peking University, Traffic Medicine Center,Beijing 100044,China

Zhang Dianying, Email:zdy8016@163.com.

BackgroundProximal humeral fractures refer to the fractures involving neck and above, which is a common upper limb fracture clinically. Non-displaced proximal humeral fractures are often treated conservatively. Currently, the locking plate fixation is often used for displaced 2-Part, 3-Part and some of the 4-Part proximal humeral fractures of Neer classification.Since locking plate fixation is eccentric and belong to the extramedullary fixation, complications such as fracture reduction loss, screw cutting out and ischemic necrosis of humeral head often appear in the treatment of osteoporotic fractures and proximal humeral fractures with large displacement. Meanwhile, several domestic and foreign literatures reported that the intramedullary nailing has its own advantages in the treatment of proximal humeral fractures including minimally invasive, small impact on the local blood supply of fractures and reliable fixation. This article summarized the curative effect and experiences of treating proximal humerus fractures with intramedullary nail.Methods（1） General data. From October 2012 to December 2014, 23 cases of proximal humerus fractures were treated with proximal humeral nail in our department. 21 cases were followed up, including 10 males and 11 females. The age ranged from 41 to 78 years with anaverage of 56 years. X-ray and 3D CT scan & reconstruction were performed preoperatively for severity evaluation. According to the Neer classification, 12 cases of 2-Part fractures and 9 cases of 3-Part fractures were involved, including 1 case of combined shoulder joint dislocation and 2 cases of combined rotator cuff injury. The Multiloc proximal humeral intramedullary nail of Synthes company and the Trigen intramedullary nail of Smith&Nephew Co Ltd. were used intraoperatively for fracture fixation. （2） Operative methods. After successful general anesthesia, the patient was put into beach chair position. Then, the operative area was routinely disinfected with iodine and alcohol and draped. The affected shoulder joint was fully exposed, and a 3-4 cm incision was made along the anterior angle of acromion. The deltoid muscle was separated through the gap between the anterior and middle parts of deltoid muscle which was vascular insufficient. The deltoid muscle, acromion and deltoid bursa were then split to expose rotator cuff. Meanwhile, the costocoracoid membrane was cut open. After the rotator cuff was split along the muscle fibers, the proximal part of humerus behind the biceps tendon was revealed. The biceps tendon and axillary nerve were protected during the operation. Manual reduction and poking reduction with Kirschner wire were guided under fluoroscopy. The junction between humeral head and greater tuberosity at the back of intertubercular sulcus was selected as the entry point of Trigen nail. The vertex of humeral head at the back of biceps tendon （intertubercular sulcus） and 1-1.5 cm proximally from the attach point of supraspinatus tendon was chosen as the entry point of Multiloc nail. The guiding pin should be placed on the anatomical axis of humeral shaft on both the anterior and posterior view and the lateral view under fluoroscopy. If necessary, the location of pin should be adjusted. Once the entry point was confirmed, the medullary cavity was opened and inserted with the proper intramedullary nail. The tail of main nail should be made into the bone. Under guiding device, the proximal locking and distal locking were conducted with 3-4 screws and 2 screws respectively. After the removal of driver-extractor and guiding device and the installation of tail cap, the rotator cuff and deltoid muscle were carefully repaired, and the wound was sutured and banded up. （3） Postoperative management. Antibiotics were given half an hour before surgery to 24 hours after operation. The affected forearm was in sling protection postoperatively, and the pendulum movement of affected shoulder was conducted 2-3 days later. After 7 to 10 days, passive movements of affected shoulder were allowed, including passive flexion and extension, abduction and internal and external rotations. Active movements such as flexion and extension, rotation,abduction and upward lifting were allowed as bone callus were visible on X-ray films 8 weeks after surgery. Strength exercises began when the fracture union was confirmed in the subsequent visit 12-16 weeks later. （4） Observation indexes. Observation indexes included operation duration and intraoperative blood loss. Follow-ups were carried out in all patients regularly, including visual analog scale （VAS） of shoulder joint, fracture healing time, range of motion of shoulder joint and postoperative complications. The good and excellent rate was evaluated by Constant-Murley score with 100 points in total, including pain in 15 points, daily life ability in 20 points, range of motion in 40 points and deltoid muscle strength in 25 points. 90-100 points were considered excellent, 80-89 points were considered good, 70-79 were considered moderate and below 70 points were considered poor. The standard of varus deformity was less than 120° of neck angle.ResultsTwenty-one patients were followed up for 7 to 37 months with an average of 17.45 months, and all of them had fracture healing. The mean operation time was 71.67 minutes （50-132 minutes）, and the intraoperative blood loss was 70.48 ml （40-150 ml）. The mean VAS during the last follow up was 0.52 points （0-5 points）. The mean range of motion was 135.24°（70-180°）for forward flexion; 130.24°（90-170°） for abduction; 33.33°（15-60°） for interal rotation; 50.71°（30-75°）for external rotation. The mean fracture healing time was 4.24 months （3-7 months）.According to the Constant-Murley scoring system: 2 cases were excellent; 15 cases were good; 3 cases were moderate; 1 case was poor. The good and excellent rate was 80.95%, and the mean postoperative Constant-Murley score was 82.48 （62-91）. No fracture nonunion, axillary nerve orradial nerve injury occurred, and no humeral head necrosis, screw backing up or screw loosening was discovered in the follow ups. One case had subcutaneous infection, and the wound remained unhealed even after repeated changing of wound dressing. The bone union was confirmed during the subsequent visit 3 months after operation. Then, the patient had internal fixator removal and debridement surgery. Three weeks later, the wound healed. One patient had bone absorption at the greater tuberosity area with exposure of intramedullary nail tail which leaded to rotator cuff injury and shoulder joint pain. After conservative treatments such as oral anti-inflammatory analgesic and heat therapy for 3 months, the pain relief of shoulder joint was not remarkable. As bone healing was confirmed by fluoroscopy, the intramedullary nail was removed 11 months after operation.Consequently, the pain in shoulder joint disappeared. One patient with 2-Part fracture had delayed union, and the fracture healed after sling fixation for 7 months.ConclusionsProximal humeral fractures are mainly caused by violence and commonly seen in elderly with osteoporosis and young people with severe injuries. The purposes of surgical treatment for displaced proximal humeral fractures include ideal reduction, blood supply protection, rigid fixation and early functional rehabilitation. The most common operative methods were plate screw fixation and intramedullary nailing. However, there is no consensus on which treatment is better. In this study, we found that the new type of intramedullary nailing in the treatment of displaced 2-Part and 3-Part proximal humeral fractures has the advantages of minimal invasion, less blood loss and reliable fixation.Hence, intramedullary nailing promotes early functional rehabilitation and good joint recovery and is one of the effective methods.

Fructure; Proximal humerus; Intramedullary nail; Surgery

2017-03-22）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10.3877/cma.j.issn.2095-5790.2017.02.007

教育部創(chuàng)新團(tuán)隊(duì)發(fā)展計(jì)劃（IRT1201）；國(guó)家自然科學(xué)基金（31640045）;國(guó)家自然科學(xué)基金（31071246）；國(guó)家重點(diǎn)研發(fā)計(jì)劃項(xiàng)目（2016YFC1101604）；北京大學(xué)人民醫(yī)院發(fā)展基金（RDY2016-07）

100044 北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)創(chuàng)傷醫(yī)學(xué)中心

張殿英，Email:zdy8016@163.com

王艷華,張曉萌,付中國(guó),等. 肱骨髓內(nèi)釘治療肱骨近端骨折的療效與體會(huì)[J/CD］.中華肩肘外科電子雜志,2017,5（2）：113-118.