馬駿 付強 葉添文 陳愛民

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微型鎖定鋼板治療肱骨大結(jié)節(jié)骨折

馬駿 付強 葉添文 陳愛民

目的 評價微型鎖定鋼板治療肱骨大結(jié)節(jié)骨折的臨床療效。方法 回顧性分析上海長征醫(yī)院應(yīng)用微型鎖定鋼板治療6例肱骨大結(jié)節(jié)骨折患者，其中男性3例、女性3例；左側(cè)3例、右側(cè)3例；患者骨折AO分型：A1-2型。采用Neer評分標(biāo)準(zhǔn)評價肩關(guān)節(jié)功能， X線片觀察骨折愈合情況。結(jié)果 6例患者平均手術(shù)時間66 min(50～85 min)，術(shù)中平均出血量87 ml(60～110 ml)。手術(shù)切口均為I期愈合，未見感染、內(nèi)固定斷裂或松動、骨折塊移位、肩峰撞擊綜合征等并發(fā)癥。患者獲得11～36個月的隨訪，平均隨訪19.8個月。X線片復(fù)查示骨折愈合時間為9～14周，平均11.3周。最后一次隨訪時，患者未出現(xiàn)肩關(guān)節(jié)疼痛，肩關(guān)節(jié)上舉、外展無明顯受限。Neer評分為89～95分，平均91.2分。結(jié)論 微型鎖定鋼板是治療肱骨大結(jié)節(jié)骨折的一種理想選擇。

肱骨大結(jié)節(jié)骨折；微型鎖定鋼板；手術(shù)治療

肱骨近端骨折臨床上較常見，其中累及大結(jié)節(jié)的骨折占13%～33%，多為高能量傷引起[1]。肱骨大結(jié)節(jié)骨折是關(guān)節(jié)周圍骨折，離斷大結(jié)節(jié)受肌腱牽拉容易移位，治療不當(dāng)可引起肩功能障礙[2]。當(dāng)大結(jié)節(jié)移位>5 mm或成角>45°時，須行手術(shù)復(fù)位內(nèi)固定治療[3]。當(dāng)前對于此類骨折內(nèi)固定方法多采用肱骨近端鎖定鋼板固定、空心拉力螺釘固定或經(jīng)骨縫合技術(shù)等。2010年9月至2014年1月，我院對6例肱骨大結(jié)節(jié)骨折患者行大結(jié)節(jié)復(fù)位微型鎖定鋼板內(nèi)固定，取得滿意效果。

資 料 與 方 法

一、一般資料

本組6例患者，其中男性3例，女性3例，年齡50～63歲，平均57.0歲，均為步行摔傷，肩部著地。左側(cè)3例，右側(cè)3例。均為新鮮閉合骨折(受傷距手術(shù)時間<6 d)，X線片顯示均為單純性大結(jié)節(jié)骨折，骨折移位>5 mm，不伴肩關(guān)節(jié)脫位，無腋神經(jīng)損傷。

二、手術(shù)方法

患者均行切開復(fù)位微型鋼板內(nèi)固定術(shù)。全身麻醉下，患者取仰臥位，患肩墊高，采用三角肌縱行劈開入路，長約4～5 cm。避免損傷關(guān)節(jié)囊、韌帶等軟組織，暴露肱骨近端骨折處，直視下復(fù)位，必要時使用克氏針臨時固定骨折塊，術(shù)中可根據(jù)骨折具體情況對微型鋼板塑形及剪切，使之充分附貼，塑形后將鋼板覆蓋在撕脫大結(jié)節(jié)上，骨折近、遠端分別予以鎖定固定。術(shù)中探查肩袖是否撕裂損傷，必要時對肩袖損傷進行縫合修補，活動肩關(guān)節(jié)，C臂機透視復(fù)位滿意后關(guān)閉切口。

三、術(shù)后康復(fù)

術(shù)后肩肘吊帶制動6周。術(shù)后1 d行患側(cè)肘腕關(guān)節(jié)被動活動；術(shù)后2周行肩外旋、內(nèi)旋主動活動；術(shù)后3周行肩前屈、后伸主動活動；術(shù)后6周增大肩關(guān)節(jié)活動范圍和上肢力量。術(shù)后4周門診復(fù)查X線，觀察內(nèi)固定位置及骨痂生長情況，術(shù)后12周正常負(fù)重。

四、術(shù)后評價

通過門診影像學(xué)結(jié)合查體，采用Neer評分標(biāo)準(zhǔn)評價治療效果，包括疼痛35分，功能30分，運動限制25分，解剖復(fù)位10分，術(shù)后總評分在>90分為優(yōu)，80～89為良，70～79為可，<70分為差。

圖1 患者女性，63歲，右肱骨大結(jié)節(jié)骨折。A.微型鎖定鋼板(邦美.美國);B.63歲老年女性，步行摔倒至右肱骨大結(jié)節(jié)骨折，術(shù)前CT三維重建;C.術(shù)后4周X線片，未見骨折端移位及內(nèi)固定松動; D.手術(shù)切口;E、F.術(shù)后12個月后肩關(guān)節(jié)功能(E外展接近180°，F(xiàn)內(nèi)旋超過90°)

結(jié) 果

患者均順利完成手術(shù)，手術(shù)平均時間66 min(50～85 min)，術(shù)中平均出血87 ml(60～110 ml)，切口均為I期愈合，未見感染、內(nèi)固定斷裂或松動、骨折塊移位、肩峰撞擊綜合征等并發(fā)癥?；颊攉@得11～36個月的隨訪，平均隨訪時間19.8個月。X線復(fù)查示骨折愈合時間為9～14周，平均11.3周。最后一次隨訪時，患者未出現(xiàn)肩關(guān)節(jié)疼痛，肩關(guān)節(jié)上舉，外展無明顯受限(圖1)。最后一次隨訪后肩關(guān)節(jié)Neer評分為89～95分，優(yōu)5例，良1例，平均91.2分。

討 論

肱骨大結(jié)節(jié)作為岡上肌、岡下肌和小圓肌的止點，對維持肩功能活動意義重大，骨折后由于各方肌肉牽拉作用不均，易發(fā)生移位，這種分離可以造成大結(jié)節(jié)骨不連，影響肩袖和肱盂關(guān)節(jié)的活動。對于骨折移位>5 mm應(yīng)該采取手術(shù)治療[3]，Park等[4]認(rèn)為對于需要手臂過頭的重體力勞動者和運動員即使移位3 mm也應(yīng)被矯正。

臨床上，此類骨折較為常見的手術(shù)方法是切開復(fù)位鎖定鋼板內(nèi)固定、空心拉力螺釘固定以及經(jīng)骨縫合技術(shù)等。這些手術(shù)方式存在一些問題，Lill等[5]認(rèn)為，傳統(tǒng)肱骨近端鋼板與骨質(zhì)接觸多，影響骨膜血供，不利于骨折愈合。植入鋼板越大，越容易導(dǎo)致繼發(fā)性肩峰撞擊綜合征[6-7]，鋼板還可能影響肱二頭肌肌腱解剖床，持續(xù)摩擦造成肱二頭肌的損傷甚至斷裂。Braunstein等[8]報道空心拉力螺釘?shù)墓潭◤姸燃凹訅毫α坑邢?，易松動。加之肱骨大結(jié)節(jié)處多為松質(zhì)骨，若合并老年患者骨質(zhì)疏松，術(shù)后骨折塊因為肌肉牽拉易發(fā)生再移位。螺空心拉力釘釘孔較粗，鉆孔及擰螺釘時易造成骨質(zhì)二次損傷，且拉力螺釘?shù)膲|圈易造成繼發(fā)性肩峰撞擊征[9]。經(jīng)骨縫合技術(shù)臨床中也在廣泛應(yīng)用，其固定肌腱-骨界面，可避免患者對于內(nèi)置物的過敏反應(yīng), 也無需再取出內(nèi)置物。長期的隨訪研究證明此方法能獲得滿意預(yù)后[9]，但如果大結(jié)節(jié)的骨折塊非常碎小，縫合線將難以將碎骨片穩(wěn)定縫壓在骨折端，縫合時可能進一步損傷周圍的軟組織，不利于碎骨片的固定[3]。

微型鎖定鋼板最初被應(yīng)用在指骨等細小長骨骨折的內(nèi)固定中，其具有創(chuàng)傷小、復(fù)位精確、固定牢固等特點。我們將這種微型鋼板應(yīng)用于治療單純肱骨大結(jié)節(jié)骨折，手術(shù)采用三角肌縱行劈開入路，此種入路成熟，切口小，軟組織剝離損傷少，最大程度的保護骨膜和血供，微型鎖定鋼板可充分覆蓋骨折塊，鎖定螺釘成角固定在骨質(zhì)疏松和粉碎骨折中具有良好的抗拉力和錨合力，能確保對骨折塊的固定強度，不易移位。鋼板具有體內(nèi)塑形及剪切功能，有助于最大程度地貼合復(fù)雜的骨表面。鋼板上多個鉆孔，可以將壓力分散在各個釘孔，且釘孔小，可最大程度的避免鉆孔時對正常骨質(zhì)的二次損傷及對碎骨塊周圍血供的破壞。因為鋼板小，可減少內(nèi)植物對肱二頭肌肌腱和結(jié)節(jié)間溝的干擾，不易造成肩峰撞擊及肩袖損傷，患者可早起行肩關(guān)節(jié)外展、前屈、后伸等功能鍛煉。

綜上所述，微型鎖定接骨板是一種理想的治療肱骨大結(jié)節(jié)骨折的內(nèi)固定植入物，其具有創(chuàng)傷小、復(fù)位精確、固定牢固等優(yōu)點。本研究也存在一些缺點和不足，如病例少、隨訪時間短、無對照研究。對于該種鋼板固定肱骨大結(jié)節(jié)骨折的生物力學(xué)的研究及大宗病例遠期結(jié)果還需進一步研究。

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[3] Gruson KI, Ruchelsman DE, Tejwani NC. Isolated tuberosity fractures of the proximal humeral: current concepts[J].Injury,2008，39(3)：284-298.

[4] Park TS, Choi IY, Kim YH, et al. A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus[J]. Bull Hosp Joint Dis, 1997, 56(3): 171-176.

[5] Lill H, Lange K, Prasse-Badde J, et al. T-plate osteosynthesis in dislocated proximal humerus fractures[J]. Unfallchirurgie, 1997, 23(5): 183-190; discussion 191-192.

[6] 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.

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[8] Braunstein V, Wiedemann E, Plitz W, et al. Operative treatment of greater tuberosity fractures of the humerus--a biomechanical analysis[J]. Clin Biomech (Bristol, Avon), 2007, 22(6): 652-657.

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(本文編輯：李靜)

馬駿,付強,葉添文，等.微型鎖定鋼板治療肱骨大結(jié)節(jié)骨折[J/CD]. 中華肩肘外科電子雜志,2015,3(3):156-159.

Treatment of humeral greater tuberosity fracture with micro locking plates

MaJun,FuQiang,YeTianwen,ChenAimin.

DepartmentofOrthopaedicTraumaSurgery,OrthopaedicInstituteofPLA,ShanghaiChangzhengHospital,SecondMilitaryMedicalUniversity,Shanghai200000,China

ChenAimin,Email:Aiminchen@aliyun.com

Background Proximal humerus fracture is a rather common fracture clinically. And the greater tuberosity fractures occupy 13%-33%, most of which are caused by high energy injury. Humerus fracture of greater tuberosity is a peri-articular fracture which is easily towed to be displaced by the greater tuberosity tendon. Improper treatment of humerus fracture of greater tuberosity may led to shoulder dysfunction. When the displacement of the greater tuberosity is greater than 5 mm or the angle is greater than 45°, reduction internal fixation operation is a necessary for treatment. Currently, the means for this fracture internal fixation are varies. Means of fixation can be adopting the proximal humerus locking plate, or two parallel annulated compression screws, or the bone suture. From September 2010 to January 2014, the internal fixation operation with restoration micro locking plate was performed in 6 cases of humerus fracture of greater tuberosity in our hospital and achieved satisfactory effects.Methods General data: 3 males and 3 females aging from 50 to 63 years old with an average age of 57.0 years old were selected to be the study subjects. They were all injured because of falling over with their shoulder strike against the floor. 3 of them injured the left shoulder and 3 of them injured the right shoulder, and all of them were fresh closed fracture (the time after injury was less than 6 days to the operation time). The X-ray picture indicated them to be exclusive humerus fracture of greater tuberosity and the displacement was more than 5 mm, without shoulder dislocation nor injury of axillary nerve.Operation methods: Open reduction micro plate internal fixation was carried out on all patients. General anesthesia and the patients lay down in supine position with their shoulders supported up. The operators adopted the incision of 4-5 mm from deltoid in lengthways. The operation should be performed cautiously to avoid damaging the joint capsule tissues, ligament tissues or other tissues. Revealed the proximal humerus fracture and restored under direct vision. Kirschner pins were necessary for temporary fixation of the fracture. The operators should shape the micro plate to fully match the fracture. After shaping, the plate was covered on the avulsion of greater tuberosity and then fixed the remote and proximal points of the fracture. The operator should check out whether the rotator cuffs were avulsion injury and suture was necessary when the rotator cuffs were injured. Move the shoulder joints properly and the incision can be closed if the perspective restoration was satisfactory through C-arm X-ray indication.Post-operation rehabilitation: After operation, the elbow should be belt immobilized for six weeks. The lateral elbow wrist joints passive movements should be started the first day after the operation. Shoulder extorsion and internal rotation active movements should be started two weeks after operation. Shoulder forward bends and rear protraction active movements should be started three weeks after operation. Six weeks after operation, the shoulder joints movement range should be enlarged and the upper body strength should be increased. Four weeks after operation, the patients should re-examination the X-ray in the outpatient department for further knowing the internal fixation location as well as the callus growing conditions. Twelve weeks after operation, the shoulder can bear burden normally.Post-operation evaluation: The curative effects were evaluated by physical examination through outpatient imaging, and adopting Neer standard for evaluation. The evaluation scores included pain 35 points, function 30 points, limitation of movement 25 points, anatomical reduction 10 points. The total post-operation evaluation points more than 90 points can be marked as excellent, 80-89 points as good, 70-79 points as ok, below 70 points as poor.Results All patients had successful operation with an average operation time of 66min (50-85 min). During the operation, the average bleeding volume was 87ml (60-110 ml). All the incisions were I phase union without any infections, internal fixation breakage, looseness, fracture dislocation, shoulder peak impingement syndrome nor other complications. The patients were followed up for 11-36 months and the average follow-up visit time was 19.8 months. The X-ray re-examination indicated that the fracture union time was 9-14 weeks, the average time was 11.3 weeks. In the last follow-up visit, the patients never complained any shoulder joints pain, and the shoulder joints lifting and outstretch were not limited. The Neer score of the last follow-up visit was 89-95, with 5 cases excellent, 1 case good, and the average points was 91.2 points.Conclusion Micro locking plate for internal fixation of the humerus fracture of greater tuberosity posses the advantages of minimal trauma, accurate restoration, firm consolidation and so on. Micro locking plate is a perfect choice for treating the humerus fracture of greater tuberosity.

Humeral greater tuberosity fracture;Locking plates;Treatment;

10.3877/cma.j.issn.2095-5790.2015.03.006

長征醫(yī)院青年啟動基金 (2012CQN09)

200000上海，第二軍醫(yī)大學(xué)附屬長征醫(yī)院骨科研究所 骨科創(chuàng)傷外科

陳愛民，Email：Aiminchen@aliyun.com

2014-12-26)