复杂肱骨近端骨折的手术治疗  

Operative treatment of the complex proximal humeral fractures

作　　者：黄强[1] 王满宜[1] 荣国威[1] 

机构地区：[1]北京积水潭医院创伤骨科,100035

出　　处：《中华骨科杂志》2005年第3期159-164,共6页Chinese Journal of Orthopaedics

摘　　要：目的回顾性分析复杂肱骨近端骨折的手术方法及疗效。方法自1999年12月至2002年2月手术治疗Neer三、四部分肱骨近端骨折、脱位40例,其中资料完整的29例。男16例,女13例;平均年龄45.1岁(22～67岁);左侧15例,右侧14例。采用Neer骨折分类法,单纯Neer三部分骨折12例;Neer三部分骨折合并肩关节前脱位4例,合并后脱位1例;单纯Neer四部分骨折4例;Neer四部分骨折合并肩关节前脱位5例,合并后脱位3例。手术采用三角肌胸大肌间隙入路。采用螺纹克氏针或改良Ender钉加张力带固定外科颈,对于大、小结节骨折采用不吸收缝线或钢丝以“8”字张力带固定。结果平均随访时间为25个月(11￣40个月),同时问卷调查患者生活工作能力的恢复情况,术后功能采用Constant-Murley绝对值评分法进行评估,平均Constant-Murley评分为81.7分(54￣96分),优良率为65%(19/29),可为24%(7/29),差为11%(3/29);平均前屈上举主动为142.5°(60°￣180°)。疼痛VAH评分平均为12分(9￣15分)。我们将X线片中肱骨头完全吸收、部分吸收以及肱骨头减小均诊断为肱骨头坏死。其中Neer三部分骨折、脱位优良率为71%,无差的病例,肱骨头坏死发生率为17%;Neer四部分骨折、脱位优良率为58%,差为25%,肱骨头坏死率达67%。结论对于复杂肱骨近端骨折。Objective To summarize the methods of operative treatment for complex proximal humeral fractures and its clinical results. Methods 40 cases with complex proximal humeral fractures underwent operation from December 1999 to February 2002. Of 40 cases, 29 were followed up with a mean of 25 months (11 to 40 months). Using Neer system, Constant-Murley rating system and questionnaire were adopted to classify the fractures and evaluated postoperative functions of the daily life and work. A deltoid-pectoral approach was used in all patients. The surgical neck fractures were fixed with the terminal threaded pin or modified Ender's nail. The tubercle fragments were sutured with non-absorbable Ethibond No.5 or '8' figure tension band wire. Results The average absolute Constant-Murley score was 81.7(54 to 96), the excellent and good rate was 65%(19/29), fair 24%(7/29), and poor 11%(3/29). The average forward elevation was 142.5°(60° to 180°). The average pain VAH score was 12(9 to 15). The humeral head avascular necrosis, detected by the follow-up X-ray film, was diagnosed if the humeral head was completely or partially absorbed or reduced. In three-part fractures, 71% cases were excellent or good results, no poor result, and 17% had humeral head necrosis; in four-part fractures, 58% cases were excellent or good results, 25% poor, and 67% were found with humeral head necrosis. The extent of the humeral head necrosis was one of main causes to the poor function for complex proximal humeral fractures. All of the fractures healed at 6 to 8 weeks postoperatively without delayed union and nonunion. Conclusion For complex proximal humeral fractures, a good clinical result can be obtained on condition of the anatomical reduction of the tubercle fragments, as well as the stable fixation of the surgical neck fracture with appropriate suture materials and proper post-operative rehabilitation. Satisfactory result is possible even while the humeral head avascular necrosis happened.

关 键 词：肱骨近端骨折 肱骨头 坏死 肩关节前脱位 后脱位 张力带固定 手术治疗 吸收 诊断 改良 

分 类 号：R687.3[医药卫生—骨科学]