切开复位内固定治疗肱骨近端三四部分骨折43例疗效分析

目的探讨应用钢板治疗肱骨近端三四部分骨折的适应证手术技巧和临床效果。方法2004年6月至2009年1月应用切开复位三叶草钢板内固定治疗肱骨近端四部分骨折患者28例,近端锁定接骨板固定（locking proximal humeral plate,LPHP）15例。根据Neer肱骨近端骨折分型将患者分为两组三型,三叶草钢板内固定组三部分外展嵌插型18例平均年龄49.2岁,典型的四部分骨折6例平均年龄56.4岁,四部分骨折脱位4例平均年龄54岁。LPHP组15例三部分外展嵌插型8例平均年龄52岁,四部分骨折7例平均年龄56.1岁。应用Constant-Murley（CM）评分1]评估治疗效果。结果除外展嵌插组4例失访外,其余39例获得随访,失访病例均为三叶草钢板内固组患者。三叶草钢板固定方法类外展嵌插组14例随访时间（18.1±11）个月,CM评分平均为（81±7.2）;典型四部分骨折组6例随访时间（31.2±14.2）个月,CM评分平均为（71±3.5）,其中发生大结节部分吸收的1例患者,CM评分为57;四部分骨折脱位组4例随访时间（22±18.5）个月,CM评分平均为（51±7.6）,其中两例出现大结节吸收,1例肱骨头坏死,另外1例三部分骨折术后3月出现钢板断裂,引起医疗事件,并行二次手术。上述4例均为三叶草钢板内固定治疗的早期患者。LPHP钢板固定组15例,随访（16±9.7）个月,CM评分平均为（85±8.3）。结论严重的肱骨近端三四部分骨折的治疗方法选择很重要,钢板可以有效应用于年龄较小的外展嵌插型,对于典型肱骨近端四部分骨折和四部分骨折脱位患者,若行切复内固定,则需坚强内固定,尽量达到解剖复位。近端锁定接骨板对三四部分骨折具有更强的内固定优势,更符合生物学内固定原则,有利于骨折的愈合。合理的手术进路,恰当的软组织修复和保护,及时的功能训练是获得手术后功能良好恢复的重要保证。

Analysis of open reduction and internal fixation with plate for 3 and 4-part proximal humeral fractures

Objective To evaluate the clinical results and indications for3 and4-part proximal humeral fractures （PHFs） treated by plate. Methods From June,2004 to Jaunary,2009,twenty-eight patients suffered from 3 and 4-part PHFs were treated by open reduction and internal fixation with plate,The patients were classified into three groups according to Neer classification. There were 14 patients aged 49. 2 in valgus impacted 4-part PHFs group,6 typical 4-part PHFs was 54. There were 4 patients aged （52. 5 ± 3. 7）in 4-part fracture-dislocation group. Constant-Murley（CM） was used to assessed shoulder function. Results 39 patients were available for following up but 4 patients in the valgus impacted 4-part were lost,the others were followed for （28. 1 ±15. 4）months,mean CM was 81 ±7. 2. CMs of the typical 4-part PHFs was（71 ± 3. 50）,they were followed up for （31. 2 ± 14. 2） months,greater tubercle absorption appeared in one patient and his CM was 57. The fracture-dislocations were followed up for（ 22 ± 18. 5） months,CM was（ 51 ± 7. 6）,humeral head osteonecrosis appeared in one patient,greater tubercle absorption appeared in two and one suffered both. we use LPHP fixing 15 typical 3 and 4-part PHFs who were followed for （16 ± 9. 7）,CM was （85 ± 8. 3）. Conclusion ORIF can be used in the treatment of younger patients suffered from valgus impacted fracture,typical 4-part and fracture-dislocations PHFs should be reduced and fixed anatomically,stably. LPHP used to cure 3 and 4-part proximal humeral fractures are more useful than plate.