肱骨干骨折顺行与逆行髓内针固定的病例 对照研究

目的：比较肱骨干骨折顺行与逆行髓内针固定的疗效。方法：入选1999年3月至2006年10月间有完整随访资料的肱骨干骨折105例,分为顺行髓内针组（A组）82例,逆行髓内针组（B组）23例。对两组的手术时间、术中出血量、并发症发生率、骨折愈合时间、骨折愈合率、Constant—Murley肩关节功能评分和Mayo肘关节功能评分等指标进行比较。结果：随访时间平均（31．2±20．9）个月。两组的手术时间、骨折愈合时间、愈合率及并发症发生率比较差异无统计学意义（P〉0．05）。B组术中出血量大于A组（P=0．002）。A组有4例（4．9％）不愈合,8例（9．8％）发生肩痛伴肩关节活动度减小,B组3例（13．0％）术中发生医源性骨折。A组肩关节功能评分低于B组（P=0．04）,肘关节功能评分两组比较差异无统计学意义（P〉0．05）。结论：顺行与逆行髓内针固定均是治疗肱骨干骨折的有效方法,但逆行髓内针固定医源性骨折发生率较高,应正确选择和制备髓内针入点。顺行髓内针固定有较高的肩痛和肩关节活动度减小的并发症发生率,注意将髓内针尾埋于肩袖下方,细致保护和修复肩袖,术后进行合理的康复练习,有利于减少肩痛和改善肩关节功能。     

Modified extra rotator-cuff entry point in antegrade humeral nailing

Introduction We describe an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing, which preserves the articular surface and rotator cuff integrity.Material and methods Thirty-two patients with humeral shaft fractures underwent antegrade intramedullary nailing using a modified insertion point located 1 cm below the crest of the greater tuberosity, in a region outside the articular surface and rotator cuff area.Results In all cases, nailing was done successfully, without any perforation of the humeral inner cortex by the nail. Extension of the fracture line to the distal metaphysis happened intraoperatively in one case of a distal diaphysis fracture. In the remainder of the patients, postoperative reduction of the fracture was successful, with no sign of an iatrogenic incident of fracture comminution. Excellent active shoulder function and full early functional recovery of the shoulder joint (to 16th week postoperatively) were established in 98% of the patients. All fractures were united in a mean period of 14 weeks.Conclusion We suggest an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing as a possible and safe technique with beneficial results for the shoulders postoperative function.     

Der „AO/ASIF-Flexnail“

BACKGROUND: The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation. METHOD: Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score. RESULTS: Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome. CONCLUSION: We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.     

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.     

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.     

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion.

OBJECTIVE: A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing. STUDY DESIGN: Prospective multicenter nonrandomized clinical study. PATIENTS: Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters. RESULTS: The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group. CONCLUSION: Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.     

Fixation of Proximal Humeral Fractures with an Intramedullary Nail: Tipps and Tricks

Abstract Antegrade interlocking nailing has been established as a valid option of treatment in proximal humeral fractures which follows the principles of minimum invasive surgery. The introduction of angular stability into intramedullary nailing has increased the stability of reconstruction even in osteoporotic fractures. The outcome of the surgical procedure essentially depends on the adequate intraoperative management of the specific features and challenges of the corresponding fracture type. The creation of the correct nail entry point is crucial for anatomic reduction and stability of the reconstruction, as well. The knowledge on intraoperative reduction aids and additional tools of enhancing the stability of the reconstruction alleviates a mechanically sound application of antegrade intramedullary nailing in most highly unstable proximal humeral fractures.     

Axillary nerve palsy after retrograde humeral nailing: clinical confirmation of an anatomical fear

Introduction  Locked antegrade or retrograde nailing of humeral shaft and proximal humerus fractures is a well etablished treatment option. Anatomic-morphological studies revealed a potential high risk of axillary nerve injury within proximal interlocking screw insertion. However, clinical experiences do not seem to confirm this, as there is a lack of interlocking screw insertion associated axillary lesions in literature. Case report  We report about a 69-year-old man with a humeral shaft fracture (AO-type 12-A3) stabilized by a retrograde implanted interlocking nail. Proximal interlocking screw insertion was performed in a posterior-to-anterior direction. The fracture healed uneventfully. In a follow-up examination 2 years later, an atrophy and paralysis of the deltoid muscle were visible. Electrophysiological evaluation confirmed an isolated axillary nerve injury. Nevertheless, the patient showed good functional recovery with almost free range of motion. Conclusion  Even for clinical practise proximal interlocking screw insertion is associated with a substantial risk of axillary nerve injury. Particularly for posterior-to-anterior screw insertion anatomic conditions should be considered. In spite of axillary nerve lesion, recovery of almost full shoulder function is possible by compensating the loss of deltoid function by rotator cuff muscles.     

Unaufgebohrte antegrade Oberarmverriegelungsnagelung

In a prospective clinical study 111 fractures of the humerus in 109 consecutive patients were stabilized with unreamed antegrade interlocking nailing. 97 patients were evaluated with individual follow-up, in the mean at 24.2 months postoperatively. Mean fracture consolidation time was 12.3 weeks (9-16 weeks). Five patients presented a non union. At follow-up 19 patients had a limitation in motion of the shoulder, in the mean with 20% compared to the opposite side. Eight patients had permanent shoulder pain, in nine patients shoulder pain occurred during manual strain of the upper limb. Neither limitation of motion nor pain at the elbow region was present in all cases at follow-up. Ultrasound examination revealed in six cases a lesion of the rotator cuff, which was linked in these cases with permanent pain at the shoulder joint. In five patients a prominent nail tip at the entrance point caused a lesion of the rotator cuff with impingement syndrome. Eight out of nine preoperative palsies of the radial nerve recovered within a mean period of 4.3 months without operative measurements. Unreamed antegrade interlocking nailing of humeral fractures is a safe technique regarding consolidation rate with advantages regarding early mobilization of the upper limb. Careful suturing of the rotator cuff and countersinking of the proximal nail tip at the entrance point is a prerequisite in avoiding permanent lesions of the rotator cuff and shoulder pain.     

Multiloc髓内钉治疗肱骨近端骨折的临床疗效分析

目的探讨Multiloc髓内钉治疗肱骨近端骨折的临床疗效。 方法回顾性分析2015年1月至2017年7月在首都医科大学附属北京朝阳医院骨科采用Multiloc髓内钉治疗并获得完整随访资料的33例肱骨近端骨折患者，年龄44~83岁，平均（68.7±15.7）岁；其中Neer分型二部分骨折22例，三部分骨折11例。分别记录手术时间、术中出血量、骨折愈合情况及手术并发症，采用视觉模拟评分（visual analogue scale，VAS）及Constant-Murley评分评价患者术后肩关节功能情况。 结果手术均顺利完成，平均手术时间为93.2 min（70~150 min），术中平均出血量为108.2 ml（30~200 ml）。随访时间最短13个月，最长40个月，平均随访时间为（22.4±7.3）个月。末次随访平均肩关节疼痛评分0.47分（0~2分）。骨折平均愈合时间为（15.7±2.9）周，肩关节活动平均活动范围：前屈140.2°，外展135.9°，内旋36.0°，外旋54.4°。术后平均Constant评分为（85.9±10.8）分，其中优11例、良17例、一般3例，优良率为90.9%。末次随访时无一例发生切口感染、骨折不愈合及肩袖损伤等并发症。 结论Multiloc髓内钉治疗肱骨近端骨折具有手术创伤小、并发症少、内固定物牢固、关节功能恢复优良，对肱骨近端Neer分型二部分和三部分骨折有满意的治疗效果。     

All-arthroscopic intramedullary nailing of 2- and 3-part proximal humeral fractures: a new arthroscopic technique and preliminary results

Purpose  

The most criticism of antegrade humeral nailing is the potentially deleterious effect on the shoulder function, which is caused by the trauma to the M. supraspinatus (SSP) at the nail insertion site. We describe a new technique of all-arthroscopical intramedullary nailing, which preserves the rotator cuff, and compare it with the conventional open procedure.     

Functional long-term outcome of the shoulder after antegrade intramedullary nailing in humeral diaphyseal fractures

Intramedullary nailing is one of the most commonly used surgical treatments for humeral diaphyseal fractures. Once an intramedullary fixation technique has been selected, the choice between antegrade or retrograde approach remains controversial. Forty patients with humeral diaphyseal fracture treated with Seidel antegrade intramedullary nailing through an "danterior deltoid incision" (ADI) were evaluated after an average period of 62 months. Clinical and functional evaluation of the shoulder was performed using the Constant Score. Results were excellent in 33 patients, good in 5 and acceptable in 2. Radiological assessment was performed using antero-posterior (AP) and latero-lateral (LL) radiographs of the humerus and AP and Neer radiographs of the shoulder. Radiographic findings demonstrated good consolidation of all fractures; nail and locking proximal screw malpositioning were detected in 2 cases (2 patients with acceptable results). The positive results obtained for shoulder function correlate with patient age and demonstrate that antegrade intramedullary nailing is a valid option for the treatment of humeral diaphyseal fractures, as long as it is performed through ADI access and with the appropriate surgical technique. Surgical technical errors will lead to functional problems of the shoulder, which in some cases will not be completely eliminated even after nail removal.     

Ergebnisse der Versorgung instabiler Oberarmkopffrakturen bei geriatrischen Patienten mit einem neuen winkelstabilen antegraden Marknagelsystem

Treating unstable proximal humeral fractures in elderly patients with osteoporosis and limited compliance is still demanding for trauma surgeons. The failure rate of operative treatment is high. We studied the use of a new antegrade intramedullary humeral nail with special locking bolts for head fixation. The first 41 procedures in 39 patients with a mean age of 81 years (61-102) were analyzed. Half of the patients were mentally deranged. There were 16 two-part, 22 three-part, and 3 four-part fractures of the humeral head treated. After closed or partial open reduction, antegrade nailing was performed via a delta split and limited incision of the rotator cuff. Greater and lesser tuberosities were fixed with screws through threaded holes of the proximal nail leading to high stability. Early functional active treatment was performed avoiding maximal rotation. Follow-up was 13 months (7-21 months). Clinical examination was performed in 32 cases. Four patients were questioned by phone. Three patients died (mean age: 92 years) before follow-up. The mean Constant score was 57+/-12. The mean age-related and side-related Constant scores were 86+/-17% and 90+/-7%. All fractures healed. Activities of daily life were possible in every case. There was only one loss of reduction after a fall out of bed. After hemiarthroplasty the patient was excluded from the study. One shaft fissure occurred during distal interlocking and healed uneventfully. Because of stable fixation, rehabilitation without immobilization was possible and led to good functional results. In comparison to common implants, the new antegrade intramedullary nail allowed a stable osteosynthesis in unstable proximal humeral fractures in old and very old patients with limited compliance without the usual implant-related complications.     

逆行置入交锁髓内钉治疗肱骨干骨折

目的　总结临床采用逆行置入交锁髓内钉治疗肱骨干骨折的经验。方法　采用 AO的专用钻头在鹰嘴窝上约 2 cm处钻孔 ,确定和准备进针入点 ,由肘向肩逆行置入 AO的非扩髓交锁髓内钉的方法治疗闭合性肱骨干骨折 15例。结果　 15例骨折在 3个月内全部骨性愈合 (8～ 12周 ) ,15例肩关节活动度于术后 3个月时已达正常对侧的 95 % ,肘关节活动度达正常的 85 %。有 2例病人肘关节活动度伸直较健侧相差 2 0°,拔钉后功能锻炼 1个月后恢复良好。结论　逆行置入交锁髓内钉治疗肱骨干骨折 ,避免了对肩袖的干扰 ,固定牢靠 ,肩肘关节功能恢复快 ,二期拆除内固定简便 ,是治疗肱骨干骨折的有效方法     

Intramedullary nailing of humeral shaft fractures with a locking flexible nail

BACKGROUND: Studies on intramedullary nailing of humeral shaft fractures in the orthopaedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of a new flexible, locking intramedullary nail that can be implanted in the humerus in either a retrograde or an antegrade manner without violating the rotator cuff mechanism or damaging the articular surface of the humeral head. METHODS: Fifty consecutive patients with fifty-one humeral shaft fractures were entered into our prospective clinical outcome study. The fracture was classified on the basis of the anatomic location and pattern. Implant positioning and fracture alignment were assessed postoperatively. Complications were recorded, and the time to union was measured. Shoulder function was evaluated with use of a combination of the Constant shoulder score, Short Form-36 (SF-36) clinical outcome data, range-of-motion measurements, and a subjective pain-rating scale. RESULTS: Forty-one patients with forty-two fractures had an adequate duration of clinical follow-up (a mean of twenty-two months) for analysis. Thirty-nine fractures healed, with a mean time to clinical union of twelve weeks (range, four to fifty weeks). Thirty-eight of the forty-two shoulders had minimal or no pain. Thirty-six shoulders had a full range of motion. The mean Constant shoulder score was 90 points. Four patients had five complications, which included two nonunions, two hardware failures, and one wound infection. All four patients had been managed with a 7.5-mm nail. A multivariate analysis demonstrated that an age of more than fifty years was associated with a lower Constant score and that the occurrence of a complication was associated with a lower physical component score on the SF-36. CONCLUSIONS: The flexible humeral nail allows both retrograde and antegrade implantation and static locking. Nail insertion can be accomplished without violating the rotator cuff or damaging the articular surface of the humeral head. Although the nail functioned well in most of our patients, the use of a small-diameter (7.5-mm) nail was associated with a higher complication rate. This implant should be used with caution in any patient with a medullary canal diameter of 相似文献   

Antegrade humeral nailing through the rotator cuff interval: a new entry portal

The conventional approach for antegrade intramedullary nailing (AIN) of humerus fractures is associated with persistent pain and compromised shoulder function. Damage to the critical hypovascular zone of the rotator cuff near its insertion on the humerus and/or irritation of the subacromial space by prominent hardware are the factors believed to be responsible for poor shoulder function after AIN of the humerus. This study describes a new entry portal through the rotator interval that minimizes iatrogenic damage to the rotator cuff at its insertion. This approach offers a solution for the disappointing postoperative shoulder function and pain scores associated with conventional antegrade nailing techniques. This study consisted of 33 patients with 34 humeral fractures followed for an average of 34 months. The overall satisfaction rate was more than 90%, according to the ASES (American Shoulder and Elbow Society) score. The mean Constant Score was 84 (SD, 14; range, 17 to 98), and primary bone union was achieved in 32 of the 34 cases.     

Treatment of humeral shaft fractures with antegrade intramedullary locking nail

Antegrade interlocked humeral nailing for stabilization of humeral fractures was introduced many years ago, and studies on this method in the orthopedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of an antegrade intramedullary nail (T2, Stryker) for the humeral fractures. Between 2005 and 2008, 52 fractures of the humeral shaft were treated operatively with this intramedullary nail in our department. Eight patients were polytraumatized, and four patients had an open fracture. The mean age of patients was 51.7 years. Forty-eight patients had an adequate duration of clinical follow-up (a mean of 18 months) for analysis. Complications were recorded, and the time to union was measured. Shoulder and elbow functions were assessed using the Constant Score and the Morrey Score, respectively. Forty-six fractures healed, with a mean time to clinical union of 10.3 weeks. Two patients developed pseudarthroses. There were four adverse events: two proximal screws backed out, one superficial infection at the insertion point, and one fracture at the distal end of the nail. Ninety-one percentage of patients had an excellent or good shoulder function. Five further operations were necessary: two for treatment of pseudarthroses, two for removal the backed out proximal screws, and one wound debridement for superficial infection. Antegrade humeral nailing is a valid therapeutic option for stabilization of humeral shaft fractures. By strictly adhering to the operation technique, the number and the severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional results is the rule.     

Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment

Introduction A variety of different treatment options are available for displaced three- or four-part fractures. In a retrospective cohort study we evaluated the results of intramedullary nailing with the ACE nail and conservative treatment of displaced proximal humeral fractures. Materials and methods Twenty-four patients suffered a neer 4, 5 or 6 proximal humeral fracture who were treated with intramedullary nailing. Sixteen patients received conservative treatment for their Neer 4, 5 or 6 fracture. Results Taking critical remarks in consideration, the results of intramedullary nailing are not very satisfactory compared to the conservative-treated group. However functional results of our operative group are comparable to those from other studies in literature. Conclusion Displaced three- or four-part proximal humeral fractures can be treated by intramedullary nailing. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful operative treatment outcome. Most complications in the operative treatment group can be avoided; inadequate reduction can lead to wrong insertion place with secondary problems (dislocation and subacromial impingement). Also future improvements in osteosynthesis like angle stable screw fixation (osteoporosis) and minimally invasive device will probably decrease the complication rate.     

逆行穿带锁髓内针治疗新鲜肱骨干骨折

目的 总结使用逆行穿带锁髓内针治疗肱骨干骨折的临床经验以提高肱骨干骨折的治疗水平。方法 1999年2月－2000年6月使用逆行穿带锁髓内针的方法治疗肱骨干新鲜骨折32例,骨折均为闭合型,手术采用从鹰嘴窝上向近端逆行穿针法。结果 32例3个月时全部骨性愈合,肩肘关节活动恢复95％以上。1例出现术后桡神经麻痹。结论 逆行穿针避免了对肩袖的干扰,髓内针能有效地稳定骨折,软组织进一步破坏小,肩肘关节功能恢复快。     

Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma

Sixty-one patients with multiple injuries, which included sixty-three fractures of the humeral diaphysis, were treated by intramedullary stabilization of the fracture with Rush rods or Ender nails. Portals of entry allowing antegrade or retrograde insertion or insertion at the epicondyles were used. For most of the patients, closed intramedullary fixation of the fracture was performed within twenty-four hours of the injury. Adequate follow-up studies were obtained for fifty-six patients (fifty-eight fractures). Stabilization by antegrade insertion gave excellent results if the portal of entry did not violate the rotator cuff. Symptoms of impingement in the shoulder and pain associated with an incorrect position of the portal for antegrade insertion required early removal of the device. Each fracture that was treated with fixation through the epicondylar portal had a poor result, and this technique is not recommended. Retrograde insertion, with the portal of entry located proximal to the olecranon fossa, yielded excellent results. Care must be taken to prevent encroachment on the olecranon fossa, which can result in a block to extension of the elbow. The surgical technique of closed fixation by retrograde insertion is presented. Immediate closed intramedullary stabilization of the fractured humeral shaft resulted in a 94 per cent rate of union and a 62 per cent rate of excellent clinical results. This technique is particularly applicable to patients with multiple trauma, as it minimizes loss of blood and the risk to neurovascular structures while providing stability for mobilization and aggressive pulmonary physiotherapy. In our opinion, however, isolated fractures of the humeral shaft should be treated by non-operative methods.