肱骨近端骨折髓内钉内固定

肱骨近端骨折常用的内固定材料包括克氏针、髓内钉、接骨板等，锁定接骨板曾被寄予厚望，但随着临床应用的增多，其并发症日渐引起人们的重视。常见并发症包括：内翻畸形愈合、螺钉穿入关节、复位丢失、螺钉切出、肩峰下撞击、骨折不愈合等。Sudkamp报道锁定接骨板治疗肱骨近端骨折的并发症高达34%，其中40%的并发症与手术技术有关。如果钢板放置位置过高可以导致肩峰撞击，如果术中忽视肩袖的修补固定，术后可出现大结节的逃逸。Thanasas报道锁定接骨板治疗肱骨近端骨折术后需要再次手术的发生率高达13.7%、螺钉切出发生率为11.6%，肱骨头坏死发生率为7.9%。导致上述并发症的主要影响因素包括：骨折类型、伤后肱骨头内翻位固定、肱骨内侧缺少支撑、老年骨质疏松等。Hertel认为导致肱骨头缺血的潜在危险因素：骨折块数目、肱骨头骨折块后内侧干骺端长度、肱骨干与肱骨头移位的最大程度、肱骨干是否向内侧或外侧移位、大小结节间的最大移位程度、肱骨头的移位成角程度、是否有盂肱关节脱位史、是否存在肱骨头压缩骨折、肱骨头劈裂是否超过20%。髓内钉治疗肱骨近端骨折是临床可选的治疗手段之一，近年来广受关注。早期的髓内钉由于进针点偏外侧，易损伤肩袖。近年来随着直钉的出现，肱骨髓内钉进针点由足印区内移至肱骨头，通过肩袖间隙进钉，减少了对肩袖的干扰，同时近端多枚不同方向的螺钉可对大结节及近端骨质进行更加可靠的固定。Hepp通过对肱骨近端骨质结构的分析认为肱骨头的后侧、内侧骨质较好，锁定钢板的螺钉很难对内侧、后侧进行固定，而新一代的髓内钉通过钉中钉技术可以实现对肱骨近端骨折块的固定，髓内钉通过中心固定，可有效避免肱骨头内翻畸形。     

锁定钢板联合植骨治疗肱骨近端骨折的研究进展

肱骨近端骨折是老年人群中比较常见的骨折类型,其中粉碎且移位明显的病例以手术治疗为主.锁定钢板联合植骨是治疗骨质疏松及内侧距粉碎性肱骨近端骨折的有效方法,可有效增加骨量,增强锁定钢板螺钉系统的稳定性,并为肱骨近端提供内侧支撑,有助于降低术后并发症发生率.植骨种类包括腓骨、髂骨、股骨头及结构型异体骨,其中以腓骨最为常见.本文通过对近十年来采用锁定钢板联合植骨治疗肱骨近端骨折的研究及临床试验进行归纳、分析、总结,为治疗肱骨近端骨折提供新的思路.     

采用肱骨近端锁定钢板治疗肱骨近端骨折临床分析

目的探讨应用肱骨近端锁定钢板治疗肱骨近端骨折的临床疗效。方法对20例肱骨近端骨折患者行锁定钢板内固定手术治疗,随访半年左右,对其愈合情况和肩关节功能进行评定。结果经过肱骨近端锁定钢板内固定治疗后,20例肱骨近端骨折患者,有19例达到骨折解剖复位标准,有1例达到骨折功能复位标准。所有患者骨折都愈合,术后随访半年,无创口感染、钢板断裂、螺钉脱出、内固定失效等严重并发症。20例肱骨近端骨折患者治疗后,肩关节功能评分:优15例,良4例,可1例,优良率为95.0%。结论应用肱骨近端锁定钢板治疗肱骨近端骨折,复位良好,术后功能恢复较满意,并发症相对较少,值得临床广泛推广。     

锁定钢板与常规手术治疗肱骨近端骨折疗效比较

目的 :比较肱骨近端锁定钢板 (LockingProximalHumerusPlate)与常规手术方法治疗肱骨近端骨折疗效。方法 :回顾性分析比较肱骨近端锁定钢板治疗肱骨近端骨折与常规手术方法的疗效与并发症。结果 :锁定钢板治疗组的疗效及并发症发生率明显优于常规手术方法组 ,治疗组的满意率 87.5 %～ 76% ,断钉断板率 <16% ,感染率 <8% ,肩峰撞击 <2 0 % ,四部分骨折肱骨头坏死率 3 3 .3 %～ 60 % ,P <0 .0 5。结论 :治疗肱骨近端骨折方法多样 ,肱骨近端锁定钢板是一种创新、优异的方法。     

加长型肱骨近端锁定接骨板内固定治疗老年肱骨干合并肱骨近端骨折

目的探讨加长型肱骨近端锁定接骨板(PHILOS)内固定治疗老年肱骨干合并肱骨近端骨折的临床疗效。方法回顾性分析自2012-05—2016-01采用加长型PHILOS钢板内固定治疗的13例老年肱骨干合并肱骨近端骨折,根据骨折线长度选用钢板,于骨折近端置入合适长度的锁定螺钉,避免螺钉穿透肱骨头进入关节腔,肱骨干远折端置入至少3枚锁定螺钉,亦可与皮质骨螺钉混合使用,远近骨折线之间根据跨度置入2或3枚锁定螺钉。结果 13例均获得随访,随访时间平均15.6(12~24)个月。切口未出现感染,均一期愈合。13例均获得骨性愈合,骨折愈合时间平均20(15~36)周。随访期间未发生肱骨头坏死、螺钉松动、螺钉拔出及钢板断裂,1例合并桡神经损伤者3个月后神经功能自行恢复。末次随访时采用Neer评分评价肩关节功能:优9例,良3例,可1例。结论加长型PHILOS钢板可有效固定老年肱骨干合并肱骨近端骨折,骨折复位维持良好,术后患者肩关节功能恢复良好。     

肱骨近端锁定钢板治疗复杂肱骨近端骨折

肱骨近端骨折是临床比较常见的骨折,其中对于三部分骨折和四部分复杂骨折的治疗较为困难,手术难度大,骨折固定往往不牢同．术后的肱骨头坏死率、肩关节功能障碍发生率较高。锁定钢板技术在各种复杂骨折治疗中广泛的应用．为复杂肱骨近端骨折的治疗开辟了最佳的手术方式。本院白2004年1月至2008年3月．采用肱骨近端锁定钢板（locking proximal humeral plate,LPHP）治疗肱骨近端骨折29例．疗效满意。现报告如下。     

肱骨近端锁定加压钢板治疗肱骨外科颈骨折效果观察

目的探讨肱骨近端锁定加压钢板治疗肱骨外科颈骨折的效果。方法选择2015-09—2016-11间遂平县人民医院收治的84例肱骨外科颈骨折患者,根据不同术式分为2组,每组42例。对照组行肱骨近端解剖钢板治疗,观察组行肱骨近端锁定加压钢板治疗。结果观察组手术时间、术中出血量、并发症发生率及骨折愈合时间均低于对照组,差异有统计学意义(P0.05)。随访3个月,观察组Neer肩关节功能评分总优良率略高于对照组,但差异无统计学意义(P0.05)。结论肱骨近端锁定加压钢板治疗肱骨外科颈骨折,能缩短骨折愈合时间,并发症发生率低,有利于改善肩关节功能。     

解剖锁定钢板联合肱骨距螺钉治疗Neer四部分肱骨近端骨折的临床疗效分析

目的探讨解剖锁定钢板联合肱骨距螺钉治疗Neer四部分肱骨近端骨折的临床疗效。方法回顾性分析自2010-01—2015-01采用解剖锁定钢板联合肱骨距螺钉内固定治疗的35例Neer四部分肱骨近端骨折,术中先行解剖复位,如果存在肩袖等软组织损伤或撕裂者,同时予以修复。结果 35例均顺利完成手术并获得完整随访,随访时间8～24个月,平均16个月。骨折愈合时间14～22周,平均17周。术后未出现骨不愈合、延迟愈合、钢板螺钉断裂、骨折再次移位等并发症。末次随访时按Neer肩关节功能评分评价疗效:优20例,良13例,可2例。结论采用解剖锁定钢板联合肱骨距螺钉内固定治疗Neer四部分肱骨近端骨折固定可靠、疗效满意,术后并发症少,是一种安全有效的手术方法。     

肱骨近端锁定钢板治疗肱骨近端粉碎性骨折

目的评价肱骨近端锁定钢板（LPHP）治疗肱骨粉碎性骨折的治疗效果。方法2004年6月～2007年12月应用肱骨近端锁定钢板治疗肱骨近端骨折32例,男14例、女18例,年龄23～85岁,平均57．1±5．8岁。根据Neer分型：二部分骨折6例,三部分骨折21例,四部分骨折5例。术后利用Constant评分评价其治疗效果。结果随诊10个月～3．5年,平均2．1±0．8年,4例失访,随访期末均顺利愈合。1例出现肱骨头部分坏死,但不影响功能;3例出现肩关节半脱位;2例保守治疗缓解;1例出现肩关节撞击征。根据Constant评分为优良率89．2％（25／28）。结论肱骨近端锁定钢板（LPHP）是治疗肱骨近端粉碎性骨折的首选方法之一．可取得较好的临床治疗结果。     

应用肱骨近端锁定钢板治疗肱骨近端骨折

目的观察、评价肱骨近端锁定钢板（LPHP）治疗肱骨近端骨折的疗效。方法通过分析自2008—01—2012—10收治并随访的52例肱骨近端二部分以上骨折。采用有限切开、透视复位、肱骨近端锁定钢板内固定的方法治疗,骨缺损患者采用自体髂骨及人工骨植骨。结果本组获得随访8—25个月（平均15个月）,肱骨近端骨折均得到了愈合,按Neer肩关节功能评分标准：优25例,良18例,可6例,差3例,优良率82．7％。未发生断板、断钉,无肱骨头缺血坏死及肩峰撞击综合征。结论应用肱骨近端锁定钢板治疗肱骨近端骨折,骨缺损者取髂骨、人工骨植骨,根据骨折类型及稳定性等指导功能锻炼,骨折愈合良好、并发症少、关节功能恢复好。     

Management of proximal humerus fractures in adults

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.     

锁定接骨板治疗老年肱骨近端骨折

目的 探讨肱骨近端锁定接骨板(LPHP)治疗肱骨近端骨折的临床疗效。方法 采PHP治疗29例肱骨近端骨折，按Neer分类法，二部分骨折11例；三部分骨折12例；四部分骨折6例。结果 平均愈合时间7．4周(6～12周)：按照Constant评分标准，功能优18例，良为8例，中为3例，优良率为89．6％。结论 肱骨近端锁定接骨板治疗眩骨近端骨折手术简单、固定可靠、并发症少、骨折愈合率高特别是老年骨质疏松患者首选治疗方法。     

A systematic review of locking plate fixation of proximal humerus fractures

Purpose

Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates.

Methods

The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias.

Results

Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%.

Discussion

Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.     

肱骨近端骨折内固定术后并发症原因分析及对策

目的探讨肱骨近端骨折内固定术后并发症的可能原因,并提出相应对策。方法回顾总结12例肱骨近端骨折内固定术后出现的并发症,分析其原因及所作的相应处理。结果 12例患者均得到随访,9例再次内固定患者术后肩关节功能经美国肩肘外科医师(ASES)评分评价,平均为68.3(36.7～83)分,骨折均愈合。结论完善术前准备、手术操作及术后功能锻炼指导,可减少肱骨近端骨折内固定术后并发症的发生。     

Calcar screw position in proximal humerus fracture fixation: Don’t miss high!

IntroductionIn locked plate fixation of proximal humerus fractures, the calcar is an important anchor point for screws providing much-needed medial column support. Most locking plate implants utilize a fixed-trajectory locking screw to achieve this goal. Consequently, adjustments of plate location to account for patient-specific anatomy may result in a screw position outside of the calcar. To date, little is known about the consequences of “missing” the calcar during plate positioning. This study sought to characterize the biomechanics associated with proximal and distal placement of locking plates in a two-part fracture model.Materials and methodsThis experiment was performed twice, first with elderly cadaveric specimens and again with osteoporotic sawbones. Two-part fractures were simulated and specimens were divided to represent proximal, neutral, and distal plate placements. Non-destructive torsional and axial compression tests were performed prior to an axial fatigue test and a ramp to failure. Torsional stiffness, axial stiffness, humeral head displacement and stiffness during fatigue testing, and ultimate load were compared between groups.ResultsCadavers: Proximal implant placement led to trends of decreased mechanical properties, but there were no significant differences found between groups. Sawbones: Distal placement increased torsional stiffness in both directions (p = 0.003, p = 0.034) and axial stiffness (p = 0.018) when compared to proximal placement. Distal placement also increased torsional stiffness in external rotation (p = 0.020), increased axial stiffness (p = 0.024), decreased humeral head displacement during fatigue testing, and increased stiffness during fatigue testing when compared to neutral placement.DiscussionThe distal and neutral groups had similar mechanical properties in many cadaveric comparisons while the proximal group trended towards decreased construct stiffness.Resultsfrom the Sawbones model were more definitive and provided further evidence that proximal calcar screw placements are undesirable and distal implant placement may provide improved construct stability.ConclusionSuccessful proximal humerus fracture reconstruction is inherent upon anatomic fracture reduction coupled with medial column support. Results from this experiment suggest that missing the calcar proximally is deleterious to fixation strength, while it is safe, and perhaps even desirable, to aim slightly distal to the intended target.     

Second generation locked plating for complex proximal humerus fractures in very elderly patients

ObjectivesHumeral head sacrificing procedures are more favored in elderly patients with complex proximal humerus fractures because of high incidence of failures and complications with osteosynthesis. The purpose of this study is to assess the outcome of second generation locked plating techniques in 3 and 4 part fractures in active elderly patients >70 years with an emphasis on function and complications.Materials and methods29 patients with displaced 3 and 4 part proximal humerus fractures were treated using the principles of second-generation proximal humerus locked plating. Fixed angle locked plating (PHILOS) using the anterolateral deltoid spilt approach augmented with traction cuff sutures was performed. Minimum of 7 locking head screws including 2 calcar screws were used. In cases with a comminuted medial calcar, an endosteal fibular strut was used. Subchondral metaphyseal bone voids were filled with injectable calcium phosphate cement. Radiological outcome (union, head – shaft angle, tuberosity reduction), functional outcome assessment (Constant and ASES scores) and complications (loss of reduction, nonunion and osteonecrosis) were assessed.ResultsThe fracture united in 24 of the 26 patients available for follow up at a mean of 27 months (12–40 months). 3 patients developed complications that required arthroplasty (fixation failure in 2 patients and osteonecrosis in 1 patient). Follow up age adjusted Constant (63.1 ± 11.9) and ASES scores (62.58 ± 7.5) showed the extent of functional improvement post surgery. Patients with fractures having a non-comminuted medial calcar and valgus displacement of the humeral head had better functional scores and fewer complications.ConclusionOsteosynthesis with second generation locked plating techniques provide satisfactory outcome in very elderly patients with complex proximal humerus fractures with minimal complications.     

Internal fixation of proximal humerus fractures using the Polarus intramedullary nail

INTRODUCTION: It has been stated that proximal humeral fractures are the last unsolved fractures in orthopedics. In this study, we evaluate the results of the Polarus nail, in order to constitute to the controversial problem of the treatment of proximal humerus fractures. PATIENTS AND METHODS: Between 2003 and 2005, 27 patients with severely displaced proximal humeral fractures were treated with the Polarus intramedullary system. The fractures were classified according to the Neer classification system. There were 16 2-part fractures and 11 3-part fractures. At the 12-months follow up we graded the clinical outcome of the patients according to the Neer scoring system. RESULTS: The duration from time of injury to operation ranged from 1 to 6 days. The mean operative time was 55 min and no need of blood transfusion was recorded. Bony union was obtained in 27 patients. There were no cases of nonunion and the period from operation to the appearance of sufficient bridging callus on radiographs was 5-11 weeks (mean 6 weeks). In one patient, a backed-out proximal screw was recorded. Stiffness of the shoulder was seen in one patient and avascular necrosis of the head of humerus in another. Related to the clinical outcome, six patients had an excellent result, 15 patients had a satisfactory result, four patients had an unsatisfactory result, and two patients had a poor result. The 77.78% of the patients had an excellent or satisfactory clinical outcome. There was significant difference in the functional outcome between patients younger than 65 years (91.55) and those older than 65 years (80.22) (P < 0.05). No significant difference was recorded in the Neer score between the patients with a 2-part fracture and the patients with a 3-part fracture (80.18) (P > 0.05). CONCLUSION: The Polarus nail is designed to provide stable fixation with a straightforward insertion and targeting procedure. The fact that 77.78% of the patients had an excellent or satisfactory clinical outcome, suggest that Polarus humeral rod system can be a worthy alternative to traditional operative methods for displaced proximal fractures of the humerus.     

锁定接骨板治疗肱骨近端复杂骨折

目的探讨肱骨近端锁定接骨板（LPHP）治疗肱骨近端复杂骨折的临床疗效。方法回顾分析本院2003年1月至2005年10月采取LPHP治疗31例肱骨近端复杂骨折。按Neer分型，3部分骨折22例；4部分骨折9例。结果31例经5～13月随访．无1例发生内固定松动、断裂，全部骨折均愈合。肩关节功能按照Constant评分标准，功能优9例，良18例，中4例，优良率87．1％。结论LPHP治疗肱骨近端复杂骨折固定可靠、骨折愈合率高、可行早期功能锻炼，功能恢复好。     

Mortality following combined fractures of the hip and proximal humerus

BACKGROUND Hip fractures and proximal humerus fractures are known to be associated with increased mortality, but the impact on mortality of combining these two common injuries is not well known.AIM To compare mortality, inpatient stay and discharge destination for patients with combined hip and proximal humerus fractures with those sustaining isolated hip fractures.METHODS Using the United Kingdom national hip fracture database, we identified all hip fracture patients over the age of 60 admitted to a single trauma unit from 2010-2016. Patients sustaining a proximal humerus fracture in addition to their hip fracture were identified using hospital coding data. We calculated the 30-d and one-year mortality for both the hip fracture cohort and the combined hip and proximal humerus fracture cohort. Other variables recorded included age, gender and whether the proximal humerus was treated with or without an operation.RESULTS We identified 4131 patients with hip fractures within the study period and out of those 40 had sustained both a hip and a proximal humerus fracture. Mean age in the hip fracture cohort was 80.9 years and in the combined fracture group 80.3 years. Out of the 40 patients in the combined group four were treated operatively. The 30-d mortality for our hip fracture cohort was 7.2% compared to the mortality of our combined cohort of 12.5%(P = 0.163). The one-year mortality for our hip fracture cohort was 26.4% compared to 40% for the combined fracture cohort(P = 0.038). We also found patients with combined injuries were less likely to return to their own home.CONCLUSION The 30-d and one-year mortality is higher for those patients who have sustained a combined hip and proximal humerus fracture when compared to those with a hip fracture alone.