T形钢板治疗肱骨近端三、四部分骨折的疗效分析

目的评价T形钢板内固定治疗肱骨近端三部分和四部分骨折的疗效。方法用T形钢板治疗三部分或四部分骨折患者63例。结果63例患者中有56例获得随访，随访时间为3～8年（平均5年）。按照Neer’s肩关节功能评定标准，优良46例，可2例，差8例。19例发生肱骨头缺血坏死，其中14例疗效评定优良。结论大多数肱骨近端三部分或四部分骨折患者行切开复位T形钢板内固定产生很好效果，对于易产生肱骨头缺血坏死的骨折脱位患者也可考虑这一方法，因为这一并发症并不意味着一定产生坏的功能结果。     

Ascending cluster pinning of the humerus inserted through the deltoid tuberosity

Summary Goal of Surgery Stable internal fixation of extraarticular proximal humeral fractures. Indications Extraarticular fractures angulated more than 30° which can be reduced closely or through a small incision. Epiphysiolysis. Fracture-dislocation of the humeral head. Contraindications Pathological fractures. Four part fractures. Segmental fractures of the humerus. Positioning and Anaesthesia Supine; the affected shoulder overhanging the edge of the table and supported by a radiolucent board. General or regional anaesthesia. Surgical Technique Closed pinning of two part and certain three part fractures of the proximal humerus being displaced, unstable, and mainly at the metaphyseal level. Introduction of Kirschner wires through a diaphyseal window and advancement into the proximal fragments after reduction which is controlled by image intensification. Postoperative Management Temporary immobilization in a sling. Passive and active assisted movements after a few days. Active movements after 2 weeks. Removal of wires after 3 months. Possible Complications Fracture of the humerus at the site of the cortical window. Injury to the radial nerve. Results 32 patients, mean age 49 years, 30 two part fractures and 2 three part fractures. Number of Kirschner wires used: 3 to 6, mean 4. Two out of 3 patients complained of pain at the site of wire insertion. All fractures consolidated. No avascular necrosis nor infection. Complications: Partial loss of internal fixation in 3 patients. One fracture of the humeral shaft. Sympathetic reflex dystrophy in 3 patients. Half of the patients had a normal range of motion. Time of follow-up: 6 to 24 (mean 10) months. Division of Orthopaedics and Traumatology, Purpan Hospital, Toulouse, France.     

闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折

目的：通过分析28例闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折的临床疗效，探讨治疗体会及教训。方法：2005年11月至2006年11月采用闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折28例，男12例，女16例；年龄31-73岁，平均54．7岁。均为新鲜骨折。骨折根据Neer分型：两部分外科颈骨折18例，外展嵌插两部分大结节骨折10例。结果：本组平均手术时间42min,口均Ⅰ期愈合，X线片显示骨折对位满意，向前成角基本矫正。外展嵌插两部分大结节骨折的颈干角从术前的平均175°（160°-200°）恢复至平均136°（128°～142°），大结节移位小于3mm。随访6-13个月，平均10．3个月，骨折均愈合，未出现肱骨头缺血坏死现象，术后8—10周取出内固定。根据ASES及Constant-Murley肩关节评分系统，本组ASES评分平均91．2分（63～100分），Constant—Mudey评分平均90．4分（67-100分）。本组优12例，良14例，一般2例。结论：闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折的操作有相当难度，且须在透视下进行，但具有损伤小、康复快的优点，是治疗特定类型肱骨近端骨折的有效方法。骨质情况是决定固定稳定程度的必要条件。     

Vergleich der offenen vs. perkutanen Versorgung der Oberarmkopffraktur

BACKGROUND: The hypothesis of this study was that percutaneous techniques lower the risk of post-traumatic avascular necrosis. MATERIALS AND METHODS: In this retrospective study 83 patients were followed up clinically and radiologically for signs of avascular necrosis and nonunion after open or percutaneous treatment of proximal humerus fractures. Mean age was 50 years. Fractures were classified in 22 patients (26.5%) as two part, in 21 patients (25.3%) as three part, in 39 patients (47%) as four part, and in 1 patient (1.2%) as fracture dislocation (Neer classification). Fractures were treated in 12 patients (14.5%) by ORIF (open reduction and internal fixation) and in 71 patients (85.5%) by CRPF (closed reduction and percutaneous fixation). Both groups were statistically equally distributed according to fracture type (Mann-Whitney U, p=0.267) and age (One-way-Annova, p=0.740). The postoperative regime did not differ between the two groups. RESULTS: Patients suffered significantly more avascular necrosis after open treatment [five patients (50%) versus eight patients (12.7%) in the percutaneous group, Mann-Whitney, p=0.004]. The risk for avascular necrosis and nonunion increased with age. Mean age of patients with avascular necrosis was 57 years, and the age of patients with nonunion was 67 years. CONCLUSION: Percutaneous treatment of humeral head fractures seems to be a reliable method for lowering the risk of avascular necrosis in young patients.     

Percutaneous pinning for proximal humerus fractures

Proximal humerus fractures are relatively frequent. The are several possibilities for fixation of proximal humerus fractures: close reduction and fixation with percutaneous pinning or intramedullary rod, open reduction and fixation with tension band or a plate. Close reduction and percutaneous pinning have the advantage to be an easy technique, with good results and it is considered to be ideal in young patients with two-part fractures. The number and the directions of the pins depend upon the number of fragments displaced, reducibility, bone quality, patient age, other pathology associated. Some authors consider being enough the placement of 2 or 3 ascending pins, while others recommend at least 4 pins, ascending and descending. Usually we prefer the techniques in witch are used 3 ascending pins. The operative technique is presented. The most common intra-operative complication in percutaneous pinning is the possibility of damaging the adjacent neuro-vascular structures or tendons. Post-operative complications which may occur are: loosing reduction, pins migrations, aseptic necrosis of humeral head, pins infection. In conclusion percutaneous pinning for proximal humerus fractures it is an easy technique with good results. In this manner are avoided large incisions to the shoulder with can lead to aseptic necrosis of the humeral head. This technique can be used in young patients, with good bone quality, but also in elderly patients, with osteoporosis and other pathology associated. In some three or four-part fractures some reduction problems can occur, but this are rare in two-part fractures.     

Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus

BACKGROUND: Controversy persists concerning the preferred treatment of displaced fractures of the proximal part of the humerus. The present study was undertaken to evaluate the results of open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus and the functional limitations of patients in whom avascular necrosis of the humeral head develops as a complication of this fracture. METHODS: We assessed the intermediate and long-term results for sixty patients with a three or four-part fracture of the proximal part of the humerus who had undergone open reduction and internal fixation with cerclage wires or a T-plate. The Constant score and a visual analog score for pain were calculated, and radiographs of the proximal part of the humerus were evaluated. RESULTS: After an average of ten years of follow-up, fifty-two patients (87%) had a good or excellent result on the basis of the Constant score whereas eight patients (13%) had a poor result. Fifty-one patients (85%) were satisfied with the result at the time of the most recent examination. Twenty-two patients (37%) had development of avascular necrosis of the humeral head, and seventeen (77%) of these twenty-two patients had a good or excellent Constant score. CONCLUSIONS: Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients. This option should be considered even for patients with fracture-dislocation patterns that are associated with a high risk for avascular necrosis of the humeral head, as this complication did not preclude a good result.     

Technique of Kirschner wire reduction and fixation of displaced two-part valgus angulated proximal humerus fractures at the surgical neck

This article describes the technique of closed reduction with percutaneous fixation using Kirschner wires in helping the reduction of two-part valgus angulated and displaced proximal humerus fractures at the surgical neck. Traditional open reduction may lead to more accurate anatomic reduction; however, extensive tissue dissection increases the risk of avascular necrosis. Thus, closed reduction of unstable fracture mostly required forceful reduction maneuvers, which can harm the vascular supply and increase hematoma formation. Reduction of the fractured sides can easily be performed by engaging Kirschner -wires with a joystick method and fixation can be secured by using threaded pins. Thirty-six consecutive patients with displaced, two-part, valgus-angulated proximal humerus fractures at the surgical neck were treated by this method. The patients were followed for an average of 38 months. All fractures healed. According to the Constant scoring system, 21 patients (58%) had excellent, 9 patients (25%) had good, and 6 patients (17%) had fair results. The technique of closed reduction with a joystick method and percutaneous fixation is regarded as a reasonable treatment alternative in displaced two-part valgus angulated proximal humerus fracture.     

External fixation of proximal humerus fracture. Clinical and cadaver study of pinning technique

The risk of injuring important anatomic structures or interfering with motion of the glenohumeral joint by transcutaneous pinning of the proximal end of the humerus was investigated in 12 cadaver shoulders and in 23 patients with displaced fractures of the proximal humerus. In the cadavers, pinning of the proximal humeral shaft from laterally more than 20 mm below the surgical neck did not injure the neurovascular structures in any case. Pin insertions into the humeral head medial to the intertubercular groove endangered the cephalic vein and interfered with shoulder function by transfixing the subacromial bursa and by restricting internal rotation. Lateral pinning did not carry such risk. In the patients closed reduction and external fixation confirmed the low risk of neurovascular injuries. Lateral pinning of the humeral head resulted in an unrestricted passive mobility of the glenohumeral joint of the anesthetized patient, whereas anterior pinning carried the risk of mechanical restriction of the internal rotation.     

Plate fixation of proximal humeral fractures with indirect reduction: surgical technique and results utilizing three shoulder scores

To determine the outcome after indirect reduction and buttress plate fixation of displaced and unstable proximal humeral fractures, we retrospectively evaluated 98 patients, an average of 34 months (range 24-72 months) after fracture fixation. The patients were reviewed and results were evaluated clinically according to the Neer, UCLA and Constant score. A radiographic evaluation of fracture healing, avascular necrosis and degenerative changes of the shoulder joint was performed in all patients. Any complications of treatment were assessed. Results were, according to the UCLA-rating system, good to excellent in 76% of fractures. According to the Constant-score and the Neer score, good to excellent results were obtained in 69 and 59% of fractures, respectively. Poor results were mainly due to secondary malunion. The avascular necrosis rate was 4%. Non-union was seen in one case. Secondary varus deformity and retroversion of the humeral head as a result of lack of rotational and angular stability of the plate developed in twelve (12%) and eight (8%) cases, respectively. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus, enabling early functional after-treatment. The incidence of avascular necrosis and nonunion are low, when fracture reduction is performed indirectly. Poor rotational and angular instability can lead to a loss of reduction.     

Locking plate fixation for proximal humerus fractures

Locking plates are increasingly used to surgically treat proximal humerus fractures. Knowledge of the bone quality of the proximal humerus is important. Studies have shown the medial and dorsal aspects of the proximal humeral head to have the highest bone strength, and this should be exploited by fixation techniques, particularly in elderly patients with osteoporosis. The goals of surgery for proximal humeral fractures should involve minimal soft tissue dissection and achieve anatomic reduction of the head complex with sufficient stability to allow for early shoulder mobilization. This article reviews various treatment options, in particular locking plate fixation. Locking plate fixation is associated with a high complication rate, such as avascular necrosis (7.9%), screw cutout (11.6%), and revision surgery (13.7%). These complications are frequently due to the varus deformation of the humeral head. Strategic screw placement in the humeral head would minimize the possibility of loss of fracture reduction and potential hardware complications. Locking plate fixation is a good surgical option for the management of proximal humerus fractures. Complications can be avoided by using better bone stock and by careful screw placement in the humeral head.     

External fixation of proximal humerus fracture: Clinical and cadaver study of pinning technique

The risk of injuring important anatomic structures or interfering with motion of the glenohumeral joint by transcutaneous pinning of the proximal end of the humerus was investigated in 12 cadaver shoulders and in 23 patients with displaced fractures of the proximal humerus. In the cadavers, pinning of the proximal humeral shaft from laterally more than 20 mm below the surgical neck did not injure the neurovascular structures in any case. Pin insertions into the humeral head medial to the intertubercular groove endangered the cephalic vein and interfered with shoulder function by transfixing the subacromial bursa and by restricting internal rotation. Lateral pinning did not carry such risk.

In the patients closed reduction and external fixation confirmed the low risk of neurovascular injuries. Lateral pinning of the humeral head resulted in an unrestricted passive mobility of the glenohumeral joint of the anesthetized patient, whereas anterior pinning carried the risk of mechanical restriction of the internal rotation.     

Rigid internal fixation of fractures of the proximal humerus in older patients

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 +/- 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus.     

Internal Fixation of Proximal Humeral Fractures: Current Concepts

Abstract Fractures of the proximal humerus are an increasingly common type of injury. Mainly elderly patients with osteoporotic bone are affected. Whereas non-displaced and stable fractures are managed successfully with conservative treatment, there is no general agreement on the surgical strategy for displaced and unstable two- to four-part fractures. The clinical outcome is influenced by the fracture type and concomitant injury to the rotator cuff. Extensive surgical manipulation of the soft tissues, non-anatomic and/or unstable fixation as well as technical errors are important contributing factors to poor clinical results.Goals of surgical treatment are to restore anatomy, to achieve fixation that is stable enough to allow early mobilization, to avoid secondary displacement and not to harm the blood supply of the humeral head in order to minimize the risk for avascular necrosis.Minimally invasive procedures using closed reduction are advantageous for protection of the arterial blood supply. Plate fixation offers superior biomechanical stability. There is a recent tendency to use fixedangle implants for proximal humeral fractures in order to avoid secondary loss of fixation. Locked plates acting as internal fixator as well as intramedullary nails better adapt according to the biomechanical and anatomical characteristics of the proximal humerus. First clinical experience with those implants is encouraging but they do not compensate for an insufficient surgical technique.     

Early reduction, arthrotomy, and cannulated screw fixation in unstable slipped capital femoral epiphysis treatment

Sixteen consecutive cases of unstable slipped capital femoral epiphysis treated with urgent reduction and pinning during a 7-year period are presented. In 2 of the 16 patients, avascular necrosis of the femoral head developed. Ten of the 16 patients were treated within 24 hours after the onset of acute symptoms by reduction, arthrotomy, and cannulated screw fixation of the hip using two screws. In none of these patients did avascular necrosis of the femoral head develop. Two patients required hardware removal for persistent pain, and one required a revision pinning after a nondisplaced femoral neck fracture. Chondrolysis did not develop in any patient, and no hip progressed after fixation. At last follow-up (mean 27 months after surgery), two patients walked with a moderate limp. Three reported persistent mild pain in the affected hip. Early reduction of unstable hips with arthrotomy and pinning using two cannulated screws to minimize the risk of avascular necrosis is recommended.     

Fractures involving splitting of the humeral head

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.     

多方向不稳定的儿童肱骨髁上骨折的治疗

目的探讨急诊手术内固定治疗多方向不稳定的儿童肱骨髁上骨折的疗效。方法对26例多方向不稳定肱骨髁上骨折患儿采用闭合或切开复位克氏针内固定,术后肘关节屈曲20°～40°位石膏托固定3周后逐步进行功能锻炼。结果26例均得到随访,时间12～50个月,26例均临床愈合,骨折愈合时间4～6周。肘关节功能评价：优23例,良2例,可1例。无畸形愈合、感染、活动受限等并发症发生。结论闭合复位克氏针内固定是治疗多方向不稳定的儿童肱骨髁上骨折的有效方法,尽早复位及稳定固定骨折端,可有效减少或避免并发症的发生,利于肢体功能的恢复。     

Fractures of the proximal humerus

Summary Proximal humeral fractures are common particularly in the elderly. The decision of the optimal treatment is dependent on many factors. On the one hand the biological age of the patient and the bone structure plays a key-role, on the other hand the living conditions and individual needs are of importance. Most fractures with minimal displacement respond satisfactorily to simple conservative treatment including short sling immobilisation and functional aftertreatment under supervision of the physiotherapist. Most recently there is a trend towards more aggressive surgical intervention with percutaneous insertion of cannulated screws also in the slightly displaced fracture situation. This protocol allows for earlier functional and less painful aftertreatment, less risk of displacement of the fracture fragments and better outcome. In severely unstable fractures with marked displacement of the fragments an operative stabilisation is advocated by most surgeons. Again there is a trend from plating towards cannulated screw fixation combined with tension absorbing (resorbable) sutures. In special cases which are described in detail a minimal invasive percutaneous screw technique with less stripping of bone and therefore preservation of the crucial blood supply of the humeral head is recommended. Instead of percutaneous pinning using K-wires only, cannulated screws are inserted today. Plating of proximal humerus joint fractures is the exception in our days, only the subcapital unstable fracture of the elderly would be an indication. LC-condylar plating seems to yield better stability than the conventional T-plate-system. In the most severe fractures of the proximal humerus (4-segment-fractures and dislocation fractures according to Neer, respectively C-2- and C-3-fractures according to the AO-classification) there is still controversy on the best management. Most authors prefer hemiarthroplasty in this situation whereas the other group of orthopaedic surgeons try open reduction and internal fixation particularly in the younger individuals. This stabilisation provides the orthopaedic surgeons with a formidable challenge and requires a lot of experience in this field. Also the understanding of the fracture morphology is needed for optimal results. In spite of good stabilisation techniques often partial or total humeral head necrosis occurs in the most severe fractures. Surprisingly enough results with reasonable function can be obtained even with partial avascular necrocis of the humeral head. A crucial part of the management is team work with the physiotherapist and an individual program for each fracture situation, depending on the stability of the fixation. Close contact between these two professions is of utmost importance. Finally it can be stated that the management of proximal humeral fractures is fairly standardised but it is always dependent on the experience and resources of the attending surgeon and must be tailored to the individual needs of the patient.      

Internal fixation of displaced proximal humeral fractures with two one-third tubular plates

BACKGROUND: Operative treatment of displaced proximal humeral fractures often results in poor functional outcome. We report a technique that provides improved rotational stability of the fracture and thus allows early functional treatment. METHODS: Seventy-one consecutive patients (67 +/- 18 years) with displaced fractures of the proximal humerus (two-part, n = 10; three-part, n = 41; four-part, n = 20) were treated by open reduction and internal fixation using two one-third tubular plates on the anterior and lateral aspects of the proximal humerus. Passive motion was started on the third postoperative day, followed by actively assisted exercises on day 6. RESULTS: Seven patients (12%) had complications (fracture redisplacement, avascular necrosis of the humeral head, frozen shoulder, subacromial impingement, and implant loosening) that required further surgical intervention. Sixty patients (85%) were available for follow-up evaluation 17 +/- 10 months after the injury. Using the Constant score, 34% of the patients had very good results, 29% had good results, 25% had fair results, and 12% had poor results. Age (< 60 years or > or = 60 years) and fracture type had no influence on functional outcome. CONCLUSION: These results demonstrate the high stability of internal fixation with two one-third tubular plates that allowed early mobilization of the shoulder in all patients and emphasize this technique as a preferred treatment option for displaced fractures of the proximal humerus.     

切开复位内固定治疗严重嵌插外展型肱骨近端骨折

目的 评价切开复位内固定治疗严重嵌插外展型肱骨近端骨折的临床效果.方法 004年4月-2008年2月,手术治疗严重嵌插外展型肱骨近端骨折23例,采用改良的Thompson切口切开复位,用肱骨近端锁定钢板固定,其中20例行一期自体骨移植,8例术中发现有明显的肩袖撕裂而行修补术.术后进行系统的肩关节功能锻炼.结果 23例获得1年以上的随访,平均随访时间为17个月(12～33个月).所有骨折均于术后2个月内愈合,最近一次X线片检查未出现内固定失效和肱骨头坏死.采用肩关节Neer评分系统评分:优9例,良10例,可3例,差1例;优良率为82.6%.患者主观满意率为91.3%.5例出现供骨区髂部疼痛.结论 采用切开复位LPHP内固定治疗严重嵌插外展型肱骨近端骨折有利于早期功能锻炼,疗效满意.     

切开复位内固定治疗严重嵌插外展型肱骨近端骨折

目的 评价切开复位内固定治疗严重嵌插外展型肱骨近端骨折的临床效果.方法 004年4月-2008年2月,手术治疗严重嵌插外展型肱骨近端骨折23例,采用改良的Thompson切口切开复位,用肱骨近端锁定钢板固定,其中20例行一期自体骨移植,8例术中发现有明显的肩袖撕裂而行修补术.术后进行系统的肩关节功能锻炼.结果 23例获得1年以上的随访,平均随访时间为17个月(12～33个月).所有骨折均于术后2个月内愈合,最近一次X线片检查未出现内固定失效和肱骨头坏死.采用肩关节Neer评分系统评分:优9例,良10例,可3例,差1例;优良率为82.6%.患者主观满意率为91.3%.5例出现供骨区髂部疼痛.结论 采用切开复位LPHP内固定治疗严重嵌插外展型肱骨近端骨折有利于早期功能锻炼,疗效满意.