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。

Comparative study of antegrade and retrograde intramedullary nailing for the treatment of humeral shaft fractures

Objective: To compare therapeutic effects between antegrade intramedullary nailing and retrograde intramedullary nailing for the treatment of humeral shaft fractures. Methods: From March 1999 to October 2006,105 patients with humeral shaft fractures were treated with locked intramedullary nail and were adequately followed up. There were 82 antegrade nailing and 23 retrograde nailing. The follow-up parameters included operation time,blood loss,fracture healing rate,healing time,complications,Constant- Murley shoulder score and Mayo elbow performance score. Results: The mean follow-up period was 31.2 months. Antegrade intramedullary nailing had significantly less blood loss than that in retrograde intramedullary nailing(P=0.002). The differences in operation time,complications,healing time and bone healing rate between the two groups had no statistical significance. Complications in the antegrade intramedullary nail group included 4 patients with nonunions,1 patient with radial nerve palsy,and 8 patients with shoulder pains and decrement in shoulder range of motion. Complications in the retrograde intramedullary nail group included 1 patient with radial nerve palsy and 3 patients with iatrogenic fractures. For shoulder joints,the difference in the average Constant-Murley shoulder score between the two groups was statistically significant(P=0.04). For elbow joints,the average postoperative Mayo elbow performance score between these two approaches did not differ significantly. Conclusion: Both the antegrade intramedullary nailing and the retrograde intramedullary nailing are good alternatives for the treatment of humeral shaft fractures. Because of higher incidence of iatrogenic fractures,the insertion point of retrograde intramedullary nailing should be carefully prepared. With antegrade insertion,it is important to bury the humeral nail below the rotator cuff to prevent the subacromial impingement,and the rotator cuff should be carefully repaired to avoid shoulder pain and improve shoulder function.