肱骨近端关节囊内骨折的预后判断标准

目的 分析肱骨近端关节囊内骨折原始X线片表现与预后的关系，为选择治疗方案提供依据。方法 1999年4月至2004年2月保守治疗肱骨近端关节囊内骨折459例，其中资料完整、随访时间大于9个月者211例，男82例，女129例；年龄17～81岁，平均54．2岁。Neer一部分骨折68例，二部分骨折39例，三部分骨折59例，四部分骨折45例。将原始X线片与随访9个月以上的X线片进行比较，按照自行设计的评估标准：Neer分型、骨折近端内侧干骺端长度、肱骨头相对肱骨干的位移、大转子相对肱骨干的位移、骨折内侧皮质的位移、肱骨头是否脱位、肱骨头是否劈裂，分析其与预后的关系，以及各个标准对预后判断的准确程度。结果 79％的骨折近端内侧干骺端长度小于8mm的骨折、84％的内侧皮质位移大于2mm的骨折及68％的Neer四部分骨折预后不良。对于预后不良预测准确度最高的指标依次为骨折内侧皮质的位移大于2mm（准确度0．85）、骨折近端内侧干骺端长度小于8mm（准确度0．83）、Neer四部分骨折（准确度0．76），而头脱位（准确度0．64）、头劈裂（准确度0．64）、肱骨头相对肱骨干的位移大于10mm（准确度0．54）的预测准确度较差。结论 新的评估标准可为肱骨近端关节囊内骨折提供精确的预后判断，从而为治疗方案的选择提供依据。

A new criterion for accurately predict the prognostic of the intracapsular fractures of the proximal humerus

Objective The purpose of this study was to evaluate the relationship between the initial X-ray display and prognosis of intracapsular fractures of the proximal humerus, and to probe a new criterion which can accurately predict the prognosis of the fracture. Methods Between April 1999 and February 2004, 459 cases of intracapsular fractures of the proximal humerus were treated conservatively, among which 211 cases had completed at least 9 months of follow-up and their complete data were available(mean age, 54.2 years; minimum, 17 years; maximum, 81 years; 82 males, 129 females), all the patients were followed up for 1.7 years on the average (ranging from 9 months to 3 years). According to the original X-ray, the fractures were classified by Neer classification. There were 68 cases of one part fractures, 39 cases of two parts fractures, 59 cases of three parts fractures and 45 cases of four parts fractures. The original X-ray and that of at least 9 months postoperatively of every case were assessed by seven structured standards and studied the relationship between the standards and prognosis. The seven standards are listed as follow: Neer classification; the length of the medial side of proximal humerus; displacement between humeral head and shaft; displacement of greater tuberculosis relative to shaft; displacement of medial cortex in fracture site; glenohumeral dislocation and humeral head split. Results 79% of the cases with a length of the medial side of proximal metaphyseal less than 8 mm, and 84% case with medial cortex displacement over 2 mm and 68% of Neer four-part fractures have a poor prognosis. The prognostic significance of predictors were listed as follow: the medial cortex displacement more than 2 mm (accuracy, 0.85), the length of the medial proximal metaphyseal less than 8 mm (accuracy, 0.83), Neer four-part fractures (accuracy, 0.76), Neer three-part fractures (accuracy, 0.72), glenohumeral dislocation (accuracy, 0.64), head-split components (accuracy, 0.64), displa-cement of the head more than 10 mm (accuracy, 0.54). Conclusion The new criterion provides a precise pr-ognosis prediction for intracapsular fractures of the proximal humerus thus it may be helpful in selecting a proper procedure.