锁定钢板与交锁髓内钉治疗肱骨近端骨折的疗效分析

Treatment of proximal humeral fractures with interlocking intramedullary nail versus locking plate

目的：分析比较锁定钢板与交锁髓内钉治疗肱骨近端骨折的治疗结果。方法对2012年1月至2013年5月的38例肱骨近端骨折患者进行回顾性分析。根据治疗方法分为锁定钢板组(24例)与交锁髓内钉组(14例)。结果所有患者均获得随访,时间为9~23个月(平均16.1个月)。两组患者在切口长度、手术时间和并发症发生率方面差异有统计学意义(t=8.857、5.323、2.460,P均<0.05),锁定钢板组患者并发症发生率低,交锁髓内钉组患者切口小、手术时间短；两组患者在颈干角、骨折愈合时间方面差异无统计学意义(t=0.548、0.459,P 均>0.05)；锁定钢板组患者的前举范围、Constant-Murley肩关节功能评分、优良率均高于交锁髓内钉组,但差异无统计学意义(t=1.470、0.905、0.133,P均>0.05)。结论锁定钢板和交锁髓内钉治疗肱骨近端骨折各有优势,如适应证合适,经过规范的手术治疗均可取得良好的治疗结果。

Background Proximal humeral fracture is usually seen in elder citizens with osteoporosis,and such a fracture in younger patients mainly results from high-energy injury.Surgical procedure is often adopted for patients with unstable or obviously displaced fracture.Open reduction and locking plate fixation or closed reduction and interlocking intramedullary nail fixation are two common treatment methods for proximal humeral fracture.In this paper,retrospective analysis was conducted to compare the clinical curative effects between locking plate and intramedullary nail in the treatment of proximal humeral fracture.Methods General data:From January 2012 to May 2013,38 patients with full information in our department were randomly selected in the retrospective analysis,including 13 male and 25 female,aged from 20 to 86,and the mean age was 66.5±16.9years.According to the different treatment methods,the patients were divided into the locking plate group(24cases)and the interlocking intramedullary nail group(14cases).All patients had unilateral closed fractures treated with locking plate or interlocking intramedullary nail,including 22 cases on the left side and 17 cases on the right side.28 patients were injured from low energy falls and 10 cases were from high energy trauma like skiing,motor accidents,etc.According to Neer classification,7cases of two-part fracture,11 cases of three-part fracture and 6cases of four-part fracture were in the locking plate group,and 8cases of two-part fracture,5cases of three-part fracture and 1case of four-part fracture were in the interlocking intramedullary nail group.In the meanwhile,on the basis of AO classification,4type 11-A cases,14 type 11-B cases and 6type 11-C cases were in the locking plate group,and 7type 11-A cases,6type 11-B cases and 1type 11-C case were in the interlocking intramedullary group.PHILOS plate of Synthes,Inc.and TRIGEN intramedullary nail of Smith &Nephew,Inc.were used in the operation.Operation methods:After successful anesthesia,the patient was placed in beach chair position.Locking plate group:Deltoid pectoralis major muscle gap approach was applied to expose the fracture end.Clean up the hematocele in the joint capsule,reduce the bone fragments and use Kirschner wire for temporary fixation.Plate fixation was done after successful C-arm fluoroscopy assisted reduction.The greater and lesser tubercles of humerus were sutured with bone graft for three and four-part fracture.Interlocking intramedullary nail group:Anterolateral incision on the acromion was made to split the rotator cuff longitudinally,and then protect the acromion and expose the humeral head.Manual or Kirschner wire poking reduction was done under fluoroscopic guidance.Choose the junction of humeral head behind intertubercular sulcus and the greater tubercles of humerus as the entry point,insert the proper nail and make sure that the nail tail was in the bone before locking the proximal and distal screws.After installing the tail cap,closely suture the rotator cuff and then stitch and bind up the wound.Functional training:The affected limb was fixed with forearm sling brace after operation.Postoperative functional training is guided on the basis of general condition,fracture type and state of surgical fixation.With the drainage tube extracted,passive movement is initiated on the second day after surgery,including pendular movement,passive anteflexion and external rotation,and then gradual passive internal rotation,adduction and abduction.With signs of callus or fracture healing seen on postoperative X-ray films,we should encourage active movement and enhance the exercises of flexion and extension,rotation,adduction and abduction,etc.The training of shoulder strength starts 3 months later,with the intensified exercises for range of motion.Follow-ups and evaluation:The content includes:(1)Regular return visit and evaluation of shoulder function with Constant-Murley score;(2)Imaging examinations:standard X-ray films(anteroposterior view of scapula,axillary view);(3)Excellent rate of shoulder function is assessed with Constant-Murley score.The total score is 100 points,regarding 90 points and above as better,80-89 as good,70-79 as normal and 70 points below as poor.The excellent rate= excellent case number/total case number*100%.The standard of varus malunion:humeral neck shaft angle is smaller than 120°.Statistical analysis Measurement data is expressed as x-±s with SPSS 13.0statistical software,using independent samples t test.Theχ2test is adopted for enumeration data.P <0.05 is considered as statistical difference.Results(1)All the patients were followed up for 9-23 months with an average of16.1months.The mean operation time(minute)of plate group and intramedullary nail group were 89.4±14.8and 65.7±10.3(t=5.323,P <0.05).The average length of incisions(mm)were 10.3±3.1and 2.7±1.1(t=8.857,P <0.05).The two indices above had statistically significant difference.(2)Assessment was based on post-operative X-ray film and Constant-Murley scoring system of shoulder joint function:The initial neck shaft angles in plate group and intramedullary nail group were 139.2°±6.40°and 137.9°±7.04°(t =0.644,P >0.05);the last neck shaft angles in plate group and intramedullary nail group were 134.7°±8°and 133.3°±6.42°(t=0.548,P >0.05)with the average decline degrees respectively 4.5°and 4.6°,and there was no statistical difference between the two groups.The ranges of forward elevation in locking plate group and intramedullary nail group were respectively 146.2°±25.3°and 135.7°±36.3°(t =1.470,P >0.05);the shoulder scores were82.9±16.7and 77.6±19.2(t=0.905,P >0.05);the excellent rates were 83.3% and 78.6% with the former better than the latter,but no statistical difference was found(χ2=0.133,P >0.05).(3)Complications of plate group:2cases of varus malunion,1case of screw cut-out,1case of screw withdrawal and 1case of subacromial impingement syndrome;Complications of intramedullary nail group:2cases of varus malunion,1case of delayed union and 2cases of acromion impingement syndrome;The incidence rate of complications in plate group was 20.8% and that in intramedullary nail group was 35.7%(χ2=2.46,P <0.05)with statistical difference.Details are seen in table 4.In a two-part fracture case of intramedullary nail group,the changes of neck shaft angle appeared as increase after decline during monthly review,and the initial-second-last neck shaft angles were 142.7°,-122.8°,-130.9°.This patient had malunion with the affected arm fixed in a sling for 7 monthsafter surgery.Conclusions Both the interlocking intramedullary nail fixation and the locking plate fixation have the merits in treatment of proximal humeral fractures.Choosing proper indications,we can get excellent curative outcomes after operation and rehabilitation.