切开复位内固定治疗肱骨近端四部分骨折的疗效分析

Outcomes for open reduction and internal fixation of 4-part proximal humeral fractures

目的探讨应用钢板治疗肱骨近端四部分骨折的适应证和临床效果。方法2004年2月—2007年9月，应用切开复位三叶草钢板内固定治疗肱骨近端四部分骨折21例。根据Neer肱骨近端骨折分型将患者分为三组：四部分外展嵌插型骨折11例，平均年龄[（53．4±9．3）岁．面±s．下同]；典型四部分骨折6例，平均年龄（55．8±4．5）岁；四部分骨折脱位4例，平均年龄（52．5±3．7）岁。采用Constant—Murley（CM）评分和简易肩关节测验（SST）问卷评估治疗效果。结果除外展嵌插组2例失访外。其余19例获得随访。四部分外展嵌插组9例随访时间平均为（28．1±15．4）个月，CM评分平均为（81．0±7．3），SST平均为（9．6±1．0）；典型四部分骨折组6例随访时间平均为（31．2±14．2）个月，CM评分平均为（72．2±9．4）。SST平均为（8．3±1．5），其中发生大结节部分吸收的1例患者CM评分为59．0，SST评分为7．0；四部分骨折脱位组4例随访时间平均为（22．0±18．5）个月，CM评分平均为（40．5±11．2），SST平均为（4．7±1．6），其中2例出现大结节吸收，1例肱骨头坏死，另1例肱骨头坏死和大结节吸收同时出现。结论严重的肱骨近端四部分骨折的治疗方法选择很重要，钢板可以有效应用于年龄较轻的外展嵌插型，对于典型肱骨近端四部分骨折和四部分骨折脱位患者，若行切开复位内固定，则需采用坚强的内固定，并尽量达到解剖复位。

Objective To discuss the indications of plate fixation of 4-part proximal humeral fractures （PHFs） and evaluate the chnical results. Methods From Feburary 2004 to September 2007 twenty-one patients who sustained 4-part PHFs were treated by open reduction and plate internal fixation. The patients were classified into three groups according to Neer classification. There were 11 patients, whose ages were （53.4 ±9.3） years, in the abduction impacted 4-part PHFs group, 6 patients in the typical 4-part PHFs group with an average age of （55.8 ±4.5） years, and 4 patients in the 4-part fracture-dislocation group with an average age of （ 52.5 ± 3.7 ） years. Constant- Murley score （CMs） and simple shoulder test （SST） were used to assess shoulder function. Results Nineteen patients were available for follow up while two patients in the abduction impacted d-part group were lost to follow-up. The mean follow-up period for the the abduction impacted d-part PHFs group was（28.1 ± 15. d ） months. Their mean CMs was （81.0 ± 7.3 ）, and SST was （9.6 ± 1.0）. CMs of the typical 4- part PHFs group was （72.2 ± 9.4 ）, while SST was （ 8.3 ± 1.5 ）. They were followed up for （ 31.2 ± ld. 2 ） months on average. Greater tubercle absorption appeared in one patient in this group and his CMs and SST was 59.0 and 7.0 respectively. Patients of the fracturedislocation group were followed up for（22.0 ± 18.5） months. Their CMs was（40.5 ± 11.2） and SST was （4.7 ± 1.6）. One patiem in this group had humeral head osteenecrosis, two patients had greater tubercle absorption, and one suffered both. Conclusion Selection of proper treatment procedures is critical in the management of 4-part proximal humeral fractures. ORIF is an effective treatmem for younger patients with abduction impacted fractures. For typical d-part and fracture-dislocation PHFs anatomical reduction and rigid fixation are required.