锁定钢板治疗老年肱骨近端三部分、四部分骨折的疗效分析

Therapeutic effect analysis of locking plate fixation for the treatment of 3-part and 4-part proximal humeral factures in the elderly

目的探讨锁定钢板治疗老年肱骨近端三部分、四部分骨折疗效。方法回顾性分析2005年1月至2012年1月绵阳市中心医院收治的年龄>60岁,Neer三部分、四部分肱骨近端骨折患者45例,其中男13例,女32例;年龄60~84岁,平均71岁;左侧22例,右侧23例,优势侧受伤者24例;受伤至手术时间3~10 d,平均5.8 d;骨折类型(Neer分型):三部分骨折24例,四部分骨折21例,其中四部分嵌插型10例,肱骨近端内侧柱骨折6例,合并肩胛盂骨折5例,无四部分解剖颈骨折。均采用切开复位锁定接骨板手术治疗,术后随访根据肩关节简明测试(simple shoulder test,SST)问卷和Constant-Mudey评分对肩关节功能进行评估。结果 43例患者获得门诊随访,平均随访时间为18个月(12~48个月)。本组患者Constant评分平均为72分。6例(14.0%)患者需翻修手术。术后再移位发生率为9.3%(4例)、不愈合7.0%(3例)、肩峰撞击7.0%(3例)、肱骨头坏死14.0%(6例)、螺钉进入肩关节11.6%(5例)。结论虽然锁定接骨板治疗老年肱骨近端三部分、四部分骨折肩关节功能恢复较好,但并发症多,医师应根据患者实际情况、骨折分型以及医师自身情况选择治疗方案。手术治疗需注重肱骨近端骨折的解剖复位、螺钉及钢板位置、螺钉长度、内侧柱支撑及稳定性,这是获得良好功能、降低并发症的关键因素。

Background Palvanen reported that 3/4 of the proximal humerus fractures occurs s in the elderly patient over 60 years with 3-part and 4-part fractures as common types,and the incidence rate in women is 3 times higher than that of men.Formost patients with proximal humeral fractures,poor bone quality and severe osteoporosis bring great challenges to the treatment.Recently,young patients with proximal humeral fractures have received good therapeutic outcome with the extensive use of locking plates.However,the complication rate in elderly patients maintains a high level.In this study,we analyzed and summarized the therapeutic effects of locking plates fixation in treating 45 cases of proximal humeral fractures occurred in elderly patients to explore the corresponding clinical effects,complications and risks.Methods I.General data.From January 2005 to January 2012,326 patients with proximal humerus fractures were treated in our hospitals.45 patients(13 males and 32 females)over 60 years with Neer 3-part and Neer 4-part fractures were included in our study and treated with locking plates fixation,The age of patients ranged from 60 to 84 withan average of 71 years.The positions of affect arm includedtwenty-two cases ofleft side and twenty-three cases of right side,and 24 cases had the affected armon the dominant sides.The time from injury to operation spanned from 3 to 10 days with an average of 5.8 days.According to the Neer classification,the group was comprised oftwenty-four cases of 3-part fractures and twenty-one cases of 4-part fractures,which included 10 cases of 4-part impacted fractures,6 cases of medial column fractures of proximal humerus,5 cases of combinedglenoid cavity fractures.No 4-part anatomical neck fractures of proximal humerus was reported.II.Treatment methods.The patient was put with the supine positionafter successful general anesthesia,and the deltopectoral interval approach was applied for exposure.The fracture was reduced withNo.2 Ethicon sutures by pulling the greater tuberosity and the lesser tuberosity to restore the normal neck-shaft angle,the retroversion angle of humeral head,and anatomical positions of greater tuberosity and lesser tuberosity,which was temporarilyfixed with a 2.0 mm thread Kirsch wire.After satisfactory fracture reduction under fluoroscopy,the proximal humeral locking plate of proper length was selected for fixation based on the fracture condition.Then,both the greater tuberosity and the lesser tuberosity werefixed on the plate with No.2 Ethicon sutures.If the case wascombined with glenoid cavity fractures,the fixation should be conducted with suture anchors or hollow screws before treated with the former method.The affected arm was in forearm sling for 2 weeks before functional rehabilitation.III.Efficacy evaluation.The fracture healing and internal fixator positions were assessed with shoulder joint X-ray films oftraumatic series at the time points of 1,3,6,12 months and the last follow-up.Since thespecific index of preoperative range of motion was not recorded for the group,the range of motion of the affected shoulder was compared with that of the contralateral side.During the last follow-up,the shoulder joint function was evaluated by the Constant-Murley score:>75 points as excellent;50-75 points as good;<50 points as poor.The subjective functional evaluation was conducted according to the SST questionnaire.Complications were documented,and influencing factors of the Constant-Murley score were analyzed.IV.Statistical methods.The SPSS 17.0 software was used for statistical processing.The measurement data were expressed as mean±standard deviation,and the paired t-test was performed to examine the comparison between the contralateral side and the affected side.Similarly,the differencebetween fracture types were verified by the group t-test.The test levelα=0.05,P<0.05 was considered as statistical difference.Results The followup conditions:40 patients were followed-up in the outpatient clinic;3 patients were followed-up via telephone;2 patients were lost to follow-up.The follow-up time ranged from 12 months to 48 months with an average of 18 months.I.The range of motion of shoulder and Constant score for the last followup.Shoulder range of motion:forward flexion and elevation of the affected shoulder joint was 60°-100°with an average of 85°;forward flexion and elevation of the contralateral shoulder joint was 130°-180°with an average of 155°.Abduction of the affected shoulder joint was 50°-150°with an average of 100°;abduction of the contralateral shoulder joint was90°-170°with an average of 145°.Constant score of the affected shoulder was 50-85 with an average of 72.3;Constant score of the contralateral shoulder was 70-100 with an average of 96.2.According to the Constant scores of the last follow-up,there were 15 cases of excellent,20 cases of good,3 cases of tolerable and 5 cases of poor.The good and excellent rate was 81.4%,and 6 cases(14.0%)requiredsurgical revision.The type of fracture was related to the Constant score.The Constant score of Neer 3-part fractures(77.5±6.5)was higher than that of Neer 4-part fractures(66.9±9.3),and there was statistical difference(P<0.01).The Constant score of valgus fracture was 75.9±7.7,which was higher than that of varus fracture(68.6±10.0),and there was statistical difference(P=0.01).II.Subjective functional evaluation for the last follow-up.A questionnaire with 10 questions were adopted for the subjective functional evaluation.The average number of the questions replied with“Yes”as the answer was 6.7(1-10).Twentypatients(46.5%)believed that there was no obvious change of life quality before and after operation.III.Postoperative complications.4 cases(9.3%)had fracture redisplacement,including 1 case of Neer 3-part fractures and 3 cases of Neer 4-part fractures;3 cases(7.0%)had fracture nonunion,which were all Neer 4-part fractures;3 cases(7.0%)had impingement syndrome,which were all Neer 4-part fractures;6 cases(14.0%)had humeral head necrosis,whichincluded 2 cases of Neer 3-part fractures and 4 cases of Neer 4-part fractures.5 cases(11.6%)had screws into the shoulder joint,including 2 cases of Neer 3-part fractures and 3 cases of Neer 4-part fractures.Among the 6 in-group patients who had proximal humeral medial column fractures,there were 3 cases of fracture redisplacement,2 cases of fracture nonunion and 2 cases of screws into shoulder joint.In the last follow-up,4 cases required surgical revision,which accounted for 2/3 of the patients who needed revision.Conclusions Currently,there is still no final conclusion about the treatment selection of the 3-part and 4-part proximal humeral fractures of Neer classification in elderly patients.The treatment plan selected by doctors should be based on practical situations,fracture types and doctor's own situations.During the treatment with locking plates and screws,attentions should be paid to anatomic reduction,position of screws and plates,screw length,medial column support and its stability.These are the key factors of obtaining good functions and reducing complications.