肱骨近端“头帽型”骨折的解剖学特点及诊疗方案研究

Special type of proximal humerus fracture: anatomical characteristics and speciality of diagnosis and treatment

目的探索适合肱骨近端特殊类型的"头帽型"骨折的诊疗方案,降低术后并发症的发生率.方法根据骨折的影像学分型、解剖学特点及术后并发症的发生率,结合北京大学人民医院创伤骨科2016年1月至2017年12月诊治的肱骨近端"头帽型"骨折患者18例诊疗结果,研究肱骨近端"头帽型"骨折的诊疗特殊性.结果符合肱骨近端"头帽型"骨折分型的18例中9例采取切开复位钢板内固定手术治疗,有2例(22%)出现了不同程度的肱骨头吸收、肱骨头骨块厚度变薄和预后肩关节活动功能差;而采取人工关节置换术的9例未出现预后肩关节活动受限等并发症.结论"头帽型"骨折术后发生肱骨头坏死、畸形愈合等风险高,应高度重视该骨折类型固定的特殊性.

Background Shoulder joint is the joint with the largest range of movement. The shoulder joints structure is complex and plays an extremely important role in people's daily life. The complex type of proximal humerus fractures has always been a complex disease in the treatment of traumatic orthopedics. The type of proximal humerus fractures and the shape of displacement depend on the mechanism of injury and the pulling of muscle around the fractures. The clinical classification of proximal humeral fractures includes Neer classification and AO classification. Neer classification is based on the affected part and displacement for fracture classification. The proximal of humerus is divided into four parts: humeral head, greater tuberosity, lesser tuberosity and humeral shaft. The classification is based on the number of fractured parts( displacement > 1 cm or > 45°), and the degree of fracture displacement refers to the position of the other three fracture blocks relative to humeral head. AO classification: type A fracture, as one fracture outside the joint;type B fracture as two fractures outside the joint;type C fracture as int ra-articular( anatomical neck) fracture. As the two types of classification are compared, AO classification is used relatively lesser in the clinical due to its large number of subtypes. On the other hand, Neer classification is most commonly used in clinical application. Neer classification can evaluate the complexity of proximal humeral fractures, determine the damage of humeral head blood supply, and guide clinical treatment plan to determine the prognosis of fractures. After more and more clinical cases, however, a special type of fracture was found. According to the Neer clas sification, it may be only a two-part fracture or a three-part fracture, but the complexity of fractures, the degree of damage to fracture block and the poor prognosis are as bad as the four-part fracture. We call it“ head-cap” fracture. Methods In the Department of Trauma and Orthopedics, Peking University People's Hospital, a total of 76 cases of proximal humeral fractures were diagnosed from January 2016 to December 2017, including 18 cases of“ head-cap” type fractures. According to the patient's imaging data, it was found that the humeral head fracture line was located in anatomical neck, and the humeral head had different degrees of compression fracture. The distance between the central region of humeral head anatomical neck plane and the humeral head cartilage surface was less than 17.7 mm, and the average thickness of radial head fracture block was( 15.6±1.2) mm. To find a suitable diagnosis and treatment program, we studied the special of the“ head-cap” fracture of proximal humerus. Results According to the Neer classification, there were 2 cases of two-part fracture, 5 cases of three-part fracture and 11 cases of four-part fracture. Among them, 9 cases were treated with artificial joint replacement, and 9 cases were treated with open reduction and internal fixation. Of the 9 c ases treated with open reduction and internal fixation, 2 c ases (22%) had different degrees of humeral head absorption. The thickness of radial head fracture block was thinner, and the prognosis of shoulder joint was poor. In the 9 cases of artificial joint replacement, no complication that the shoulder mobility was limited was found. Conclusions The risk of humeral head necrosis, malunion and greater tuberosity absorption is very high after the operation of humeral proximal "head-cap" fracture. The orthopedic surgeons should not simply develop a treatment plan based on traditional fracture classification when the corresponding type of fractures is met. According to the specific fracture condition of patients, the surgical treatment should be adjusted. The high risk of humeral head necrosis and malunion after operation for such type of fractures should be taken seriously. The depth of nail should be controlled during internal fixation operation. The screw tip must be strictly 5 mm within joint surface as close as possible, and the crossing of joint surface should be avoided. At the same time, the exact stable fixation of greater and lesser tuberosity is particularly important. The possibility of tuberosity absorption after non-exactly fixation is very high, which may result in serious consequences that cannot be repaired. Arthroplasty is a good treatment option to avoid the complication of humeral head absorption after proxim al humeral“ head-cap” fracture.