闭合复位老年肩关节前脱位过程中发生医源性肱骨颈骨折的成因分析和对策

Causes analysis and countermeasures of iatrogenic humerus neck fracture in the process of closed reduction of senile anterior shoulder dislocation

目的分析在闭合复位老年肩关节前脱位的过程中发生医源性肱骨颈骨折的原因并探索避免的方法。方法对上海市第一人民医院2012年1月至2017年1月在肩关节前脱位复位过程中发生肱骨颈骨折患者的临床资料和影像学特点进行回顾性分析。结果共5例患者在闭合复位过程中发生肱骨颈骨折,导致肱骨头、颈分离。这些患者的特征:(1)老年女性,低能量损伤,初次肩关节脱位;(2)复位前肩关节正位片:肩关节前脱位伴大结节骨折;(3)肱骨头内移至喙突下方或内侧;(4)均为无麻醉下采取Hippocrates足蹬法复位。结论闭合复位肩关节前脱位过程中发生肱骨颈骨折的原因与复位前遗漏盂肱关节脱位时伴随的肱骨颈骨折有关。老年肩关节前脱位有其特点,在治疗上应与年轻患者加以区别。对老年初次肩关节前脱位伴大结节骨折的患者应加以特别重视,复位前规范的影像学检查以除外肱骨颈骨折是避免此类医源性并发症的关键。

Background Acute anterior shoulder dislocation is the most common joint dislocation in orthopedic emergency,accounting for approximately 45%of all acute joint dislocations.The primarysenile anterior shoulder dislocation accounts for approximately 20%-40%of the anterior shoulder dislocation,and the elderly women of over 70 years old are the predisposed population.The traumatic mechanism and comorbidity of senile anterior shoulder dislocation are different from those of younger occurrence,and the incidence and severity of anterior shoulder dislocation combined with proximal humeral fractureincrease with age.However,in addition to greater tuberosity fracture,the majority of concomitant humeral neck fractureis not obviously displaced.If the humeral neck fracture is missed,severe complications such as the complete separation ofhumeral head andshaft may occur during reduction.Currently,the number of senile anterior shoulder dislocation is on rise,and there are frequent reports of such complication in elderly patient.The blood supply of humeral head is severely damaged after the complication.The necrosis rate of humeral head is high after open reduction and internal fixation.Although shoulder arthroplasty is indicated for this population of elderly patient,it is expensive and difficult to achieve good result.The occurrence of such complications during the reduction process is an urgent problem to be solved.Objective To analyze the possible reasons of iatrogenic humeral neck fracture in the process of closed reduction of senile anterior shoulder dislocation and explore the methods of avoidance.Methods From 2012 to 2017,the clinical data and imaging characteristics of patient with humerus neck fracture during the reduction of anterior shoulder dislocationin our hospital were retrospectively analyzed.Results A total of 5 patients suffered from humerus neck fracture during closed reduction,and the separation of humeral head and neck was resulted.The characteristics of these patientsincluded elderly women,low energy injuryand primary shoulder dislocation.The anteroposterior view of shoulder joint before reduction revealed anterior shoulder dislocation with greater tuberosity fracture and the moving inward of humeral head to the inferior or medial of coracoid process.All the reductions were performed without anesthesia using Hippocrates method.Conclusion The cause of humeral neck fracture in the reduction process ofanterior shoulder dislocationisrelated to the humeral neck fractureaccompanied during the missed glenohumeral joint dislocation.The senile anterior shoulder dislocation has its own characteristics and should be distinguished from younger occurrence in the treatment.Special attention should be paid to primary senile anterior shoulder dislocation with greater tuberosity,and the exclusion of humeral neck fracture by standard imaging examination is the key to avoid such iatrogenic complications.