20例复杂肱骨近端骨折术后肱骨头坏死的特点分析

Characterization of 20 cases of humeral head necrosis after complex proximal humeral fracture

目的分析复杂肱骨近端骨折切开复位解剖锁定钢板固定后出现的肱骨头坏死的特点。方法回顾性分析自2012年9月至2020年6月北京积水潭医院创伤骨科收治的复杂肱骨近端骨折术后出现的20例肱骨头坏死患者资料。男7例,女13例;年龄平均57.4岁(35~84岁)。分析其骨折分型、肱骨头坏死塌陷的时间,测量内侧残余骨距长度、肱骨头厚度并评估肩关节功能。结果20例患者术后获8~104个月(平均48.3个月)随访。根据Neer分型:三部分骨折8例,四部分骨折12例;合并肩关节脱位10例。根据AO-OTA分型:C型骨折16例,B型骨折4例。内侧残余骨距长度平均4.8 mm(0~10.7 mm);18例内侧软组织合页有破坏,肱骨头厚度平均为20.6 mm(13.6~33.0 mm)。骨折均一期愈合,临床愈合时间平均8.4周(5~12周)。诊断肱骨头坏死的平均时间为16.5个月(8~24个月)。末次随访时患侧Constant-Murley评分平均为53.4分(22~74分),健侧平均为85.5分(53~98分),患侧与健侧比为62.43%(27.95%~82.70%)。结论复杂肱骨近端骨折术后容易出现肱骨头坏死,多为三、四部分骨折或合并肩关节脱位,多数患者内侧软组织合页有破坏,残余内侧骨距长度多<8 mm,坏死时间发生晚,肩关节功能较健侧明显降低。

Objective To characterize the humeral head necrosis after open reduction and anatomic locking plate fixation of complex proximal humeral fractures.Methods A retrospective study was conducted of the 20 patients who had been treated for humeral head necrosis after surgery of complex proximal humeral fracture at Department of Traumatic Orthopaedics,Beijing Jishuitan Hospital from September 2012 to June 2020.They were 7 males and 13 females with an average age of 57.4 years(from 35 to 84 years).Analyzed were their fracture types,time for diagnosis of humeral head necrosis,length of the medial residual bone,thickness of the humeral head and shoulder function.Results The 20 patients were followed up for 8 to 104 months(average,48.3 months).According to the Neer classification,there were 8 three-part fractures and 12 four-part fractures;shoulder dislocation was complicated in 10 cases.According to the AO-OTA classification,there were 16 type C fractures and 4 type B fractures.The length of the medial residual bone averaged 4.8 mm(from 0 to 10.7 mm);the medial soft tissue hinge was damaged in 18 cases and the thickness of the humeral head averaged 20.6 mm(from 13.6 to 33.0 mm).All fractures got united at the first stage after an average time of 8.4 weeks(from 5 to 12 weeks).The time for diagnosis of humeral head necrosis averaged 16.5 months(from 8 to 24 months).At the final follow-up,the Constant-Murley score of the affected side averaged 53.4(from 22 to 74)while that of the healthy side 85.5(from 53 to 98),with a ratio of affected side to healthy side of 62.43%(from 27.95 to 82.70%).Conclusions Necrosis of the humeral head was common after surgery for complex proximal humerus fractures,most of which were three-or four-part ones or combined with shoulder dislocation.In most of the patients,the medial soft tissue hinge was damaged and the length of the residual medial bone usually shorter than 8 mm.Necrosis of the humeral head happened late after surgery.The function of the affected shoulder was significantly lower than that of the healthy side.