外翻嵌插型肱骨近端骨折的研究进展

Research progress on valgus impacted proximal humeral fractures

目的对外翻嵌插型肱骨近端骨折的研究进展进行综述。方法广泛查阅国内外有关外翻嵌插型肱骨近端骨折的文献,从定义、分类、病理解剖和治疗等方面进行总结。结果外翻嵌插型肱骨近端骨折的颈干角≥160°,重要特征是肱骨头干骺端内侧区域无移位或轻度移位,有助于维持骨折后内侧骨膜完整性,降低肱骨头坏死发生率。因此,与肱骨近端其他复杂骨折相比,该类型骨折预后较好。Neer分型将其归为三部分或四部分骨折,国际内固定研究协会(AO/ASIF)分型将其归为C型(C1.1)。该类型骨折的治疗,可以根据患者年龄和骨折移位程度选择保守或外科治疗。保守治疗优点为无创,但存在无法获得解剖复位和并发症多等不足。外科治疗包括切开复位结合钢丝或锁定钢板和/或不可吸收缝线内固定、骨间缝合技术以及肩关节置换术等。微创手术有助于保存肱骨头血供,降低肱骨头坏死发生风险,减少骨和软组织术后并发症。对于骨折粉碎、移位严重,骨质疏松且不适合内固定的老年患者,肩关节置换术是一种最佳治疗方式。结论外翻嵌插型肱骨近端骨折在骨折分类、肱骨头血运以及治疗等方面研究已取得一定进展,但微创技术的临床安全性、生物力学稳定性以及适应证等方面尚需进一步研究。

Objective To review the advancement made in the understanding of valgus impacted proximal humeral fracture(PHF).Methods The domestic and foreign literature about the valgus impacted PHF was extensively reviewed and the definition,classification,pathological features,and treatment of valgus impacted PHFs were summarized.Results PHF with a neck shaft angle≥160°is recognized as a valgus impacted PHF characterized by the preservation of the medial epiphyseal region of the humeral head,which contributes to maintenance of the medial periosteum’s integrity after fracture and reduces the occurrence of avascular necrosis.Therefore,the valgus impacted PHF has a better prognosis when compared to other complex PHFs.The Neer classification designates it as a three-or four-part fracture,while the AO/Association for the Study of Internal Fixation(AO/ASIF)categorizes it as type C(C1.1).In the management of the valgus impacted PHF,the selection between conservative and surgical approaches is contingent upon the patient’s age and the extent of fracture displacement.While conservative treatment offers the advantage of being noninvasive,it is accompanied by limitations such as the inability to achieve anatomical reduction and the potential for multiple complications.Surgical treatment includes open reduction combined with steel wire or locking plate and/or nonabsorbable suture,transosseous suture technology,and shoulder replacement.Surgeons must adopt personalized treatment strategies for each patient with a valgus impacted PHF.Minimally invasive surgery helps to preserve blood supply to the humeral head,mitigate the likelihood of avascular necrosis,and reduce postoperative complications of bone and soft tissue.For elderly patients with severe comminuted and displaced fractures,osteoporosis,and unsuitable internal fixation,shoulder joint replacement is the best treatment option.Conclusion Currently,there has been some advancement in the classification,vascular supply,and management of valgus impacted PHF.Nevertheless,further research is imperative to assess the clinical safety,biomechanical stability,and indication of minimally invasive technology.