肱骨近端严重骨折半肩关节置换术后护理与康复治疗

Nursing and rehabilitation after shoulder hemi-arthroplasty for severe proximal humeral fracture

目的探讨肱骨近端骨折行半肩关节置换术后的护理与康复效果。方法将67例行半肩关节假体置换术的肱骨近端粉碎性骨折患者,术后康复锻炼分为早期、中期和晚期3个阶段,并对患者的功能康复锻炼进行指导。对67例患者进行了平均9个月的随访和功能锻炼指导,按照Neer评分标准进行评价。结果 67例患者中优38例,良18例,可11例,差0例,优良率达83.58%。结论对肱骨近端粉碎骨折肩关节置换术患者,进行精心的护理和规范化的康复指导,是取得患者肩关节良好功能恢复的重要因素之一。

Background Proximal humeral fracture refers to the fractures within surgical neck of humerus and at the positions above it,and such fracture cases accounts for 4%-5% of all fracture cases;Most of proximal humeral fractures are complicated and unstable fractures with displacements and mainly occur among the elder population.At present,plaster external fixation or open reduction and internal fixation (ORIF)therapy is mainly adopted in most of hospitals.However,majority of scholars believe that,when an elderly patient suffers from 4 parts of proximal humeral fractures,in particular when such fracture is accompanied with comminuted humeral head fracture or dearticulation,blood supply to humeral head has suffered non-reversible injury;In case of failure after Phase I internal fixation,performance of joint replacement at Phase I will affect the operation effect and the recovery of shoulder joint functions.For some aged patients,in particular some patients with osteoporosis,their fractures are 3 parts or 4 parts fractures in Neer typing.Although they have received internal/external fixation therapy,it is difficult to obtain satisfactory results in the recovery of shoulder joint functions.For such cases,shoulder arthroplasty is no doubt a effective therapy with more advantage.In terms of range of joint replacement,shoulder arthroplasty is divided into humeral head hemi-arthroplasty and total shoulder arthroplasty. The careful nursing and normalized rehabilitation after shoulder arthroplasty has been paid more and more attention.The postoperative standardized and continuous rehabilitation is one of the significant factors that may determine whether the shoulder joint functions can be recovered to the maximum extent.During the period from January 2004 to June 2013,our department performed half shoulder joint prosthesis replacement for 67 cases with shoulder replacement indications. Through careful peri-operative nursing, no case had complication;In addition,after the patients have been discharged from hospital,our department performed follow-up and instruction for functional exercise and rehabilitation with duration of 9&nbsp;months on average.At each time of follow-up,our department made effect evaluation with reference to Neer scoring criterion,and 67 cases had recovered their shoulder joint functions with good effect. Now,our experiences in nursing and rehabilitation are introduced as follows.Method I.General materials:According to clinical diagnosis, 67 cases with closed comminuted proximal humeral fractures received shoulder hemi-arthroplasty,including 1 9 male cases and 48 female cases,aged at 52-90 years,with an average age of 73.06 years.Neer typing:29 cases with 3-part fracture,9 cases with 3-part fracture dislocation,23 cases with 4-part fractures and 6 cases with 4-part fracture dislocation.67 patients had basically normal pre-injury extremity functions and self-care ability of daily life,and were competent for routine work.II.Nursing:(1)Preoperative psychological nursing:Prior to operation,we introduced to the patients the importance of active rehabilitation exercise to the recovery of shoulder joint functions, and also emphasized the arduous and long-term course of rehabilitation training on shoulder joint. In general, rehabilitation exercise for 6-12 months is necessary to achieve obvious effect.In this way,we can help the patients to make sufficient mental preparation and establish the confidence in rehabilitation.(2 )General nursing:After operation,we performed conventional nursing.Allow the patient to take horizontal position or low-scope lying position,use forearm suspension bandage to fix the affect limb at abduction 40°-50° and internal rotation 30°,namely,obliquely place the forearm of affected limb cushion nearby the affected side breast wall,so as to raise the affected limb and promote extinction of edema.It is necessary to keep close observation on the vital signs of the patients,paying attention to the skin temperature and color of affected limb as well as wound condition,and being alert on symptom expressions of neurovascular injury such as finger and affected limb skin numbness,cyanosis and swelling.Upon finding any abnormal circumstance,timely report the physician for treatment.(3)Nursing of the drainage tube:Unobstructed post-operative drainage is one of the keys to successful operation.It is necessary to properly fix the wound drainage tube and keep it unobstructed,prevent the drainage tube from compression,bending,blocking and falling,keep close observation on the color,flow and property of drainage liquid and accurately record the results.If a log of blood is continuously drained in short time,it is necessary to pay high attention to the existence of active hemorrhage or not. III. Rehabilitation exercise:According to the shoulder joint rehabilitation procedures established by Brown et al, in combination with the physical circumstances of the patients as well as the surgical characteristics, we established the post-operative rehabilitation protocol after shoulder hemi-arthroplasty.The post-operative rehabilitation exercise is divided into 3 stages,which are early stage, intermediate stage and late stage. We provided the instructions for the functional rehabilitation exercise in the whole process.First stage (1d-6 weeks post operation):After operation,according to the fracture type and fracture fixation condition of the patients,upon disappearance of anaesthesia, allow the elbow joint and distal limbs to perform active motion,mainly allow the shoulder joint to perform passive motion;Except for the training time,it is necessary to wear special sling for shoulder joint.This stage can be divided into 5 procedures:(1 )After disappearance of anaesthesia,start the active exercise on fingers,wrist joint and elbow joint,the passive motion of shoulder joint,and on the postoperative 7d,increase pendulum exercise;(2 )In the 2nd week post operation,the affected shoulder joint and adjacent joint perform rear traction without load as well as internal and external rotation motion;(3)In the 3rd week post operation,use healthy hand to protect the affected side to perform low load rear traction of both shoulder joints as well as chest extension exercise;(4)Iin the 4th week post operation, perform gravity-assisted pendulum exercise and anteflexion exercise, shoulder abduction,external rotation and uplifting function exercise;(5 ) In the 6th week post operation,after the healing of rotator cuff and big/small tubercles has been verified through X-ray examination,start active function exercise and increase functional training on supraspinous muscle and musculus deltoideus as well as wall-climbing exercise.At this stage,it is necessary to pay special attention to the training on the range of joint motion and muscle strength.Training on range of joint motion:(1 )Pendulum exercise:Allow the patient to bend down,so that trunk is parallel with&nbsp;ground,relax and hang the affected side upper limb,allow the upper limb and the trunk to present an angle of 90°, use heath side hand to support the affected side forearm to make clockwise or counterclockwise circle moment;with 10 circles as 1 group,respectively exercise for 1 group in the morning and at afternoon respectively.(2)Passive anteflexion and uplifting exercise on shoulder joint:Remove pillow,allow the patient to lie on his/her back,allow the affected side arm to flex elbow by 90°and put arm on body side(rest position);The therapist use one hand to hold up the affected side upper arm and use another hand to hold the affected side forearm,make passive anteflexion and uplifting of shoulder joint in scapula plane (30 °-45 ° in front of coronal plane);If pain occurs or resistance is met when flexion motion has proceeded to a certain angle,stop movement for 5s,the gradually return to rest position;with repetition for 4 times as 1 group,respectively exercise for 1 group in the morning and at afternoon respectively.(3)Passive external rotation exercise:Allow the patient to take dorsal position,remove the pillow,perform abduction of upper limb by 30°,keep the limbs in the scapula plane,and perform elbow joint flexion.The therapist uses one hand to hold up the affected side upper arm and uses another hand to hold the affected side wrist to make passive external rotation of shoulder joint in the direction away from the centre line of body.With repetition for 4 times as 1 group,respectively exercise 1 group in the morning and at afternoon.(4)Passive abduction,adduction and internal rotation exercise (Start from the 5th week post operation):Allow the patient to take dorsal position,the therapist help the patient to perform passive abduction, adduction and internal rotation (Abduction by 90°,internal rotation)training on shoulder joint;With repetition for 4 times as 1 group,respectively exercise 1 group in the morning and at afternoon. Muscle strength training:The training of isometric contraction of shoulder girdle is started from the 3rd week post operation.From the 6th week post operation,start isometric contraction training on shoulder internal and external rotation muscle groups.(1)Training on the shoulder joint anteflexion muscle group:Allow the patient to take standing position,face towards door or wall,allow the affected side elbow to flex by 90°and put the elbow on body side,use heath side hand to hold up the affected side hand,make a fist to push forward,try to make the motion of shoulder joint anteflexion, without generation of joint movement,however.(2)Training on abductor muscle group:Allow the patient to take standing position,allow the affected side elbow to flex by 90° and put the elbow on body side,use heath side hand to hold up the affected side hand,allow the outside of affected side upper arm to completely contact door or wall,allow elbow to push outward and perform shoulder adbution.(3)Training on shoulder joint extensor muscle group:Allow the patient to take standing position,allow the affected side elbow to flex by 90°and put the elbow on body side,use heath side hand to hold up the affected side hand,allow the back side of affected side upper arm to completely contact the door or wall,use elbow to push the door or wall backwards and perform rear protraction motion.(4)Training on muscle group lifting the shoulder blades:Allow the patient to take standing position,allow the affected side elbow to flex by 90°and put the elbow on body side,use heath side hand to hold up the affected side hand,and allow both sides to make shoulder shrugging motion at the same time.(5)Training on muscle group adducting the shoulder blade:Allow the patient to take standing position,allow the affected side elbow to flex by 90° and put the elbow on body side,use heath side hand to hold up the affected side hand,allow the affected side shoulder joint to try to perform internal rotation motion,and use health side hand to hinder the shoulder joint to generate motion.(7)Training on the extortor group:Keep the posture for training on intorters,allow the affected side shoulder joint to try to perform body side external rotation motion.At each time, continue effort in performing each motion for 5 s;with repetition for 10 times as 1 group,respectively exercise 1 group in the morning and at afternoon.Second stage (7-12 weeks post operation):Whether the suspender can be removed shall be determined according to the healing degree of greater/lesser tubercles.At this stage,training is mainly of active motion of shoulder joint.In addition to the training on the range of joint motion and the muscle strength,endurance training is increased.(1 ) ROM training:Continue the traction training on shoulder joint in various directions,and start the closed chain trainings such as pulley traction training and wall/ladder climbing.(2 )Muscle strength training:Continue the isometric contraction training of previous stage,and start isotonic contraction of muscles of shoulder girdle as well as isotonic contraction of musculus biceps brachii and musculus triceps brachii.(3)Endurance training:Gradually increase the amount of exercise (with 20 times as 1 group)and exercise duration (each action continues for 10 s).Third stage (12 weeks post operation):At this stage,start intensive training on muscle strength aginst resistance,and mainly perform exercises aginst resistance,including shoulder joint traction training and resistive exercise as well as the rotation of scapula and the intensified exercise on musculus deltoideus.At this stage,in addition to ROM training,muscle strength training and endurance training,athletic ability training is increased. ROM training:Continue the traction training on shoulder joint in various directions (can increase strength),such as traction with the help of doorframe.Muscle strength training:Mainly perform exercise against resistance.When each motion reaches the maximum extent,stay for 5 s;with repetition for 10 times as 1 group,respectively exercise 2 groups in the morning and at afternoon.(1) Anteflexion and abduction aginst resistance:Allow the patient to take standing position,take a elastic strap in length of 1 m,allow the patient to trample on one end of strap and hold another hand in hand to perform anteflexion uplifting and abduction uplifting exercise.(2)Rear traction aginst resistance:Allow the patient to take standing position,straighten the affected side arm and face towards the elastic strap;one end of the elastic strap is fixed at the height equivalent to wrist joint;allow the shoulder to flex forward by 60°,so that the elastic strap has certain tension (It is noted that the tension may not be too high).Allow the patient to pull the elastic strap,and let down the arm to make rear traction motion.(3 )Internal rotation and external rotation aginst resistance:Allow the patient to take standing position,tie an elastic strap on a door or furniture at the height of elbow joint. In the process of internal rotation,the affected side approaches the elastic strap,the upper limit adducts on body side,perform elbow flexion by 90°;with elbow joint as axis,allow the forearm and hand to perform the motion of exceeding centre line of body,and make every effort to stretch the elastic force.The external rotation motion is made in the opposite direction of internal rotation.When the muscle strength has been enhanced,use wall pulley to perform exercise against resistance. Endurance training:At this stage,it is allowed to increase the amount of exercise (with repetition of each motion for 30 times as 1 group,respectively exercise 2 groups in the morning and at afternoon) and the movement duration (keep each movement for 1 5 s).Athletic ability training:Allow the patient to take part in sports,including proprioceptive sense training.Within the comfort degree of the patients,the patient is allowed to perform any motion,but contact sports shall be avoided.The optimal sports items include swimming and table tennis.IV.Neer scoring:After operation,67 cases obtained 9-month follow-up on average; According to Neer scoring criterion, we evaluated the function of affected side shoulder joint of the patients,where pain accounts for 35 points,daily life function accounts for 30 points,positive-operative range of joint motion accounts for 25 points and post-operative anatomical position accounts for 10 points.Excellent:90-100 points;Good:80-89 points;Acceptable:70-79 points;and poor:< 70 points.Results After the said normalized and systemic postoperative nursing and rehabilitation exercise,67 patients in this group obtained post-operative follow-up for 9 on average.According to Neer scoring criterion,we evaluated the affected side shoulder joint functions of the patients,and the results displayed that,among 67 cases,there were 38 cases with excellent score,18 cases with good score,1 1 cases with acceptable score and 0 case with poor score, with good rate up to 83.58%. There is no case with complication. After rehabilitation exercise,each patient can completely realize self-care in daily life and achieve satisfactory rehabilitation effect.Conclusion Careful nursing and normalized rehabilitation instruction for the patient with comminuted fractures of proximal humerus after shoulder joint arthroplasty is one of significant factors for achieving satisfactory functional rehabilitation of shoulder joint.