锁定钢板治疗肱骨外科颈复杂高能量性骨折

目的探讨锁定铜板治疗肱骨外科颈高能量性复杂骨折的适应症、手术进路并了解其临床疗效。方法对2003年2月～2007年12月收住入院的61例肱骨外科颈高能量复杂骨折，采用切开复位锁定钢板内固定的治疗方法。其中，无移位型0例，外展型39例（63．93％），内收型22例（36．07％），均为间接暴力损伤。根据Neer分类法结合X线平片和X—CT影像学检查分型，一部分型骨折均门诊保守治疗，统计忽略。本组二部分型17例（27．87％），三部分型24例（39．34％），四部分型11例（18．03％），五部分型7例（11．48％），六部分型2（3．28％）。手术选择三角肌胸大肌间入路，显露时尽量减少对骨折块骨膜等软组织附处的剥离和损坏，以减少骨组织局部的缺血损害，手法复位时高度重视关节面的解剖对位。锁定钢板固定通常选择肱骨的前侧外方，结节间沟后方5～10mm，大结节下方5mm处，将移位的大结节固定于钢板上，如同时存在肩袖损伤或其他软组织损伤时，应在手术中加以修补。结果术后随访7～22个月，平均随访12．35个月，按肩关节功能评定手术后疗效，优26例（42．62％），良25例（40．98％），可7例（11.48％），差3例（4．92％），优良率达83．61％，2例并发肱骨头无菌性坏死，其中1例肩关节功能并不影响日常生活。结论手术需要尽量减少骨膜与关节囊的剥离，以减少局部血循环的进一步损害。锁定钢板符合肱骨外科颈解剖，设计合理，是治疗肱骨外科颈高能量性复杂骨折理想的内固定器械。另外，手术后容易影响肩关节功能，需定期随访，指导患者合理的肩关节功能训练。

Complications in the management of closed high-energy proximal tibial plateau fractures

Purpose： To report complications in the management of complex closed proximal tibial fractures. Method： A retrospective study was conducted to analyze the infectious and noninfectious complications encountered in the management of high-energy Schatzker type V and VI tibial plateau fractures. All patients were treated at the level 1 trauma centre between January 20tl and March 2014. Sixty two patients were included in the study. The mean patient age was （43.16 ±11.59） years with 60 males and 2 females. Infectious complications like superficial and deep infection, wound dehiscence, malalignment in the immediate postoperative period and in follow-up period were noted. Results： The overall complication rate was 30.65% （19 out of 62）. Infectious complications were noted in 20.97% cases （13162）. In majority of the cases （8113）, superficial infection was seen which managed with regular dressing and antibiotic administration. The patients （5/13） who had developed deep-seated infection were subjected to repeated debridements, flap coverage, implant removal or amputation depending upon the host response. Thirteen patients had experienced noninfectious complications. Hardware related complications were noticed in six patients and four among them received a secondary procedure. Malalignment was observed in seven patients but only single patient underwent subsequent operative intervention. Conclusion： Proximal tibial plateau fractures especially Shatzker type V and VI are associated with extensive soft tissue damage even in closed injuries. The complications encountered in the management of these fractures can be minimized with appropriate patient selection and minimal soft tissue dissection.