肱骨干骨折的兩種內固定技術對肩關節功能影響的中長期研究

栗劍 張光武 張昆 呂鵬飛 薛濤

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肱骨干骨折的兩種內固定技術對肩關節功能影響的中長期研究

栗劍 張光武 張昆 呂鵬飛 薛濤

目的 回顧性研究肱骨干骨折采用鋼板內固定和順行髓內釘固定后的肩關節癥狀、功能和運動范圍。 方法 回顧性分析19例鋼板和20例順行髓內釘內固定對肩關節功能的影響。隨訪肩關節HSS、JOA、VAS評分,肩關節運動范圍。鋼板組平均隨訪7.3年(1～11年)；髓內釘組平均隨訪6年(1～10年)。結果 HSS評分優良率：鋼板組84.2%，髓內釘組65%；JOA評分優良率：鋼板組78.9%，髓內釘組60%；VAS評分：鋼板組1.78分，髓內釘組2.3分；肩關節運動范圍：鋼板組在前屈、外展、外旋運動方面優于髓內釘組。在肩關節評分、肩關節疼痛和運動范圍方面，鋼板組和髓內釘組間差異無統計學意義。結論 兩種內固定技術治療后大部分肩關節功能可恢復到正常狀態。順行髓內釘固定只要提高手術操作技巧，防止醫源性損傷，就能明顯減少肩關節損傷。

肱骨骨折；髓內釘；鋼板；內固定

肱骨干骨折是上肢常見的損傷類型，文獻報道肱骨干骨折在所有骨折中約占3%[1]。常見的手術治療方法包括鋼板固定和髓內釘固定。多數學者認為鋼板固定技術是比較各種手術固定方法的金標準。有關順行髓內釘固定是否影響肩關節功能尙存爭議[2-5]。通過對我院2001年1月至2012年9月收治且獲得隨訪的39例肱骨鋼板和順行髓內釘患者進行回顧性分析，旨在探討兩種內固定技術對肩關節功能的影響。

資 料 與 方 法

一、一般資料

本組39例，男性25例，女性14例；平均年齡43.9歲(21～75歲)。致傷原因:摔傷21例，交通傷9例，墜落傷3例，機器絞傷2例，運動傷2例，暴力打擊傷1例，病理性骨折1例。按照AO分型:A1型5例，A2型6例，A3型11例，B1型11例，B2型4例，C1型2例。開放性骨折: Gustilo Ⅰ型2例，Ⅱ型2例，Ⅲa型1例。從發生骨折到進行手術的平均時間為1.2 d。

二、手術方法

所有手術均采用臂叢麻醉或全身麻醉。鋼板組手術采用前外側入路17例，后側入路2例。內固定物選擇普通鋼板，動力加壓鋼板(dynamic compression plate, DCP)或鎖定加壓鋼板(locking compression plate, LCP)。按照AO分型原則行穩定固定。確保遠、近骨折端必須至少各用3～4枚螺絲釘固定。髓內釘組選擇匈牙利產索娜盟托肱骨順行交鎖髓內釘，主釘近端弧度11°～13°，近端3個鎖孔，遠端2個鎖孔，實現交鎖。采用順行方式置入。順行帶鎖髓內釘的進釘入點在前后位像上緊靠大結節內側的溝內，在側位像上正在肱骨干的中軸線上。

三、術后處理

1.運動康復: 術后頸腕吊帶制動。從術后即開始非負重的主、被動功能鍛煉，包括鐘擺樣運動和前屈、外展、外旋、內收、內旋練習。X線片示骨折愈合前避免患肢負重。

2.術后隨訪及評價標準:所有患者術后進行常規隨訪，項目包括： (1) X線片檢查； (2) 對肩關節的癥狀和功能評估采用HSS、JOA評分。肩關節的疼痛評估采用視覺模擬量表VAS。運動范圍的測量使用測角計，見表1。

四、統計學處理

應用PASW Statistics 18.0統計軟件進行統計學分析，采用Mann-Whitney秩和檢驗判斷鋼板組與髓內釘組的運動范圍，HSS、JOA和VAS評分是否存在差異，P<0.05為差異有統計學意義。

結 果

鋼板組平均隨訪7.3年(1～11年)，髓內釘組平均隨訪6年(1～10年)。39例患者骨折獲愈合，骨折愈合時間平均13.1周(8～24周)。兩組隨訪及統計學分析結果見表1。鋼板組與髓內釘組之間在肩關節功能評分、疼痛、運動范圍方面的參數經統計學分析證明差異無統計學意義。

表1 術后肩關節功能和療效評定±s)

討 論

McCormack等[6]采用ASES評價標準對鋼板固定和髓內釘固定的兩組患者的肩關節功能進行統計學分析，結果表明差異無統計學意義。這與本組結果一致。肱骨骨折的治療目標之一是獲得最大限度的上肢功能。特別是肩關節功能。綜合文獻報道，大多數學者認為順行髓內釘引起的肩關節功能問題要高于鋼板固定[7-10]，且主要原因在于髓內釘干擾和損害了肩袖的正常結構和功能[4]。以上文獻所涉及的有些問題在本組患者中也有發生。探討這兩種內固定技術對肩關節功能的影響因素。

一、鋼板固定的影響因素

1.初始損傷的輕重可能影響肩關節功能: 鋼板組中HSS和JOA得分低的患者共有3例。第1例為高速旋轉的傳送帶將上肢卷入機器內致傷。第2例為壓面機將上肢卷入兩滾軸之間夾軋致傷。這兩例的致傷因素中均有高能量釋放于組織中，造成上肢的骨與關節以及軟組織的廣泛損傷。第3例為投擲骨折。患者在投擲手榴彈過程中，當肩關節由外展、外旋狀態急速轉變為內收、內旋狀態時可使崗上肌腱與肩胛下肌腱分離，形成所謂“肩袖間隙撕裂”。肩袖間隙是肩袖的薄弱部位，上述兩肌腱的分裂使臂上舉運動的合力減弱，使肱骨頭依附關節盂的力量下降，使盂肱關節易發生滑脫和松動而造成不穩定。

2.手術本身對肩關節功能的影響：對發生于胸大肌腱止點和三角肌止點附近的骨折，無論在顯露、復位，還是放置鋼板過程中都難以避免對胸大肌或三角肌產生干擾和損傷，從而影響到術后肩關節的內收，內旋、外展、前屈和后伸功能。

二、髓內釘的影響因素

1.醫源性因素: 本組有2例因釘尾未完全埋入肱骨頭的關節面，使釘尾端撞擊肩峰下，引起肩關節功能受損。其中1例術后1年取出髓內釘后關節功能恢復正常。許多學者認為肩袖撞擊是影響肩關節功能的重要因素[4]。造成肩袖損傷的因素有: (1)進釘入點顯露過程中，忽視保護肩袖，通過肩袖做橫切口。正確方法是順著肩袖的腱纖維平行做切口。手術中要全層縫合肩袖。 (2)在擴髓過程中，特別是在使用近端擴髓器時直接損傷肩袖。(3)釘尾未完全埋入肱骨頭的關節面，使釘尾端撞擊肩峰下或肩袖而引起肩關節功能受損。 (4)進釘點位置有誤差，導致髓內釘打入方向偏離中軸線及擴髓時使用暴力等，造成骨劈裂和關節軟骨面損傷。本組發生1例。推薦使用順行弧形髓內釘，避免使用順行直釘。其他醫源性因素包括:肩峰下滑囊炎、肩鎖關節炎、鎖釘突出到三角肌、崗上肌腱斷裂及喙突骨折[4，7]。

2.年齡因素: 髓內釘組患者平均年齡52.8歲。其中HSS和JOA低分患者有7例，占全組的35%，這7例平均年齡57.7歲。鋼板組患者平均年齡34.5歲。在HSS和JOA評分方面相比較，髓內釘組均低于鋼板組。這與文獻報道一致[7]。顯示年齡>50歲的患者肩關節功能評分較低。這可能與下列因素有關: (1)受傷前就存在肩袖結構和功能的退行性改變；(2)手術創傷的影響；(3)術后主動配合功能鍛煉的依從性降低。此外，在本組的低分患者中有5例致傷原因為摔傷(占本組的25%)。提示年齡>50歲的患者，即使是低能量的損傷因素也可能會影響肩關節功能。老年患者應慎重選擇手術治療。

肱骨干骨折術后肩關節功能損害的原因有待于進一步研究。順行髓內釘固定應提高手術操作技巧。應重視患肢功能的早期康復治療(特別是50歲以上患者)。進一步對兩種內固定技術進行大樣本量的隨機對照比較是必要的。

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(本文編輯：李靜)

栗劍，張光武，張昆，等.肱骨干骨折的兩種內固定技術對肩關節功能影響的中長期研究[J/CD]. 中華肩肘外科電子雜志,2015,3(3):160-163.

Medium and long term research on the effects of two internal fixations on functions of shoulder joints in humeral shaft fracture

LiJian,ZhangGuangwu,ZhangKun,LyuPengfei,XueTao.

DepartmentofOrthopaedicsSurgery,PekingUniversity,ShougangHospital,Beijing100144,China

LiJian，Email：shougangguke@163.com

Background The humeral shaft fracture is a common injury among upper limbs fractures. There have been documents reporting that the humeral shaft fracture occupy 3% among all fractures. The common operation methods include plate fixation and intramedullary nail fixation. Most scholars think that plate fixation is the golden criteria for comparing all kinds of fixations. And whether the intramedullary nail fixation can affect the shoulder joints functions are still controversial. This thesis has retrospective analysis on 39 patients who performed humeral plate fixation and intramedullary nail fixation in our hospital from January 2001 to September 2012, aiming at studying the effects of shoulder joints functions performed by two internal fixations .Methods General data: 39 patients, 25 males and 14 females aging 21-75 years old with the average age 43.9 years old were selected as the study subjects. Injury reasons: 21 cases were due to falling down, 9 cases were due to traffic accident injury, 3 cases were due to high falling accident injury, 2 cases were due to machine injury, 2 cases were due to exercise injury, 1 case was due to violence injury, 1 case was pathological fracture. According to the AO types, 5 cases were with A1 type, 6 cases were with A2 type, 11 cases were with A3 type, 11 cases were with B1 type, 4 cases were with B2 type, 2 cases were with C1 type. Open fracture: 2 cases were with Gustilo I type, 2 cases were with II type, 1 case was with IIIa type. The average time from being injured to operation was 1.2 days.Operation methods: All patients were given brachial plexus anesthesia or general anesthesia. 17 cases in the plate fixation group adopted the incision from anterolateral side, 2 cases adopted posterior side. The materials of internal fixation were ordinary plate, dynamic compression plate (DCP) or locking compression plate (LCP). The plate will be fixed according to the AO type principles. At least 3 to 4 screws should be used to the distal and proximal fractures for fixation. The intramedullary nail fixation group selected the Hungary Sanatmetal interlocking intramedullary nails which have proximal radian 11-13 degrees in the main nail, and 3 lock holes in the proximal points, 2 lock holes in the distal points can achieve the interlocking. They were inserted in direct motion ways. The intramedullary nails which were inserted into the anteroposterior position were tightly attached to the furrow of the inner side of greater tuberosity, and the ones that were inserted into the side position were located to the axle wire located in humeral shaft.Post-operative treatment:(1)Movement rehabilitation: post-operative neck wrist belt immobilization. After operation, the patients should not burden any weights, and keep doing the active and passive movements including clock pendulum movements, forward flexion, outstretch, adduction, internal rotation practice. If the X-ray film indicates the nonunion of fracture, the patients should not burden any weights.(2)Post-operation follow-up visit and evaluation criteria: All patients were followed up after operation. The items included: (1) X-ray check. (2) adopted HSS and JOA evaluation systems to evaluate the shoulder joints symptoms and functions. The shoulder joint pain evaluation system adopted visual assessment simulation (VAS). The movement range measurement adopted the angle tester.(3)Statistically treatment: Apply PASW Statistics 18.0 statistical software to statistical analysis. Adopted Mann-Whitney rank sum test to decide the movement ranges, HSS and JOA evaluation of the plate fixation group and the intramedullary nail fixation group, and judge whether the VAS evaluation exist differences.P<0.05 regarded the difference have statistically significance.Results The patients in the plate fixation group were followed up from 1-11 year, with an average of 7.3 years. Patients in the intramedullary nail fixation group were followed up from 1-10 year, and the average was 6 years. 39 cases got fracture union, and the average fracture union time was 13.1 weeks (8-24 weeks). The difference between the plate group and intramedullary nail fixation group have no statistically significance in the parameters of shoulder joint function evaluation, pain degree and movement ranges.Conclusion The injury reasons for shoulder joint dysfunction in humeral shaft fracture need to be further investigated. The operation skills for intramedullary nail fixation in direct motion should be enhanced. The patients should attach importance to the fracture functional rehabilitation in early phase, especially those patients above 50 years old. It is necessary to have randomly comparison of the two fixations in large samples.

Humeral fractures;Intramedullary nailing;Plating;Internal fixation

10.3877/cma.j.issn.2095-5790.2015.03.007

首都十大疾病科技成果推廣脊柱關節退行性疾病治療關鍵技術推廣(Z131100002613002)

100144北京大學首鋼醫院骨科

栗劍，Email：shougangguke@163.com

2014-07-21)