孔祥燕

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肱骨近端嚴重骨折半肩關節(jié)置換術后護理與康復治療

孔祥燕

目的 探討肱骨近端骨折行半肩關節(jié)置換術后的護理與康復效果。方法 將67例行半肩關節(jié)假體置換術的肱骨近端粉碎性骨折患者，術后康復鍛煉分為早期、中期和晚期3個階段，并對患者的功能康復鍛煉進行指導。對67例患者進行了平均9個月的隨訪和功能鍛煉指導，按照Neer評分標準進行評價。結果 67例患者中優(yōu)38例，良18例，可11例，差0例，優(yōu)良率達83.58%。結論 對肱骨近端粉碎骨折肩關節(jié)置換術患者，進行精心的護理和規(guī)范化的康復指導，是取得患者肩關節(jié)良好功能恢復的重要因素之一。

肱骨骨折，近端；肩關節(jié)置換；康復；護理

肱骨近端骨折是指包括肱骨外科頸在內(nèi)及其以上部位的骨折，約占全身骨折的4%～5%，且大多為復雜、移位和不穩(wěn)定的骨折[1-2]，在老年人群中較多見。目前，在大部分醫(yī)院多采用石膏外固定或切開復位內(nèi)固定治療，但大多數(shù)學者認為老年患者肱骨近端4部分骨折，尤其是伴有肱骨頭粉碎性骨折或關節(jié)脫位時，肱骨頭血供已受到不可逆損傷，如一期內(nèi)固定后失敗，二期再行關節(jié)置換手術將會影響手術效果和肩關節(jié)功能的恢復[3-4]。對于一些高齡患者，尤其是骨質(zhì)疏松的患者，骨折為Neer分型中的3部分或4部分骨折[5]，雖然經(jīng)過了內(nèi)、外固定治療，但肩關節(jié)功能卻難以取得滿意的效果。對于這種情況，肩關節(jié)置換術無疑是一種有效的更有優(yōu)勢的治療方式[3]。肩關節(jié)置換術按照置換范圍大小分為半肩關節(jié)人工肱骨頭置換和全肩關節(jié)置換。肩關節(jié)置換術后的精心護理與規(guī)范化康復治療越來越受到人們的重視[6]，肩關節(jié)置換術后規(guī)范化、持續(xù)的康復治療是能否最大限度地恢復肩關節(jié)功能的重要因素之一。我科于2004年1月至2013年6月對67例具備肩關節(jié)置換適應證的患者施行半肩關節(jié)假體置換術，經(jīng)過圍手術期的精心護理，無一例發(fā)生并發(fā)癥，并在患者出院后進行平均9個月的隨訪與功能鍛煉康復指導，每次隨訪參照Neer評分標準進行效果評定，67例患者肩關節(jié)功能恢復良好，現(xiàn)將護理與康復治療體會介紹如下。

資 料 與 方 法

一、一般資料

67例臨床診斷均為閉合性肱骨近端粉碎性骨折行半肩關節(jié)置換術的患者，其中男性19例，女性48例。年齡52～90歲，平均73.06歲。Neer分型：3部分骨折29例，3部分骨折-脫位9例，4部分骨折23例，4部分骨折-脫位6例。67例患者傷前肢體功能基本正常，生活可自理，可勝任日常工作。

二、護理

(一)術前心理護理

術前向患者介紹積極的康復鍛煉對肩關節(jié)功能恢復的重要性，同時也要給患者及家屬強調(diào)肩關節(jié)康復鍛練的艱苦性與長期性，一般需要6～12個月的康復鍛煉才能獲得顯著效果，這樣可以使患者做好充分的思想準備，建立康復的信心。

(二)一般護理

術后行常規(guī)護理，患者取平臥或低坡臥位，患肢用前臂懸吊巾固定在外展40°～50°，內(nèi)旋30°。即患肢前臂斜放在患側胸壁旁的軟墊上，以抬高患肢，促進水腫消退。嚴密觀察患者生命體征，注意患肢皮溫、色澤以及傷口情況，警惕有無手指及患肢皮膚麻木、青紫、腫脹等神經(jīng)血管損傷的表現(xiàn)，發(fā)現(xiàn)異常及時報告醫(yī)生處理。

(三)引流管護理

術后引流通暢是手術成功的關鍵之一，應妥善固定傷口引流管并保持通暢，防止引流管受壓、曲折、阻塞、脫落等，注意觀察引流液的顏色、流量、性質(zhì)并準確記錄。若短時間內(nèi)持續(xù)引出大量血液，應引起高度重視是否存在活動性出血。

三、康復鍛煉

根據(jù)Brown等[7]的肩關節(jié)康復治療程序，結合患者的具體情況及手術特點，制定半肩關節(jié)置換術后康復治療方案。將患者術后康復鍛煉分為3個階段，分別為早期、中期和晚期，全程對患者的功能康復鍛煉進行指導。

(一)第一階段(術后1 d～6周)

術后根據(jù)患者骨折類型及固定情況，麻醉消失后即可進行肘關節(jié)以遠肢體的主動活動[8]，肩關節(jié)以被動活動為主，除訓練時間外，均需配帶肩關節(jié)專用吊帶。該階段具體可分為5個步驟[9]：(1)麻醉消失后，開始進行手指、腕關節(jié)及肘關節(jié)的主動鍛煉和肩關節(jié)的被動活動，術后7 d增加鐘擺練習；(2)術后2周,患肩關節(jié)及鄰近關節(jié)無負重下行后伸及內(nèi)外旋轉運動；(3)術后3周健手保護患側低負重雙肩關節(jié)后伸及擴胸練習；(4)術后4周進行重力輔助下的鐘擺練習及前屈練習,肩外展、外旋、上舉功能鍛煉；(5)術后6周X線檢查確定肩袖及大小結節(jié)愈合后，開始進行主動功能鍛煉，增加岡上肌、三角肌功能鍛煉及爬墻練習。該階段應重點關注關節(jié)活動度及肌力的訓練。

1.關節(jié)活動度訓練：(1)鐘擺練習[10]：患者彎腰使軀干與地面平行，患側上肢放松、懸垂，與軀干成90°，用健側手托住患側前臂做順時針或逆時針畫圈運動， 10圈為1組，上、下午各練習1組。(2)肩關節(jié)被動前屈上舉練習：患者去枕仰臥，患側臂屈肘90°放于體側(休息位)。治療師一手托住患側上臂，一手握住患側前臂，在肩胛骨平面 (冠狀平面之前30°～45°) 做肩關節(jié)被動前屈上舉，當前屈到一定角度出現(xiàn)疼痛或遇到阻力時停留5 s，然后逐漸回到休息位，重復4 次為1組，上、下午各練習1組。(3) 被動外旋練習：患者仰臥位，去枕，上臂外展30°保持肢體在肩胛骨平面，肘關節(jié)屈曲。治療師一手托住患側上臂，一手握住患側腕部向遠離身體中線的方向做肩關節(jié)被動外旋。重復4次為1組，上、下午各練習1組。(4)被動外展、內(nèi)收和內(nèi)旋練習(從術后第5周開始) ：患者仰臥位，治療師幫助患者行肩關節(jié)被動外展、內(nèi)收、內(nèi)旋(外展90°內(nèi)旋) 訓練，重復4 次為1組，上、下午各練習1組。

2.肌力訓練：肩帶肌等長收縮訓練從術后第3周開始，術后第6周開始行內(nèi)、外旋肌群等長收縮訓練。(1)肩關節(jié)前屈肌群訓練：患者立位，面對門或墻，患側屈肘90°放于體側，然后用健側手托住患側手，手握拳向前用力推，試圖做肩關節(jié)前屈的動作，但不產(chǎn)生關節(jié)運動。(2)外展肌群訓練：患者立位，患側屈肘90°放于體側，用健側手托住患側手，患側上臂外側完全接觸門或墻，肘部用力向外推，做外展動作。(3)肩關節(jié)伸肌群訓練：患者立位，患側屈肘90°放于體側，然后用健側手托住患側手，患側上臂背側完全接觸門或墻，肘部用力向后推門或墻做后伸動作。(4) 提肩胛骨肌群訓練：患者立位，患側屈肘90°放于體側，然后用健側手托住患側手，雙側同時用力做聳肩動作。(5)內(nèi)收肩胛骨肌群訓練：患者立位，患側屈肘90°放于體側，然后用健側手托住患側手，雙側同時用力做內(nèi)收肩胛骨動作。(6)內(nèi)旋肌群訓練：患者站立位，患側屈肘90°放于體側，健側手握住患側前臂，患側肩關節(jié)試圖做內(nèi)旋動作，健側手阻礙肩關節(jié)產(chǎn)生運動。(7)外旋肌群訓練：保持內(nèi)旋肌訓練的姿勢，患側肩關節(jié)試圖做體側的外旋動作。每次每個動作持續(xù)用力5 s，重復10次為1組，上、下午各練習1組。

(二)第2階段(術后7～12周)

能否去掉吊帶需根據(jù)患者大小結節(jié)愈合程度決定。此階段訓練以肩關節(jié)主動活動為主，除關節(jié)活動度和肌力訓練外，增加了耐力訓練。

1.活動度訓練：繼續(xù)肩關節(jié)各方向的牽拉訓練，可開始進行滑輪牽拉訓練和爬墻梯/爬墻等閉鏈訓練。

2.肌力訓練：繼續(xù)上一階段的等長收縮訓練，開始行肩帶肌等張收縮及肱二頭肌、肱三頭肌等張收縮。

3.耐力訓練：逐漸增加運動量(20次為1組) 和運動持續(xù)時間(每個動作持續(xù)10 s) 。

(三)第3階段(術后12周)

此階段開始進行肌肉抗阻力的強化訓練, 以抗阻訓練為主，包括肩關節(jié)牽拉訓練、抗阻力訓練、肩胛的旋轉和三角肌強化練習。此階段除關節(jié)活動度、肌力及耐力訓練外，增加了運動能力訓練。

1.活動度訓練：繼續(xù)肩關節(jié)各個方向的牽拉訓練(強度可增加)，如借助門框牽拉。

2.肌力訓練：以抗阻訓練為主。每個動作達最大限度時停留5 s，重復10次為1組，上、下午各練習1組。(1)抗阻前屈和外展：患者站立位，取一根長1 m的彈力帶，一端踩在腳下，一端握在手里進行前屈上舉和外展上舉練習。(2)抗阻后伸：患者站立位，患側臂伸直面對彈力帶，彈力帶一端固定在相當于腕關節(jié)的高度，肩前屈約60°使彈力帶具有一定張力，注意張力不要過高，患者牽拉彈力帶，放下手臂做后伸動作。(3)抗阻內(nèi)旋和外旋：患者站立位，將一根彈力帶系在約肘關節(jié)高度的門或家具上。內(nèi)旋時，患側靠近彈力帶，上臂內(nèi)收于體側，屈肘90°，以肘關節(jié)為軸，前臂和手做超過身體中線的動作，盡量拉長彈力帶。外旋動作與內(nèi)旋方向相反。當肌力增強后，可改用墻壁拉力器進行抗阻訓練。

3. 耐力訓練：此期可增加運動量(每個動作重復30次為1組，上、下午各2組)和運動持續(xù)時間(每個動作保持15 s)。

4. 運動能力訓練：參加體育運動，包括本體感覺訓練。在患者舒適度以內(nèi)，可進行任何活動，但應避免接觸性運動，最佳運動有游泳、打乒乓球等。

四、Neer評分

術后67例患者平均獲得9個月的隨訪，根據(jù)Neer評分標準評估患者的患側肩關節(jié)功能，其中疼痛占35分，日常生活功能占30分，術后肩關節(jié)活動范圍占25分，術后解剖位置占10分。90～100分為優(yōu)，80～89分為良，70～79分為可，<70分為差。

結 果

本組67例患者經(jīng)過以上規(guī)范、系統(tǒng)地術后護理和康復鍛煉并進行術后平均9個月的隨訪。根據(jù)Neer評分標準評估患者的患側肩關節(jié)功能，結果顯示，67例患者中優(yōu)38例，良18例，可11例，差0例，優(yōu)良率達到83.58%。無一例并發(fā)癥，經(jīng)康復鍛煉后患者生活完全能夠自理，康復效果滿意。

討 論

肱骨近端骨折在肩部骨折中較為常見，治療效果與患者的肩關節(jié)功能、日?；顒蛹吧钯|(zhì)量直接相關。目前肩關節(jié)置換術的適應證范圍尚未完全明確，傳統(tǒng)上認為包括老齡骨質(zhì)疏松性骨折、骨折/脫位、頭劈裂性骨折及累及關節(jié)面>40%的壓縮骨折可選用半肩關節(jié)置換術[11]。雖然嫻熟的手術技巧對治療的成功起著重要作用，但術后的護理和康復鍛煉也同樣不可忽視，過于保守的康復訓練會導致關節(jié)僵硬，肌肉過度萎縮，影響肩關節(jié)的活動范圍及功能，而過量的康復訓練又會使愈合的關節(jié)囊、大小結節(jié)受到二次損害，影響肩關節(jié)的穩(wěn)定性和功能。與其他關節(jié)置換術后的護理和康復截然不同的是，肩關節(jié)的康復所需的時間更長，可達12個月之久。因此，制定一套完整的能讓患者接受的護理和規(guī)范的功能鍛煉方法是至關重要的，這對于肱骨近端內(nèi)固定術后患者和肩關節(jié)置換患者同樣適用。有研究表明，術后配合積極的康復鍛煉，不僅可以控制術后感染的發(fā)生，還能夠促進傷口愈合，安全有效地避免術后骨不愈合和骨髓炎等并發(fā)癥的發(fā)生[11-12]。

人工肩關節(jié)置換術與人工髖、膝關節(jié)置換術幾乎是同時代的手術技術，但是人工肩關節(jié)置換術的實施數(shù)量及長期效果目前仍達不到人工髖、膝關節(jié)置換術那樣令人滿意的效果，之所以產(chǎn)生這樣差異，主要是由于肩關節(jié)的特殊功能要求和解剖特點決定的[13]。肩關節(jié)是人體各關節(jié)中活動度最大的關節(jié)，占整個上肢功能的60%，對關節(jié)的靈活性要求較高。另外，肩周肌肉豐富，肱骨幾乎是由肩周軟組織懸吊于肩胛上，因此肩周軟組織功能的恢復程度對術后肩關節(jié)的功能就顯得極其重要。

在骨質(zhì)疏松的肱骨近端的Neer 4部分骨折或3部分骨折伴脫位患者中，肩關節(jié)置換術較為常用，因為此類型骨折常常破壞了肩部最重要的動力穩(wěn)定結構——肩袖的止點處的大、小結節(jié)。精確復位大、小結節(jié)于假體頭下是肩關節(jié)置換術最重要的步驟之一，并在術后一段時間達到大、小結節(jié)之間以及大、小結節(jié)和肱骨干之間的骨性愈合[14]，在大、小結節(jié)沒有達到骨性愈合之前，功能鍛煉中應避免肩袖肌肉主動收縮，以免造成結節(jié)骨折移位，影響術后效果?；贾谋Ｗo在早期康復鍛煉中更為重要，因為此時骨折尚未愈合，錯誤的鍛煉方式會造成二次損傷，影響預后，在早期康復鍛煉過程中應強調(diào)進行正確的被動鍛煉，6周后骨折初步愈合后才可進行主動鍛煉。由此可見，肱骨近端骨折患者行肩關節(jié)置換術的最終效果，不單純是手術技術所決定的，其術后規(guī)范化的康復訓練治療也是一個不可或缺的因素。

肩關節(jié)置換術后早期康復治療是存在一定的風險的，大、小結節(jié)骨折塊移位等問題在某些時候是無法完全避免的。因此，我們需要與臨床醫(yī)師及康復醫(yī)師進行溝通，并制定個性化的康復方案，這樣才能更好的針對每位患者進行康復指導。第一階段行肩關節(jié)被動活動時，向手術醫(yī)師了解術中情況，對于被動活動的角度應參考術中記錄的安全活動范圍，并根據(jù)患者的傷情、術式及其全身情況制定康復方案。第二階段行肩關節(jié)主動活動的時間應在X線片顯示有骨折愈合征象證據(jù)之后并根據(jù)隨訪查體情況進行。本研究復雜肱骨近端骨折的患者均施行半肩關節(jié)置換術，與全肩關節(jié)置換術不同，大、小結節(jié)重建的問題需要重視，若過早進行主動活動，則增加結節(jié)移位的風險，如大結節(jié)在岡上肌、岡下肌、小圓肌的牽拉下向后上方移動，則可能繼發(fā)肩峰下撞擊等。肩關節(jié)不穩(wěn)定是肩關節(jié)置換術后常見并發(fā)癥之一。使肩關節(jié)盡快恢復功能的方法之一就是肌力訓練，這種方法還可減少不穩(wěn)定的發(fā)生率。肩關節(jié)置換患者康復的全過程均需要肌力訓練，只是不同階段需要不同的訓練內(nèi)容。如第一階段以肩帶肌等長收縮為主，第二階段以肩帶肌等張收縮為主，第三階段以抗阻肌力訓練為主。通過肩帶肌的系統(tǒng)訓練，可增強肩關節(jié)的穩(wěn)定性，預防肌源性肩關節(jié)不穩(wěn)定的發(fā)生[15]。對于肱骨近端粉碎性骨折肩關節(jié)置換術的患者，進行詳盡細致的護理和規(guī)范的康復指導治療，是取得患者肩關節(jié)良好功能恢復的重要因素。經(jīng)過上述細致的護理及系統(tǒng)的康復治療，患者在術后6～12個月一般都能恢復滿意的肩關節(jié)功能，但要提醒患者6個月后應繼續(xù)鞏固訓練并定期復查。

結論：對肱骨近端粉碎性骨折肩關節(jié)置換術患者進行精心的護理和規(guī)范化的康復指導治療，是取得患者肩關節(jié)良好功能恢復的重要因素之一。

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(本文編輯：胡桂英)

孔祥燕.肱骨近端嚴重骨折半肩關節(jié)置換術后護理與康復治療[J/CD]. 中華肩肘外科電子雜志,2015,3(3):167-174.

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

KongXiangyan.

DepartmentofTraumaandOrthopaedics,PekingUniversityPeople′sHospital,PekingUniversityTrafficMedicineCenter,Beijing100044,China

KongXiangyan,Email:kxy1766@163.com

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

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 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 19 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 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 1m, 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 15 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, 11 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.

Humeral fracture,proximal;Shoulder joint arthroplasty;Rehabilitation;Nursing

10.3877/cma.j.issn.2095-5790.2015.03.009

衛(wèi)生部衛(wèi)生公益性行業(yè)科研專項基金(201002014)

100044北京大學人民醫(yī)院創(chuàng)傷骨科 北京大學交通醫(yī)學中心(Email：kxy1766@163.com)

2015-02-06)