馬明太 付中國(guó) 張殿英 陳建海 黃偉 徐海林

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·論著·

ITS肱骨近端鎖定鋼板治療肱骨近端骨折療效觀察

馬明太 付中國(guó) 張殿英 陳建海 黃偉 徐海林

目的 探討ITS肱骨近端鎖定鋼板治療肱骨近端骨折的療效。方法 自2012年10月至2013年11月采用ITS肱骨近端鎖定鋼板治療肱骨近端骨折的11例患者，其中男性3例，女性8例；年齡57～86歲，平均80.5歲；骨折按Neer分型：Ⅱ型3例，Ⅲ型6例，Ⅳ型2例。記錄患者手術(shù)時(shí)間，術(shù)中出血量，術(shù)中和術(shù)后并發(fā)癥發(fā)生情況，術(shù)后肩關(guān)節(jié)Constant-Murley評(píng)分及骨折愈合時(shí)間等。分別于術(shù)后4、8、12、24和48周預(yù)約患者來(lái)院復(fù)查隨訪，常規(guī)拍攝肩胛骨正側(cè)位片及腋位片。結(jié)果 11例患者均獲隨訪，隨訪時(shí)間為11～23個(gè)月，平均16個(gè)月，均達(dá)到骨性愈合，平均愈合時(shí)間為12周。根據(jù)肩關(guān)節(jié)Constant-Murley評(píng)分標(biāo)準(zhǔn)，優(yōu)良率為81.8%。結(jié)論 ITS肱骨近端鎖定鋼板具有穩(wěn)定性可靠，操作簡(jiǎn)單、快捷, 并發(fā)癥少等優(yōu)點(diǎn)，用于治療肱骨近端骨折獲得滿意療效。

肱骨近端，骨折；骨折固定術(shù)；鎖定鋼板

肱骨近端骨折為臨床常見(jiàn)的骨折類型，約占所有骨折的5%[1]。70%的肱骨近端骨折發(fā)生在60歲以上老年骨質(zhì)疏松人群，由低能量跌倒所致[1-2]。在老年人群中，是繼髖部及橈骨遠(yuǎn)端骨折之后最常見(jiàn)的骨折類型[1,3]。此外，肱骨近端骨折也常見(jiàn)于年輕患者的高能量損傷，這類患者常合并其他部位骨折或臟器損傷。根據(jù)Neer分型[4,10]骨折移位超過(guò)1 cm或成角超過(guò)45°視為移位骨折，約20%的肱骨近端骨折為移位骨折，對(duì)于這類骨折手術(shù)治療已成為多數(shù)醫(yī)師的共識(shí)[1]。治療該骨折有多種內(nèi)固定方式，臨床上常用的有肱骨近端鎖定鋼板。目前，常見(jiàn)的有AO PHILOS、ITS肱骨近端鎖定鋼板、Zimmer、Accumed肱骨近端系列等。有關(guān)AO PHILOS鋼板的研究報(bào)道較多，查閱相關(guān)文獻(xiàn)，未見(jiàn)ITS肱骨近端鎖定鋼板相關(guān)報(bào)道。2012年10月至2013年11月采用ITS肱骨近端鎖定鋼板手術(shù)治療11例肱骨近端骨折患者，療效滿意，現(xiàn)報(bào)道如下。

資 料 與 方 法

一、一般資料

2012年10月至2013年11月，我院共對(duì)11例肱骨近端骨折患者進(jìn)行切開(kāi)復(fù)位ITS鋼板內(nèi)固定手術(shù)。其中男性3例，女性8例；年齡57～86歲，平均80.5歲；左側(cè)4例，右側(cè)7例；低能量損傷(跌傷)10例，高能量損傷(交通傷)1例；合并內(nèi)科基礎(chǔ)疾病7例，合并其他部位骨折1例；從受傷到手術(shù)的時(shí)間平均為5.5 d；骨折按Neer分型：Ⅱ型3例，Ⅲ型6例，Ⅳ型2例，均為閉合骨折。

二、手術(shù)方法

所有患者均采用全身麻醉，沙灘椅體位。手術(shù)取三角肌胸大肌間隙入路，依次切開(kāi)皮膚、皮下組織，顯露并保護(hù)頭靜脈，自兩肌間隙剝離，將頭靜脈連同胸大肌拉向內(nèi)側(cè)，三角肌拉向外側(cè)。切開(kāi)骨膜并適當(dāng)剝離，顯露骨折端，將骨塊復(fù)位。如大、小結(jié)節(jié)骨折移位明顯，使用愛(ài)惜康4843縫線縫合肩袖，牽拉骨塊幫助復(fù)位，使用克氏針進(jìn)行臨時(shí)固定。鋼板近端置于大結(jié)節(jié)頂點(diǎn)下方0.8 cm。鋼板側(cè)方與骨干平行，位于結(jié)節(jié)間溝偏背側(cè)0.5～1.0 cm。首先在長(zhǎng)結(jié)合孔擰入1枚3.5 mm皮質(zhì)骨螺釘，C臂機(jī)透視確認(rèn)骨折復(fù)位滿意及鋼板位置合適后，逐個(gè)鉆孔擰入鎖釘。根據(jù)術(shù)中所見(jiàn)骨質(zhì)缺損情況，酌情進(jìn)行植骨。

由于ITS鋼板采用無(wú)預(yù)設(shè)螺紋，螺釘頭部擠壓嵌入鋼板進(jìn)行鎖定的設(shè)計(jì)，可以根據(jù)不同骨折固定需要，每顆螺釘滿足±15°任意方向的固定，達(dá)到萬(wàn)向鎖定效果。ITS接骨板近端有5個(gè)釘孔，通常都要進(jìn)行固定，遠(yuǎn)端依據(jù)接骨板長(zhǎng)度使用3枚左右螺釘。

鎖釘固定后，將肩袖預(yù)留縫線固定于鋼板近端縫扎孔進(jìn)一步復(fù)位固定骨塊?；顒?dòng)肩關(guān)節(jié)有無(wú)摩擦感，透視確認(rèn)鋼板位置及螺釘長(zhǎng)度合適，無(wú)螺釘穿出。沖洗傷口并止血，逐層縫合傷口，放置引流管。術(shù)前0.5 h及術(shù)后24 h內(nèi)使用抗生素，常規(guī)術(shù)后2 d拔除引流管。

三、術(shù)后功能鍛煉

根據(jù)患者全身狀況及術(shù)中固定的牢固程度，指導(dǎo)患者術(shù)后功能鍛煉。對(duì)于固定可靠者，術(shù)后3 d即開(kāi)始被動(dòng)功能鍛煉，以肩關(guān)節(jié)鐘擺活動(dòng)和被動(dòng)功能鍛煉為主。鍛煉間期需使用懸臂吊帶固定。4周后摘掉懸臂吊帶，逐步增加肩關(guān)節(jié)各方向的活動(dòng)練習(xí)，此后可依照患者復(fù)查情況逐步增加被動(dòng)的內(nèi)旋、內(nèi)收及外展練習(xí)。術(shù)后8～12周拍片證實(shí)骨折初步愈合后開(kāi)始力量鍛煉并加強(qiáng)各方向的活動(dòng)練習(xí)。

四、觀察指標(biāo)及療效評(píng)定標(biāo)準(zhǔn)

記錄患者手術(shù)時(shí)間，術(shù)中出血量，術(shù)中和術(shù)后并發(fā)癥發(fā)生情況、術(shù)后肩關(guān)節(jié)Constant-Murley評(píng)分及骨折愈合時(shí)間等。分別于術(shù)后4、8、12、24和48周預(yù)約患者來(lái)院復(fù)查隨訪，常規(guī)拍攝肩胛骨正側(cè)位片及腋位片。根據(jù)患者術(shù)后疼痛、日常活動(dòng)能力、患肢活動(dòng)范圍及肌力進(jìn)行肩關(guān)節(jié)Constant-Murley評(píng)分，療效標(biāo)準(zhǔn)為：優(yōu)≥90分，良80～89分，可70～79分，差<70分。

結(jié) 果

手術(shù)切口長(zhǎng)度5～11 cm，平均為8 cm；手術(shù)時(shí)間60～115 min，平均80 min；術(shù)中出血量100～190 ml，平均150 ml；術(shù)后引流量50～120 ml，平均91 ml。11例患者術(shù)后隨訪11～23個(gè)月，平均16個(gè)月。本組患者均達(dá)到骨性愈合，骨折愈合時(shí)間9～16周，平均12周。所有患者未出現(xiàn)術(shù)中、術(shù)后并發(fā)癥。根據(jù)患者術(shù)后疼痛、日?；顒?dòng)能力、患肢活動(dòng)范圍及肌力，進(jìn)行肩關(guān)節(jié)Constant-Murley評(píng)分。本組患者優(yōu)6例，良3例，可2例，優(yōu)良率為81.8%。典型病例手術(shù)前后X線片和功能相片見(jiàn)圖1。

圖1 患者，女性，80歲，右側(cè)肱骨近端骨折，合并骨質(zhì)疏松。A、B為術(shù)前肩關(guān)節(jié)正側(cè)位X線片；C、D為術(shù)后正側(cè)位X線片；E、F、G為術(shù)后1年功能相

討 論

隨著人口老齡化的進(jìn)程，肱骨近端骨折的發(fā)病率有逐年增加的趨勢(shì)。有研究報(bào)道老年肱骨近端骨折患者的發(fā)病率在近30年增長(zhǎng)了近3倍[5]。該骨折的治療方式通常根據(jù)患者的骨折類型、骨質(zhì)量、年齡及身體一般狀況來(lái)制定。約20%的肱骨近端骨折是移位骨折，對(duì)于這類骨折，通常需要手術(shù)治療[1]。肱骨近端骨折手術(shù)治療的目的是：力爭(zhēng)解剖復(fù)位、堅(jiān)強(qiáng)內(nèi)固定、早期功能鍛煉、盡量恢復(fù)關(guān)節(jié)功能[4,6,8-9]。

肱骨近端骨折手術(shù)治療的方式包括非可吸收縫線固定、張力帶固定、空心螺釘固定、普通鋼板固定、解剖型鎖定鋼板固定、髓內(nèi)釘固定及人工肩關(guān)節(jié)置換等[1-2,4]。雖然可選擇的固定方式很多，但對(duì)于肱骨近端骨折的治療方案至今仍沒(méi)有統(tǒng)一的金標(biāo)準(zhǔn)，其治療方式選擇仍存在很多爭(zhēng)議[1-3]。作者認(rèn)為，在需要手術(shù)治療的肱骨近端骨折中，解剖型鎖定鋼板可用于治療大多數(shù)病例。對(duì)于肱骨頭關(guān)節(jié)面壓縮超過(guò)50%、肱骨頭劈裂，尤其是嚴(yán)重骨質(zhì)疏松、骨質(zhì)難以承載內(nèi)固定系統(tǒng)的患者，如能耐受手術(shù)，我們通常一期行人工半肩關(guān)節(jié)置換術(shù)。而對(duì)于年輕患者(<50歲)仍首選切開(kāi)復(fù)位鋼板內(nèi)固定術(shù)。

肱骨近端解剖型鎖定鋼板的優(yōu)點(diǎn)：(1)鋼板外形與肱骨近端匹配，貼服好，無(wú)需預(yù)彎；(2)鎖定成角穩(wěn)定性通過(guò)鋼板螺釘間的牢固鎖定起到內(nèi)支架作用，接骨板和骨面不產(chǎn)生壓力，保留骨折區(qū)的血供；(3)接骨板邊緣的縫合孔可將肩袖進(jìn)行縫合固定進(jìn)一步加強(qiáng)骨折復(fù)位固定；(4)鋼板近端多個(gè)方向螺釘孔的設(shè)計(jì)保證螺釘把持力更強(qiáng)，尤其適用于骨質(zhì)疏松患者。除以上優(yōu)點(diǎn)外，ITS鋼板釘孔無(wú)預(yù)設(shè)螺紋，由于螺釘為鈦合金材質(zhì)，接骨板鈦純度99.1%，致使螺釘比接骨板質(zhì)地稍硬，螺釘頭部擠壓嵌入并進(jìn)行鎖定。根據(jù)不同骨折固定需要，每顆螺釘可以滿足±15°任意方向的固定，達(dá)到萬(wàn)向鎖定效果，這樣操作簡(jiǎn)單快捷，可節(jié)省手術(shù)時(shí)間。由于ITS螺釘比接骨板質(zhì)地稍硬，可有效避免出現(xiàn)鎖定螺釘冷焊接效應(yīng)，此設(shè)計(jì)可使內(nèi)固定取出更容易。由于ITS接骨板近端釘孔為5孔，釘孔相對(duì)較少，對(duì)于嚴(yán)重骨質(zhì)疏松患者，骨折復(fù)位后的把持力可能不夠，因此不建議用于嚴(yán)重骨質(zhì)疏松患者。

肱骨近端骨折鋼板內(nèi)固定術(shù)后常見(jiàn)并發(fā)癥包括：螺釘穿出、接骨板撞擊肩峰、接骨板斷裂、傷口感染、肱骨頭壞死、肱骨頭內(nèi)翻畸形、延遲愈合等[1]。本組病例未出現(xiàn)此類并發(fā)癥，這可能與我們術(shù)后康復(fù)鍛煉較為保守以及術(shù)中鋼板正確放置有關(guān)。Owsley等[7]曾對(duì)53例肱骨近端骨折鎖定鋼板固定術(shù)后的患者進(jìn)行了隨訪，認(rèn)為術(shù)后晚期出現(xiàn)的螺釘穿出與肱骨頭初始復(fù)位不良以及此后肱骨頭持續(xù)的復(fù)位丟失有關(guān)。我們放置鋼板時(shí)將鋼板近端置于大結(jié)節(jié)頂點(diǎn)下方0.8 cm，這樣既可以保證鋼板螺釘對(duì)肱骨頭的支撐同時(shí)避免發(fā)生肩峰撞擊。因此，本組患者中未出現(xiàn)接骨板撞擊肩峰現(xiàn)象。

肱骨近端骨折切開(kāi)復(fù)位鋼板內(nèi)固定，術(shù)中應(yīng)盡量達(dá)到滿意的骨折復(fù)位，尤其近年來(lái)國(guó)內(nèi)外學(xué)者提出內(nèi)側(cè)柱支撐的恢復(fù)尤其重要[11-12]。鋼板位置放置合理可以避免鋼板撞擊肩峰的發(fā)生。術(shù)后待骨折獲得初步愈合后進(jìn)行功能鍛煉，可能對(duì)減少螺釘穿出有幫助。使用ITS肱骨近端鎖定鋼板治療肱骨近端骨折可獲得滿意療效，其具有穩(wěn)定性可靠，操作簡(jiǎn)單、快捷，并發(fā)癥少，可有效避免出現(xiàn)鎖定螺釘冷焊接效應(yīng)等優(yōu)點(diǎn)。

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(本文編輯：李靜)

馬明太,付中國(guó),張殿英,等.ITS肱骨近端鎖定鋼板治療肱骨近端骨折療效觀察[J/CD]. 中華肩肘外科電子雜志,2015,3(4):206-210.

Observation of the therapeutic effects of ITS locking proximal humerus plate therapy on proximal humeral fractures

MaMingtai,FuZhongguo,ZhangDianying,ChenJianhai,HuangWei,XuHailin.

DepartmentofTraumaandOrthopaedics,PekingUniversityPeople′sHospital,PekingUniversityTrafficMedicineCenter,Beijing100044,China

Correspondingauthor：XuHailin，Email:xhl166@sohu.com

Background Proximal humerus fracture is a clinical common fracture type, accounting for 5% of all fracture cases. 70% of proximal humerus fractures occur among the elder population over 60 years old with osteoporosis and are caused by low energy falling. Among the elderly population, proximal humerus fracture is the most common fracture type, only next to distal hip and radial fractures. In addition, proximal humeral fractures are also commonly seen in the high energy injuries to young patients, and such cases are often associated with fractures or organ injuries on other parts. According to Neer fracture classification, if fracture displacement exceeds 1cm or fracture angle exceeds 45°, such case is regarded as displaed fracture. About 20% of proximal humerus fractures are displaced fractures. For such type of factures, operative treatment has become a consensus among majority of physicians. There are many internal fixation modes for treatment of such fracture, and the clinically common modes include locking proximal humerus plate. At present, many companies have released locking proximal humerus plates, and common similar products include AO PHILOS and ITS locking proximal humerus plates as well as Zimmer and Accumed proximal humerus series. There are many research reports related to AO PHILOS plate. By referring to relevant literatures, we have not found relevant report on ITS locking proximal humerus plate. During the period from October 2012 to November 2013, Orthopedic trauma department of Peking University People′s Hospital adopted ITS locking proximal humerus plates in the operative treatment of 11 cases of proximal humerus fractures, and achieved satisfactory therapeutic effects. These cases are reported as follows.Methods Ⅰ.General materials:During the period from October 2012 to November 2013, our hospital conducted open reduction and ITS plate internal fixation operations for 11 proximal humerus fracture cases, including 3 male cases and 8 female cases; aged 57-86 years, with average age of 80.5 years; 4 left side cases, and 7 right side cases; 10 cases of low energy injuries (falling) and 1 case of high energy injury (traffic injury); 7 cases of combined medical underlying diseases, and 1 case of combined with fracture on other sites; the average duration from injury to operation is 5.5 d; Neer fracture classification: 3 cases of type Ⅱ, 6 cases of type Ⅲ, 2 cases of type Ⅳ, all of which are closed fractures.Ⅱ. Operative method:For all the patients, adopt general anesthesia and beach chair position. Adopt the clearance between deltoid and pectoralis major as operative approach, slice through skin and subcutaneous tissues in turn, expose and protect cephalic vein, perform stripping from the intermuscular space between two muscles, pull the cephalic vein in together with musculus pectoralis major inward, and pull the deltoid outward. Perform periosteotomy and appropriate stripping, expose the fracture end and reset the bone block. For obvious lesser tubercle/major tubercle fracture displacement, use Ethicon 4843 suture to stitch rotator cuff, pull the bone block to help bone reduction; use kirschner pin for temporary fixation. Place the proximal end of plate at 0.8 cm below the peak of greater tubercle. The lateral side of plate is parallel with the backbone and is located at 0.5-1.0 cm from dorsal part of the intertubercular sulcus. Firstly, screw in one 3.5 mm cortical bone screw into the long combination hole. After having validated satisfactory fracture reduction and appropriate plate position through C-arm fluoroscopy, drill holes and screw in locking screws one by one. According to the bony defect observed during operation, perform bone grafting. Since ITS plate is so designed that no preset thread is provided and the screw head is extruded and embedded into plate to perform locking, it is feasible to use each screw to perform fixation in any direction of ±15°and realize universal locking effect according to different requirments for fracture fixation. There are 5 screw holes at distal end of ITS bone fracture plate, which generally need fixation. At the distal end, use about screws more or less according to the length of bone fracture plate. After fixation of locking screw, fix the reserved suture in the rotator cuff in the proximal stitching hole of steel plate to further reset and fix the bone blocks. Activate the shoulder joint to determine whether there is friction feeling; Through fluoroscopy, validate whether the position of plate and the length of screw are appropriate, and whether there is screw threading out. Wash the wound and perform haemostasis, stitch the wound layer by layer, and place a drainage tube. In preoperative 0.5 h and postoperative 24 h use antibiotics, and remove the drainage Tube in 2 d after conventional operation.Ⅲ. Postoperative functional exercise:According to the systemic conditions of the patients as well as the firmness of fixation during operation, instruct the patients to perform postoperative functional exercise. In case of reliable fixation, start passive functional exercise on postoperative 3 d, with training exercise mainly including shoulder joint pendulum exercise and passive functional exercise. At the exercise interval, it is necessary to use cantilever suspender for fixation. 4 weeks later, take off the cantilever suspender, gradually increase the active exercise of shoulder joint in various directions. Subsequently, according to the reexamination conditions of the patients, it is feasible to gradually increase the passive internal rotation, adduction and abduction exercises. At postoperative 8-12 weeks, after having validated initial fracture union through X-ray film, start strength exercises and intensify the active exercises in various directions. IV. Observation indices and curative effect evaluation criteria:Record the operation time of the patients, the intraoperatve blood loss, the intraoperative and postoperative occurrence of complications, the postoperative shoulder joint Constant- Murley scoring and fracture union time, etc. Respectively at 4, 8, 12, 24 and 48 weeks after operation, order the patient to receive reexamination and follow-up in hospital, and perform conventional radiography of anterioposterior and lateral film and axillary film. According to the postoperative pain and daily living activity of the patients, the range of activities of affected limbs and muscle force, perform shoulder joint Constant-Murley scoring. The criterion of therapeutic effects: Excellent ≥90 points, good 80-89 points, acceptable 70-79 points, poor <70 points.Results Operative incision has length of 5-11 cm, with average value of 8 cm; the operative time is 60-115 min, with average value of 80 min; the intraoperatve blood loss is 100-190 ml, with average value of 150 ml; the postoperative drainage flow is 50-120 ml, with average value of 91 ml. 11 cases obtained postoperative follow-up for 11-23 months, with average value of 16 months. This group of the patients realized bone union, and the fracture union time is 9-16 weeks, with average value of 12 weeks. All the patients have no intraoperative and postoperative complications. According to the postoperative pain, daily living activity, range of motion of affected limbs and muscle force of the patients, we performed shoulder joint Constant-Murley scoring. This group of the patients include 6 excellent cases, 3 good cases and 2 acceptable cases, with good rate of 81.8%.Conclusion ITS locking proximal humerus plate has such advantages as high stability and reliability, simple and quick operation and less complications, and can achieve satisfactory therapeutic effects in the treatment of proximal humeral fracture.

Humerus fracture,proximal;Fracture internal fixation;Locking plate

10.3877/cma.j.issn.2095-5790.2015.04.

衛(wèi)生公益性行業(yè)科研專項(xiàng)(201002014、201302007)；教育部創(chuàng)新團(tuán)隊(duì)(IRT1201)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

徐海林,Email：xhl166@sohu.com

2015-02-26)