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(nèi)固定技術(shù)對(duì)肩關(guān)節(jié)功能影響的中長(zhǎng)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(nèi)固定和順行髓內(nèi)釘固定后的肩關(guān)節(jié)癥狀、功能和運(yùn)動(dòng)范圍。 方法 回顧性分析19例鋼板和20例順行髓內(nèi)釘內(nèi)固定對(duì)肩關(guān)節(jié)功能的影響。隨訪肩關(guān)節(jié)HSS、JOA、VAS評(píng)分,肩關(guān)節(jié)運(yùn)動(dòng)范圍。鋼板組平均隨訪7.3年(1～11年)；髓內(nèi)釘組平均隨訪6年(1～10年)。結(jié)果 HSS評(píng)分優(yōu)良率：鋼板組84.2%，髓內(nèi)釘組65%；JOA評(píng)分優(yōu)良率：鋼板組78.9%，髓內(nèi)釘組60%；VAS評(píng)分：鋼板組1.78分，髓內(nèi)釘組2.3分；肩關(guān)節(jié)運(yùn)動(dòng)范圍：鋼板組在前屈、外展、外旋運(yùn)動(dòng)方面優(yōu)于髓內(nèi)釘組。在肩關(guān)節(jié)評(píng)分、肩關(guān)節(jié)疼痛和運(yùn)動(dòng)范圍方面，鋼板組和髓內(nèi)釘組間差異無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論 兩種內(nèi)固定技術(shù)治療后大部分肩關(guān)節(jié)功能可恢復(fù)到正常狀態(tài)。順行髓內(nèi)釘固定只要提高手術(shù)操作技巧，防止醫(yī)源性損傷，就能明顯減少肩關(guān)節(jié)損傷。

肱骨骨折；髓內(nèi)釘；鋼板；內(nèi)固定

肱骨干骨折是上肢常見(jiàn)的損傷類型，文獻(xiàn)報(bào)道肱骨干骨折在所有骨折中約占3%[1]。常見(jiàn)的手術(shù)治療方法包括鋼板固定和髓內(nèi)釘固定。多數(shù)學(xué)者認(rèn)為鋼板固定技術(shù)是比較各種手術(shù)固定方法的金標(biāo)準(zhǔn)。有關(guān)順行髓內(nèi)釘固定是否影響肩關(guān)節(jié)功能尙存爭(zhēng)議[2-5]。通過(guò)對(duì)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(nèi)釘患者進(jìn)行回顧性分析，旨在探討兩種內(nèi)固定技術(shù)對(duì)肩關(guān)節(jié)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(jī)器絞傷2例，運(yùn)動(dòng)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(fā)生骨折到進(jìn)行手術(shù)的平均時(shí)間為1.2 d。

二、手術(shù)方法

所有手術(shù)均采用臂叢麻醉或全身麻醉。鋼板組手術(shù)采用前外側(cè)入路17例，后側(cè)入路2例。內(nèi)固定物選擇普通鋼板，動(dòng)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(wěn)定固定。確保遠(yuǎn)、近骨折端必須至少各用3～4枚螺絲釘固定。髓內(nèi)釘組選擇匈牙利產(chǎn)索娜盟托肱骨順行交鎖髓內(nèi)釘，主釘近端弧度11°～13°，近端3個(gè)鎖孔，遠(yuǎn)端2個(gè)鎖孔，實(shí)現(xiàn)交鎖。采用順行方式置入。順行帶鎖髓內(nèi)釘?shù)倪M(jìn)釘入點(diǎn)在前后位像上緊靠大結(jié)節(jié)內(nèi)側(cè)的溝內(nèi)，在側(cè)位像上正在肱骨干的中軸線上。

三、術(shù)后處理

1.運(yùn)動(dòng)康復(fù): 術(shù)后頸腕吊帶制動(dòng)。從術(shù)后即開始非負(fù)重的主、被動(dòng)功能鍛煉，包括鐘擺樣運(yùn)動(dòng)和前屈、外展、外旋、內(nèi)收、內(nèi)旋練習(xí)。X線片示骨折愈合前避免患肢負(fù)重。

2.術(shù)后隨訪及評(píng)價(jià)標(biāo)準(zhǔn):所有患者術(shù)后進(jìn)行常規(guī)隨訪，項(xiàng)目包括： (1) X線片檢查； (2) 對(duì)肩關(guān)節(jié)的癥狀和功能評(píng)估采用HSS、JOA評(píng)分。肩關(guān)節(jié)的疼痛評(píng)估采用視覺(jué)模擬量表VAS。運(yùn)動(dòng)范圍的測(cè)量使用測(cè)角計(jì)，見(jiàn)表1。

四、統(tǒng)計(jì)學(xué)處理

應(yīng)用PASW Statistics 18.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析，采用Mann-Whitney秩和檢驗(yàn)判斷鋼板組與髓內(nèi)釘組的運(yùn)動(dòng)范圍，HSS、JOA和VAS評(píng)分是否存在差異，P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

鋼板組平均隨訪7.3年(1～11年)，髓內(nèi)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(shí)間平均13.1周(8～24周)。兩組隨訪及統(tǒng)計(jì)學(xué)分析結(jié)果見(jiàn)表1。鋼板組與髓內(nèi)釘組之間在肩關(guān)節(jié)功能評(píng)分、疼痛、運(yùn)動(dòng)范圍方面的參數(shù)經(jīng)統(tǒng)計(jì)學(xué)分析證明差異無(wú)統(tǒng)計(jì)學(xué)意義。

表1 術(shù)后肩關(guān)節(jié)功能和療效評(píng)定±s)

討 論

McCormack等[6]采用ASES評(píng)價(jià)標(biāo)準(zhǔn)對(duì)鋼板固定和髓內(nèi)釘固定的兩組患者的肩關(guān)節(jié)功能進(jìn)行統(tǒng)計(jì)學(xué)分析，結(jié)果表明差異無(wú)統(tǒng)計(jì)學(xué)意義。這與本組結(jié)果一致。肱骨骨折的治療目標(biāo)之一是獲得最大限度的上肢功能。特別是肩關(guān)節(jié)功能。綜合文獻(xiàn)報(bào)道，大多數(shù)學(xué)者認(rèn)為順行髓內(nèi)釘引起的肩關(guān)節(jié)功能問(wèn)題要高于鋼板固定[7-10]，且主要原因在于髓內(nèi)釘干擾和損害了肩袖的正常結(jié)構(gòu)和功能[4]。以上文獻(xiàn)所涉及的有些問(wèn)題在本組患者中也有發(fā)生。探討這兩種內(nèi)固定技術(shù)對(duì)肩關(guān)節(jié)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(guān)節(jié)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(zhuǎn)的傳送帶將上肢卷入機(jī)器內(nèi)致傷。第2例為壓面機(jī)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(guān)節(jié)以及軟組織的廣泛損傷。第3例為投擲骨折?；颊咴谕稊S手榴彈過(guò)程中，當(dāng)肩關(guān)節(jié)由外展、外旋狀態(tài)急速轉(zhuǎn)變?yōu)閮?nèi)收、內(nèi)旋狀態(tài)時(shí)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(yùn)動(dòng)的合力減弱，使肱骨頭依附關(guān)節(jié)盂的力量下降，使盂肱關(guān)節(jié)易發(fā)生滑脫和松動(dòng)而造成不穩(wěn)定。

2.手術(shù)本身對(duì)肩關(guān)節(jié)功能的影響：對(duì)發(fā)生于胸大肌腱止點(diǎn)和三角肌止點(diǎn)附近的骨折，無(wú)論在顯露、復(fù)位，還是放置鋼板過(guò)程中都難以避免對(duì)胸大肌或三角肌產(chǎn)生干擾和損傷，從而影響到術(shù)后肩關(guān)節(jié)的內(nèi)收，內(nèi)旋、外展、前屈和后伸功能。

二、髓內(nèi)釘?shù)挠绊懸蛩?/p>

1.醫(yī)源性因素: 本組有2例因釘尾未完全埋入肱骨頭的關(guān)節(jié)面，使釘尾端撞擊肩峰下，引起肩關(guān)節(jié)功能受損。其中1例術(shù)后1年取出髓內(nèi)釘后關(guān)節(jié)功能恢復(fù)正常。許多學(xué)者認(rèn)為肩袖撞擊是影響肩關(guān)節(jié)功能的重要因素[4]。造成肩袖損傷的因素有: (1)進(jìn)釘入點(diǎn)顯露過(guò)程中，忽視保護(hù)肩袖，通過(guò)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(shù)中要全層縫合肩袖。 (2)在擴(kuò)髓過(guò)程中，特別是在使用近端擴(kuò)髓器時(shí)直接損傷肩袖。(3)釘尾未完全埋入肱骨頭的關(guān)節(jié)面，使釘尾端撞擊肩峰下或肩袖而引起肩關(guān)節(jié)功能受損。 (4)進(jìn)釘點(diǎn)位置有誤差，導(dǎo)致髓內(nèi)釘打入方向偏離中軸線及擴(kuò)髓時(shí)使用暴力等，造成骨劈裂和關(guān)節(jié)軟骨面損傷。本組發(fā)生1例。推薦使用順行弧形髓內(nèi)釘，避免使用順行直釘。其他醫(yī)源性因素包括:肩峰下滑囊炎、肩鎖關(guān)節(jié)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(nèi)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(píng)分方面相比較，髓內(nèi)釘組均低于鋼板組。這與文獻(xiàn)報(bào)道一致[7]。顯示年齡>50歲的患者肩關(guān)節(jié)功能評(píng)分較低。這可能與下列因素有關(guān): (1)受傷前就存在肩袖結(jié)構(gòu)和功能的退行性改變；(2)手術(shù)創(chuàng)傷的影響；(3)術(shù)后主動(dòng)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?yàn)樗?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(huì)影響肩關(guān)節(jié)功能。老年患者應(yīng)慎重選擇手術(shù)治療。

肱骨干骨折術(shù)后肩關(guān)節(jié)功能損害的原因有待于進(jìn)一步研究。順行髓內(nèi)釘固定應(yīng)提高手術(shù)操作技巧。應(yīng)重視患肢功能的早期康復(fù)治療(特別是50歲以上患者)。進(jìn)一步對(duì)兩種內(nèi)固定技術(shù)進(jìn)行大樣本量的隨機(jī)對(duì)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(nèi)固定技術(shù)對(duì)肩關(guān)節(jié)功能影響的中長(zhǎng)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(guān)節(jié)退行性疾病治療關(guān)鍵技術(shù)推廣(Z131100002613002)

100144北京大學(xué)首鋼醫(yī)院骨科

栗劍，Email：shougangguke@163.com

2014-07-21)