周啟榮 曹烈虎 翁蔚宗 陳曉 張軍 汪林 王堯 蘇佳燦

·論著·

交鎖髓內(nèi)釘與鎖定鋼板治療肱骨近端骨折的臨床對(duì)比研究

周啟榮 曹烈虎 翁蔚宗 陳曉 張軍 汪林 王堯 蘇佳燦

目的探討交鎖髓內(nèi)釘與鎖定鋼板治療肱骨近端骨折的療效對(duì)比。方法將2015年5月至10月第二軍醫(yī)大學(xué)附屬長(zhǎng)海醫(yī)院創(chuàng)傷骨科收治的51例肱骨近端骨折患者按手術(shù)方式分為髓內(nèi)釘組（n=25）及鎖定鋼板組（n=26）。記錄患者平均手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、骨折愈合時(shí)間、術(shù)后并發(fā)癥的發(fā)生情況，采用肩關(guān)節(jié)Neer評(píng)分法和美國(guó)肩與肘協(xié)會(huì)評(píng)分系統(tǒng)（American shoulder elbow surgeons'form，ASES）綜合評(píng)估肩關(guān)節(jié)功能。結(jié)果髓內(nèi)釘組患者各項(xiàng)手術(shù)指標(biāo)顯著優(yōu)于鎖定鋼板組（P＜0.05）。髓內(nèi)釘組術(shù)后并發(fā)癥發(fā)生率為4.00%，鎖定鋼板組術(shù)后并發(fā)癥發(fā)生率為23.08%，髓內(nèi)釘組術(shù)后并發(fā)癥發(fā)生率低于鎖定鋼板組。兩組患者術(shù)后5個(gè)月肩關(guān)節(jié)功能優(yōu)良率分別為96.00%、88.46%，髓內(nèi)釘組肩關(guān)節(jié)功能優(yōu)良率明顯高于鎖定鋼板組（P＜0.05）。結(jié)論交鎖髓內(nèi)釘用于治療肱骨近端骨折，能縮短手術(shù)時(shí)間、住院時(shí)間，減少出血量，在固定骨折穩(wěn)定性方面與鎖定鋼板固定相比并沒(méi)有明顯的差異，在手術(shù)并發(fā)癥方面也較鎖定鋼板固定更具優(yōu)勢(shì)，值得臨床推廣。

肱骨近端骨折； 交鎖髓內(nèi)釘； 鎖定鋼板

肱骨近端骨折占四肢骨折的5%[1］，肱骨近端骨折的發(fā)生率每年在105～342/10 000人。在通常情況下，非移位骨折通常采取保守治療，移位骨折采取手術(shù)治療。在骨質(zhì)疏松的老年人中，由于致傷能量低，通常導(dǎo)致穩(wěn)定或微移位的骨折，大多數(shù)患者通過(guò)保守治療能夠獲得肩關(guān)節(jié)功能的恢復(fù)，只有大約20%的患者需要手術(shù)治療。一般認(rèn)為，頭干位移大于50%的干部直徑、內(nèi)翻或外翻角比正常頭干傾斜角大20°以上的骨折需考慮手術(shù)治療。手術(shù)治療方法包括經(jīng)骨縫合固定術(shù)、經(jīng)皮克氏針固定術(shù)、帶鎖髓內(nèi)釘固定術(shù)、鋼板螺釘固定術(shù)[2］。髓內(nèi)釘內(nèi)固定術(shù)和鎖定鋼板內(nèi)固定術(shù)是臨床應(yīng)用較多的手術(shù)方法，髓內(nèi)釘一般適用于移位較小的涉及干骺端或骨干的三、四部分骨折，切開(kāi)復(fù)位鋼板內(nèi)固定術(shù)的適應(yīng)證是包含大小結(jié)節(jié)或肱骨頭移位的二、三、四部分骨折，一般認(rèn)為切開(kāi)固定能使骨折塊獲得更好的解剖復(fù)位，但手術(shù)并發(fā)癥的發(fā)生率更高。髓內(nèi)釘創(chuàng)傷小，但固定的穩(wěn)定性不如鎖定鋼板。手術(shù)方式的選擇仍存在較大爭(zhēng)議，有研究顯示在治療肱骨近端二部分骨折時(shí)，髓內(nèi)釘明顯優(yōu)于鋼板，且并發(fā)癥的發(fā)生率更低[2］。但另有多中心研究顯示，兩種固定方式經(jīng)長(zhǎng)期隨訪(fǎng)后，在治療效果和并發(fā)癥方面并無(wú)明顯區(qū)別，髓內(nèi)釘固定術(shù)導(dǎo)致醫(yī)源性肩袖損傷需要肩關(guān)節(jié)鏡治療的比率更高[3-4］。

所以在肱骨近端骨折的治療中，仍缺少明確的指南或證據(jù)來(lái)指導(dǎo)臨床治療，作為一種相對(duì)常見(jiàn)的骨折類(lèi)型，關(guān)于其治療的隨機(jī)對(duì)照研究卻很少。一部分原因是由于肱骨近端骨折類(lèi)型多變，治療方法多樣，使臨床隨機(jī)對(duì)照研究很難實(shí)施，且各個(gè)研究間常缺乏統(tǒng)一的標(biāo)準(zhǔn)和準(zhǔn)則，使相互間結(jié)果對(duì)比異常困難[4-5］。為了給臨床治療肱骨近端骨折提供一定的參考，針對(duì)以上問(wèn)題，本院對(duì)2015年5月至10月收治的51例肱骨近端骨折的患者分別進(jìn)行了鎖定鋼板內(nèi)固定和髓內(nèi)釘固定，并對(duì)這兩種固定方式進(jìn)行研究和對(duì)比，現(xiàn)將治療結(jié)果報(bào)道如下。

資料與方法

一、一般資料

選擇2015年5月至10月收治的51例肱骨近端骨折患者進(jìn)行研究，患者骨折類(lèi)型按肱骨近端骨折Neer分型分為二部分骨折30例，三部分骨折21例。按手術(shù)方式分為髓內(nèi)釘組和鎖定鋼板組。髓內(nèi)釘組患者共25例，其中男12例，女13例；年齡35～67歲，平均（46.46±5.78）歲；鎖定鋼板組患者共26例，其中男15例，女11例；年齡30～65歲，平均（43.45±6.34）歲。兩組患者在年齡、性別及骨折分型上差異無(wú)統(tǒng)計(jì)學(xué)意義（P＞0.05）。手術(shù)均由接受過(guò)專(zhuān)業(yè)肩肘外科訓(xùn)練的副主任醫(yī)師配合主治醫(yī)師完成。

二、納入及排除標(biāo)準(zhǔn)

1.納入標(biāo)準(zhǔn)：（1）年齡大于18歲，無(wú)嚴(yán)重合并癥；（2）符合Neer骨折分型的二、三部分骨折；（3）無(wú)明顯血管、神經(jīng)損傷；（4）在入院后1～4 d接受手術(shù)，術(shù)后無(wú)嚴(yán)重并發(fā)癥。

2.排除標(biāo)準(zhǔn)：（1）年齡小于18歲；（2）嚴(yán)重的血管神經(jīng)損傷；（3）嚴(yán)重多發(fā)傷；（4）術(shù)后出現(xiàn)嚴(yán)重并發(fā)癥。

三、治療方法

1.髓內(nèi)釘組：采用臂叢麻醉或全身麻醉，在肩峰前外側(cè)面做斜行切口，在三角肌的前、中1/3交界處沿肌纖維走形劈開(kāi)三角肌，保護(hù)腋神經(jīng)，劈開(kāi)三角肌不能超過(guò)肩峰遠(yuǎn)端5 cm，順纖維切開(kāi)肩袖。在擴(kuò)髓時(shí)使用全層縫合保護(hù)肩袖免受損害。牽拉復(fù)位后，透視下插入導(dǎo)針至適當(dāng)位置，連續(xù)擴(kuò)髓后，將髓內(nèi)釘插入骨髓腔，確保釘尾埋入肱骨頭的關(guān)節(jié)面，利用外裝設(shè)備從前側(cè)擰入近端、遠(yuǎn)端鎖釘。直視下全層縫合修復(fù)肩袖。透視確認(rèn)復(fù)位情況和螺釘?shù)奈恢眉伴L(zhǎng)度。術(shù)后行早期肩關(guān)節(jié)功能鍛煉。

2.鎖定鋼板組：采用臂叢麻醉或全身麻醉，胸三角入路暴露近端肱骨，剝離三角肌暴露骨折部位，復(fù)位后克氏針臨時(shí)固定，透視復(fù)位確定復(fù)位情況后，鋼板置于大結(jié)節(jié)上，臨時(shí)用克氏針固定，透視確定鋼板位置正確，先擰入鎖定釘固定肱骨頭，1～2枚固定肱骨干，透視確定螺釘在軟骨下位置和復(fù)位質(zhì)量，確認(rèn)復(fù)位后，透視下擰入固定螺釘。術(shù)后行早期肩關(guān)節(jié)功能鍛煉。

四、評(píng)價(jià)標(biāo)準(zhǔn)

分別記錄兩組患者手術(shù)指標(biāo)，包括平均手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、骨折愈合時(shí)間、隨訪(fǎng)術(shù)后并發(fā)癥的發(fā)生情況。

采用美國(guó)肩與肘協(xié)會(huì)評(píng)分系統(tǒng)（American shoulder elbow surgeons'form，ASES）綜合評(píng)估肩關(guān)節(jié)功能。優(yōu)：復(fù)位滿(mǎn)意，骨折無(wú)畸形愈合，肩關(guān)節(jié)外展及肘關(guān)節(jié)屈伸運(yùn)動(dòng)無(wú)受限，正常臂力，上肢功能恢復(fù)，無(wú)疼痛；良：復(fù)位滿(mǎn)意，骨折無(wú)畸形愈合，肩關(guān)節(jié)主動(dòng)上舉大于140°，正常臂力，肩周偶有輕微疼痛或成角；一般：復(fù)位基本滿(mǎn)意，關(guān)節(jié)主動(dòng)上舉大于100°，活動(dòng)時(shí)有疼痛，基本正常臂力；差：復(fù)位較差，骨折端移位大于1 cm，成角畸形大于30°，骨折愈合困難，骨不連，內(nèi)固定松動(dòng)、斷裂，患者疼痛明顯而持久，肩肘關(guān)節(jié)功能活動(dòng)明顯受限。

五、統(tǒng)計(jì)學(xué)分析

應(yīng)用SPSS17.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析，計(jì)量資料采用 x-±s表示，組間比較采用t檢驗(yàn)，計(jì)數(shù)資料采用卡方檢驗(yàn)，P ＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

一、手術(shù)指標(biāo)比較

兩組患者的平均手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間及骨折愈合時(shí)間見(jiàn)表1。髓內(nèi)釘組患者各項(xiàng)手術(shù)指標(biāo)顯著優(yōu)于鎖定鋼板組（P ＜0.05）。

二、術(shù)后并發(fā)癥發(fā)生情況比較

術(shù)后對(duì)兩組患者進(jìn)行隨訪(fǎng)，隨訪(fǎng)時(shí)間為術(shù)后5個(gè)月，髓內(nèi)釘組術(shù)后并發(fā)癥發(fā)生率為4.00%，鎖定鋼板組術(shù)后并發(fā)癥發(fā)生率為23.08%，髓內(nèi)釘組術(shù)后并發(fā)癥發(fā)生率低于鎖定鋼板組，見(jiàn)表2。

表2 兩組患者術(shù)后并發(fā)癥的比較[例（%）］

三、肩關(guān)節(jié)功能恢復(fù)情況比較

兩組術(shù)后5個(gè)月肩關(guān)節(jié)功能優(yōu)良率分別為96.00%、88.46%，髓內(nèi)釘組肩關(guān)節(jié)功能優(yōu)良率明顯高于鎖定鋼板組（P ＜0.05），見(jiàn)表3。

四、影像學(xué)觀察對(duì)比

如圖1，從影響學(xué)圖片中可以看出，髓內(nèi)釘和鎖定鋼板對(duì)肱骨近端骨折都能進(jìn)行良好的固定，術(shù)后3個(gè)月時(shí)觀察，兩種固定方式都實(shí)現(xiàn)了良好的愈合。

表1 兩組患者手術(shù)指標(biāo)比較（± s）

表1 兩組患者手術(shù)指標(biāo)比較（± s）

組別 例數(shù) 手術(shù)時(shí)間（min） 術(shù)中出血量（ml） 住院時(shí)間（d） 骨折愈合時(shí)間（d）髓內(nèi)釘組 25 69.20±7.30 99.20±9.30 7.50±1.20 105.00±13.00鎖定鋼板組 26 96.50±12.10 137.30±17.80 13.30±4.60 146.00±21.00t值 3.261 8.733 7.358 7.312P值 0.011 0.024 0.018 0.015

表3 兩組患者肩關(guān)節(jié)功能恢復(fù)情況比較[例（%）］

圖1 兩組患者術(shù)前及術(shù)后3個(gè)月愈合情況對(duì)比 圖A為髓內(nèi)釘固定術(shù)前；圖B為髓內(nèi)釘固定術(shù)后；圖C為鎖定鋼板固定術(shù)前；圖D為鎖定鋼板固定術(shù)后

討 論

肱骨近端骨折手術(shù)治療的方法眾多，因而要選擇恰當(dāng)?shù)氖中g(shù)治療方法往往比較困難，臨床根據(jù)各種情況，應(yīng)用較多的是切開(kāi)復(fù)位鎖定鋼板內(nèi)固定和交鎖髓內(nèi)釘固定，兩種固定方法都各有優(yōu)缺點(diǎn)。切開(kāi)復(fù)位鎖定鋼板內(nèi)固定可更好地對(duì)骨折塊進(jìn)行操作，因此各種類(lèi)型的肱骨近端骨折都可用鎖定鋼板進(jìn)行固定，由于肱骨頭固定較差而導(dǎo)致畸形愈合或不愈合等并發(fā)癥較多，此外，廣泛的軟組織剝離增加了肱骨頭壞死的可能，并導(dǎo)致肩關(guān)節(jié)疼痛及功能受限。一個(gè)多中心研究顯示，在12個(gè)月的觀察期內(nèi)，155例患者中，有52例發(fā)生了并發(fā)癥，其中28例是由于拙劣的手術(shù)技術(shù)造成的[6］。另一項(xiàng)包含154例患者的回顧性分析中描述并發(fā)癥發(fā)生率為48.8%，其中包含了13.8%的正畸率[7］。在本研究中，鎖定鋼板固定較髓內(nèi)釘固定出現(xiàn)了更多的并發(fā)癥，由于放置鋼板需更多的暴露和剝離，更長(zhǎng)的切口，所以在神經(jīng)損傷和切口感染方面鋼板較髓內(nèi)釘有更高的發(fā)生率。

在固定的穩(wěn)定性方面仍存在爭(zhēng)議，Kitson等[8］進(jìn)行的尸體研究發(fā)現(xiàn)，髓內(nèi)釘較鋼板在外翻、前屈和后伸三個(gè)方面穩(wěn)定性更好;而Sanders[9］學(xué)者根據(jù)自己的研究結(jié)果認(rèn)為，鋼板在外翻負(fù)荷下更加堅(jiān)強(qiáng)，其他的負(fù)荷矢量上則無(wú)區(qū)別。在本研究中，全部病例在5個(gè)月的隨訪(fǎng)觀察中，均未出現(xiàn)內(nèi)固定失效的情況，進(jìn)一步的固定效果仍需更長(zhǎng)時(shí)間的觀察。

在手術(shù)操作過(guò)程中肩袖損傷是髓內(nèi)釘固定時(shí)容易出現(xiàn)的問(wèn)題，會(huì)導(dǎo)致術(shù)后的肩關(guān)節(jié)疼痛，影響治療效果，但髓內(nèi)釘術(shù)后產(chǎn)生的肩關(guān)節(jié)疼痛比鋼板固定嚴(yán)重仍存爭(zhēng)議[9］。朱等學(xué)者發(fā)現(xiàn)，在治療肱骨近端二部分骨折時(shí)，髓內(nèi)釘在固定骨折方面能提供與鋼板相同的穩(wěn)定性，3年的隨訪(fǎng)發(fā)現(xiàn)，兩種固定方式術(shù)后的疼痛、肩關(guān)節(jié)運(yùn)動(dòng)并無(wú)明顯不同，鋼板固定術(shù)中的失血量更多，髓內(nèi)釘?shù)男g(shù)后并發(fā)癥發(fā)生率也更低[10-11］。另一個(gè)納入152例患者的配對(duì)多中心研究中，對(duì)二、三、四部分骨折的病例分別進(jìn)行順行和側(cè)滑穩(wěn)定的近端交鎖髓內(nèi)釘固定和鋼板固定，經(jīng)過(guò)1年的隨訪(fǎng)后，發(fā)現(xiàn)二者的功能評(píng)分相同，穩(wěn)定交鎖髓內(nèi)釘固定術(shù)與鋼板固定術(shù)相比具有相同的并發(fā)癥發(fā)生率，且髓內(nèi)釘固定術(shù)導(dǎo)致醫(yī)源性肩袖損傷需要肩關(guān)節(jié)鏡治療的比率更高[12］。在本研究中，髓內(nèi)釘固定組有1例出現(xiàn)早期肩關(guān)節(jié)疼痛，隨著隨訪(fǎng)的時(shí)間延長(zhǎng)，疼痛消失，且兩組在肩關(guān)節(jié)功能評(píng)分方面并沒(méi)有明顯的差異。中期回顧中還未發(fā)現(xiàn)畸形愈合的病例，證明兩種固定方式在固定的穩(wěn)定性方面并無(wú)明顯差異，但是髓內(nèi)釘固定在手術(shù)時(shí)間、出血量、住院時(shí)間方面都具有明顯的優(yōu)勢(shì)，手術(shù)過(guò)程中，鎖定釘從前側(cè)打入，可避免損傷橈神經(jīng)，術(shù)中所需透視的次數(shù)也明顯減少，進(jìn)一步減少手術(shù)時(shí)間，降低了手術(shù)風(fēng)險(xiǎn)。但同時(shí)Lundy等[13］學(xué)者研究發(fā)現(xiàn)，髓內(nèi)釘置釘點(diǎn)不正確，骨折累及置釘點(diǎn)或延伸至外側(cè)干骺端的復(fù)雜骨折，都會(huì)影響髓內(nèi)釘固定的效果。所以，髓內(nèi)釘固定手術(shù)應(yīng)由經(jīng)驗(yàn)豐富的外科醫(yī)師完成，才能真正體現(xiàn)髓內(nèi)釘治療的優(yōu)勢(shì)，特別是肱骨近端骨折在老年人中發(fā)病率最高。在已經(jīng)步入老齡化社會(huì)的中國(guó)，如何對(duì)此類(lèi)骨折進(jìn)行治療將成為一個(gè)重大的社會(huì)問(wèn)題。隨著老年骨折患者數(shù)量增加和手術(shù)技術(shù)的改進(jìn)，更多的微移位骨折選擇采取手術(shù)治療，所以對(duì)老年患者來(lái)說(shuō)，手術(shù)時(shí)間的長(zhǎng)短、手術(shù)創(chuàng)傷、術(shù)后并發(fā)癥將成為手術(shù)方式選擇的重要方面。

本研究中患者數(shù)量少，為回顧性研究，在一定程度上缺少說(shuō)服力，且為中期隨訪(fǎng)，更進(jìn)一步的結(jié)果還需進(jìn)一步隨訪(fǎng)觀察。

綜上所述，交鎖髓內(nèi)釘用于治療肱骨近端骨折，能縮短手術(shù)時(shí)間、住院時(shí)間，減少出血量，在固定骨折穩(wěn)定性方面與鎖定鋼板固定相比并沒(méi)有明顯的差異，在手術(shù)并發(fā)癥方面較鎖定鋼板固定更具優(yōu)勢(shì)，特別是在老年骨折的手術(shù)處理固定上，將有更廣闊的應(yīng)用，值得臨床推廣。

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A clinical research of interlocking intramedullary nail and locking plate in the treatment of proximal humerus fractures

Zhou Qirong, Cao Liehu, Weng Weizong, Chen Xiao, Zhang Jun, Wang Lin,Wang Yao, Su Jiacan. Department of Orthopaedic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China

Su Jiacan, Email:drsujiacan@163.com

BackgroundProximal humerus fracture accounts for 5% of limb fractures, and the incidence affects 105-342/10 000 people per year. While non-displaced fractures are usually treated conservatively, displaced fractures are treated by surgery. As elderly patients with osteoporosis usually suffer from low energy injury that causes stable or slightly displaced fractures,most of them can obtain the recovery of shoulder joint function with conservative treatment with only about 20% of patients required for surgery. It is generally accepted that surgical treatment should be considered if the displacement of head and shaft is over 50% of shaft diameter, or the angle of varus or valgus is 20° greater than the normal head-shaft angle. Operative treatment methods include transosseous suture fixation, Kirschner wire fixation, intramedullary nail fixation and locking plate fixation. Intramedullary nail fixation and locking plate fixation are more applicable clinically.Intramedullary nailing is indicated for minimally displaced Part-3 and Part-4 fractures that involve humeral metaphyseal or shaft, while open reduction and interal plate fixation is indicated for Part-2,Part-3 and Part-4 fractures that involve greater and lesser tuberosity or humeral head. It is widely accepted that better anatomic reduction can be obtained by open fixation, but the rate of operative complications is higher. Intramedullary nailing is less traumatic, but its fixation stability is inferior to that of locking plate. Thus, the choice of operative methods is still controversial. Studies have shown that intramedullary nailing is superior to plate and has lower complication rate. However,another multicenter study shows that there is no significant difference in curative effect and the incidence of complications between two methods after long-term follow-ups. Intramedullary nail fixation leads to a higher rate of iatrogenic rotator cuff injury which requires further arthroscopic treatment.Therefore, there is still not enough clear guideline or evidence to guide the clinical treatment of proximal humeral fractures. As a relatively common type of fracture, it is seldomly studied by any randomized controlled study. Since the treatment method varies from multiple fracture types, it is difficult to carry out studies. Furthermore, there is no unified standard or guideline for the comparison of results among groups in various studies. In order to provide certain reference for the clinical treatment of proximal humeral fractures, 51 patients were treated with locking plate or intramedullary nail respectively from May to October in 2015 for study and comparison of these two fixation methods.Methods（1）General Information.From May 2015 to October, 51 patients with proximal humeral fractures were treated. According to the Neer classification, 30 cases of Part-2 fracture and 31 cases of Part-3 fracture were included. Patients were divided into two groups based on operative methods. 25 cases belonged to the intramedullary nailing group, including 12 males and 13 females; the age ranged from 35 to 67 years with an average of （46.46±5.78） years. 26 cases belonged to the locking plate group, including 15 males and 11 females; the age ranged from 30 to 65 years with an average of （43.45±6.34） years.There was no statistical difference in age, gender and fracture classification between two groups （P＞0.05）. The operation was performed by the deputy chief physician trained for professional shoulder and elbow surgery with the cooperation of the attending physician.（2）Inclusive and exclusive criteria.Inclusion criteria: ①age over 18 years without server complication;②Part-2 or Part-3 fracture based on Neer classification; ③ no obvious neurovascular injury; ④ operation performed 1-4 days after admission and no serious postoperative complications.Exclusion criteria:①age less than 18 years;② severe neurovascular injuries; ③ severe multiple injuries; ④ severe postoperative complications.（3）Treatment methods.Intramedullary nail group: after brachial plexus block or general anesthesia, an oblique incision was made on the anterolateral side of acromion. With the protection of axillary nerve, the deltoid muscle was split along muscle fibers at the 1/3 junction of anterior and middle parts of deltoid muscle. The splitting of deltoid muscle should not exceed the distal of acromion for more than 5 cm, and the rotator cuff was cut open along fibers. Full thickness suture was used to protect rotator cuff from damage during medullar cavity reaming. After traction reduction, the guide pin was inserted into the appropriate position of marrow cavity. After continuous reaming, the intramedullary nail was screwed in until the tail has been embedded under the articular surface of humeral head. Then, the proximal and distal locking screws were inserted from the front side with the help of external equipment. The rotator cuff was repaired with full-thickness suture under direct vision. Fluoroscopy was used to confirmed reduction and the position and length of screws. Early shoulder joint function exercises were performed postoperatively. Locking plate group:after brachial plexus block or general anesthesia, the proximal humerus was exposed through deltopectoral approach. The fracture ends were made visible by stripping deltoid muscle, and reduction was temporarily fixed with Kirschner wires. After the reduction condition was confirmed by fluoroscopy, the plate was placed on greater tuberosity and temporarily fixed with Kirschner wires. As the plate position was confirmed properly by fluoroscopy, locking screws were inserted into humeral head for fixation. Afterward, 1-2 screws were for humeral shaft fixation. The position of screws in articular cartilage and the quality of reduction were confirmed under fluoroscopy. In the end, the fixation screws were inserted under fluoroscopy. Early shoulder joint function exercises were performed after surgery. （4）Evaluation criteria.The operation indexes of two groups were recorded, including average operation duration, intraoperative blood loss, hospitalization time,fracture healing time and postoperative complications.American shoulder and elbow surgeons' form（ASES） was used for shoulder joint function evaluation. Excellent : satisfactory reduction, no fracture malunion, no restriction of shoulder abduction and elbow flexion and extension , normal armwrestle, full recovery of upper limb function , no pain; Good: satisfactory reduction, no fracture malunion,＞140° of active shoulder elevation , normal arm wrestle, mild pain or slight angulation around shoulder ;Poor: poor reduction,＞1 cm of fracture displacement ,＞30° of angular deformity , difficulty of fracture healing , nonunion, loosening and breakage of internal fixator, obvious and lasting pain, obviously limited shoulder and elbow movements.（5）Statistical analysis.The SPSS 17.0 software was used for statistical analysis, and the measurement data was expressed as . The t test was used between the groups, and the chi square test was used for enumeration data. The difference was statistically significant ifP＜0.05.Results（1）Comparison of operative indexes.The mean operation time, intraoperative blood loss, hospitalization and fracture healing time for the intramedullary nail group were significantly better than those for the locking plate group （P＜0.05）. （2）Comparison of postoperative complications.The two groups were followed up for 5 months after surgery. The postoperative complication rate of intramedullary nail group was 4.00%, which was lower than that of locking plate group （23.08%）. （3） Comparison of shoulder function recovery.The good and excellent rates of shoulder function for two groups 5 months after operation were 96% and 88.46% respectively, and the excellent and good rate of shoulder function for intramedullary nail group was significantly higher than that for locking plate group （P＜0.05）.（4）Contrast of imaging observation.As what can be seen from images, proximal humeral fractures can be well fixed with both intramedullary nail and locking plate. After 3 months of observation, two fixation methods have both achieved good healing.ConclusionsInterlocking intramedullary nail for the treatment of proximal humeral fractures can shorten the time of operation and hospitalization and reduce blood loss. There is no obvious difference between two strategies in fixing fracture stability.In terms of surgical complications, the interlocking intramedullary nail has more advantages compared to locking plates. Especially in the treatment of senile fracture fixation, the interlocking intramedullary nail has broader applications and is worth of clinical promotion.

Proximal humeral fracture; Intramedullary nail; Locking plate

2016-10-13）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10.3877/cma.j.issn.2095-5790.2017.02.002

國(guó)家自然國(guó)際合作基金（8141101156）；上海市科委生物醫(yī)藥專(zhuān)項(xiàng)（154119500600）

200433 上海，第二軍醫(yī)大學(xué)附屬長(zhǎng)海醫(yī)院創(chuàng)傷骨科

蘇佳燦，Email:drsujiacan@163.com

周啟榮,曹烈虎,翁蔚宗,等.交鎖髓內(nèi)釘與鎖定鋼板治療肱骨近端骨折的臨床對(duì)比研究[J/CD］.中華肩肘外科電子雜志,2017,5（2）：84-89.