肱骨髓内钉治疗肱骨近端骨折的疗效与体会

王艳华 张晓萌 付中国 陈建海 党育 杨明 张殿英

·论著·

肱骨髓内钉治疗肱骨近端骨折的疗效与体会

王艳华 张晓萌 付中国 陈建海 党育 杨明 张殿英

目的探讨肱骨近端髓内钉治疗有移位肱骨近端骨折（Neer分型二部分、三部分骨折）的疗效。方法回顾性分析2012年10月至2014年12月北京大学人民医院创伤骨科采用髓内钉治疗且获得完整随访的21例肱骨近端骨折患者，其中Neer分型二部分骨折12例，三部分骨折9例。分别记录患者手术时间、术中出血量和手术并发症，采用Constant评分评价肩关节功能。结果随访时间最短7个月，最长37个月，平均随访时间为17.45个月。所有患者骨折均愈合。平均手术时间为71.67 min，术中平均出血量为70.48 ml。末次随访平均肩关节疼痛评分0.52分。骨折平均愈合时间为4.24个月，肩关节活动平均活动范围:前屈135.24°，外展130.24°，内旋33.33°，外旋50.71°。术后平均肩关节Constant-Murley评分为82.48分，其中优2例、良15例、可3例、差1例，优良率为80.95%。1例延迟愈合、1例术后肩痛、1例伤口渗液不愈合。结论采用髓内钉治疗肱骨近端二部分和三部分骨折创伤小、固定牢固、可允许术后早期进行功能锻炼，关节功能恢复好，是治疗肱骨近端骨折的有效手段之一。

骨折； 肱骨近端； 髓内钉； 手术

肱骨近端是指包括肱骨外科颈在内及以上部位的骨折，是临床常见的上肢骨折。无移位的肱骨近端骨折常采取保守治疗，对于有移位的Neer分型二部分、三部分骨折和部分四部分肱骨近端骨折，目前临床上多采用锁定钢板进行固定。但由于锁定钢板固定为偏心、髓外固定，在治疗骨质疏松性骨折以及移位较大的肱骨近端骨折时常出现骨折复位丢失、螺钉切割穿出、肱骨头缺血坏死等并发症[1-2］。同时国内外多篇文献报道髓内钉在治疗肱骨近端骨折时有其自身优势：创伤小、对骨折局部血供影响小、固定牢靠。自2012年，本科尝试采用肱骨近端髓内钉治疗有移位的Neer分型二部分、三部分肱骨近端骨折，疗效满意。本文就髓内钉治疗肱骨近端骨折的疗效和体会总结如下。

资料与方法

一、一般资料

自2012年10月至2014年12月，本科采用肱骨近端髓内钉治疗肱骨近端骨折患者23例，获完整随访21例，男10例，女11例；年龄41～78岁，平均年龄56岁。术前行X线及三维CT扫描及重建评估伤情。按Neer分类法分类：二部分骨折12例，三部分骨折9例。其中伴肩关节脱位1例，肩袖撕裂2例。

二、手术方法

患者全麻后取沙滩椅位，常规碘酒、酒精消毒术区并铺巾，充分暴露患侧肩部，于肩峰前角行长3～4 cm切口，沿肩峰前角经三角肌前中部间隙乏血管区纵向分离三角肌，分离肩峰及三角肌下滑囊显露肩袖，同时切开胸锁筋膜，沿肌纤维走行方向劈开肩袖。显露肱二头肌肌腱后方的肱骨近端，术中注意保护肱二头肌腱及腋神经。术中使用Synthes公司的Multiloc肱骨近端髓内钉和Smith&Nephew公司的Trigen髓内钉对骨折进行固定。在透视引导下行手法及克氏针撬拨复位，Trigen髓内钉选择结节间沟后方肱骨头和大结节交界处为进针点，Multiloc髓内钉进针点选择在肱二头肌腱（结节间沟）后方、冈上肌腱附着点近侧1～1.5 cm处的肱骨头顶点，置入定位针后须在透视下确定位于肱骨干正侧位片的解剖轴线上，如果位置不良，必需进行调整。确认进针点后开髓并置入合适髓内钉，尽量使主钉尾端没入骨质内，经瞄准器进行近端和远端锁定,近端3～4枚,远端2枚。取出打拔器及瞄准器,安装尾帽，仔细缝合肩袖和三角肌，缝合包扎伤口。

三、术后处理

术前0.5 h开始应用抗生素至术后24 h。术后前臂吊带固定保护患肢，术后2～3 d进行患肩钟摆样运动，7～10 d视患者情况进行患肩被动活动，包括被动屈伸、外展、内外旋转活动。术后8周复查X线片见骨痂愈合后进行屈伸、旋转、外展上举等主动活动锻炼。术后12～16周复查见骨折愈合后开始行肩部力量锻炼。

四、观察指标

观察指标包括手术时间、术中出血量。定期对所有患者进行随访，随访内容包括肩关节视觉模拟评分（visual analog scale，VAS）、骨折愈合时间、肩关节活动范围、术后并发症。优良率采用Constant-Murley肩关节功能评分，总分为100分，疼痛15分，日常生活能力20分，活动度40分，三角肌力量25分，90～100分为优秀，80～89分为良，70～79分为可，70分以下为差。内翻畸形愈合标准为颈干角 ＜120°。

结 果

21例患者获得完整随访，随访时间最短7个月，最长37个月，平均随访时间为17.45个月。所有患者骨折均愈合，平均手术时间为71.67 min（50～132 min），术中平均出血量为70.48 ml（40～150 ml）。末次随访平均肩关节VAS评分0.52分（0～5）分、肩关节活动平均活动范围:前屈135.24°（70～180°），外展 130.24°（90～170°），内旋 33.33°（15～60°），外旋 50.71°（30～75°）。骨折平均愈合时间为 4.24个月（3～7个月），按照Constant-Murley肩关节功能评分标准，优2例、良15例、可3例、差1例，优良率为80.95%，术后平均肩关节Constant-Murley评分为82.48分（62～91）分。无骨折不愈合，无腋神经和桡神经损伤，随访中未发现肱骨头坏死，无退钉和螺钉松动。

1例患者发生皮下感染，伤口不愈合，予以反复换药伤口不愈合，术后3个月复查见骨折愈合后，行内固定去除加清创术，术后3周伤口愈合。1例患者术后5个月出现髓内钉大结节区骨质吸收，螺钉尾部外露，致肩袖损伤肩关节疼痛，予以抗炎止痛、热敷理疗等保守治疗3个月，肩痛症状缓解不明显，复查X线片见骨折愈合于术后11个月将髓内钉取出，肩痛症状消失。1例二部分骨折患者出现延迟愈合，经过吊带固定后于术后7个月愈合。

讨 论

肱骨近端骨折多由于暴力所致，常见于骨质疏松的老年人和暴力损伤后的年轻人。有移位的肱骨近端骨折手术治疗的目的是争取骨折理想复位，保护血运，坚强固定，早期进行功能锻炼。最常用的手术方法是钢板螺钉固定和髓内钉固定。但到底采用哪种治疗方式效果最佳，目前尚无共识。在本研究中发现，采用新型髓内钉治疗有移位的Neer分型肱骨近端骨折手术切口小、术中出血少、固定牢靠、术后Constant-Murley评分82.48分，优良率为80.95%，疗效确切。

肱骨近端骨折治疗的关键是骨折理想复位，尤其是大、小结节及肱骨头下内侧皮质骨折的复位和固定。对于移位型肱骨近端骨折，只有对骨折进行解剖复位和坚强固定，才可以使骨折患者早期开展功能锻炼，从而获得最佳的功能恢复。本研究中，患者术后最后一次随访X线片发现大、小结节骨性愈合，术后颈干角125～135°，未发现复位丢失。这提示髓内钉治疗肱骨近端骨折复位满意，固定牢固。关于复位，Stefaan等[3］认为肱骨近端“解剖”复位的标准包括：①关节内的骨折移位完全纠正；②肱骨头既不内翻也不外翻；③肱骨头相对肱骨干的前倾角或后倾角小于20°；④任何方向上大、小结节骨折块的移位均 ＜3 mm；⑤肱骨头和肱骨干之间的移位 ＜5 mm。如果大结节因复位不良而畸形愈合，将导致术后肩峰撞击和肩袖撕裂。而如果大结节骨折愈合良好，即使术后发生肱骨头坏死。患者仍能保留一定的肩关节活动范围。因此应重视骨折尤其是大结节的解剖复位与固定。本文21例髓内钉固定患者大结节无畸形愈合。这与新型髓内钉重视大结节骨折固定的设计有关，Trigen髓内钉近端螺钉4枚：3枚螺钉分别由后向前和由外向内固定大结节骨折块，1枚由前向后固定小结节骨折块，四个层面的固定增加了固定的稳固性。而Multiloc肱骨近端髓内钉的近端螺钉预留有缝线孔，便于术中根据需要利用缝线固定大结节，以减少肩袖的张力、增加固定的稳定性[4］。此外在复位过程中应重视肱骨头下内侧皮质的复位与重建，肱骨头下内侧皮质在维持骨折复位中具有重要意义[5］,尤其是对于骨质疏松患者，如果术中内侧皮质复位不良，将导致肱骨头关节受到轴向压力时塌陷及螺钉切割穿出关节面、肱骨头高度丢失及内翻畸形。因此如果内侧皮质缺损严重，应考虑植骨重建。在对肱骨颈下内侧皮质固定支撑方面，Multiloc较Trigen有优势，该钉设计有斜向内上方的骨矩螺钉，该螺钉对肱骨骨矩的固定可明显增加髓内钉的轴向稳定性，为防止肱骨头术后发生内翻移位，还增加了“钉中钉”设计，进一步固定头部骨折块并防止螺钉的退钉和穿出[3,6］。

肩袖损伤是髓内钉广为诟病的缺点之一。由于髓内钉进钉点多位于肱骨头和大结节的交界处，此处进钉可造成肩袖损伤及足印区骨缺损或大结节骨折块的分离，一旦损伤后很难再修复，从而残留术后肩关节疼痛和外展上举困难。但随着新一代髓内钉的出现，髓内钉的外形由曲型变为直型。直型髓内钉的进针点内移到肱骨头的最高点。通过沿肌纤维劈开冈上肌肌腱可有效避免入钉点损伤足印区腱骨结合部，从而减少对肩袖的损伤。但从应用的经验来看，不论4°外展曲度的Trigen髓内钉，还是直钉Multiloc，只要术中谨慎剥离并及时缝合修复，二者术后功能并无太大差异。本文21例患者通过闭合复位或有限切开对骨折进行复位，避免了损坏肩袖及肱骨头的血供，尤其是避免了术中损伤旋肱后动脉，而旋肱后动脉提供肱骨头64%的血供，旋肱前动脉提供其余36%的血供[7］。

近端螺钉松动退钉也是髓内钉治疗肱骨近端骨折常见并发症，固定大结节的螺钉由于退钉可导致肩峰撞击、大结节骨折固定失效或畸形愈合，进而引起术后肩关节疼痛僵硬和骨折不愈合。本组病例有1例出现近端螺钉撞击肩峰而导致肩关节疼痛伴功能受限。考虑原因为固定大结节的螺钉拧入过浅所致。为了避免上述情况发生，在固定大结节时尽量将螺钉拧入皮质下，避免外留钉尾，术中应仔细活动肩关节，确认无撞击后方可关闭创口。选用的新一代髓内钉设计更合理，Trigen近端锁定孔衬有带螺纹的聚乙烯内衬，可实现螺钉和髓内钉之间的锁定，有效地防止退钉情况的出现，而髓内钉近端几何形态增强了其在髓腔内的旋转稳定性。Multiloc则是螺钉和髓内钉之间实现双皮质锁定。

有文献报道髓内钉治疗肱骨近端骨折术后可导致肩关节功能障碍。这主要由于长期的固定以及钉尾对肩峰下组织的撞击导致肩峰下滑囊分泌液体增多,引起组织纤维化,使肩袖的肌腱群、关节囊、韧带相互粘连,从而发生肩关节功能障碍[8-9］。因此在髓内钉置入时，应尽可能将主钉钉尾埋入关节面以下，避免影响肩峰下间隙。同时应重视肩关节术后的功能康复锻炼。此外，本文中有1例患者出现伤口感染，二次清创将局部组织送检未检出细菌，彻底清创并将固定大结节的缝线拆除后伤口愈合。考虑可能是机体对缝线的排异反应所致。

采用肱骨近端髓内钉治疗有移位的、不稳定的肱骨近端骨折，多位学者报道疗效满意[10-12］。认为髓内钉可提供足够的稳定性以允许患者早期活动，即使较复杂的骨折也可以应用髓内钉治疗。Hessmann等[13］认为，肱骨近端髓内钉的适应证是：Neer分型的二、三和四部分骨折；肱骨近端骨折合并肱骨干的节段性骨折；延伸到干部的肱骨近端骨折。禁忌证为肱骨头劈裂骨折合并肱骨近端外科颈骨折的肱骨近端骨折。Kloub等[14］报道髓内钉治疗四部分骨折肱骨头坏死率高。俞银贤等[15］认为对于四部分骨折，尽量不采用髓内钉治疗，因为四部分骨折复位困难，难以做到闭合复位，如果扩大切口，对软组织损伤和肱骨近端血供的破坏较大，可能失去了髓内钉微创治疗的意义，而且由于内、外侧支撑均破坏，很容易造成术后的复位丢失。作者比较认同Cuny等[16］的观点，即对于Neer分型的二、三部分骨折和外翻崁插四部分骨折可尝试采用髓内钉进行固定，但对于有移位的关节内骨折尽量避免使用髓内钉。此外髓内钉治疗肱骨近端骨折需要一定的学习曲线，因此在早期开展这项技术时，应尽量选择肱骨近端二部分骨折，当逐渐熟练掌握了该项技术时，可以扩大到部分三部分骨折[15］。因为，对于二部分骨折，若髓内钉进针点选择合适，一般闭合复位都较容易[17］。总之从本文21例患者的应用体会来看，对于Neer分型二、三部分骨折，肱骨近端髓内钉创伤小、固定牢固、可允许术后早期进行功能锻炼、疗效确切，是肱骨近端骨折的有效治疗手段之一。

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Curative effect observation and application experience of intramedullary nailing for displaced proximal humeral fractures

Wang Yanhua, Zhang Xiaomeng, Fu Zhongguo, Chen Jianhai, Dang Yu,Yang Ming, Zhang Dianying. Department of Trauma and Orthopeadics, Peking University People's Hospital, Peking University, Traffic Medicine Center,Beijing 100044,China

Zhang Dianying, Email:zdy8016@163.com.

BackgroundProximal humeral fractures refer to the fractures involving neck and above, which is a common upper limb fracture clinically. Non-displaced proximal humeral fractures are often treated conservatively. Currently, the locking plate fixation is often used for displaced 2-Part, 3-Part and some of the 4-Part proximal humeral fractures of Neer classification.Since locking plate fixation is eccentric and belong to the extramedullary fixation, complications such as fracture reduction loss, screw cutting out and ischemic necrosis of humeral head often appear in the treatment of osteoporotic fractures and proximal humeral fractures with large displacement. Meanwhile, several domestic and foreign literatures reported that the intramedullary nailing has its own advantages in the treatment of proximal humeral fractures including minimally invasive, small impact on the local blood supply of fractures and reliable fixation. This article summarized the curative effect and experiences of treating proximal humerus fractures with intramedullary nail.Methods（1） General data. From October 2012 to December 2014, 23 cases of proximal humerus fractures were treated with proximal humeral nail in our department. 21 cases were followed up, including 10 males and 11 females. The age ranged from 41 to 78 years with anaverage of 56 years. X-ray and 3D CT scan & reconstruction were performed preoperatively for severity evaluation. According to the Neer classification, 12 cases of 2-Part fractures and 9 cases of 3-Part fractures were involved, including 1 case of combined shoulder joint dislocation and 2 cases of combined rotator cuff injury. The Multiloc proximal humeral intramedullary nail of Synthes company and the Trigen intramedullary nail of Smith&Nephew Co Ltd. were used intraoperatively for fracture fixation. （2） Operative methods. After successful general anesthesia, the patient was put into beach chair position. Then, the operative area was routinely disinfected with iodine and alcohol and draped. The affected shoulder joint was fully exposed, and a 3-4 cm incision was made along the anterior angle of acromion. The deltoid muscle was separated through the gap between the anterior and middle parts of deltoid muscle which was vascular insufficient. The deltoid muscle, acromion and deltoid bursa were then split to expose rotator cuff. Meanwhile, the costocoracoid membrane was cut open. After the rotator cuff was split along the muscle fibers, the proximal part of humerus behind the biceps tendon was revealed. The biceps tendon and axillary nerve were protected during the operation. Manual reduction and poking reduction with Kirschner wire were guided under fluoroscopy. The junction between humeral head and greater tuberosity at the back of intertubercular sulcus was selected as the entry point of Trigen nail. The vertex of humeral head at the back of biceps tendon （intertubercular sulcus） and 1-1.5 cm proximally from the attach point of supraspinatus tendon was chosen as the entry point of Multiloc nail. The guiding pin should be placed on the anatomical axis of humeral shaft on both the anterior and posterior view and the lateral view under fluoroscopy. If necessary, the location of pin should be adjusted. Once the entry point was confirmed, the medullary cavity was opened and inserted with the proper intramedullary nail. The tail of main nail should be made into the bone. Under guiding device, the proximal locking and distal locking were conducted with 3-4 screws and 2 screws respectively. After the removal of driver-extractor and guiding device and the installation of tail cap, the rotator cuff and deltoid muscle were carefully repaired, and the wound was sutured and banded up. （3） Postoperative management. Antibiotics were given half an hour before surgery to 24 hours after operation. The affected forearm was in sling protection postoperatively, and the pendulum movement of affected shoulder was conducted 2-3 days later. After 7 to 10 days, passive movements of affected shoulder were allowed, including passive flexion and extension, abduction and internal and external rotations. Active movements such as flexion and extension, rotation,abduction and upward lifting were allowed as bone callus were visible on X-ray films 8 weeks after surgery. Strength exercises began when the fracture union was confirmed in the subsequent visit 12-16 weeks later. （4） Observation indexes. Observation indexes included operation duration and intraoperative blood loss. Follow-ups were carried out in all patients regularly, including visual analog scale （VAS） of shoulder joint, fracture healing time, range of motion of shoulder joint and postoperative complications. The good and excellent rate was evaluated by Constant-Murley score with 100 points in total, including pain in 15 points, daily life ability in 20 points, range of motion in 40 points and deltoid muscle strength in 25 points. 90-100 points were considered excellent, 80-89 points were considered good, 70-79 were considered moderate and below 70 points were considered poor. The standard of varus deformity was less than 120° of neck angle.ResultsTwenty-one patients were followed up for 7 to 37 months with an average of 17.45 months, and all of them had fracture healing. The mean operation time was 71.67 minutes （50-132 minutes）, and the intraoperative blood loss was 70.48 ml （40-150 ml）. The mean VAS during the last follow up was 0.52 points （0-5 points）. The mean range of motion was 135.24°（70-180°）for forward flexion; 130.24°（90-170°） for abduction; 33.33°（15-60°） for interal rotation; 50.71°（30-75°）for external rotation. The mean fracture healing time was 4.24 months （3-7 months）.According to the Constant-Murley scoring system: 2 cases were excellent; 15 cases were good; 3 cases were moderate; 1 case was poor. The good and excellent rate was 80.95%, and the mean postoperative Constant-Murley score was 82.48 （62-91）. No fracture nonunion, axillary nerve orradial nerve injury occurred, and no humeral head necrosis, screw backing up or screw loosening was discovered in the follow ups. One case had subcutaneous infection, and the wound remained unhealed even after repeated changing of wound dressing. The bone union was confirmed during the subsequent visit 3 months after operation. Then, the patient had internal fixator removal and debridement surgery. Three weeks later, the wound healed. One patient had bone absorption at the greater tuberosity area with exposure of intramedullary nail tail which leaded to rotator cuff injury and shoulder joint pain. After conservative treatments such as oral anti-inflammatory analgesic and heat therapy for 3 months, the pain relief of shoulder joint was not remarkable. As bone healing was confirmed by fluoroscopy, the intramedullary nail was removed 11 months after operation.Consequently, the pain in shoulder joint disappeared. One patient with 2-Part fracture had delayed union, and the fracture healed after sling fixation for 7 months.ConclusionsProximal humeral fractures are mainly caused by violence and commonly seen in elderly with osteoporosis and young people with severe injuries. The purposes of surgical treatment for displaced proximal humeral fractures include ideal reduction, blood supply protection, rigid fixation and early functional rehabilitation. The most common operative methods were plate screw fixation and intramedullary nailing. However, there is no consensus on which treatment is better. In this study, we found that the new type of intramedullary nailing in the treatment of displaced 2-Part and 3-Part proximal humeral fractures has the advantages of minimal invasion, less blood loss and reliable fixation.Hence, intramedullary nailing promotes early functional rehabilitation and good joint recovery and is one of the effective methods.

Fructure; Proximal humerus; Intramedullary nail; Surgery

2017-03-22）

（本文编辑：胡桂英；英文编辑：陈建海、张晓萌、张立佳）

10.3877/cma.j.issn.2095-5790.2017.02.007

教育部创新团队发展计划（IRT1201）；国家自然科学基金（31640045）;国家自然科学基金（31071246）；国家重点研发计划项目（2016YFC1101604）；北京大学人民医院发展基金（RDY2016-07）

100044 北京大学人民医院创伤骨科 北京大学创伤医学中心

张殿英，Email:zdy8016@163.com

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