孔祥燕



肱骨近端严重骨折半肩关节置换术后护理与康复治疗

孔祥燕

目的 探讨肱骨近端骨折行半肩关节置换术后的护理与康复效果。方法 将67例行半肩关节假体置换术的肱骨近端粉碎性骨折患者，术后康复锻炼分为早期、中期和晚期3个阶段，并对患者的功能康复锻炼进行指导。对67例患者进行了平均9个月的随访和功能锻炼指导，按照Neer评分标准进行评价。结果 67例患者中优38例，良18例，可11例，差0例，优良率达83.58%。结论 对肱骨近端粉碎骨折肩关节置换术患者，进行精心的护理和规范化的康复指导，是取得患者肩关节良好功能恢复的重要因素之一。

肱骨骨折，近端；肩关节置换；康复；护理

肱骨近端骨折是指包括肱骨外科颈在内及其以上部位的骨折，约占全身骨折的4%～5%，且大多为复杂、移位和不稳定的骨折[1-2]，在老年人群中较多见。目前，在大部分医院多采用石膏外固定或切开复位内固定治疗，但大多数学者认为老年患者肱骨近端4部分骨折，尤其是伴有肱骨头粉碎性骨折或关节脱位时，肱骨头血供已受到不可逆损伤，如一期内固定后失败，二期再行关节置换手术将会影响手术效果和肩关节功能的恢复[3-4]。对于一些高龄患者，尤其是骨质疏松的患者，骨折为Neer分型中的3部分或4部分骨折[5]，虽然经过了内、外固定治疗，但肩关节功能却难以取得满意的效果。对于这种情况，肩关节置换术无疑是一种有效的更有优势的治疗方式[3]。肩关节置换术按照置换范围大小分为半肩关节人工肱骨头置换和全肩关节置换。肩关节置换术后的精心护理与规范化康复治疗越来越受到人们的重视[6]，肩关节置换术后规范化、持续的康复治疗是能否最大限度地恢复肩关节功能的重要因素之一。我科于2004年1月至2013年6月对67例具备肩关节置换适应证的患者施行半肩关节假体置换术，经过围手术期的精心护理，无一例发生并发症，并在患者出院后进行平均9个月的随访与功能锻炼康复指导，每次随访参照Neer评分标准进行效果评定，67例患者肩关节功能恢复良好，现将护理与康复治疗体会介绍如下。

资 料 与 方 法

一、一般资料

67例临床诊断均为闭合性肱骨近端粉碎性骨折行半肩关节置换术的患者，其中男性19例，女性48例。年龄52～90岁，平均73.06岁。Neer分型：3部分骨折29例，3部分骨折-脱位9例，4部分骨折23例，4部分骨折-脱位6例。67例患者伤前肢体功能基本正常，生活可自理，可胜任日常工作。

二、护理

(一)术前心理护理

术前向患者介绍积极的康复锻炼对肩关节功能恢复的重要性，同时也要给患者及家属强调肩关节康复锻练的艰苦性与长期性，一般需要6～12个月的康复锻炼才能获得显著效果，这样可以使患者做好充分的思想准备，建立康复的信心。

(二)一般护理

术后行常规护理，患者取平卧或低坡卧位，患肢用前臂悬吊巾固定在外展40°～50°，内旋30°。即患肢前臂斜放在患侧胸壁旁的软垫上，以抬高患肢，促进水肿消退。严密观察患者生命体征，注意患肢皮温、色泽以及伤口情况，警惕有无手指及患肢皮肤麻木、青紫、肿胀等神经血管损伤的表现，发现异常及时报告医生处理。

(三)引流管护理

术后引流通畅是手术成功的关键之一，应妥善固定伤口引流管并保持通畅，防止引流管受压、曲折、阻塞、脱落等，注意观察引流液的颜色、流量、性质并准确记录。若短时间内持续引出大量血液，应引起高度重视是否存在活动性出血。

三、康复锻炼

根据Brown等[7]的肩关节康复治疗程序，结合患者的具体情况及手术特点，制定半肩关节置换术后康复治疗方案。将患者术后康复锻炼分为3个阶段，分别为早期、中期和晚期，全程对患者的功能康复锻炼进行指导。

(一)第一阶段(术后1 d～6周)

术后根据患者骨折类型及固定情况，麻醉消失后即可进行肘关节以远肢体的主动活动[8]，肩关节以被动活动为主，除训练时间外，均需配带肩关节专用吊带。该阶段具体可分为5个步骤[9]：(1)麻醉消失后，开始进行手指、腕关节及肘关节的主动锻炼和肩关节的被动活动，术后7 d增加钟摆练习；(2)术后2周,患肩关节及邻近关节无负重下行后伸及内外旋转运动；(3)术后3周健手保护患侧低负重双肩关节后伸及扩胸练习；(4)术后4周进行重力辅助下的钟摆练习及前屈练习,肩外展、外旋、上举功能锻炼；(5)术后6周X线检查确定肩袖及大小结节愈合后，开始进行主动功能锻炼，增加冈上肌、三角肌功能锻炼及爬墙练习。该阶段应重点关注关节活动度及肌力的训练。

1.关节活动度训练：(1)钟摆练习[10]：患者弯腰使躯干与地面平行，患侧上肢放松、悬垂，与躯干成90°，用健侧手托住患侧前臂做顺时针或逆时针画圈运动， 10圈为1组，上、下午各练习1组。(2)肩关节被动前屈上举练习：患者去枕仰卧，患侧臂屈肘90°放于体侧(休息位)。治疗师一手托住患侧上臂，一手握住患侧前臂，在肩胛骨平面 (冠状平面之前30°～45°) 做肩关节被动前屈上举，当前屈到一定角度出现疼痛或遇到阻力时停留5 s，然后逐渐回到休息位，重复4 次为1组，上、下午各练习1组。(3) 被动外旋练习：患者仰卧位，去枕，上臂外展30°保持肢体在肩胛骨平面，肘关节屈曲。治疗师一手托住患侧上臂，一手握住患侧腕部向远离身体中线的方向做肩关节被动外旋。重复4次为1组，上、下午各练习1组。(4)被动外展、内收和内旋练习(从术后第5周开始) ：患者仰卧位，治疗师帮助患者行肩关节被动外展、内收、内旋(外展90°内旋) 训练，重复4 次为1组，上、下午各练习1组。

2.肌力训练：肩带肌等长收缩训练从术后第3周开始，术后第6周开始行内、外旋肌群等长收缩训练。(1)肩关节前屈肌群训练：患者立位，面对门或墙，患侧屈肘90°放于体侧，然后用健侧手托住患侧手，手握拳向前用力推，试图做肩关节前屈的动作，但不产生关节运动。(2)外展肌群训练：患者立位，患侧屈肘90°放于体侧，用健侧手托住患侧手，患侧上臂外侧完全接触门或墙，肘部用力向外推，做外展动作。(3)肩关节伸肌群训练：患者立位，患侧屈肘90°放于体侧，然后用健侧手托住患侧手，患侧上臂背侧完全接触门或墙，肘部用力向后推门或墙做后伸动作。(4) 提肩胛骨肌群训练：患者立位，患侧屈肘90°放于体侧，然后用健侧手托住患侧手，双侧同时用力做耸肩动作。(5)内收肩胛骨肌群训练：患者立位，患侧屈肘90°放于体侧，然后用健侧手托住患侧手，双侧同时用力做内收肩胛骨动作。(6)内旋肌群训练：患者站立位，患侧屈肘90°放于体侧，健侧手握住患侧前臂，患侧肩关节试图做内旋动作，健侧手阻碍肩关节产生运动。(7)外旋肌群训练：保持内旋肌训练的姿势，患侧肩关节试图做体侧的外旋动作。每次每个动作持续用力5 s，重复10次为1组，上、下午各练习1组。

(二)第2阶段(术后7～12周)

能否去掉吊带需根据患者大小结节愈合程度决定。此阶段训练以肩关节主动活动为主，除关节活动度和肌力训练外，增加了耐力训练。

1.活动度训练：继续肩关节各方向的牵拉训练，可开始进行滑轮牵拉训练和爬墙梯/爬墙等闭链训练。

2.肌力训练：继续上一阶段的等长收缩训练，开始行肩带肌等张收缩及肱二头肌、肱三头肌等张收缩。

3.耐力训练：逐渐增加运动量(20次为1组) 和运动持续时间(每个动作持续10 s) 。

(三)第3阶段(术后12周)

此阶段开始进行肌肉抗阻力的强化训练, 以抗阻训练为主，包括肩关节牵拉训练、抗阻力训练、肩胛的旋转和三角肌强化练习。此阶段除关节活动度、肌力及耐力训练外，增加了运动能力训练。

1.活动度训练：继续肩关节各个方向的牵拉训练(强度可增加)，如借助门框牵拉。

2.肌力训练：以抗阻训练为主。每个动作达最大限度时停留5 s，重复10次为1组，上、下午各练习1组。(1)抗阻前屈和外展：患者站立位，取一根长1 m的弹力带，一端踩在脚下，一端握在手里进行前屈上举和外展上举练习。(2)抗阻后伸：患者站立位，患侧臂伸直面对弹力带，弹力带一端固定在相当于腕关节的高度，肩前屈约60°使弹力带具有一定张力，注意张力不要过高，患者牵拉弹力带，放下手臂做后伸动作。(3)抗阻内旋和外旋：患者站立位，将一根弹力带系在约肘关节高度的门或家具上。内旋时，患侧靠近弹力带，上臂内收于体侧，屈肘90°，以肘关节为轴，前臂和手做超过身体中线的动作，尽量拉长弹力带。外旋动作与内旋方向相反。当肌力增强后，可改用墙壁拉力器进行抗阻训练。

3. 耐力训练：此期可增加运动量(每个动作重复30次为1组，上、下午各2组)和运动持续时间(每个动作保持15 s)。

4. 运动能力训练：参加体育运动，包括本体感觉训练。在患者舒适度以内，可进行任何活动，但应避免接触性运动，最佳运动有游泳、打乒乓球等。

四、Neer评分

术后67例患者平均获得9个月的随访，根据Neer评分标准评估患者的患侧肩关节功能，其中疼痛占35分，日常生活功能占30分，术后肩关节活动范围占25分，术后解剖位置占10分。90～100分为优，80～89分为良，70～79分为可，<70分为差。

结 果

本组67例患者经过以上规范、系统地术后护理和康复锻炼并进行术后平均9个月的随访。根据Neer评分标准评估患者的患侧肩关节功能，结果显示，67例患者中优38例，良18例，可11例，差0例，优良率达到83.58%。无一例并发症，经康复锻炼后患者生活完全能够自理，康复效果满意。

讨 论

肱骨近端骨折在肩部骨折中较为常见，治疗效果与患者的肩关节功能、日常活动及生活质量直接相关。目前肩关节置换术的适应证范围尚未完全明确，传统上认为包括老龄骨质疏松性骨折、骨折/脱位、头劈裂性骨折及累及关节面>40%的压缩骨折可选用半肩关节置换术[11]。虽然娴熟的手术技巧对治疗的成功起着重要作用，但术后的护理和康复锻炼也同样不可忽视，过于保守的康复训练会导致关节僵硬，肌肉过度萎缩，影响肩关节的活动范围及功能，而过量的康复训练又会使愈合的关节囊、大小结节受到二次损害，影响肩关节的稳定性和功能。与其他关节置换术后的护理和康复截然不同的是，肩关节的康复所需的时间更长，可达12个月之久。因此，制定一套完整的能让患者接受的护理和规范的功能锻炼方法是至关重要的，这对于肱骨近端内固定术后患者和肩关节置换患者同样适用。有研究表明，术后配合积极的康复锻炼，不仅可以控制术后感染的发生，还能够促进伤口愈合，安全有效地避免术后骨不愈合和骨髓炎等并发症的发生[11-12]。

人工肩关节置换术与人工髋、膝关节置换术几乎是同时代的手术技术，但是人工肩关节置换术的实施数量及长期效果目前仍达不到人工髋、膝关节置换术那样令人满意的效果，之所以产生这样差异，主要是由于肩关节的特殊功能要求和解剖特点决定的[13]。肩关节是人体各关节中活动度最大的关节，占整个上肢功能的60%，对关节的灵活性要求较高。另外，肩周肌肉丰富，肱骨几乎是由肩周软组织悬吊于肩胛上，因此肩周软组织功能的恢复程度对术后肩关节的功能就显得极其重要。

在骨质疏松的肱骨近端的Neer 4部分骨折或3部分骨折伴脱位患者中，肩关节置换术较为常用，因为此类型骨折常常破坏了肩部最重要的动力稳定结构——肩袖的止点处的大、小结节。精确复位大、小结节于假体头下是肩关节置换术最重要的步骤之一，并在术后一段时间达到大、小结节之间以及大、小结节和肱骨干之间的骨性愈合[14]，在大、小结节没有达到骨性愈合之前，功能锻炼中应避免肩袖肌肉主动收缩，以免造成结节骨折移位，影响术后效果。患肢的保护在早期康复锻炼中更为重要，因为此时骨折尚未愈合，错误的锻炼方式会造成二次损伤，影响预后，在早期康复锻炼过程中应强调进行正确的被动锻炼，6周后骨折初步愈合后才可进行主动锻炼。由此可见，肱骨近端骨折患者行肩关节置换术的最终效果，不单纯是手术技术所决定的，其术后规范化的康复训练治疗也是一个不可或缺的因素。

肩关节置换术后早期康复治疗是存在一定的风险的，大、小结节骨折块移位等问题在某些时候是无法完全避免的。因此，我们需要与临床医师及康复医师进行沟通，并制定个性化的康复方案，这样才能更好的针对每位患者进行康复指导。第一阶段行肩关节被动活动时，向手术医师了解术中情况，对于被动活动的角度应参考术中记录的安全活动范围，并根据患者的伤情、术式及其全身情况制定康复方案。第二阶段行肩关节主动活动的时间应在X线片显示有骨折愈合征象证据之后并根据随访查体情况进行。本研究复杂肱骨近端骨折的患者均施行半肩关节置换术，与全肩关节置换术不同，大、小结节重建的问题需要重视，若过早进行主动活动，则增加结节移位的风险，如大结节在冈上肌、冈下肌、小圆肌的牵拉下向后上方移动，则可能继发肩峰下撞击等。肩关节不稳定是肩关节置换术后常见并发症之一。使肩关节尽快恢复功能的方法之一就是肌力训练，这种方法还可减少不稳定的发生率。肩关节置换患者康复的全过程均需要肌力训练，只是不同阶段需要不同的训练内容。如第一阶段以肩带肌等长收缩为主，第二阶段以肩带肌等张收缩为主，第三阶段以抗阻肌力训练为主。通过肩带肌的系统训练，可增强肩关节的稳定性，预防肌源性肩关节不稳定的发生[15]。对于肱骨近端粉碎性骨折肩关节置换术的患者，进行详尽细致的护理和规范的康复指导治疗，是取得患者肩关节良好功能恢复的重要因素。经过上述细致的护理及系统的康复治疗，患者在术后6～12个月一般都能恢复满意的肩关节功能，但要提醒患者6个月后应继续巩固训练并定期复查。

结论：对肱骨近端粉碎性骨折肩关节置换术患者进行精心的护理和规范化的康复指导治疗，是取得患者肩关节良好功能恢复的重要因素之一。

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孔祥燕.肱骨近端严重骨折半肩关节置换术后护理与康复治疗[J/CD]. 中华肩肘外科电子杂志,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

卫生部卫生公益性行业科研专项基金(201002014)

100044北京大学人民医院创伤骨科 北京大学交通医学中心(Email：kxy1766@163.com)

2015-02-06)