栗剑 张光武 张昆 吕鹏飞 薛涛



肱骨干骨折的两种内固定技术对肩关节功能影响的中长期研究

栗剑 张光武 张昆 吕鹏飞 薛涛

目的 回顾性研究肱骨干骨折采用钢板内固定和顺行髓内钉固定后的肩关节症状、功能和运动范围。 方法 回顾性分析19例钢板和20例顺行髓内钉内固定对肩关节功能的影响。随访肩关节HSS、JOA、VAS评分,肩关节运动范围。钢板组平均随访7.3年(1～11年)；髓内钉组平均随访6年(1～10年)。结果 HSS评分优良率：钢板组84.2%，髓内钉组65%；JOA评分优良率：钢板组78.9%，髓内钉组60%；VAS评分：钢板组1.78分，髓内钉组2.3分；肩关节运动范围：钢板组在前屈、外展、外旋运动方面优于髓内钉组。在肩关节评分、肩关节疼痛和运动范围方面，钢板组和髓内钉组间差异无统计学意义。结论 两种内固定技术治疗后大部分肩关节功能可恢复到正常状态。顺行髓内钉固定只要提高手术操作技巧，防止医源性损伤，就能明显减少肩关节损伤。

肱骨骨折；髓内钉；钢板；内固定

肱骨干骨折是上肢常见的损伤类型，文献报道肱骨干骨折在所有骨折中约占3%[1]。常见的手术治疗方法包括钢板固定和髓内钉固定。多数学者认为钢板固定技术是比较各种手术固定方法的金标准。有关顺行髓内钉固定是否影响肩关节功能尙存争议[2-5]。通过对我院2001年1月至2012年9月收治且获得随访的39例肱骨钢板和顺行髓内钉患者进行回顾性分析，旨在探讨两种内固定技术对肩关节功能的影响。

资 料 与 方 法

一、一般资料

本组39例，男性25例，女性14例；平均年龄43.9岁(21～75岁)。致伤原因:摔伤21例，交通伤9例，坠落伤3例，机器绞伤2例，运动伤2例，暴力打击伤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。开放性骨折: Gustilo Ⅰ型2例，Ⅱ型2例，Ⅲa型1例。从发生骨折到进行手术的平均时间为1.2 d。

二、手术方法

所有手术均采用臂丛麻醉或全身麻醉。钢板组手术采用前外侧入路17例，后侧入路2例。内固定物选择普通钢板，动力加压钢板(dynamic compression plate, DCP)或锁定加压钢板(locking compression plate, LCP)。按照AO分型原则行稳定固定。确保远、近骨折端必须至少各用3～4枚螺丝钉固定。髓内钉组选择匈牙利产索娜盟托肱骨顺行交锁髓内钉，主钉近端弧度11°～13°，近端3个锁孔，远端2个锁孔，实现交锁。采用顺行方式置入。顺行带锁髓内钉的进钉入点在前后位像上紧靠大结节内侧的沟内，在侧位像上正在肱骨干的中轴线上。

三、术后处理

1.运动康复: 术后颈腕吊带制动。从术后即开始非负重的主、被动功能锻炼，包括钟摆样运动和前屈、外展、外旋、内收、内旋练习。X线片示骨折愈合前避免患肢负重。

2.术后随访及评价标准:所有患者术后进行常规随访，项目包括： (1) X线片检查； (2) 对肩关节的症状和功能评估采用HSS、JOA评分。肩关节的疼痛评估采用视觉模拟量表VAS。运动范围的测量使用测角计，见表1。

四、统计学处理

应用PASW Statistics 18.0统计软件进行统计学分析，采用Mann-Whitney秩和检验判断钢板组与髓内钉组的运动范围，HSS、JOA和VAS评分是否存在差异，P<0.05为差异有统计学意义。

结 果

钢板组平均随访7.3年(1～11年)，髓内钉组平均随访6年(1～10年)。39例患者骨折获愈合，骨折愈合时间平均13.1周(8～24周)。两组随访及统计学分析结果见表1。钢板组与髓内钉组之间在肩关节功能评分、疼痛、运动范围方面的参数经统计学分析证明差异无统计学意义。

表1 术后肩关节功能和疗效评定±s)

讨 论

McCormack等[6]采用ASES评价标准对钢板固定和髓内钉固定的两组患者的肩关节功能进行统计学分析，结果表明差异无统计学意义。这与本组结果一致。肱骨骨折的治疗目标之一是获得最大限度的上肢功能。特别是肩关节功能。综合文献报道，大多数学者认为顺行髓内钉引起的肩关节功能问题要高于钢板固定[7-10]，且主要原因在于髓内钉干扰和损害了肩袖的正常结构和功能[4]。以上文献所涉及的有些问题在本组患者中也有发生。探讨这两种内固定技术对肩关节功能的影响因素。

一、钢板固定的影响因素

1.初始损伤的轻重可能影响肩关节功能: 钢板组中HSS和JOA得分低的患者共有3例。第1例为高速旋转的传送带将上肢卷入机器内致伤。第2例为压面机将上肢卷入两滚轴之间夹轧致伤。这两例的致伤因素中均有高能量释放于组织中，造成上肢的骨与关节以及软组织的广泛损伤。第3例为投掷骨折。患者在投掷手榴弹过程中，当肩关节由外展、外旋状态急速转变为内收、内旋状态时可使岗上肌腱与肩胛下肌腱分离，形成所谓“肩袖间隙撕裂”。肩袖间隙是肩袖的薄弱部位，上述两肌腱的分裂使臂上举运动的合力减弱，使肱骨头依附关节盂的力量下降，使盂肱关节易发生滑脱和松动而造成不稳定。

2.手术本身对肩关节功能的影响：对发生于胸大肌腱止点和三角肌止点附近的骨折，无论在显露、复位，还是放置钢板过程中都难以避免对胸大肌或三角肌产生干扰和损伤，从而影响到术后肩关节的内收，内旋、外展、前屈和后伸功能。

二、髓内钉的影响因素

1.医源性因素: 本组有2例因钉尾未完全埋入肱骨头的关节面，使钉尾端撞击肩峰下，引起肩关节功能受损。其中1例术后1年取出髓内钉后关节功能恢复正常。许多学者认为肩袖撞击是影响肩关节功能的重要因素[4]。造成肩袖损伤的因素有: (1)进钉入点显露过程中，忽视保护肩袖，通过肩袖做横切口。正确方法是顺着肩袖的腱纤维平行做切口。手术中要全层缝合肩袖。 (2)在扩髓过程中，特别是在使用近端扩髓器时直接损伤肩袖。(3)钉尾未完全埋入肱骨头的关节面，使钉尾端撞击肩峰下或肩袖而引起肩关节功能受损。 (4)进钉点位置有误差，导致髓内钉打入方向偏离中轴线及扩髓时使用暴力等，造成骨劈裂和关节软骨面损伤。本组发生1例。推荐使用顺行弧形髓内钉，避免使用顺行直钉。其他医源性因素包括:肩峰下滑囊炎、肩锁关节炎、锁钉突出到三角肌、岗上肌腱断裂及喙突骨折[4，7]。

2.年龄因素: 髓内钉组患者平均年龄52.8岁。其中HSS和JOA低分患者有7例，占全组的35%，这7例平均年龄57.7岁。钢板组患者平均年龄34.5岁。在HSS和JOA评分方面相比较，髓内钉组均低于钢板组。这与文献报道一致[7]。显示年龄>50岁的患者肩关节功能评分较低。这可能与下列因素有关: (1)受伤前就存在肩袖结构和功能的退行性改变；(2)手术创伤的影响；(3)术后主动配合功能锻炼的依从性降低。此外，在本组的低分患者中有5例致伤原因为摔伤(占本组的25%)。提示年龄>50岁的患者，即使是低能量的损伤因素也可能会影响肩关节功能。老年患者应慎重选择手术治疗。

肱骨干骨折术后肩关节功能损害的原因有待于进一步研究。顺行髓内钉固定应提高手术操作技巧。应重视患肢功能的早期康复治疗(特别是50岁以上患者)。进一步对两种内固定技术进行大样本量的随机对照比较是必要的。

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(本文编辑：李静)

栗剑，张光武，张昆，等.肱骨干骨折的两种内固定技术对肩关节功能影响的中长期研究[J/CD]. 中华肩肘外科电子杂志,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广脊柱关节退行性疾病治疗关键技术推广(Z131100002613002)

100144北京大学首钢医院骨科

栗剑，Email：shougangguke@163.com

2014-07-21)