微创治疗肱骨近端骨折.doc

Treatment of Proximal Humerus Fractures肱骨近端骨折的治疗现状Summary: The majority of proximal humerus fractures are treated nonoperatively with good functional results. Multiple options exist for treating displaced fractures, without a clear advantage of anyone method for a given fracture type. Goals include an adequate reduction and stable fixation to initiate early motion and rehabilitation. Decision-making should be based on patient and injury specifics and surgeons experience. Various types of fixation, including plates, nails, or percutaneous pins, can maintain sufficient stability to promote shoulder mobility and function. Any of these methods will have few complications when undertaken with appropriate patient selection and careful surgical technique. Preliminary results of locking plates in the proximal humerus suggest that this is a favorable treatment option for displaced, comminuted proximal humerus fractures, which compares well with established methods. Locked plating may improve fracture stability in some complex patterns and facilitate early rehabilitation. It is possible that some fractures previously treated with hemiarthroplasty may be managed successfully with locking plates. Prospective study to assess the complications, outcomes, and cost effectiveness of nonoperative management compared to various surgical treatment options is warranted.大多数肱骨近端骨折采用非手术治疗常能获得良好的功能疗效。对移位骨折治疗存在多种治疗选择，对于某个特定的骨折而言，没有一种方法明显优越于另外一种方法。治疗目标包括充分的复位及稳定的固定以早期活动和康复。治疗决策的制定应该基于患者、损伤特点和外科医生的经验与喜好。不同类型的固定，包括钢板、髓内钉或经皮穿针，能保持骨折端的充分稳定以促进肩关节的活动和功能。当选择合适的病例和进行精心的外科治疗，这些方法很少发生并发症。早期疗效显示，肱骨近端锁定钢板是治疗移位粉碎肱骨近端骨折的一个较好的方法，与其他治疗方法相比疗效满意。在一些复杂病例中，锁定钢板能改善骨折的稳定性，有利于早期的术后康复。一些以前需要行半关节置换的骨折可能通过锁定钢板成功治愈。应当进行非手术疗法和各种手术疗法的关于并发症、疗效和花费疗效比的前瞻性研究。KeyWords: proximal humerus fracture, humerus nail, locking plate, Shoulder关键词：肱骨近端骨折，肱骨髓内钉，锁定钢板，肩关节INTRODUCTION介绍Proximal humerus fractures occur in a dual distribution. Young people sustain these injuries in falls and high-energy accidents, whereas those older than 50 years old experience these fractures with increased incidence as they age.1,2 About three fourths of proximal humerus fractures occur in individuals older than 60 years old, with an occurrence 3 times more often in women than in men.1,3 As the population ages and life-expectancy increases, the frequency of these injuries is rising. The majority of proximal humerus fractures are nondisplaced or minimally displaced and stable. These are successfully treated nonoperatively with early rehabilitation. However, closed reductions of comminuted or severely displaced fractures are difficult to achieve and to maintain. Previous studies have reported less satisfactory results for 3- and 4-part fractures treated by closed reduction, with only as few as 10% of patients achieving satisfactory function.47 Consequently, displaced 3- and 4-part fractures in healthy, active individuals are now typically treated surgically to optimize shoulder function.肱骨近端骨折的发生存在双重分布。年轻人多发生于坠落及高能量损伤等情况下，而50岁以上的老年人随着年龄的增高其发病率升高。四分之三的肱骨近端骨折发生在60岁以上的人，女性的发病率是男性的3倍。随着人口老龄化以及预期寿命的延长，这些损伤的发生率正在上升。大部分肱骨近端骨折为非移位性或移位较小的稳定骨折。这些可以通过非手术治疗和早期的康复治疗而成功治疗。然而，粉碎或严重移位的骨折闭合复位困难，并难于维持复位。以前的研究显示，闭合复位对于3，4部分骨折而言很少能够获得满意的疗效，仅有10的患者疗效满意。因此，目前对健康的、活动较多的患者多采用手术治疗以得到良好的肩关节功能。Historically there has been difficulty in establishing guidelines for surgical treatment. Neer proposed that his classification system would improve clarity in understanding these injuries and in determining effective treatment.5,6 He noted particular difficulty with 3-part and 4-part fractures and sought to compare the results of various treatment modalities for this subgroup of patients.6 Many years later considerable controversy remains regarding the optimal strategy for these injuries; therefore, there is no consensus on the best management for patients with displaced proximal humerus fractures. Many techniques/fixation have been described in the literature, with treatment options focused on the displaced fracture fragments because these may have limited vascularity and may benefit from reduction and fixation.历史上，对手术治疗指导的制定存在困难。Neer提出，他的分型系统有助于进一步理解这些损伤，以及选择有效的治疗。他强调，对3、4部分骨折的处理尤其困难，并试图对比这些骨折亚型的各种治疗模式的疗效。多年以后，对这些损伤的治疗策略仍存在相当的争议；因此，对肱骨近端移位骨折的最佳治疗方案仍然没有一致的意见。文献描述的大量的技术/固定方法，治疗的选择主要集中于移位的骨折段，因为其血运有限，并可能从复位中获益。OPERATIVE TREATMENT手术治疗Despite general agreement that displaced or more complex fractures should be treated operatively, there is no consensus on the type of surgical fixation that should be used. Various methods, such as closed reduction and percutaneous pinning (CRPP), tension band wiring, intramedullary nailing, plate fixation, and hemiarthroplasty have all demonstrated mixed results. Fracture pattern, fracture displacement, bone quality, preexisting rotator cuff disease or arthrosis, and patient function are important factors to consider in developing a treatment plan. The primary goal should be a construct sufficiently stable to begin early range of motion of the shoulder.814 尽管普遍认为移位或更加复杂的骨折应该手术治疗，但对于手术固定的方式仍没有统一的意见。不同的方法，比如闭合复位经皮穿针固定（CRPP），钢丝张力带固定，髓内钉，接骨板固定和半关节置换均有不同疗效的报告。骨折类型、骨折移位、骨质量、既存肩袖疾患或关节炎以及患者的功能是制定治疗计划的重要因素。治疗的主要目标应该是重建充分稳定的结构以早期开始肩关节活动。Displaced 2-part and some 3-part proximal humerus fractures may be managed with CRPP in selected cases. Alternatively, intramedullary nails (IM) designed specifically for proximal humerus fixation may be advantageous in some of these fractures. Open reduction and internal fixation (ORIF) has also been widely used in 2-part, 3-part, and 4-part fractures. Valgus-impacted 4-part fractures are less likely to have disruption to the humeral head blood supply and develop osteonecrosis; thus, ORIF is generally recommended for these injuries.1519 In contrast, displaced 3-part and 4-part fractures are associated with higher rates of osteonecrosis and other complications.5,6,15,2022 Open reduction and internal fixation is advocated for patients who are young and active, but patients who are elderly may be better treated with hemiarthroplasty, depending on their bone quality and physiologic age.2326 Recent advances in internal fixation, with locked plate-screw constructs, have extended our ability to retain the humeral head in some of these patients.27 The results and outcomes of internal fixation versus hemiarthroplasty in this group of patients have not been compared. The following discussion will review various surgical treatment options. 在一些选择的病例，移位的两部分和一些三部分肱骨近端骨折可以进行CRPP治疗。另外，为肱骨近端特殊设计的髓内钉可能对这些骨折也是有益的。切开复位内固定（ORIF）也广泛应用于2、3、4部分骨折。外翻嵌插骨折可能对肱骨近端的血供影响较小，发生骨坏死的机会较低。因此，ORIF经常用于这些损伤；相反，移位的3、4部分骨折骨坏死和其他并发症的发生率较高。ORIF被推荐用于年轻活动量大的患者，但老年患者最好进行半关节置换，这有赖于他们的骨量和生理年龄。在这些患者（老年患者）当中，内固定的新进展（锁定钢板螺钉系统）扩充了我们保留肱骨头的能力。还没有此类患者关于内固定和半关节置换的疗效和结果的对比研究。以下部分将围绕不同手术治疗的选择进行综述。Percutaneous Pins经皮穿针First described by Jaberg, this technique is demanding, but it can be very effective for unstable 2-part surgical neck fractures and even some 3-part or 4-part fractures in patients with good bone quality.2830 Closed reduction, with or without percutaneous assistance, is performed, and 2.5-mm terminally threaded Schanz pins are used to stabilize the fracture. Knowledge of the anatomy of the axillary and musculocutaneous nerves is essential in avoiding injury to these structures.22,31,32 Pins should be placed in a divergent fashion to optimize stability. Three to 4 pins are directed proximally across the surgical neck fracture, and 1 or 2 pins are placed through the greater tuberosity into the medial cortex. These augment the fixation of the surgical neck fracture and will also stabilize a greater tuberosity fragment. Multiple, tangential fluoroscopic views should be obtained to avoid penetration of the articular cartilage. Passive range of motion is initiated postoperatively. Pins placed through the greater tuberosity will limit abduction until they are removed after 34 weeks. The other pins are removed after 68 weeks.最早由Jaberg描述，该技术要求较高，但对一些不稳定的2部分外科颈骨折，甚至骨量较好的一些三部分、四部分骨折也非常有效。进行闭合复位（用或不用经皮辅助），2.5mm末端带螺纹的Schanz钉用来稳定骨折。必须了解腋神经和肌皮神经的解剖学，以避免这些结构的损伤。针应该扇形分布以得到最佳的稳定性。3-4枚针向近端通过肱骨外科颈骨折，1或2枚针通过大结节进入内侧皮质。这有助于加强外科颈骨折的稳定并能够稳定大结节骨块。通过多功能透视设备以避免穿透关节软骨。术后进行早期的被动活动。通过大结节固定的针会影响外展，3-4周时予以拔除。其他的针于6-8周拔除。Surgical trauma to the soft tissues and fracture fragments is minimized with percutaneous pinning. This results in less blood loss and scar tissue and better preservation of fracture biology compared with other techniques. One recent study reviewed 71 patients treated with percutaneous pinning, versus a cohort of patients matched for age and fracture pattern treated with ORIF. These authors noted that the incidence of osteonecrosis was higher after ORIF, potentially secondary to surgical trauma.30 Percutaneous pinning is a viable option, particularly in young patients with suitable bone quality. It is speculated that earlier return of mobility and better final range of motion may also be possible with this method. However, complications include pin infections, loss of reduction, and pin migration. Careful patient selection will minimize these problems. This method is best suited to patients who have good bone quality and who can comply with postoperative activity instructions. It is not appropriate for anatomic neck fractures, fractures with humeral head comminution, or severely impacted fractures with valgus angulation. Rather, it works well for 2-part fractures and for 3-part fractures with minimal greater tuberosity displacement.经皮穿针对软组织和骨折块的创伤很小。与其他技术相比，这导致更少的血供丢失和疤痕组织形成，从而对骨折进行更好的生物学保护。最近的一项研究回顾了71例经皮穿针治疗的患者，与年龄和骨折类型相匹配的一组ORIF患者进行对比。作者注意到，ORIF后骨坏死的发生率较高，有潜在的二次手术创伤。经皮穿针是一个可行的选择，特别是合适骨量的年轻患者。据推测，这种方法也有利于早期活动和恢复最终的活动范围。然而，并发症包括针道感染、复位丢失、针易位。仔细的病例选择有利于减少这些问题。这种方法最适宜于骨量良好并能遵从术后活动指导的患者。CRPP不适合于解剖颈骨折、肱骨头粉碎或严重的外翻嵌插骨折。另外，CRPP能良好的固定2部分或大结节移位较小的三部分骨折。Jaberg reported 95% fracture union after 68 weeks with CRPP but had 4 cases (7%) of pin tract infection.28 Fenichel et al retrospectively reviewed 50 patients with unstable 2-part and 3-part proximal humerus fractures treated with this method.33 They had no pin infections, osteonecrosis, or neurovascular problems. However, 7 patients experienced a loss of reduction, 3 of whom underwent revision fixation. They recommended careful patient selection and close follow-up in the first 4 weeks after surgery to minimize loss of reduction and fixation. Better functional outcomes were noted in patients who did not have an associated fracture of the greater tuberosity, which is consistent with the experience of other authors.22,28,29Jaberg报告，95%的CRPP骨折于6-8周愈合，7例(7%)发生针道感染。Fenichel等回顾性研究了这种方法治疗的50例不稳定型2-3部分肱骨近端骨折。他们的病例没有发生针道感染、骨坏死或神经血管问题。然而，7例患者发生复位的丢失，其中3例进行了翻修固定。他们建议，仔细选择病例以及术后4周内的密切随访以减少复位和内固定的丢失。和其他作者的经验一样，不伴有大结节骨折的患者疗效更好。Intramedullary Nails髓内钉Intramedullary nails are effective in stabilizing some proximal humerus fractures.9,3439 Preservation of blood supply through indirect reduction is an advantage of this technique. A greater propensity for maintenance of reduction is likely in 2-part surgical neck fractures as opposed to those with associated fractures of the tuberosities. Several manufacturers offer nails specifically designed for proximal humerus fractures, with multiplanar locking, blade fixation for the proximal fragment, or both. These implants may be particularly useful for proximal humerus fractures in combination with humeral shaft injuries.34,36 Disadvantages include potential damage to the rotator cuff and chronic shoulder pain.髓内钉能有效稳定某些肱骨近端骨折。通过间接复位保护血供是该技术的优点。与伴发结节骨折的患者不同，该技术能有效维持两部分外科颈骨折的复位。几个生产商提供了专门为肱骨近端设计的髓内钉，带有多向锁定，刃片固定近端骨块，或者两者均有。这些内植物特别适用于伴有肱骨干骨折的肱骨近端骨折。缺点包括潜在损伤肩袖和慢性的肩痛。An anterior acromial approach is recommended for antegrade humeral nailing. This minimizes surgical trauma to the rotator cuff, versus a lateral acromial approach, which can injure the insertions of teres minor and infraspinatus muscles. Care should be taken to protect the axillary nerve. Blunt dissection and visualization to bone can protect the axillary nerve from damage when proximal interlocking bolts are directed from lateral to medial.40 A lateral starting point or failure to achieve reduction of the proximal fragment will result in varus malalignment.36 Meticulous technique and understanding of the associated anatomy and radiographic landmarks will prevent this problem. Displaced 2-part fractures are most amenable to nailing. If 3-part fractures are treated with this method, the greater tuberosity should be reduced and provisionally stabilized with Kirschner wires before the starting point for the nail is developed. 肱骨顺行髓内钉建议采用肩峰前侧入路。与肩峰外侧入路相比，前测入路能减小肩袖的损伤，前者可能损伤小圆肌和冈下肌的止点。应注意保护腋神经。当肱骨近端锁钉由外向内方向锁入时，应钝性分离并直视骨骼以保护腋神经免遭损伤。入点偏外或近端折块复位失败将导致内翻对线不良。精细的技术和对相关解剖和放射标记的理解能避免这些问题发生。移位的2部分骨折最适合髓内钉固定。如果用该技术固定3部分骨折，在建立髓内钉入口前应该先复位大结节并用克氏针临时固定Agel et al reported the results of 20 patients with proximal humerus fractures that were treated with a Polarus nail.35 This implant has options for proximal interlocking in several directions. Although only 11 of 20 patients healed without any complications, this implant can be effective for certain fracture patterns. The authors cautioned against using a nail when the lateral metaphysis is comminuted or if the starting point extends into the greater tuberosity. In such cases fracture displacement, fixation failure, or both are more likely.35,41 Similarly, Rajasekhar et al also demonstrated success with this implant, in both young and elderly patients.37 Their population of 30 patients included primarily 2-part fractures and had 80% satisfactory to excellent results. Other intramedullary implants more recently developed for use in proximal humerus fractures include proximal blade fixation or multiplanar locking options, some with threaded screws to stabilize greater tuberosity and lesser tuberosity fragments.9,36 The early results of these implants appear promising, even in elderly patients.9Agel等报告了20例用Polarus钉治疗的肱骨近端骨折患者的疗效。这种内置物在近端交锁上有几个不同方向的选择。尽管仅11例患者没有发生并发症而愈合，但这种内置物对某些骨折类型是有效的。当外侧干骺端粉碎或进针点扩展到大结节时，作者反对应用Polarus钉。在这些病例中，可能更容易发生骨折移位或内固定失败。同样地，Rajasekhar等也证明这些内置物在年轻人和老年人都是成功的。他们的30例病例主要为2部分骨折，80的病例疗效为优或良。最近为肱骨近端骨折而设计的其他髓内钉包括近端刃片固定或多位锁定选择，一些有螺纹钉设计以稳定大结节和小结节骨块。甚至在老年患者，这些内置物的早期疗效都是令人振奋的。Open Reduction and Internal Fixation切开复位内固定Open reduction and internal fixation is an effective method of treatment for proximal humerus fractures. It is frequently used for displaced 3-part and 4-part fractures and valgus-impacted 4-part humerus fractures to promote early motion of the shoulder.15,17,18,22,42 Multiple fixation options have been described, ranging from tension band fixation5,13,43 to conventional large fragment and small fragment plates and screws18,26,4450 to new locked plate and screw constructs.27,5161 No comparative clinical studies to date have been done to determine clear indications and limitations of these methods.切开复位内固定是治疗肱骨近端骨折的有效方法之一。其经常用于移位的3、4部分骨折和外展嵌插4部分肱骨近端骨折，以促进早期肩关节活动。多种内固定选择已经应用，包括张力带固定，传统大钢板、小钢板螺钉固定，新型锁定钢板螺钉系统。目前仍没有关于这些方法的临床比较研究以确定明确的适应症和限制。Conventional Plates传统钢板A deltopectoral approach or deltoid-splitting approach may be performed, depending on the fracture pattern and surgeon experience.18,19 Care should be taken to preserve rotator cuff attachments and the humeral head blood supply in all cases.19,26,30,47,6265 Articular fractures should be anatomically reduced, and relationships of the tuberosities and their associated rotator cuff insertions should be restored. Shortening of the humerus, through impaction of a comminuted surgical neck fracture, may be desirable. This improves the stability of the construct by increasing the surface area of bony contact and providing an intact medial buttress.54 Careful attention to safe implant placement is essential. Plates should not impinge on the acromion, the biceps tendon, or rotator cuff insertions. Screw trajectories should be strategic and divergent to optimize purchase in the humeral head. Central and inferior placement, with some screws in the medial cortex, may be beneficial.54,66 The fixation should ideally be rigid enough to romote early rehabilitation.可以通过三角肌胸大肌入路或三角肌劈开入路，这依赖于骨折类型和外科医生的经验。所有的病例应注意保护肩袖的附着部和肱骨头血供。关节面骨折应该解剖复位，应当修复结节的关系以及相关肩袖止点。通过粉碎外科颈骨折的嵌插短缩肱骨，可能是有希望的。这将通过增加骨接触面积和提供完整的内侧支撑来提高结构的稳定性。必须细心的将内置物放于安全的位置。接骨板不应该撞击肩峰、二头肌腱或肩袖止点。螺钉的轨迹应该是有计划的散开以优化其在肱骨头那的把持力。在钢板的中下位置安放一些内侧皮质螺钉是有益的。固定应当足够的坚固以促进早期康复。Initial reports of ORIF reviewed experiences with the AO large fragment T-plate.26,46,48,67 By Neers criteria, Kristiansen et al reported only 45% satisfactory results for 3-part fractures.46 Fixation failures and some of the poor results could be attributed to deficient bone quality in elderly patients. Placing the T-plate more inferiorly on the greater tuberosity avoids impingement on the acromion and increases the number of good results, particularly in 3-part fractures.48 However, both of these early studies had high rates of intraarticular screw placement. Precise attention to surgical technique to ensure accuracy of screw placement will prevent this complication. In a group of younger patients (2040 years old), 83% satisfactory results were obtained with careful placement of a T-plate or semitubular blade plate.67 However, poor results were seen in patients with underlying rotator cuff damage. In an attempt to reduce complications associated with the use of the T-plate, Esser advocated a cloverleaf plate.44 This is a small fragment implant with more options for proximal fixation. It can be modified by removing the arm on the end of the plate to reduce the potential for prominence on the humeral head. In 26 patients with a mean age of 55 years who had 3-part and 4-part fractures, 92% good results were obtained with no nonunions and no osteonecrosis.44 Other authors have reported success with this method18,22,26,42 and by applying principles of indirect reduction and fixation with meticulous attention to the surrounding soft tissues.ORIF的早期报告回顾了AO大T型钢板的经验。按照Neer的标准，Kristiansen等报告的3部分骨折仅45疗效满意。固定失败和一些差的疗效主要归因于老年患者的骨量不足。将T型板靠下安放于大结节上，避免撞击肩峰并能增加优良疗效的