肱骨近端骨折

Proximal humeral fractures,PT Lv Haisheng,Introduction,Definition:,Proximal humeral fractures:humeral head, anatomicsurgical neck of the humeral,Fractures of the proximal humerus are not uncommon, especially in older age groups. They have been reported to account for 4% to 5% of all fractures,Classification,by Neer in 1970,The Neers classification system is currently the most widely used system. It is based upon accurate identification of each of four potential fracture fragments: the articular head, lesser tuberosity, greater tuberosity, and shaft,Neer2 partDisplaced tuberosity FDisplaced/angulated surgical neck3 partSN+GT or LTAN+GT or LT4 partneck+both tuberosities+/- dislocationNeers definition of displacement: 1cm or 45 degrees,Mechanism of injury,Caused by a fall on an elbow or outstretched hand, especially in an elderly patient ,or by trauma to the lateral aspects of the shoudler. Seizures can occasionally result in fracture/dislocation of the shoudler,Treatment Goals,Orthopaedic objectives,Alignment,Stability,External immobilization : for nondispaced stableInternal fixation : displaced two-part or three part Endoprosthesis : four-part,Maintain a normal relationship between the humeral head and the glenoidReduce the greater and lesser tuberosities to maintain rotator cuff functionObtain a neck shaft angle of 130 to 150 degrees and a retroversion angle of 30 degrees,Rehabilitation objectives,Range of Motion,Restore the full range of motion of the shoulder in all planesFrequently, there may be residual loss of range of motion secondary to the fractures,Muscle Strength,Functional Goals,Improve the strength of the following muscles and attempt to regain full strength against maximum resistance,Improve and restore the function of the shoulder in self-care ,dressing, and grooming. in addition ,shoulder movement and strength are vital in almost all sports activities,Shoulder range of motion,One third to one half of the full range of motion is considered functionTo reach maximal flexion or forward elevation, slight abduction and external rotation are requiredTo reach maximal extension or posterior elevation, slight internal rotation is required,Expected Time of Bone Healing,Expected Duration of Rehabilitation,Six to 8 weeks,Twelve weeks to 1 year,Methods of Treatment,Sling,Biomechanics :Stress-sharing deviceMode of bone healing: secondaryIndications: nondisplaced, impacted or minimally displaced for 2-3 weeks,Open reduction and internal fixation,Biomechanics :Stress shielding with plate fixationMode of bone healing: primary when rigid fixation secondary when rigid fixation notIndications: two-part, three-part or those that may also require repair of the rotator cuff,Closed reduction and percutaneousFixation/Cannulated screw Tension Banding,Prosthetic Artheroplasty,Biomechanics :Stress-sharing deviceMode of bone healing: secondary, with callus formationIndications: for two-part with no significant rotator cuff tears for displaced surgical neck fracture,Biomechanics :Stress-sharing deviceMode of bone healing: Tuberosities secondaryIndications: with significant risk of avascular necrosis,Closed reduction and immobilization?,External fixator,Biomechanics :Stress-sharing deviceMode of bone healing: secondaryIndications:used if satisfactory reduction is achieved,Biomechanics :Stress-sharing deviceMode of bone healing: secondary, with callus formationIndications: Used for open and severely comminuted fractures,Age Articular involvementAvascular necrosisMalunion/nonunin,Special considerations of the fracture,Stiffness: elderly vs younger50% involvement of the articular-Hemiarthroplasty Predisposes to degenerative changesFour-part, anatomic F with extensive soft-tissue and periosteal strippingMalunion-tolerated, subacromial impingementNonunin-uncommon,occur soft-tissue interpositon or inadequate immobilization,rotator cuff tears neurovascular injuries four-part fractures Posterior dislocation,Associated injury,Associated with displacement of either tuberosity and require repairAssociated with anterior or inferior dislocations invoice axillary or posterior cord of the brachial plexus, EMG 3 weeks, Four-part may be associated with axillary artery injuries May occur with isolated tuberosity fractures,Weight bearing,Gait,The involved extremity should be non-weight bearingAvoid supporting the bodys weight until clinically and radiographically united,Arm swing is initially absent and may be reduced on a long-term basis,Treatment,Treatment :early (day of injury to one week),stability at fracture site :noneStage of bone healing: Inflammatory fhase,the fracture hematoma is colonized by inflammatory cells, and debridement of the fracture beginsX-ray: No callus ,the fractures line is visible,Orthopaedic and rehabilizationConsiderations,Physical examinationDangers RadiographyWeight bearingRomMuscle strengthFunctional activities,pain, paresthesia ,pin discomfort, drainage ,malodor -infection, assess capillary refill, sensation, a/promVascular injury, neurologic statusFor loss of correction and compare NWB ROM is not allowed, Pendulum-stable, nondisplacedencouraged activitely to flex and extend the wristFull active ROM to the digits is prescribedreflex inhibition, no muscle strength exercises,at end of the first week ,the wrist isometric and isotonicFunctional activities use the uninvolved,Methods of treatment :specific aspects,Sling Open reducion and internal fixation Closed reduction , percutaneous fixation, and cannulated screwsHemiarthroplasty,90 degrees, lesser tuberosity fracture across the chest; at the end of 2 weeks ,removedCheck the wound. avoid stress to the rotator cuff and tuberosity repairs. With repair of the rotator cuff are not permitted active flextion(forward elevation), active external rotation or assisted internal rotation until 6 weeks after surgery In an early rehabilitation program. motion is immediately begun to prevent the adhesions粘连,pendulum exercises with gravity elimination are started ,rehabilitation is aimed at maintaining joint stability and obtaining ROM with reasonable muscle control,Prescription,Day one to one weekPrecautions: Avoid shoulder motionRom: None at the shoulder and elbow ,Gentle pendulum exercises with elimination of gravity are allowed for nondisplaced fractures and hemiarthroplastyMuscle strength: No strengthening exercises to the elbow/shoulderFunctional activities: with uninvolved extremity, needed assistanceWeight bearing: None on affected extremity,Treatment : two to four weeks,stability at fracture site :none to minimalStage of bone healing: beginning of reparative phase. Osteoprogenitor cells differentiate into osteoblasts wich lay down woven boneX-ray: No callus ;fracture line is still visible,prescription,Two to four weeksPrecautions: Avoid internal/external rotation of the shoulderRom :Patients treated conservatively with a sling can continue with pendulum active to gentle passive-assistive exercise to the shoulder Patients treated surgically should start passive-assistive ROM in supine positon,No AROM to the shoulderMuscle strength: isometric with sling only, No strengthening for surgical intervention ball-squeezingFunctional activities: with uninvolved extremity, needed assistanceWeight bearing: None,Treatment : four to six weeks,stability at fracture site :With bridging callus.the fracture is usually stable confirm with physical examinationStage of bone healing:reparative phase.further organization of the callus and formation of lamellar 薄片bone begins. once callus is observed bridging the fracture site.the fracture is usually stable ,however, the strength of this callus especially with torsional load,is significantly lower than that of normal bone. further protection (if not further immobilization) is required to avoid refractureX-ray: Bridging callus is visible .with increased rigidity of the fixation ,less bridging callus is noted ,and healing with endosteal骨内膜 callus predominates占优势 . expect less callus in end-of bone fractures than in midshaft fracturers,prescription,four to six weeksPrecautions: Do not apply force in attempting to regain the full range of motionRom: Shoulder limited range Flexion/abduction up 100 to 110 degrees Inernal/external rotation-limited Pendulum exercise against gravity Elbow full ROM in flexion, extension, supination, and pronation Surgically treated patients may continue with passive-assistive ROM exercisesMuscle strength: Shoulder-avoid exercises to the deltoid if it is incised during surgery Elbow-isometric and isotonic Functionnal activities: used for dressing and grooming as tolerated need assistance in house cleaning and preparing mealsWeight bearing: None on affected extremity,Treatment : six to eight weeks,stability at fracture site :with bridging callus, the fractures is usually stable; confirm with physical examinationStage of bone healing: reparative phase. Further protection of bone avoiding refracture, the strength with torsional load is significantly lower than that of normal lamellar boneX-ray: bridging callus is visible. With increased rigidity, less bridging callu Is noted ,and healing with endosteal callus predominates. The fracture line is less distinct清楚,prescription,six to eight weeksPrecautions: avoid forced ROMRom: AROM, gentle PROM and active-assistive ROM to the shoulder and elbow in all planes, to tolerance Muscle strength: isometric to the shoulder isometric and isotonic to the elbow start PRE for patient with a slingFunctional activities: the involved extremity is for self-care and feeding some self-care activities used the uninvolved