Locking plate for the treatment of 3-part and 4-part fracture of proximal humerus

doi:10.3969/j.issn.2095-4344.2013.04.020

Abstract

Abstract:

BACKGROUND: The locking plate is a new type of internal fixation plates which can improve the clinical treatment effect of proximal humeral fractures.
OBJECTIVE: To explore the effect of locking plate fixation for the treatment of 3-part and 4-part fracture of proximal humerus, and to explore the incidence of complications.
METHODS: Thirty-one proximal humeral fracture patients (13 males and 18 females, aged from 28 years to 81 years, averaged in 56.4 years) treated with locking plate fixation were selected from Department ofOrthopedics, Qingpu Branch of Zhongshan Hospital, Fudan University between January 2008 and December 2009. The clinical data of the 31 patients was retrospectively analyzed. The type of fracture was classified with Neer classification, and found that 19 patients had 3-part fracture and 12 patients had 4-part fracture. The internal fixation was performed with pectoralis major deltoid interscalene approach and then the proximal humeral locking plate fixation was performed. The literatures on the locking plate for the treatment of 3-part and 4-part fracture of proximal humerus were searched to analyze the incidence of complications. The efficacy of clinical cases and in the incidence of complications the retrieved documents were comprehensively analyzed, and the features of locking plate for the treatment of 3-part and 4-part fracture of proximal humerus were obtained.
RESULTS AND CONCLUSION: All the 31 patients mentioned above were followed-up for 13-49 months, average in 19.8 months. The fracture of all the patients were healed without fixation failure and the clinical healing time was 8-16 months. The shoulder function was assessed according to the Constant assessment criteria, and found that excellent in 11 patients, good in 16 patients, average in 3 patients and poor in 1 patient. Locking plate fixation is the reliable and effective method for the treatment of 3-part and 4-part fracture of proximal humerus. But the screw loosening, humeral head necrosis and other related complications may also occur. Therefore, we should pay attention to protect the blood supply of the humeral head during fixation and reset the medial humeral neck fracture and firmly fixed, in order to reduce the complications and improve the treatment effect of fixation.

Key words: bone and joint implants, academic discussion of bone and joint implants, locking plate, humerus, fracture, internal fixation, complications, humeral head, greater tuberosity, acromion, steel plate, Kirschner wire, screws

CLC Number:

R318

He Xiao-jian, Zhuang Jian, Zhou Kai-hua, Chen Ming-ji, Gao Ru-feng, Zheng Fen, Pan Fu-gen. Locking plate for the treatment of 3-part and 4-part fracture of proximal humerus[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(4): 688-695.

Figures/Tables 5

2.3 治疗结果 31例患者均得到13-49个月随访，平均随访19.8个月。骨折均愈合，无内固定失效，临床愈合时间为8-16周。根据Constant评分标准评定肩关节功能：优11例，良16例，可3例，差1例。所有患者均未见螺钉松脱、穿出、断裂等情况，也未见肱骨头坏死、骨不连等相关并发症发生。 2.4 临床应用体会肱骨近端骨折发生率约占全身骨折的5%[14]，好发于骨质疏松的老年患者。在所有老年人骨折发病率中位列第3。其治疗目标和其它关节内骨折一致：尽可能解剖复位恢复关节面的平整、固定牢靠利于肩关节早期进行功能锻炼。但由于肱骨近端三、四部分骨折较难复位，软组织剥离过多容易缺血坏死或骨不连，加上老年患者骨量丢失内固定失效的发生概率较高，预后较差，是创伤骨科的难点[15]。以往对于此类骨折一般采用肩关节假体置换。但上肢对灵活性的要求较高，使假体置换并不像在下肢中那样成功[16]。解剖型肱骨近端锁定钢板在临床中应用的特点，使手术治疗肱骨近端骨折的并发症有所下降。文献报道，所有三部分骨折及不伴有肩关节脱位的四部分骨折患者均可采用内固定治疗，而无需置换关节[17]。文章研究结果也表明，应用锁定钢板治疗肱骨近端三、四部分骨折，疗效满意，术后并发症低，未见螺钉松脱、穿出、断裂等情况，也未见肱骨头坏死、骨不连等并发症发生。与早期钢板相比，PHOLOS钢板具有成角稳定性，抗拔出能力强，螺钉锁定不会退出，不易松动。但是随着锁定钢板的广泛的应用，内固定失效的报告也引起人们的关注。研究认为提高疗效、减少内固定失效主要应该注意以下几方面。骨折复位：在肱骨近端骨折内固定失效的患者中，肱骨头内翻移位、螺钉切出较为常见。与骨折复位不良、肱骨外科颈内侧皮质粉碎失去支撑有关，肱骨头颈内下方力学特性与股骨距相似，发生骨折时此处由于肱二头肌长头腱阻挡，能量得以部分吸收，骨折片相对外侧完整。内侧能否重建稳定的支撑直接影响内固定的稳定，故复位时应遵循由内而外的原则，首先复位内侧骨块，当内侧有良好的骨质接触后，再复位外侧骨块，肱骨大结节骨块可留待最后复位。钢板螺钉的放置：据文献报道，钢板放置过高会引起肩峰撞击，放置偏前则易压迫或磨损肱二头肌长头腱。螺钉太短，不能完全固定骨折块，容易松动脱钉，螺钉太长则穿破肱骨头关节面，减少此类并发症的发生是治疗成功的关键。钢板应放置在肱骨大结节顶点下5 mm，结节间沟后缘5-10 mm处较为稳妥。螺钉则以达到关节软骨下骨下5 mm为佳。术中应多角度透视确认螺钉没有穿出。此外，由于肱骨颈内侧结构的重要性，应至少有2枚螺钉固定此处骨质，起到加强和支撑作用。软组织保护：对于肱骨近端三、四部分骨折，肱骨头缺血坏死仍是影响疗效的重要因素[18]，文献报道，四部分骨折肱骨头坏死率可达37%。文章复旦大学附属中山医院青浦分院骨科锁定接骨板内固定治疗31例患者中，四部分骨折12例，无1例坏死。临床经验是在显露并复位骨折时，尽可能少剥离附着在骨折块的软组织，以免损伤骨折块血供。以结节间沟为标志，依靠间接复位技术进行复位，注意软组织保护，尤其是内侧软组织对于肱骨头的血供有重要作用，更应该注意保护，上述操作对于预防肱骨头坏死具有重要意义。 2.5 锁定接骨板治疗肱骨近端三、四部分骨折的并发症北京大学人民医院创伤骨科付中国等[11]对锁定接骨板治疗肱骨近端三、四部分骨折的52例患者进行跟踪随访，40例患者为三部分大结节骨折合并外科颈骨折，其中有9例患者还同时合并盂肱关节前脱位；12例患者为四部分骨折，其中9例为外展嵌插型，3例合并脱位。对52例患者进行锁定接骨板内固定治疗，结果12例患者出现相关并发症，并发症发生率为23.07%，其中延迟愈合1例，治疗后出现大结节移位2例，接骨板撞击肩峰2例，螺钉穿出3例，肱骨头坏死3例，肱骨头内翻畸形愈合4例，其中3例患者同时合并2种以上并发症，详细结果见表1。北京大学积水潭医院运动损伤科鲁谊等[12]对33例肱骨近端三、四部分骨折应用锁定接骨板内固定治疗的患者进行跟踪随访，17例为三部分大结节骨折，其中5例合并肱骨头前脱位，1例合并肱骨头后脱位；15例为四部分骨折，其中9例为外展嵌插型，2例合并肱骨头脱位。对33例患者进行锁定接骨板内固定治疗，结果8例患者出现相关并发症，并发症发生率为24.24%，其中肱骨头缺血坏死5例，螺钉穿出1例，螺钉松动1例，腋静脉损伤1例，8例患者均为单一并发症，详细结果见表2。"

从上述2组应用锁定接骨板治疗肱骨近端三、四部分骨折后的并发症统计结果可以看出患者年龄、性别、骨折类型、骨折的严重程度以及内固定钢板的类型均是并发症发生的风险因素。其中螺钉穿出、螺钉松动、接骨板撞击肩峰、大结节移位为内固定相关并发症，延迟愈合、腋静脉损伤、肱骨头坏死以及肱骨内翻畸形愈合为非内固定相关并发症[19]。锁定接骨板内固定治疗肱骨近端三、四部分骨折虽然可以获得较好的治疗效果，但是同时也存在很多的不足，因此，在应用时要综合考虑患者全身状态、上肢功能、肱骨头血运及软组织完整性等多方面因素严格合理选择合适的治疗方法，严格规范操作，良好的复位以及对周围血运良好保护，同时辅助影像学检查，尽量避免任何并发症的发生[20-22]。 2.6 锁定接骨板治疗肱骨近端三、四部分骨折的优缺点锁定接骨板是根据生物接骨术理念和肱骨近端局部解剖特点及生物力学特性研究设计的新一代接骨板[23]，锁定接骨板的出现改善了传统钢板的内固定效果，其应用于治疗肱骨近端三、四部分骨折的优点可以总结为以下几点[13]：①作为解剖型接骨板，适合肱骨近端特殊的解剖形态，术中无需预弯。②作为一种内固定支架，改变了接骨板与骨骼间以摩擦力为基础的传统固定模式，使接骨板与骨面间的压力降至最低，最大程度保护了骨膜和骨的血运从而使骨折愈合有更好的生物学环境。③螺钉与接骨板的角度固定，对骨折端产生了良好的稳定作用。④肱骨头固定螺钉向不同方向交叉设计，提高了内固定物的抗拔出力，特别适合于骨质疏松患者。⑤钉板间锁定固定有较好的锚合力和较高的抗拉力，可防止螺钉退出和内固定松动，对肱骨头的支持固定较其它钢板得到明显加强，尤其是应用于骨质疏松性骨折或粉碎性骨折。⑥锁定接骨板近端边缘有多个缝合孔，有利于关节囊及肩袖损伤的修复，也可以作为克氏针临时固定骨块的针孔。⑦体积小，操作简单，减少对软组织的剥离和刺激，降低肩峰撞击症的发生率。锁定接骨板治疗肱骨近端三、四部分骨折有很多的优点，但是文章研究显示其应用也可以发生大结节移位、肩峰撞击、螺钉松动及穿出、肱骨头坏死、肱骨头内翻畸形愈合、感染、延迟愈合以及神经血管损伤等相关并发症，并且锁定接骨板价格昂贵，因此应用时综合考虑患者的整体状态以及经济能力等多种因素进行选择，以达到最佳的临床治疗效果，减少并发症的发生[24-25]。 2.7 PubMed数据库2012年收录锁定接骨板治疗肱骨近端骨折10篇相关研究文献举例见表3。"

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