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中华肩肘外科电子杂志 ›› 2019, Vol. 07 ›› Issue (04) : 329 -334. doi: 10.3877/cma.j.issn.2095-5790.2019.04.007

所属专题: 文献

论著

经皮微创钢板固定治疗肱骨干骨折的疗效分析
任东1, 邢丹谋1,(), 肖志宏1, 陈焱1, 冯伟1, 赵志明1, 王欢1, 张明1   
  1. 1. 430033 武汉市第四医院肩肘外科
  • 收稿日期:2019-04-18 出版日期:2019-11-05
  • 通信作者: 邢丹谋
  • 基金资助:
    武汉市卫生健康委员会科研项目(WJ17Q21)

Clinical outcome analysis of minimally invasive percutaneous plate fixation for treatment of humeral shaft fracture

Dong Ren1, Danmou Xing1,(), Zhihong Xiao1, Yan Chen1, Wei Feng1, Zhiming Zhao1, Huan Wang1, Ming Zhang1   

  1. 1. Department of Shoulder and Elbow Surgery, Wuhan NO.4 Hospital, Wuhan 430033, China
  • Received:2019-04-18 Published:2019-11-05
  • Corresponding author: Danmou Xing
  • About author:
    Corresponding author: Xing Danmou, Email:
引用本文:

任东, 邢丹谋, 肖志宏, 陈焱, 冯伟, 赵志明, 王欢, 张明. 经皮微创钢板固定治疗肱骨干骨折的疗效分析[J/OL]. 中华肩肘外科电子杂志, 2019, 07(04): 329-334.

Dong Ren, Danmou Xing, Zhihong Xiao, Yan Chen, Wei Feng, Zhiming Zhao, Huan Wang, Ming Zhang. Clinical outcome analysis of minimally invasive percutaneous plate fixation for treatment of humeral shaft fracture[J/OL]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2019, 07(04): 329-334.

目的

探讨经皮微创钢板内固定术治疗肱骨干骨折的方法及疗效。

方法

2014年5月至2017年5月,应用锁定加压钢板经皮微创固定治疗肱骨干骨折患者26例,男18例、女8例;平均年龄42.6岁(19~72岁);右侧19例,左侧7例。致伤原因:交通伤11例,平地摔伤8例,高处坠落伤4例,扭伤3例。根据AO分型:A型6例,B型15例,C型5例。其中1例合并桡神经麻痹,1例合并同侧尺桡骨干骨折,1例合并同侧桡骨远端骨折,1例合并对侧肱骨髁间骨折,1例合并同侧股骨粗隆间骨折。受伤距手术时间为3~12 d(平均7.2 d)。其中20例采用前侧入路,6例采用后外侧入路进行经皮微创钢板内固定术。术后患者每2周复查记录功能恢复情况,每4周摄X线片了解骨折愈合情况。

结果

经过12~35个月的随访(平均16.4个月),所有骨折均获得骨性愈合,平均愈合时间14.8周(10~22周)。末次随访时,患者美国加州大学肩关节评分(the university of California at Los Angeles shoulder rating scale,UCLA)为24~35分(平均34.1分),肘关节Mayo功能评分为91~100分(平均93.3分)。1例患者术后出现桡神经麻痹,3个月后症状消失;另1例术前即合并桡神经损伤患者,术中未显露探查桡神经,神经功能亦于术后2个月恢复。

结论

采用经皮微创钢板固定的方式治疗复杂肱骨干骨折,手术创伤更小,操作简单安全,骨折愈合率高,临床疗效满意。

Background

The humeral shaft fracture accounts for about 1% to 3% of the total body fractures. Although most of these fractures can be treated by conservative treatment, the limbs need to be immobilized for a long time. About 40% of patients with humeral shaft fractures have been reported in the literature to remain different degrees of shoulder and elbow function loss after conservative treatment. Therefore, the surgical treatments of displaced humeral shaft fractures have become a consensus in the field. In the choice of surgical methods, most doctors still advocate open reduction and internal fixation, but the traditional surgery requires extensive dissection of soft tissue, and the big scar remains after surgery. In recent years, the interlocking intramedullary nails have been increasingly used in the treatment of humeral shaft fractures, but it is difficult to use for distal third of the humeral shaft because of flattened and narrowed distal cannel. In contrast, minimally invasive plate osteosynthesis (MIPO) is increasingly recognized and popularized for its biological advantages and satisfactory results.

Methods

1.General Information:From May 2014 to May 2017, our department applied MIPO technology combined with locking compression plate to treat humeral shaft fractures and obtained 26 cases of follow-up, all of which were closed humeral shaft fractures, including 18 males and 8 females; average age was 42.6 years old (19 to 72 years old) ; 19 cases were on the right side and 7 cases were on the left side. Causes of injury: 11 cases were traffic injuries, 8 cases were flat falls, 4 cases were falls from height, and 3 cases were sprain injuries. According to the AO classification, 6 cases were type A, 15 cases were type B, and 5 cases were type C. One patient had radial nerve paralysis, one patient had ipsilateral ulnar and radial shaft fractures, one had ipsilateral distal radial fracture, one had contralateral humeral intercondylar fracture, and one had ipsilateral intertrochanteric fracture. The time from injury to surgery was 3 to 12 days (average 7.2 days) . 2.Surgical Methods: (1) The anterior lateral approach:In this group, 20 cases used the anterior lateral approach. The operation was performed under general anesthesia. The patient was in supine position with upper arm abduction and forearm supination. The proximal incision was located between the medial edge of the deltoid muscle and the lateral edge of the biceps muscle and was 3 to 5 cm long. If the fracture was on the upper segment, the incision could be moved up to the deltoid pectoralis major space. The distal incision had the same length and was from the proximal end of the elbow transverse line, close to the lateral side of the biceps muscle. The biceps muscle was retracted to the medial side, the brachialis muscle was cut open lengthwise to reveal the lower part of the humerus cortex. The channel for the plate was prepared using a periosteal elevator. The reduction was achieved by traction in the posture of elbow flexion. The corrections of shortening, angulation and rotational deformity were confirmed under X-ray. For most A, B type fractures, percutaneous Kirschner wire fixation could be used to temporarily maintain the reduction. A narrow 4.5 mm locking compression plate (LCP) of sufficient length was placed through the proximal incision, and two locking screws were drilled into each of the proximal and distal bone blocks. For the older patients with significant osteoporosis, three locking screws could be used at each bone block. (2) The posterior lateral approach:In this group of patients, 4 cases were B-type fractures of the distal 1/3 of the humerus, and the wedge-shaped bone block was located on the anterior side, resulting in a lack of sufficient space on the anterior side of the distal bone to screw in 2 screws. Two cases had the skin abrasion of the anterior side of the arm. So the posterior lateral approach was selected in this group. The proximal incision started from 6 to 7 cm below the acromion. The deltoid muscle was cut open lengthwise to avoid damage to the axillary nerve. The distal incision was located at the lateral edge of the triceps muscle. The plate was placed on the posterolateral side of the humerus. When preparing the channel for the plate in this approach, it should be noted that the process should be gentle and close to the cortex to avoid damage to the radial nerve. (3) Postoperative treatment:Except for the radial nerve injury patients, the other patients did not need the external fixation. On the first day after surgery, the patient was instructed to perform shoulder and elbow function exercises without stress, and the suture was removed 2 weeks later. The follow up examination was performed every 2 weeks after surgery, and the functions of the shoulder and elbow were recorded. AP and LAT X-ray of the humurus were taken every 4 weeks to observe the fracture healing process.3.Observation indicators:The healing of the incision was observed and recorded. The shoulder and elbow function scores were recorded every 2 weeks postoperatively. The Ellman method of the UCLA shoulder scoring system was used to evaluate the recovery of shoulder function (A total of 35 points included 10 points of pain, 10 points of function. 5 points of active flexion motion, 5 points of flexion strength test, and 5 points of satisfaction; 34 to 35 was excellent, 28 to 33 was good, and 21 to 27 was fair, less than 21 was poor) . Elbow function was evaluated using Mayo elbow function score (A total score of 100 points included 45 points of pain, 20 points of motor function, 10 points of stability and 25 points of daily activities; 90 points or more was excellent, 75 to 89 points was good, 60 to 74 points was fair, less than 60 was poor) . For patients with radial nerve paralysis, the recovery of the nerve function was recorded. X-ray films were taken every 4 weeks to record fracture healing process and healing time.

Results

The incisions of all patients were primary healed. The average follow-up time was 16.4 months (12-35 months) , and bony union was achieved in all fractures. The average healing time was 14.8 weeks (10-22 weeks) . There was no looseness or breakage of internal fixation. At the last follow-up, the UCLA scores of the shoulder were 24-35 points, of which 19 were excellent, 6 were good, and 1 was fair. The excellent and good rate was 96.1%. The Mayo elbow scored 91 to 100 points, and all 26 patients were excellent. The only one patient with fair shoulder function was a 72-year-old woman with a C3 type fracture of the middle and upper humerus caused by a car accident. The fracture line involved the head and neck of the humerus. The anterior lateral approach was performed with an extended PHILOS fixation. The patient also had an ipsilateral femoral intertrochanteric fracture. It was difficult for her to cooperate with functional exercise due to fear of pain. At 6 months postoperatively, the shoulder UCLA score was 24 points.Among the patients in this group, 1 patient had radial nerve paralysis after operation, and after oral administration of neurotrophic drugs, the functions of radial nerve was completely restored after 3 months; the other patient was complicated with radial nerve injury before operation. The radial nerve was not exposed in the surgery, and the neurological function recovered 2 months after surgery.

Conclusions

The minimally invasive percutaneous plate fixation treating complex humeral shaft fractures had the advantage of a smaller surgical trauma, a safer and easier operation, a higher fracture union rate, and a higher satisfaction rate.

图1 典型病例1:患者,女,30岁,摔伤致右肱骨下段骨折,肱骨干B1型骨折MIPO技术内固定 图A、B:术前正侧位X线片示肱骨下段螺旋形骨折,有楔形骨片分离移位;图C:采用后外侧入路MIPO技术操作,近远端各用2枚锁定螺钉固定;图D:术后正侧位X线片示复位良好;图E、F、G、H:术后12个月,肩肘功能恢复良好;图I、J:术后12个月正侧位X线片显示骨折愈合
图2 典型病例2:患者,女,29岁,高坠伤致左肱骨下段骨折,肱骨干B2型骨折MIPO技术内固定 图A:术前X线正位片示肱骨下段斜形骨折;图B:术前CT三维重建示肱骨下段B2型骨折;图C:采用后外侧入路MIPO技术,切口情况;图D:术后X线正位片示骨折复位良好;图E、F、G、H:术后25个月,肩肘功能恢复良好;图I:术后25个月,正侧位X线片示骨折愈合良好
[1]
Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the treatment of fractures of the humeral diaphysis[J]. J Bone Joint Surg Am,2000,82(4):478-486.
[2]
Chapman JR, Henleyel MB, Agel J, et al. Randomized prospective study of humeral shaft fracture fixation:intramedullary nails versus plates[J]. J Orthop Trauma,2000,14(3):162-166.
[3]
Bleeker WA, Nijsten MW, ten Duis HJ. Treatment of humeral shaft fractures related to associated injuries: a retrospective study of 237 patients[J]. Acta Orthop Scand, 1999,62(2):148-153.
[4]
Fan Y, Li YW, Zhang HB, et al. Management of humeral shaft fractures with intramedullary interlocking nail versus locking compression plate[J]. Orthopedics,2015,38(9):e825-829.
[5]
Zhiquan A, Bingfang Z, Yeming W,et al. Minimally invasive plating osteosynthesis(MIPO) of middle and distal third humeral haft fractures[J]. J Orthop Trauma,2007,21(9):628-633.
[6]
Kobayashi M, Watanabe Y, Matsushita T. Early full range lf shoulder and elbow motion is possible after minimally invasive plate osteosynthesis for humeral shaft fractures[J]. J Orthop Trauma,2010,24(4):212-216.
[7]
Sachit M, Simon T, Shekhar S, et al. Minimally invasive plate osteosynthesis using a locking compression plate for diaphyseal humeral fractures[J]. J Orthop Surg,2012,20(3):292-296.
[8]
Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction[J]. J Bone Joint Surg Am,1986,68(8):1136-1144.
[9]
Krettek C, Schandelmaier P, Miclau T, et al. Minimally invasive percutaneous plate osteosynthesis(MIPPO) using the DCS in proximal and distal femoral fractures[J]. Injury,1997,28(Suppl 1):A20-A30.
[10]
Fernandez Dell’Oca AA.The principle of helical implants. Unusual ideas worth considering[J]. Injury,2002,33(Suppl 10):SA1-SA27.
[11]
Lopez-Arevalo R, de Llanv-Temboruy AQ, Serrano-Montilla J, et al. Treatment of diaphyseal humeral fractures with the minimally invasive percutaneous plate(MIPPO) technique: a cadaveric study and clinical results[J]. J Orthop Trauma,2011,25(5):294-299.
[12]
张培训,付中国,王依林,等. 应用MIPPO技术前侧入路预旋转塑形锁定板钉治疗肱骨干中段B型、C型骨折[J/CD]. 中华肩肘外科电子杂志,2017,5(1):3-8.
[13]
Stoffel K, Dieter U, Stachowiak G, et al. Biomechanical testing of the LCP-how can stability in locked internal fixators be controlled?[J]. Injury,2003,34(2):B11-B19.
[14]
Shao YC, Harwood P, Grotz MRW,et al. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review[J]. J Bone Joint Surg Br, 2005,87(12):1647-1652.
[15]
Liu G, Zhang C, Wu H. Comparison of initial nonoperative and operative management of radial nerve palsy associated with acute humeral shaft fuactures[J]. Orthopedics, 2012,l35(8):702-708.
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