两种手术方法治疗Neer Ⅲ型肱骨近端骨折的临床研究

doi:10.3877/cma.j.issn.2095-5790.2021.04.009

目的

观察比较采用单纯外侧PHILOS钢板和外侧PHILOS钢板结合内侧支撑钢板治疗NeerⅢ型肱骨近端骨折的临床疗效。

方法

2015年1月至2020年1月本科室收治的NeerⅢ型肱骨近端骨折患者65例，其中32例采用单纯外侧PHILOS钢板治疗（单钢板组），另33例采用PHILOS钢板结合内侧支撑钢板治疗（双钢板组）。对比两组的手术时间、术中出血量、骨折愈合时间、术后第12个月肱骨颈干角、术后6个月和12个月的Neer评分及Constant评分等相关指标。

结果

两组患者术中均无神经血管损伤情况发生，伤口均I期愈合。所有患者均获得随访12个月。双钢板组在手术时间、术中出血量、骨折愈合时间明显大于单钢板组（P<0.01）。双钢板组在术后第6个月和第12个月Neer评分和Constant肩关节评分系统的评分明显高于单钢板组（P<0.01）。在术后第12个月末次随访时，双钢板组的肱骨颈干角较单钢板组更加接近正常值（P<0.01）。

结论

对于NeerⅢ型肱骨近端骨折合并内侧柱损伤的患者来说，采用外侧PHILOS钢板结合内侧支撑钢板治疗,可以提高肱骨近端内侧稳定性及肱骨近端整体牢固性,降低术后骨折复位丢失、肱骨头内翻、内固定失效等并发症的发生率,可以早日行肩关节康复功能锻炼，恢复肩关节功能。

关键词: 肱骨近端骨折, NeerⅢ型, PHILOS钢板, 支撑钢板

Background

With the continuous progress of domestic aging, the occurrence of proximal humeral fractures is second only to distal radius fractures and hip fractures, ranking third with an incidence of approximately 4%-5%. The first choice for the treatment of patients with Neer type III or IV proximal humeral fractures is the locking plate technique. With the increasing number of proximal humerus fractures in recent years, the postoperative complications of locking plate technique alone have been increasingly concerned. Relevant studies in recent years have found that the poor quality of proximal humerus and the loss of medial column are the main reasons for postoperative complications. In this study, a buttress plate was placed on the inner side of the proximal humerus to enhance the overall stability and firmness of proximal humerus and reduce postoperative complications.

Objective

To observe and compare the clinical efficacy of the simple lateral PHILOS plate and the lateral PHILOS plate combined with the medial buttress plate in the treatment of Neer type Ⅲ proximal humeral fractures.

Methods

From January 2015 to January 2020, 65 patients with Neer type Ⅲ proximal humeral fractures were admitted into our department. Among them, 32 cases were treated with lateral PHILOS plate, and the other 33 cases were treated with PHILOS plate combined with medial buttress plate. The operation time, intraoperative blood loss, fracture healing time, humeral neck shaft angle in the 12th month after operation, Neer score and Constant score in the 6th and 12th months after operation were compared between the two groups.

Results

No neurovascular injury occurred in the two groups of patients during the operation, and the wounds healed at first stage. All patients were followed up for 12 months. The operation time, intraoperative blood loss, and fracture healing time of the double-plate group were significantly longer than those of the single-plate group (P<0.01) . The Neer score and Constant score of the double-plate group in the 6th and 12th months after surgery were significantly higher than those of the single-plate group (P<0.01) . At the last follow-up in the 12th month after surgery, the humeral neck shaft angle of the double-plate group was closer to the normal angle than that of the single-plate group (P<0.01) .

Conclusion

For patients with Neer type Ⅲ proximal humeral fractures combined with medial column injury, treatment with lateral PHILOS plate combined with medial buttress plate can improve the medial stability and overall firmness of proximal humerus, and reduce the incidence of reduction loss, humeral head varus, fixation failure, etc, which is helpful for early shoulder rehabilitation and shoulder function restoration.

Key words: Proximal humeral fracture, Neer type Ⅲ, PHILOS plate, Buttress plate

图1 肱骨颈干角的测量方法注：ab线为肱骨头基底部最长径；cd线垂直于ab线；ef线平行于肱骨干；cd线和ef线所形成的夹角α角即为肱骨干颈干角

表1 两组患者手术情况相关指标对比表（±s）

组别	例数	手术时间（min）	术中出血量（ml）	骨折愈合时间（周）	术后第12月肱骨颈干角（°）	并发症（例）
单钢板组	32	87.09±12.47	128.49±29.62	12.21±3.99	115.93±4.68	6
双钢板组	33	119.17±10.37	167.81±31.67	10.32±3.61	135.15±3.61	0
t值		7.281	7.386	3.193	8.918	0
P值		<0.001	<0.001	<0.001	<0.001	<0.001

表1 两组患者手术情况相关指标对比表（±s）

组别	例数	手术时间（min）	术中出血量（ml）	骨折愈合时间（周）	术后第12月肱骨颈干角（°）	并发症（例）
单钢板组	32	87.09±12.47	128.49±29.62	12.21±3.99	115.93±4.68	6
双钢板组	33	119.17±10.37	167.81±31.67	10.32±3.61	135.15±3.61	0
t值		7.281	7.386	3.193	8.918	0
P值		<0.001	<0.001	<0.001	<0.001	<0.001

表2 两组患者术后第6个月和第12个月的Neer和Constant评分对比表（分，±s）

组别	例数	Neer评分		Constant评分
组别	例数	术后6个月	术后12个月	术后6个月	术后12个月
单钢板组	32	73.19±6.93	79.38±7.91	86.06±5.73	92.15±2.93
双钢板组	33	74.51±6.72	80.14±8.63	87.38±4.51	93.01±3.17
t值		1.602	1.312	1.636	1.358
P值		<0.001	<0.001	<0.001	<0.001

表2 两组患者术后第6个月和第12个月的Neer和Constant评分对比表（分，±s）

组别	例数	Neer评分		Constant评分
组别	例数	术后6个月	术后12个月	术后6个月	术后12个月
单钢板组	32	73.19±6.93	79.38±7.91	86.06±5.73	92.15±2.93
双钢板组	33	74.51±6.72	80.14±8.63	87.38±4.51	93.01±3.17
t值		1.602	1.312	1.636	1.358
P值		<0.001	<0.001	<0.001	<0.001

图2 患者，女性，69岁，左肱骨近端骨折（NeerⅢ型），行单纯PHILOS钢板固定治疗　图A-B：术前X线片及CT层扫断面片；图C：患者术后6个月复查平片示骨折解剖复位，内固定在位牢固，骨折线模糊，愈合良好；图D：患者术后12个月去除内固定后的X线片

图3 患者，女性，63岁，左肱骨近端骨折（NeerⅢ型），行PHILOS钢板结合内侧3.0锁定支撑钢板固定治疗　图A-B：术前X线片及CT层扫断面片；图C：患者术后6个月复查平片示骨折解剖复位，内固定在位牢固，骨折线模糊，愈合良好；图D：患者术后12个月去除内固定后的X线片

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Clinical study of two surgical methods for the treatment of Neer typeⅢ proximal humeral fractures

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Clinical study of two surgical methods for the treatment of Neer typeⅢ proximal humeral fractures