评估比较双钢板与髓内钉固定治疗伴肱骨内侧距粉碎性肱骨近端骨折的影像学及临床效果。

回顾性分析2017年1月至2024年7月在本院创伤中心接受手术治疗的46例肱骨近端骨折伴肱骨内侧距粉碎的患者。患者接受了双钢板（n = 24）或髓内钉（n = 22）固定治疗。按照Neer分型，其中二部分骨折16例，三部分骨折30例。致伤原因为：交通伤21例，摔倒17例，高坠8例。在术后1、3、6、12个月门诊随访期间对以上患者进行肩关节X片影像学及临床疗效评估，同时评估患者术后并发症发生情况。功能评估指标包括：肩关节活动度、美国肩肘外科医师协会（American shoulder and elbow surgeons, ASES）评分和Constant-Murley评分以评估肩关节功能。

除1例患者骨折在术后5个月愈合外，其余患者骨折均在术后3个月愈合。双钢板组有2例发生螺钉穿透，进行了翻修手术。两组各有1例患者发生近端螺钉松动，但无需再次手术。两组均未发现肱骨头缺血性坏死。在两组患者术前及术后12个月的影像学检查中，颈干角无显著差异。双钢板组的肩关节活动度、平均ASES评分和Constant-Murley评分均优于锁定髓内钉组，但术后12个月随访时差异无统计学意义。

双钢板与髓内钉固定治疗伴肱骨内侧距粉碎性肱骨近端骨折均可获得满意的治疗效果。两者在关节活动度、ASES和Constant-Murley评分方面没有显著差异。采用髓内钉治疗有发生医源性肩袖损伤的风险，而双钢板固定患者术后肩关节功能恢复呈较好趋势。

Proximal humeral fractures account for approximately 6% of all fractures and are one of the most common fracture types in elderly patients, with about 20% requiring surgical treatment. Locking plates offer advantages such as anatomical-morphology matching, built-in suture holes, and angular stability. In recent years, they have been widely used in the internal fixation treatment of proximal humeral fractures and have achieved good clinical efficacy. However, for proximal humeral fractures with comminuted medial calcar, since the Philos locking plate placed on the lateral side cannot directly perform anatomical reduction on the comminuted medial calcar to provide sufficient support, postoperative complications such as varus deformity, internal fixation failure, and non-union are often prone to occur. In light of this, various methods have been adopted in clinical practice to support and stabilize humeral fractures. The Philos locking plate, placed on the lateral side of the humerus, with its spacing screws, can directly support the crushed medial column of the humerus. However, for petite patients (such as short women), its applicability is often limited. Fibula bone graft support can provide biomechanical strength and shows good mechanical stability. However, once conditions such as humeral head necrosis or obvious greater tuberosity absorption occur, surgical revision becomes significantly more difficult. The double-plate fixation treatment technology of outer PHILOS locking plates combined with auxiliary micro-plates has been widely applied recently. It significantly enhances stability and has a clear therapeutic effect. In addition, as one of the commonly used fixation methods for proximal humeral fractures, intramedullary nail fixation can preserve the blood supply to the humeral head through minimally invasive surgical procedures. Its load-dispersion design and the way the humeral center is fixed give it significant biomechanical advantages in stabilizing medial-compression fractures of the proximal humerus. Although double-plate fixation and intramedullary nail fixation are currently used for proximal humeral fractures with medial calcar comminution, direct comparative evidence remains limited.

To evaluate and compare the imaging and clinical effects of double plate and intramedullary nail fixation in the treatment of comminuted proximal humeral fractures with medial calcar of the humerus.

A retrospective analysis was conducted on 46 patients with proximal humeral fractures accompanied by fragmentation of the medial humeral calcar who underwent surgical treatment at the trauma center of our hospital from January 2017 to July 2024. Patients underwent double-plate fixation (n = 24) or intramedullary nails fixation (n = 22). According to the Neer classification, there were 16 cases of two-part fractures and 30 cases of three-part fractures. The causes of injury were as follows: 21 cases of traffic injuries, 17 cases of falls, and 8 cases of falls from heights. During outpatient follow-up at 1, 3, 6, and 12 months after the operation, shoulder joint X-ray imaging and clinical efficacy evaluation were performed for the above patients, and postoperative complications were also evaluated at the same time. Functional assessment indicators include: Shoulder joint range of motion (ROM), the American shoulder and elbow surgeons (ASES) score, and the Constant-Murley score to evaluate shoulder joint function.

Except for one patient whose fracture healed 5 months after the operation, the fractures of the remaining patients all healed 3 months after the operation. In the double-plate group, 2 cases had screw penetration and underwent revision surgery. One patient in each group experienced proximal screw loosening, but no reoperation was required. Ischemic necrosis of the humeral head was not found in either group. In imaging examinations of the two groups of patients before the operation and 12 months after, there was no significant difference in the neck-shaft angle. The shoulder joint range of motion, average ASES score, and Constant-Murley score in the double plate group were all better than those in the locked intramedullary nail group. Still, there was no statistically significant difference at the 12-month follow-up after the operation.

Double plate and intramedullary nail fixation treatment with comminuted proximal humeral fractures of the medial calcar of the humerus can all achieve satisfactory therapeutic effects. There were no significant differences between the two in terms of joint ROM, ASES, and Constant-Murley scores. Intramedullary nail treatment carries the risk of iatrogenic rotator cuff injury, while patients with double plate fixation have better recovery of shoulder joint function after surgery.