張培訓(xùn) 付中國(guó) 王依林 馬明太 薛峰

·論著·

應(yīng)用MIPPO技術(shù)前側(cè)入路預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨干中段B型、C型骨折

張培訓(xùn) 付中國(guó) 王依林 馬明太 薛峰

目的探討采用微創(chuàng)經(jīng)皮鋼板內(nèi)固定（minimally invasive percutaneous plate osteosynthesis，MIPPO）技術(shù)經(jīng)前側(cè)手術(shù)入路預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨干中段B型和C型骨折的臨床療效。方法2012年1月至2015年12月，北京大學(xué)人民醫(yī)院應(yīng)用MIPPO技術(shù)前側(cè)入路預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨干中段B型、C型骨折患者16例，其中男6例，女10例；年齡43～70歲，平均（55．8±9．1）歲；根據(jù)AO分型：B型11例，C型5例；所有患者均為閉合性骨折，不伴隨橈神經(jīng)損傷。患者行骨折遠(yuǎn)、近端上臂前方小切口，透視下閉合復(fù)位骨折，并于肱骨前方肱骨表面放置預(yù)旋轉(zhuǎn)處理的鎖定加壓鋼板（locking compression plate，LCP）橋接固定，LCP近端放置在肱骨外側(cè)，遠(yuǎn)端放置在肱骨前側(cè)。記錄手術(shù)時(shí)間、術(shù)后并發(fā)癥、骨折愈合時(shí)間、肩關(guān)節(jié)及肘關(guān)節(jié)活動(dòng)范圍。肩關(guān)節(jié)功能采用美國(guó)加州大學(xué)洛杉磯分校（University of California，Los Angeles，UCLA）評(píng)分評(píng)價(jià)，肘關(guān)節(jié)功能采用Mayo評(píng)分評(píng)價(jià)。結(jié)果16例患者均獲得了8～24個(gè)月隨訪，平均（16．13±4．54）個(gè)月，手術(shù)時(shí)間45～120min，平均（70．5±18．5）min。16例患者中有1例出現(xiàn)術(shù)中的醫(yī)源性橈神經(jīng)損傷，經(jīng)營(yíng)養(yǎng)神經(jīng)藥物和電刺激的治療，術(shù)后1個(gè)月時(shí)腕關(guān)節(jié)和拇指的背伸功能完全恢復(fù)。16例患者骨折愈合時(shí)間10～21周，平均（13．5±3．0）周。肩關(guān)節(jié)外展105～120°，平均（112．5±4．6）°；前屈150～170°，平均（165．4±6．0）°。肘關(guān)節(jié)伸直0～8°，平均（4．8±2．0）°；屈曲120～140°，平均（132．5±5．8）°。肩關(guān)節(jié)功能依據(jù)UCLA評(píng)分標(biāo)準(zhǔn)：優(yōu)15例，良1例。肘關(guān)節(jié)功能依據(jù)Mayo評(píng)分標(biāo)準(zhǔn)：優(yōu)14例，良2例。結(jié)論應(yīng)用MIPPO技術(shù)前側(cè)手術(shù)入路預(yù)旋轉(zhuǎn)塑形鎖定加壓板釘治療肱骨干中段B型和C型骨折臨床療效較好，手術(shù)操作方便，骨折斷端血運(yùn)影響小，恢復(fù)快，值得進(jìn)一步臨床推廣。

MIPPO；LCP；內(nèi)固定；肱骨干；骨折

肱骨干骨折臨床常見(jiàn)，約占全身骨折的2%［1］。近年來(lái)肱骨干骨折的治療方式已從傳統(tǒng)保守石膏固定發(fā)展到鈦板螺釘及髓內(nèi)釘固定，應(yīng)用鈦板螺釘進(jìn)行切開(kāi)復(fù)位內(nèi)固定或者閉合復(fù)位髓內(nèi)釘內(nèi)固定已成為肱骨干骨折手術(shù)治療的金標(biāo)準(zhǔn)［2］。采用切開(kāi)復(fù)位鈦板內(nèi)固定術(shù)治療肱骨干骨折，需要較大范圍的剝離軟組織肌肉，干擾了骨折斷端的血運(yùn)，且存在橈神經(jīng)損傷的風(fēng)險(xiǎn)［3］。隨著AO骨折生物固定理論的更新，重視保護(hù)骨折斷端周?chē)浗M織血運(yùn)的骨折間接復(fù)位技術(shù)得到了蓬勃發(fā)展。通過(guò)微創(chuàng)經(jīng)皮鋼板內(nèi)固定（minimally invasive percutaneous plate osteosynthesis，MIPPO）技術(shù)肱骨前方或外側(cè)經(jīng)皮置入鋼板固定肱骨干骨折成為可能，國(guó)內(nèi)屢有報(bào)道，骨折愈合快，并發(fā)癥少［4］。肱骨解剖形態(tài)存在特異性，肱骨的前側(cè)有縱行的嵴，鈦板放置在正前方存在較大困難；鈦板放置在前外側(cè)對(duì)橈神經(jīng)的干擾較大；鈦板放置在前內(nèi)側(cè)對(duì)內(nèi)側(cè)血管神經(jīng)束也存在干擾，且肱骨骨折線較高時(shí)近端鈦板放置位置過(guò)高也會(huì)對(duì)肩關(guān)節(jié)的功能造成影響。肱骨中段骨折切開(kāi)復(fù)位鈦板內(nèi)固定的治療中，理想的鈦板放置位置可能是骨折近端放置在肱骨的外側(cè)，骨折遠(yuǎn)端放置在肱骨的前側(cè)，因此預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨中段骨折成為可能。北京大學(xué)人民醫(yī)院創(chuàng)傷骨科自2012年1月至2015年12月，采取MIPPO技術(shù)經(jīng)前側(cè)入路預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨干中段B型、C型骨折患者16例，取得了較好的治療效果，現(xiàn)將臨床療效及觀察結(jié)果進(jìn)行總結(jié)。

資料與方法

一、一般資料

2012年1月至2015年12月，應(yīng)用MIPPO技術(shù)經(jīng)前側(cè)入路預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨干中段B型、C型骨折患者16例，其中男6例，女10例；年齡43～70歲，平均（55．8±9．1）歲；根據(jù) AO分型：B型11例，C型5例。所有患者均為閉合性骨折，不伴隨橈神經(jīng)損傷。2例患者因交通事故合并頭面部及下肢軟組織開(kāi)放傷，均遠(yuǎn)離骨折部位。致傷原因：交通事故5例，摔傷9例，高處墜落傷2例。受傷至手術(shù)時(shí)間1～6d，平均（2．5±1．5）d。

二、手術(shù)方法

14例患者手術(shù)采用臂叢麻醉，2例合并其他部位外傷患者采用全身麻醉。術(shù)中應(yīng)用4．5mm干骺端鎖定加壓鋼板（locking compression plate，LCP）（辛迪思公司）或者肱骨外側(cè)解剖板（美國(guó)邦美公司）。手術(shù)開(kāi)始前進(jìn)行鈦板的預(yù)塑形處理，將鈦板的遠(yuǎn)、近端進(jìn)行6～8°的旋轉(zhuǎn)塑形?；颊哐雠P，患肢置于可透視外展手術(shù)板上，前臂旋后。首先于肘橫紋上行縱形切口，長(zhǎng)約4cm，于肱橈肌和肱肌之間找到橈神經(jīng)（不必游離神經(jīng)）后，于橈神經(jīng)內(nèi)側(cè)縱行劈開(kāi)肱肌，顯露肱骨遠(yuǎn)端前方。另取上臂近端縱形切口，長(zhǎng)約4cm，于三角肌及胸大肌間隙進(jìn)入，顯露肱骨近端。分別從遠(yuǎn)、近端切口作肱骨前方骨膜外肌下隧道，屈肘牽引復(fù)位，由上臂近端切口經(jīng)肌下隧道插入10～12孔預(yù)旋轉(zhuǎn)塑形處理過(guò)的LCP，LCP近端放置在肱骨外側(cè)，遠(yuǎn)端放置在肱骨前側(cè)。C型臂透視下見(jiàn)鈦板放置位置，骨折對(duì)位、對(duì)線及旋轉(zhuǎn)滿意后，骨折遠(yuǎn)、近端各擰入3～4枚鎖定螺釘固定，清洗傷口后逐層縫合關(guān)閉傷口。

三、術(shù)后處理

術(shù)后前臂吊帶懸垂保護(hù)3周，術(shù)后第2天起，患者在疼痛允許范圍內(nèi)行被動(dòng)肩關(guān)節(jié)及肘關(guān)節(jié)功能鍛煉。術(shù)后3周后行主動(dòng)肩關(guān)節(jié)和肘關(guān)節(jié)功能鍛煉。

四、臨床療效評(píng)價(jià)指標(biāo)

術(shù)后4個(gè)月內(nèi)每個(gè)月行X線檢查1次，以確定骨折愈合時(shí)間；4個(gè)月后每3個(gè)月行X線檢查1次；1年后每6個(gè)月行X線檢查1次。記錄手術(shù)時(shí)間、術(shù)后并發(fā)癥、骨折愈合時(shí)間、肩關(guān)節(jié)及肘關(guān)節(jié)活動(dòng)范圍。最后一次隨訪進(jìn)行肩關(guān)節(jié)和肘關(guān)節(jié)功能評(píng)分，肩關(guān)節(jié)功能采用美國(guó)加州大學(xué)洛杉磯分校（University of California，Los Angeles，UCLA）評(píng)分，肘關(guān)節(jié)功能采用Mayo評(píng)分。UCLA肩關(guān)節(jié)功能評(píng)分是評(píng)價(jià)肩關(guān)節(jié)功能的常用指標(biāo)，內(nèi)容包括疼痛（10分），活動(dòng)度（10分），向前屈曲活動(dòng)度（5分），向前屈曲力量（5分）及患者滿意度（5分）。Mayo肘關(guān)節(jié)功能評(píng)分系統(tǒng)是評(píng)價(jià)肘關(guān)節(jié)功能的常用指標(biāo)，內(nèi)容包括疼痛（45分）、關(guān)節(jié)活動(dòng)范圍（20分）、穩(wěn)定程度（10分）及日常功能（25分）方面的評(píng)價(jià)內(nèi)容。

結(jié) 果

所有患者均獲得了8～24個(gè)月隨訪，平均（16．13±4．54）個(gè)月；手術(shù)時(shí)間45～120min，平均（70．5±18．5）min。16例患者中有1例出現(xiàn)術(shù)中醫(yī)源性橈神經(jīng)損傷，經(jīng)營(yíng)養(yǎng)神經(jīng)藥物和電刺激的治療，術(shù)后1個(gè)月時(shí)腕關(guān)節(jié)和拇指的背伸功能完全恢復(fù)。骨折愈合時(shí)間10～21周，平均（13．5±3．0）周。肩關(guān)節(jié)外展105～120°，平均（112．5±4．6）°；前屈150～170°，平均（165．4±6．0）°。肘關(guān)節(jié)伸直0～8°，平均（4．8±2．0）°；屈曲 120～140°，平均 （132．5±5．8）°。在本組患者的隨訪中，肩關(guān)節(jié)功能依據(jù)UCLA評(píng)分標(biāo)準(zhǔn)：優(yōu)15例，良1例。肘關(guān)節(jié)功能依據(jù)Mayo評(píng)分標(biāo)準(zhǔn)：優(yōu)14例，良2例。

討 論

肱骨干骨折臨床常見(jiàn)，手術(shù)治療方法多采用髓內(nèi)針固定術(shù)及切開(kāi)復(fù)位板釘內(nèi)固定術(shù)［2］。目前肱骨干骨折的髓內(nèi)釘?shù)闹委熑源嬖跔?zhēng)議，順行入釘?shù)乃鑳?nèi)釘?shù)娜脶旤c(diǎn)會(huì)不可必免的損傷肩袖，從而影響肩關(guān)節(jié)的功能；逆行入釘?shù)乃鑳?nèi)釘也面臨肱骨遠(yuǎn)端背側(cè)皮質(zhì)較薄，手術(shù)操作難度較大以及容易發(fā)生骨化性肌炎等缺點(diǎn)。切開(kāi)復(fù)位板釘內(nèi)固定，目前認(rèn)為是治療肱骨干骨折最可靠的的手術(shù)方法［5］。切開(kāi)復(fù)位板釘內(nèi)固定存在手術(shù)創(chuàng)傷較大，軟組織骨膜血運(yùn)破壞較重等缺點(diǎn)。現(xiàn)在隨著生物固定的發(fā)展和進(jìn)步，微創(chuàng)和充分保護(hù)骨折斷端血運(yùn)的理念逐步被接受，采用MIPPO技術(shù)治療四肢骨折越來(lái)越普遍［6］。采用小切口經(jīng)皮插入鈦板，切口遠(yuǎn)離骨折部位，骨折斷端不干預(yù)，盡量保護(hù)骨膜，局部軟組織損傷少，最大程度保護(hù)了骨折斷端的血供，骨折愈合時(shí)間明顯縮短，減少了延遲愈合和不愈合的發(fā)生［7］。

根據(jù)AO分型和固定理念，A型骨折和部分B型骨折屬于簡(jiǎn)單骨折，適用于斷端加壓的堅(jiān)強(qiáng)內(nèi)固定［8］；而部分B型及C型骨折斷端相對(duì)粉碎，屬于相對(duì)復(fù)雜骨折，骨折斷端血供保護(hù)的要求較高，適用于生物學(xué)橋接固定。因此，MIPPO橋接技術(shù)尤其適用于B型及C型骨折［9］。有學(xué)者報(bào)道骨折線應(yīng)與冠狀窩的距離在6cm以上，才能保證肱骨骨折的遠(yuǎn)端部分能有足夠空間容納3枚鎖定螺釘［10］。本文報(bào)道16例病例均選擇為肱骨中段的骨折，且AO分型均為B型及C型骨折，術(shù)后隨訪均達(dá)到骨性愈合。

MIPPO技術(shù)治療肱骨干骨折盡量選擇鎖定板釘，可選擇鎖定加壓鈦板以及有限接觸鎖定加壓鈦板等。作者建議在考慮到肱骨長(zhǎng)度的個(gè)體差異的前提下，盡量選擇較長(zhǎng)的鈦板，骨折線遠(yuǎn)近端盡量要滿足至少3枚鎖定螺釘?shù)墓潭芏?。在本組16例患者中，選擇辛迪思公司干骺端4．5mm LCP或者美國(guó)邦美公司的解剖鎖定板釘作為內(nèi)固定物，術(shù)前將鈦板預(yù)旋轉(zhuǎn)塑形處理，使得鈦板近端放置在肱骨的外側(cè)，遠(yuǎn)端放置在肱骨的前側(cè)，具備了更高的貼合效應(yīng)，取得了很好的治療效果。通過(guò)MIPPO橋接技術(shù)獲得骨折斷端的穩(wěn)定，需要術(shù)中輔助通過(guò)間接閉合手法復(fù)位來(lái)達(dá)到，這種斷端未實(shí)現(xiàn)完全解剖復(fù)位的間接復(fù)位方法在獲得肱骨的解剖力線上是有一定難度的，術(shù)中進(jìn)行閉合復(fù)位的過(guò)程中不僅要維持肱骨的有效長(zhǎng)度、注意成角畸形的發(fā)生，還要注意出現(xiàn)旋轉(zhuǎn)畸形的可能［11］。作者的經(jīng)驗(yàn)是：術(shù)中將上肢充分外展以避免內(nèi)翻畸形，肘關(guān)節(jié)屈曲并保持前臂持續(xù)牽引以避免矢狀位成角畸形，術(shù)中多角度透視正位、側(cè)位及斜位，確保鈦板的位置和肱骨的大體解剖力線。術(shù)中將肱骨干遠(yuǎn)端在中立位通過(guò)屈肘90°確定肱骨干的前方，近端通過(guò)同一切口在結(jié)節(jié)間溝處打入1枚克氏針，通過(guò)調(diào)整克氏針，將克氏針調(diào)整到與肱骨遠(yuǎn)端內(nèi)外側(cè)髁連線相垂直的位置，同時(shí)結(jié)合X線透視正位X線片，來(lái)確定旋轉(zhuǎn)對(duì)位［12］。本組16例患者中術(shù)后肘關(guān)節(jié)的內(nèi)外翻與正常側(cè)對(duì)照均在3～5°的范圍內(nèi)，旋轉(zhuǎn)移位2～5°，肘關(guān)節(jié)的功能基本不受影響，同時(shí)隨訪中也未發(fā)現(xiàn)螺釘拔出、折斷及鈦板斷裂、移位等情況。當(dāng)然，微創(chuàng)技術(shù)相對(duì)于切開(kāi)復(fù)位內(nèi)固定技術(shù)需要術(shù)中更多次的進(jìn)行透視確認(rèn)，在初期會(huì)增加患者及術(shù)者的射線暴露，隨著技術(shù)及操作的成熟，后期可將這一弊端盡可能降低，相對(duì)于切開(kāi)復(fù)位對(duì)患者造成的創(chuàng)傷，認(rèn)為這些不利影響是可以接受的。

本組16例患者中，早期出現(xiàn)過(guò)1例醫(yī)源性橈神經(jīng)損傷，術(shù)后短時(shí)間內(nèi)出現(xiàn)患側(cè)不能腕關(guān)節(jié)背伸，虎口區(qū)域麻木不適，術(shù)后1個(gè)月隨訪時(shí)腕關(guān)節(jié)背伸功能恢復(fù)。作者認(rèn)為，此1例醫(yī)源性橈神經(jīng)損傷的出現(xiàn)是由于開(kāi)展該技術(shù)早期，對(duì)橈神經(jīng)的游離保護(hù)性措施的不當(dāng)有關(guān)。早期在遠(yuǎn)端切口內(nèi)找到橈神經(jīng)分離橡皮條牽引保護(hù)，可能與分離、牽拉有關(guān)。后期在進(jìn)行遠(yuǎn)端切口顯露時(shí)，找到橈神經(jīng)后，不做游離，在橈神經(jīng)內(nèi)側(cè)縱行切開(kāi)肱肌，將橈神經(jīng)連同肱肌一并牽向外側(cè)，術(shù)中始終保持肘關(guān)節(jié)屈曲，橈神經(jīng)松弛，未再次出現(xiàn)醫(yī)源性橈神經(jīng)損傷現(xiàn)象。

本組16例患者觀察結(jié)果顯示：雖然骨折愈合時(shí)間不同，但均達(dá)到臨床骨性愈合。應(yīng)用MIPPO橋接技術(shù)治療肱骨干骨折，骨折達(dá)到二期愈合，較一期愈合強(qiáng)度更高，骨折經(jīng)過(guò)再塑形后所能達(dá)到的強(qiáng)度更高［13］。在獲得隨訪的病例中，未發(fā)現(xiàn)拆除鈦板后再骨折病例。將鎖定鈦板預(yù)旋轉(zhuǎn)塑形后，鈦板更加貼合肱骨前外側(cè)的解剖學(xué)形狀。預(yù)旋轉(zhuǎn)塑形后的鎖定鈦板與MIPPO技術(shù)相結(jié)合，減少了對(duì)肌肉軟組織的刺激，有效的保護(hù)了骨折斷端的血運(yùn)，較好的保護(hù)了橈神經(jīng)，提高了手術(shù)的安全性。

本研究是回顧性病例治療經(jīng)驗(yàn)總結(jié)，存在一定局限性，療效是否確切還需要較大規(guī)模的臨床前瞻性隨機(jī)對(duì)照研究。

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Treatment of humeral shaft fracture （Type B，C）with pre－rotating moulding locking plate by anterior approach MIPPO technique

Zhang Peixun，F(xiàn)u Zhongguo，Wang Yilin，Ma Mingtai，Xue Feng．Department of Trauma and Orthopedics，Peking University People′s Hospital，Beijing 100044，China

Xue Feng，Email：drxuefeng＠163．com

BackgroundHumeral shaft fractures are common，accounting for 2%of the total cases．In recent years，the treatment of humeral shaft fracture has been developed from traditional conservative plaster fixation to plate－screw and intramedullary nail fixation．The application of plate screw for open reduction and internal fixation or closed reduction intramedullary nail fixation has become the golden standard for surgical treatment of humeral shaft fractures．The treatment of humeral shaft fracture with open reduction and internal plate fixation requires the stripping of soft tissuesand muscles．This operation interferes with the blood supply of fracture ends and increases therisk of radial nerve injury．With the renewal of biological fixation theory of AO，indirect reduction technique which emphasizes the protection of soft tissue around fracture has been thrived．It has been reported repeatedly in nation that humeral shaft fracture can be treat with percutaneous plate fixation through minimally invasive percutaneous osteosynthesis，a strategy that results in high curing speed and less complication．Because of the specific anatomical structure of the humeral shaft，it is difficult to put a plate in front of the anterior longitudinal ridge．While the plate placed on the anterolateral side usually interferes with the radial nerve，the plate placed on the anteromedial side of the shaft also interferes with the neurovascular bundle．When the humeral fracture line is high，the corresponding proximal plate placement will affect the function of the shoulder joint．To treat the humeral shaft fracture with open reduction and plate fixation，the ideal position of the plate placement may be the lateral side of the humeral shaft when the plate is proximal to humeral fracture and the front side of the humeral shaft whenthe plate isdistal to humeral fracture．Therefore，the pre－rotating moulding locking plate become a possible solution for the treatment of humeral shaft fracture．From January 2012to December 2015，16cases of humeral shaft type B and type C fractures were treated with anterior approach pre－rotating moulding locking plate．The clinical curative effects and observations are summarized as follows．Methods（1）General data．16patients（6males and 10females）aging from 43 to 70years old （55．8±9．1）was documented．According to AO classification，11cases are type B fracture，and 5cases are type C fracture．Of the total 16cases，5cases were caused by traffic accidents，9cases by tumble，and 2cases by falling injury．All fractures were closed without radial nerve injury，while 2patients with traffic accident suffered from combined head and lower limb soft tissue injury away from the fracture site．（2）Treatment measures．14patients

brachial plexus anesthesia，and the other 2patients received general anesthesia．4．5mm locking compressed plate or lateral humeral anatomical plate（Biomed，USA）was used during the surgical operation，and 6°to 8°of plastic rotating moulding were made beforehand．The patient was supine，and the affected limb was placed on the X－ray abduction surgical plate．First of all，a longitudinal incision of approximately 4cm in length were performed on the cubital upstream．After the radial nerve between the brachioradialis and brachialis was found，the front of the humeral distal part was exposed by splittingthe obrachialis under the radical nerve．Then，the proximal humerus was exposed with another 4cm proximal longitudinal incision between the deltoid and pectoralis．A lateral muscle tunnel beyond the periosteum was drawn between distal and proximal incisions．With elbow flexion and traction reduction，a 10－12 holes pre－rotating moulding plate was inserted into the muscle channel with the proximal end placed on the lateral side of proximal humerus and the distal end placed on the front sideof distal humerus．After being placed properly under the intraoperative fluoroscopy，the plate was fixed with 3－4locking screws on both the proximal and the distal side．Finally，the wound was closed after cleaning．（3）Postoperative treatment．All patients received forearm sling suspension protection for 3weeks after the surgical operation．Starting from the second day of the surgery，passive shoulder joint and elbow joint functional exercise were performed within the range of pain tolerance of the patients．Active shoulder joint and elbow joint functional exercise were performed 3weeks after the surgery．For the purpose of assessing the fracture curing time，the patients received X－ray check per month within 4months of the operation，per 3months after 4months of the operation，and per 6months after one year of the operation．The time of surgery，postsurgical complications，fracture curing time，and the range of motions ofshoulder joint and elbow jointwere also recorded．During the last time of postoperative follow－up，the visitors adopted the University of California Los Angeles（UCLA）systems and Morrey elbow joint function evaluation systems to evaluate the functions of shoulder and elbow．Functions of shoulder joint were assessed by the UCLA grading standard，a criterion that includes the shoulder joint pain（10points），range of motion（10points），the initiative lift angle on anterior direction（5 points），muscle strength（5points），and patients′subjective satisfaction（5points）．The functions were evaluated from 4aspects：the pain degree（45points），range of motion（20points），stability（10 points），and daily life ability（25points）．The total score is 100points：90－100points is excellent；75－89points is good；60－74is ok；less than 60points is poor．Results All patients had been followed up for 8to 24months（16．13±4．54）．The surgical operation time rangesfrom 45to 120minutes（70．5±18．5），and the curing of the fracture take 10to 21weeks（13．5±3．0）．The abduction of shoulder joint ranges from 105°to 120°（112．5°±4．6°）；the forward flexion ranges from 150°to 170°（165．4°±6．0°）．The extension of elbow joint ranges from 0°to 8°（4．8°±2．0°）；the flexion ranges from 120°to 140°（132．5°±5．8°）．Out of the 16treated patients，there was only one case of clinical triggered damage of radical nerve．With the treatment of neurotrophic drugs and electrostimulation，the dorsiflexion of wrist and thumb fully recovered one month after the surgery．In the last postoperative assessment，the UCLA score were excellent for 15patients and good for 1patient．During the last postoperative followup，the visitors further adopted the Morrey evaluation system for the evaluation of the functions of elbow and joint．The score were excellent for 14patients and good for 2patients．Conclusions

Nowadays，open reduction and internal fixation is considered asthe most reliable surgical method for the treatment of humeral shaft fractures．Open reduction and plate fixation may result in large operative trauma and severe destruction of the blood supply toward soft tissues and periosteal．With the current development of the biological fixation，the concepts of minimally invasive treatment and the protection for blood supply toward fracture ends aregradually accepted．Moreover，the use of MIPPO technology for the treatment of limb fractures is becoming more and moreprevalent．Humeral shaft fractures treated with MIPPO technology can achieve better outcomes，and fractures after remodeling can achieve higher strength．The locking plate with pre－rotating moulding anatomically fits better to the anterolateral side of humerus．Locking plate with pre－rotating moulding combined with MIPPO technology reduce the irritation to muscle and soft tissue，effectively protect the blood supply toward the fracture site and the radial nerve，and improve the safety of the surgical operation．

Minimally invasive percutaneous plate osteosynthesis；Locking compressed plate；Internal fixation；Humeral shaft；Fracture

2016－05－31）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10．3877/cma．j．issn．2095－5790．2017．01．002

國(guó)家科技部973計(jì)劃（2014CB542201）；國(guó)家科技部863計(jì)劃（SS2015AA020501）；教育部創(chuàng)新團(tuán)隊(duì)（IRT1201）；國(guó)家自然科學(xué)基金（31571235）；國(guó)家自然科學(xué)基金（31271284）；國(guó)家自然科學(xué)基金（31171150）；教育部新世紀(jì)優(yōu)秀人才計(jì)劃（BMU20110270）

100044 北京大學(xué)人民醫(yī)院創(chuàng)傷骨科

薛峰，Email：drxuefeng＠163．com

張培訓(xùn)，付中國(guó)，王依林，等．應(yīng)用MIPPO技術(shù)前側(cè)入路預(yù)旋轉(zhuǎn)塑形鎖定板釘治療肱骨干中段B型、C型骨折 ［J/CD］．中華肩肘外科電子雜志，2017，5（1）：3－8．