周金華 戴峰 劉杰 鄭志良 袁霆

干骺端LCP前側(cè)微創(chuàng)與外側(cè)切開治療肱骨中下段骨折的臨床療效分析

周金華1戴峰1劉杰1鄭志良1袁霆2

目的探討干骺端鎖定加壓鋼板（locking compression plates，LCP）前側(cè)微創(chuàng)與外側(cè)切開治療肱骨中下段骨折的臨床療效。方法回顧性分析溧陽市人民醫(yī)院2009年1月至2015年1月收治的肱骨中下段骨折患者30例，其中男17例，女13例，年齡22～80歲，平均51.2歲。分別采用干骺端LCP前側(cè)微創(chuàng)經(jīng)肱肌中外1/3入路(A組）和外側(cè)經(jīng)肱橈肌與肱肌間隙解剖橈神經(jīng)入路（B組）治療，兩組各15例。記錄手術(shù)時(shí)間、術(shù)中失血量、術(shù)后平均住院時(shí)間、平均骨折愈合時(shí)間、醫(yī)源性橈神經(jīng)麻痹發(fā)生率、切口感染的發(fā)生率、Mayo肘關(guān)節(jié)功能評(píng)分及臂、肩、手功能障礙功能評(píng)分。結(jié)果所有患者術(shù)后均獲隨訪，隨訪時(shí)間為12～18個(gè)月，平均15.3個(gè)月。兩組患者在術(shù)后平均骨折愈合時(shí)間、術(shù)后切口感染的發(fā)生率上差異無統(tǒng)計(jì)學(xué)意義（P＞0.05）。A組手術(shù)時(shí)間、術(shù)中失血量、醫(yī)源性橈神經(jīng)麻痹發(fā)生率、平均住院時(shí)間低于B組（P ＜0.05）；A組Mayo肘關(guān)節(jié)功能評(píng)分及臂、肩、手功能障礙功能評(píng)分優(yōu)于B組（P ＜0.05）。結(jié)論采用干骺端LCP前側(cè)微創(chuàng)治療肱骨中下段骨折臨床療效優(yōu)于外側(cè)切開。

鎖定加壓鋼板； 肱骨中下段； 微創(chuàng)

肱骨中下段骨折的治療方法較多，效果也各不相同。保守治療骨折愈合率高，但易畸形愈合，且因外固定時(shí)間長(zhǎng)而導(dǎo)致關(guān)節(jié)功能障礙，傳統(tǒng)外側(cè)切開手術(shù)需解剖橈神經(jīng)，手術(shù)時(shí)間較長(zhǎng)、出血多、二期取內(nèi)固定可能更易損傷橈神經(jīng)。近年來,微創(chuàng)鋼板內(nèi)固定術(shù)因具有創(chuàng)傷小、骨折愈合率高的優(yōu)點(diǎn),在臨床上應(yīng)用逐步增多。本院2009年1月至2015年1月共收治的肱骨中下段骨折患者30例，分別采用干骺端鎖定加壓鋼板（locking compression plates，LCP）前側(cè)微創(chuàng)經(jīng)肱肌中外1/3入路和外側(cè)經(jīng)肱橈肌與肱肌間隙解剖橈神經(jīng)入路治療，治療結(jié)果報(bào)道如下。

資料與方法

一、一般資料

按手術(shù)入路的不同將所有患者分為A組（1～15號(hào)）、B組（16～30號(hào)），兩組各15例。A組：男8例，女7例；年齡22～78歲，平均年齡55.5歲；骨折AO骨折分型：A型8例，B型4例，C型3例。B組：男9例，女6例；年齡27～80歲，平均年齡58.5歲；骨折AO骨折分型：A型7例，B型4例，C型4例。所有患者均為閉合型骨折，且術(shù)前均無橈神經(jīng)損傷癥狀。

二、手術(shù)方法

（一）術(shù)前準(zhǔn)備

常規(guī)行各項(xiàng)術(shù)前檢查，先行排除及治療內(nèi)科疾??；檢查有無橈神經(jīng)損傷癥狀，有癥狀者行肌電圖檢查，肌電圖顯示有神經(jīng)損傷者排除在本研究外。

（二）影像學(xué)觀察

所有患者術(shù)前均拍肱骨正側(cè)位片，行CT及三維重建檢查，以求明確骨折類型。

（三）手術(shù)方法

1. A組：頸叢加臂叢麻醉下，沙灘位，上臂外展90°，前臂旋后位，置可透視手術(shù)桌上。首先在骨折端處前外側(cè)作3 cm輔助小切口，將肱二頭肌牽向內(nèi)側(cè)并顯露肱肌，沿肱肌中外1/3縱向鈍性劈開，暴露骨折端，骨膜下剝離，手法復(fù)位后克氏針或拉力螺釘固定；然后于上臂近端前方，三角肌與肱二頭肌交界處作3 cm的縱向切口，骨膜下剝離并連通骨折端切口；最后于肘橫紋近端前側(cè)作約3 cm切口，較骨折端輔助切口偏內(nèi)側(cè)，縱向鈍性劈開肱二頭肌肌腹及肱肌，插入骨膜剝離器，向近端行骨膜下剝離，直至骨折端切口。從上向下插入盡量長(zhǎng)的干骺端LCP。在此過程中，助手協(xié)助屈肘，以放松前臂屈肌便于操作。于鋼板兩端的釘孔各打入1枚2.0克氏針，臨時(shí)固定。透視機(jī)確認(rèn)鋼板遠(yuǎn)端位于冠狀窩上緣，鋼板與肱骨干長(zhǎng)軸一致，骨折斷端無分離和短縮。在鋼板兩端（肱骨中1/3以外）各打入3～4枚鎖定螺釘。

2. B組：頸叢加臂叢麻醉下，沙灘位，常規(guī)消毒鋪單，取肱骨中下段外側(cè)切口，約12 cm，逐層切開皮膚、皮下筋膜，從肱二頭肌和肱三頭肌間隙進(jìn)入暴露骨折端，從肱肌和肱橈肌間隙中暴露橈神經(jīng)，見橈神經(jīng)無明顯挫傷，牽開予以保護(hù)，牽引復(fù)位肱骨，清除骨折端軟組織及血凝塊，復(fù)位，置入肱骨干鎖定鋼板，遠(yuǎn)、近端各3～4枚鎖定釘固定。

三、術(shù)后處理

術(shù)后24 h內(nèi)應(yīng)用抗生素，術(shù)后48 h拔除引流管，術(shù)后2周拆線。術(shù)后患肢頸腕帶保護(hù)，術(shù)后第1天即囑患者進(jìn)行肩關(guān)節(jié)和肘關(guān)節(jié)的主動(dòng)活動(dòng)。術(shù)后 1、2、3、6、9、12、18個(gè)月復(fù)診，拍攝肱骨正側(cè)位片，見圖1，2。

四、評(píng)價(jià)指標(biāo)

記錄手術(shù)時(shí)間、術(shù)中失血量、術(shù)后平均住院時(shí)間、平均骨折愈合時(shí)間、醫(yī)源性橈神經(jīng)麻痹發(fā)生率、切口感染的發(fā)生率、Mayo肘關(guān)節(jié)功能評(píng)分及臂、肩、手功能障礙（disabilites of the arm，shoulder and hand，DASH）功能評(píng)分。

五、統(tǒng)計(jì)學(xué)分析

采用SPSS 22.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)量資料以 x-±s表示，組間比較采用兩獨(dú)立樣本均數(shù)t檢驗(yàn)，P ＜0.05認(rèn)為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

所有患者術(shù)后均獲隨訪，隨訪時(shí)間為12～18個(gè)月，平均（15.3±1.3）個(gè)月。術(shù)后平均骨折愈合時(shí)間A組患者為（13.7±0.7）周，B組為（14.0±0.7）周，兩者差異無統(tǒng)計(jì)學(xué)意義（P＞0.05）。兩組患者術(shù)后均無手術(shù)切口感染發(fā)生。平均手術(shù)時(shí)間A組為100.5 min，B組為129.3 min，兩者差異有統(tǒng)計(jì)學(xué)意義（P ＜0.05）。平均術(shù)中失血量A 組為（96.3±9.7）ml，B 組為（238.7±60.2）ml,兩者差異有統(tǒng)計(jì)學(xué)意義（P ＜0.05）。B組術(shù)后出現(xiàn)2例橈神經(jīng)麻痹癥狀，經(jīng)保守治療后4個(gè)月左右恢復(fù)，考慮術(shù)中牽拉所致。平均住院時(shí)間A 組 為（7.3±1.0）d，B組 為（13.5±1.2）d， 兩者差異有統(tǒng)計(jì)學(xué)意義（P ＜0.05）。末次隨訪平均Mayo肘關(guān)節(jié)功能評(píng)分A組為（95.0±1.4）分，B組為（81.2±4.8）分，兩者差異有統(tǒng)計(jì)學(xué)意義（P ＜0.05）。平均DASH上肢功能評(píng)分A組為（12.1±1.1）分，B組為（24.3±1.9）分，兩者差異有統(tǒng)計(jì)學(xué)意義（P ＜0.05）?；颊呋举Y料見表1。

討 論

一、肱骨中下段骨折治療方法

肱骨干骨折約占全身骨折的1%，是一種常見的上肢創(chuàng)傷。肱骨周圍解剖結(jié)構(gòu)復(fù)雜，其近段前側(cè)有肌皮神經(jīng)，內(nèi)側(cè)有正中神經(jīng)、尺神經(jīng)、肱動(dòng)脈和肱靜脈通過，中1/3段后側(cè)有橈神經(jīng)通過，行走于肱骨干下1/3外側(cè)。肱骨干本身形態(tài)也較復(fù)雜，中段以上為圓形且較粗，至下1/3段逐漸變成扁三角形，并稍向前傾，故肱骨干中下段骨折在臨床上較常見［1］。肱骨干中下段骨折目前的治療方法尚無定論。非手術(shù)治療愈合率較高，但易發(fā)生畸形愈合，且因長(zhǎng)時(shí)間制動(dòng)而導(dǎo)致肩、肘關(guān)節(jié)功能障礙［2-3］。髓內(nèi)釘固定對(duì)于肱骨干中下段骨折沒有優(yōu)勢(shì)［4］，順行髓內(nèi)釘?shù)墓ぷ骶嚯x太長(zhǎng)，骨折線距離遠(yuǎn)端鎖釘太近，穩(wěn)定性差；逆行髓內(nèi)釘易造成醫(yī)源性肱骨髁上骨折［5］。外固定支架也是一種方法，但容易并發(fā)釘?shù)栏腥?、松?dòng)，影響生活和肘關(guān)節(jié)的功能［6］。切開復(fù)位鋼板固定是目前治療肱骨干中下段骨折最主要的方法，其優(yōu)點(diǎn)在于骨折可獲解剖復(fù)位，肩、肘關(guān)節(jié)功能影響較小，缺點(diǎn)在于軟組織剝離較多，易發(fā)生醫(yī)源性橈神經(jīng)損傷，同時(shí)切開復(fù)位導(dǎo)致骨折斷端血供受損加重，骨不連發(fā)生率增高。近年來微創(chuàng)技術(shù)的發(fā)展，閉合復(fù)位內(nèi)固定術(shù)的興起，避免了解剖橈神經(jīng)，縮短了手術(shù)時(shí)間。

表1 所有患者基本資料

二、外側(cè)切開解剖橈神經(jīng)治療肱骨中下段骨折

通常認(rèn)為外側(cè)切開復(fù)位鋼板內(nèi)固定是最可靠的治療方法［7-8］，但存在創(chuàng)傷大，骨不連發(fā)生率高的缺點(diǎn)［9-10］。外側(cè)入路切開復(fù)位者，需要游離橈神經(jīng)，并用橡皮條輕輕加以保護(hù)，以免術(shù)中將其誤切。骨折復(fù)位固定后，要將橈神經(jīng)置于健康組織內(nèi)，切忌將橈神經(jīng)直接置于鋼板或骨質(zhì)的表面，避免損傷組織形成瘢痕壓迫橈神經(jīng)，或者鋼板及骨質(zhì)對(duì)橈神經(jīng)形成硬性壓迫。本研究B組15例患者術(shù)前均無橈神經(jīng)損傷，術(shù)后有2例患者出現(xiàn)一過性橈神經(jīng)麻痹癥狀，考慮術(shù)中牽拉損傷所致，2例患者術(shù)后3個(gè)月內(nèi)均恢復(fù)正常。術(shù)中對(duì)橈神經(jīng)的解剖及內(nèi)固定置入后的妥善處理至關(guān)重要，二期取內(nèi)固定時(shí)因組織粘連更應(yīng)謹(jǐn)慎。

圖1 患者男性，36歲，跌傷致右肱骨中下段骨折，術(shù)前拍正側(cè)位X線片（A，B）示B1型骨折；采用干骺端LCP微創(chuàng)前側(cè)治療（C），術(shù)后3 d（D、E）、6個(gè)月（F、G）復(fù)查正側(cè)位X線；術(shù)后12個(gè)月取內(nèi)固定時(shí)功能位照片（H）,術(shù)后患者對(duì)治療效果滿意

三、干骺端LCP微創(chuàng)前側(cè)治療肱骨中下段骨折

肱骨干前側(cè)骨面平整，表面覆蓋肱肌和肱二頭肌，沒有重要的血管和神經(jīng)通過，適合鋼板內(nèi)固定的放置。但如果前方行傳統(tǒng)的切開復(fù)位，需要全程切開前方覆蓋的肱肌，創(chuàng)傷較大［11］。針對(duì)于此，僅切開肱肌的兩端、在其下方插入鋼板固定的微創(chuàng)方法，被一些學(xué)者開始應(yīng)用。安智全等［12］解剖學(xué)研究證明前側(cè)鋼板固定肱骨中下段的骨折時(shí)，鋼板絕大部分被肱肌肌腹覆蓋，鋼板與橈神經(jīng)在穿過外側(cè)肌間隔的部位與鋼板之間的距離＞1.0 cm。在距離最近的冠狀窩上緣水平，鋼板外側(cè)緣和橈神經(jīng)之間的距離也＞5.0 mm。因此在上臂前側(cè)經(jīng)皮、肌下的微創(chuàng)插入鋼板固定肱骨中下段的骨折不會(huì)影響橈神經(jīng)功能，本研究A組15例患者術(shù)后無一例出現(xiàn)橈神經(jīng)損傷，也表明干骺端LCP微創(chuàng)前側(cè)治療肱骨中下段骨折是安全的。與安智全等介紹的全程微創(chuàng)不暴露骨折端的操作不同的是，本研究加用了骨折端前外側(cè)小切口輔助復(fù)位。因?yàn)?，作者發(fā)現(xiàn)在全程微創(chuàng)操作過程中，如果不暴露骨折端，通過間接復(fù)位的方法往往難以有效糾正骨折端的錯(cuò)位。通過輔助小切口，可以直視下復(fù)位骨折端，獲得解剖或近似解剖的復(fù)位，節(jié)省手術(shù)時(shí)間。此外，采用骨折端小切口輔助復(fù)位的微創(chuàng)方式，對(duì)于某些螺旋型骨折（復(fù)位時(shí)可能將橈神經(jīng)夾在骨折端），較全程微創(chuàng)有著明顯優(yōu)勢(shì)，可以直視下確保骨折端中無軟組組，減少了術(shù)中損傷橈神經(jīng)的可能。國(guó)外學(xué)者提出橈神經(jīng)肱肌支存在率為81.6%，其中從肱肌外側(cè)面下面進(jìn)入肱肌的為83%，從肱肌中1/3處進(jìn)入的為17%［13］。陳琳等［14］對(duì)國(guó)人橈神經(jīng)肱肌支研究后發(fā)現(xiàn)，橈神經(jīng)肱肌支存在率達(dá)51.4%。故為了保存肱肌的屈肌功能，作輔助小切口時(shí)向內(nèi)側(cè)牽開肱二頭肌肌腹，肱肌中外1/3縱形鈍性劈開。作遠(yuǎn)端小切口時(shí)同樣鈍性分離無法內(nèi)側(cè)牽拉的肱二頭肌和下方的肱肌，同時(shí)盡量偏內(nèi)側(cè)，避免損傷前臂外側(cè)皮神經(jīng)。

綜上所述，認(rèn)為采用干骺端LCP微創(chuàng)前側(cè)治療肱骨中下段骨折是一種安全、有效的方法，可以減輕手術(shù)創(chuàng)傷、縮短住院天數(shù)、降低醫(yī)源性橈神經(jīng)損傷以及更好的關(guān)節(jié)功能恢復(fù)。

圖2 患者男性,27歲，跌傷致左肱骨中段骨折，術(shù)前拍正位X線片（A）示A1型骨折；采用外側(cè)入路解剖橈神經(jīng)內(nèi)固定治療，術(shù)后3 d（B、C）、6個(gè)月（D、E）復(fù)查正側(cè)位X線片；術(shù)后12個(gè)月功能位照片（F）,術(shù)后患者對(duì)治療效果滿意

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Yuan Ting, Email: terrenceyuan@gmail.com

Clinical efficacy analysis of minimally invasive plate osteosynthesis via anterior approach versus conventional fixation technique via lateral approach in the treatment of middle-inferior fracture of humeral shaft

Zhou Jinhua1, Dai Feng1, Liu Jie1, Zheng Zhiliang1, Yuan Ting2.1Department of Orthopaedics,Liyang People's Hospital, Liyang 213300, China;2Department of Orthopaedics, The 6th Affiliated People's Hospital of Shanghai Jiaotong University,Shanghai 200233,China

BackgroundThe treatment for the middle-inferior fracture of humeral shaft is numerous, and the effect is variant. Conservative treatment has high rate of fracture healing. Because of malunion and long duration of external fixation, however, this type of treatment leads to joint dysfunction easily. Traditional lateral incision requires the anatomy of radial nerve, long operation time and more bleeding. Furthermore, the removal of internal fixator during the secondary procedure may cause radical nerve injury more easily. In recent years, minimally invasive plate osteosynthesis（MIPO） has been widely used on clinic due to its advantages of small trauma and high rate of bone healing. From January 2009 to January 2015, 30 patients with middle-inferior humeral shaft fractures were treated respectively with locking compression plates （LCP） in minimally invasive anterior approach （via the medial and lateral 1/3 of brachialis） and lateral approach （via the intermuscular space between radial muscle and brachial muscle for radial nerve anatomy） in our hospital. This study provides a retrospective analysis of treatment result.MethodsI. General Information.All patients had closed fractures, and none of them showed symptoms of radial nerve injury. According to the difference between surgical approaches, the patients were divided into group A （No. 1-15） and group B （No. 16-30）. The fracture patterns were classified based on AO classification. Group A: 8 males and 7 females; age range: 22-78 years with an average of 55.5 years; AO classification: 8 cases of type A, 4 cases of type B and 3 cases of type C. Group B: 9 males and 6 females; age range: 27-80 years with an average of 58.5 years; AO classification: 7 cases of type A, 4 cases of type B and 4 cases of type C. II. Operative methods. （1）Preoperative preparation: Preoperative examinations were performed routinely to exclude and treat internal disease firstly. The symptoms of radial nerve injury were checked, and EMG examination was performed on the symptomatic patients. The patients with nerve injury showed by the EMG were excluded from this study.（2）Imaging observation: To define the type of fracture, all patients were carried out with the X-ray films of humeral shaft in anteroposterior and lateral views and the CT scan with 3 dimensional reconstruction preoperatively.（3）Operative methods: Group A: Under cervical plexus and brachial plexus blocks, the patient was in beach chair position with the affected upper arm abducted in 90° and the forearm supinated on the operation table. Firstly, a 3 cm small assisted incision was made at the anterolateral side of fracture end, and the biceps was retracted medially to expose brachial muscle. The brachial muscle was bluntly and longitudinally split along the mediolateral 1/3 part to expose fracture end. After subperiosteal dissection and manual reduction, the fracture was temporarily fixed with Kirschner wire or lag screw;then, a 3 cm longitudinal incision was made at the juncture of deltoid and biceps, which was anterior to the proximal end of upper arm. The subperiosteum was dissected to connect the incision of fracture end; finally, an incision of approximately 3 cm was made before the proximal end of cubital crease,which was medial to the assisted incision of fracture end. The biceps and brachialis were split bluntly and longitudinally to insert periosteum detacher, and the subperiosteum was dissected proximally till the incision of fracture end. The metaphysis LCP of the largest possible length was inserted from the top down. During this process, the assistant assisted elbow flexion to relax the forearm flexors for easy operation. The nail holes on both ends of plate were inserted with a 2.0 kirschner wire respectively for temporary fixation. With the confirmation under fluoroscopy, the distal end of plate was located at the upper margin of coronary fossa, and the plate was in accordance with the long axis of humeral shaft without the separation and shortening of fracture end. Both ends of the plate （apart from the 1/3 of humerus） were inserted with 3-4 locking screws respectively.Group B: Under cervical plexus and brachial plexus blocks, the patient was in beach chair position with conventional disinfection and draping. An incision of approximately 12 cm was made at the middle - lower segment of lateral humerus, and the skin and subcutaneous fascia were cut layer by layer. The fracture end was exposed via the gap between biceps and triceps, and the radial nerve was exposed through the gap between brachialis and brachioradialis. Being confirmed with no obvious damage, the radial nerve was retracted for protection. After the soft tissue and blood clots at fracture end were debrided, the humerus was reduced by traction. The locking plate of humeral shaft was inserted, which was fixed with 3-4 locking screws on the distal and proximal ends respectively. III. Postoperative treatment:Antibiotic was applied within 24 hours after operation. After surgery, the drainage tube and stich were removed 48 hours and 2 weeks later respectively. The affected limb was in neck-wrist sling for protection after operation, and active movements of shoulder and elbow joints were performed on the 1st postoperative day. Further consultation was carried out in the 1st, 2nd, 3rd, 6th, 12th and 18th postoperative months, and the X-ray films of humeral shaft were taken in anteroposterior and lateral views every time.IV. Evaluation index:The operation time, intraoperative blood loss, postoperative hospitalization time, mean time of fracture healing, incidence of iatrogenic radial nerve palsy, incidence of incision infection, Mayo elbow function score and DASH score of upper limb function were recorded.V. Statistical analysis:The SPSS 22.0 statistical software was used for statistical analysis. The measurement data were expressed asx-±s , and the t tests of two independent sample means were used for comparison between groups.P＜0.05 was considered as statistical difference.ResultsAll patients were followed up for 12-18 months with an average of （15.3±1.3） months. The mean healing times for patients in group A and group B were （13.7±0.7） weeks and （14±0.7） weeks respectively, and there was no significant statistical difference between the two groups （P＞0.05）. No incision infection occurred in both the groups after operation. The mean operation times for group A and group B were 100.5 min and 129.3 min respectively, and there was significant statistical difference between the two groups （P＜0.05）. The average intraoperative blood losses for group A and group B were （96.3±9.7） ml and （238.7±60.2）ml respectively, and there was significant statistical difference between the two groups （P＜0.05）. Due to the intraoperative nerve traction, 2 cases of radial nerve paralysis occurred after operation in group B and recovered after approximately 4 months of conservative treatment. The average hospitalization durations for group A and group B were （7.3±1.0） days and （13.5±1.2） days respectively, and there was significant statistical difference between the two groups （P＜0.05）. During the last follow up, the average Mayo elbow function scores for group A and group B were （95.0±1.4） points and （81.2±4.8）points respectively, and there was significant statistical difference between the two groups （P＜0.05）.The average DASH upper limb function scores for group A and group B were （12.1±1.1） points and（24.3±1.9） points respectively, and there was significant statistical difference between the two groups（P＜0.05）ConclusionsMinimally invasive anterior approach in combined with metaphyseal LCP is a safe and effective method to treat the middle-inferior fracture of humeral shaft. This strategy reduces surgical trauma, shortens hospital stay, reduces iatrogenic radial nerve injury and facilitates better joint function recovery.

Locking compression plate; Humeral middle-inferior fracture of shaft;Minimally invasive plate osteosynthesis

10.3877/cma.j.issn.2095-5790.2017.03.006

213300 溧陽市人民醫(yī)院骨科1； 200233 上海交通大學(xué)附屬第六人民醫(yī)院骨科2

袁霆，Email:terrenceyuan@gmail.com

2017-02-12）

（本文編輯：李靜；英文編輯：陳建海、張曉萌、張立佳）

周金華,戴峰,劉杰,等. 干骺端LCP前側(cè)微創(chuàng)與外側(cè)切開治療肱骨中下段骨折的臨床療效分析［J/CD］.中華肩肘外科電子雜志,2017,5（3）：186-193.