The importance of medial support in locked plating of proximal humerus fractures
The importance of medial support in locked plating of proximal humerus fractures
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DOI：
10.1097/bot.0b013e3180333094
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发表时间：
2007-03-01
影响因子：
2.3
通讯作者：
Lorich, Dean G.
中科院分区：
文献类型：
--
作者：
Gardner, Michael J.;Weil, Yoram;Lorich, Dean G.
目的：本研究的目的是确定哪些因素影响肱骨近端骨折锁定钢板术后维持骨折复位，特别是内侧柱支撑的作用。地点：大学医疗中心。干预：对 35 名因肱骨近端骨折接受锁定钢板治疗的患者进行随访直至愈合。对于初始和最终的射线照片，垂直于板轴绘制 2 条线，一条在板的顶部，一条在肱骨头的顶部，测量它们之间的距离作为复位损失的指标。如果内侧皮质在解剖学上复位，如果近端骨折块在远端骨干骨折块中受到横向冲击，或者如果倾斜锁定螺钉位于近端肱骨头骨折块的内侧，则认为存在内侧支撑。 主要结果测量：进行多元线性回归以确定年龄、性别、骨折类型、骨水泥增强和内侧支撑对复位损失的影响。结果：内侧支撑的存在对骨折复位的程度有显着影响。随后减少损失（P < 0.001）。年龄、性别、骨折类型或骨水泥强化对维持复位没有影响。 18 名患者被确定有足够的机械内侧支撑（+MS 组），其余 17 名患者没有内侧支撑（-MS 组）。 +MS组中，肱骨头高度平均损失1.2mm，并发生1例关节螺钉穿透，需要拆除。在-MS组中（没有适当放置的下内侧斜螺钉和非解剖性肱骨头复位不良并伴有轴横向移位或内侧粉碎），肱骨高度平均损失5.8毫米（P <0.001）。本组出现螺钉穿透关节面5例（P=0.02），其中2例需再次手术取出。两组的所有骨折均立即愈合，且均无需进行关节置换术。结论：实现肱骨近端内侧区域的机械支撑对于维持骨折复位似乎很重要。一般来说，锁定钢板似乎并不是治疗这些骨折的灵丹妙药，并且无法从横向张力带位置单独支撑肱骨头。然而，有几个因素是外科医生可以控制的，可以改善机械环境。实现解剖学或轻微影响的稳定复位，以及在近端碎片的下内侧区域小心地放置一个向上定向的倾斜锁定螺钉，可以实现更稳定的内侧柱支撑，并允许更好地维持复位。
Objectives: The purpose of this study was to determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support.Setting: University medical center.Intervention: Thirty-five patients who underwent locked plating for a proximal humerus fracture were followed up until healing. For the initial and final radiographs, 2 lines were drawn perpendicular to the shaft of the plate, one at the top of the plate and one at the top of the humeral head, and the distance between them was measured as an indicator of loss of reduction. Medial support was considered to be present if the medial cortex was anatomically reduced, if the proximal fragment was impacted laterally in the distal shaft fragment, or if an oblique locking screw was positioned inferomedially in the proximal humeral head fragment.Main Outcome Measurements: Multivariate linear regressions were performed to determine the effects that age, sex, fracture type, cement augmentation, and medial support had on loss of reduction.Results: The presence of medial support had a significant effect on the magnitude of subsequent reduction loss (P < 0.001). Age, sex, fracture type, or cement augmentation had no effect on maintenance of reduction. Eighteen patients were determined to have adequate mechanical medial support (+MS group), and the remaining 17 patients did not have medial support (-MS group). In the +MS group, the average loss of humeral head height was 1.2 mm, and I case of articular screw penetration occurred that required removal. In the -MS group (without an appropriately placed inferomedial oblique screw and either nonanatomic humeral head malreduction with lateral displacement of the shaft or medial comminution), loss of humeral height averaged 5.8 mm (P < 0.001). There were 5 cases in this group in which screw penetration of the articular surface occurred (P = 0.02), 2 of which required reoperation for removal. All fractures in both groups healed without delay, and none required revision to arthroplasty.Conclusions: Achieving mechanical support of the inferomedial region of the proximal humerus seems to be important for maintaining fracture reduction. Locked plates in general do not appear to be a panacea for these fractures and are unable to support the humeral head alone from a lateral tension-band position. However, there are several factors that are in the surgeon's control that may improve the mechanical environment. Achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.