Plecko Michael, Kraus Aurel
Unfallkrankenhaus Graz der Allgemeinen Unfallversicherungsanstalt, Göstingerstrasse 24, A-8021, Gra, Osterreich.
Oper Orthop Traumatol. 2005 Feb;17(1):25-50. doi: 10.1007/s00064-005-1120-8.
Stable fixation of unstable proximal humerus fractures until bony consolidation. Early mobilization of the shoulder and early active rehabilitation program to ensure a good functional outcome and a good restoration of the activities of daily living.
Unstable two-, three- and four-part fractures of the proximal humerus (classified according to the AO classification as: 11-A2, A3, B1, B2, B3, C1, C2, C3). Nonunions of the proximal humerus, especially at the neck. Pathologic fractures of the proximal humerus.
Comminuted humeral head fractures in old patients, which cannot be reconstructed adequately. Proximal humerus fractures in the immature patient. Local infection after previous surgery.
Deltopectoral approach. Blunt mobilization of the deltoid muscle. Suture loops through the supraspinatus tendon, the infraspinatus tendon, and the subscapularis tendon close to their bony insertion. Careful indirect reduction of the fracture fragments without further damage to their blood supply. Correct positioning of the LPHP (Locking Proximal Humerus Plate) on the lateral side of the humerus, approximately 5 mm below the tip of the greater tuberosity. Indirect approximation of the subcapital fracture component to the plate, by tightening a standard 3.5-mm cortical bone screw inserted into the first hole distal to the metaphyseal fracture line. Temporary fixation of the plate with 1.8-mm Kirschner wires. Fixed-angle fixation of the plate to the bone, using locking screws. Additional stabilization of the tuberosities to the plate with suture loops.
Between January 1, 1997 and April 30, 2002, 64 patients with acute fractures of the proximal humerus were treated with fixed-angle plating at the UKH Graz. 36 patients meeting the inclusion criteria (that is primary operative stabilization within 14 days after trauma in a standardized way and minimal follow-up period of 12 months) were assessed 31 months after surgery on average, using the Constant Score and the DASH Score. The mean age of the 22 women and 14 men was 57.5 years (21-78 years). According to the AO classification eight fractures were classified as 11-A3, one fracture as B1, five fractures as B2, three fractures as B3, one fracture as C1, 16 fractures as C2, and two fractures as C3. A mean Constant Score of 62.6 points and an age-related Constant Score of 80.7% on average, as well as a DASH Score of 18.0 points were obtained, constituting a satisfactory result in three quarters of all patients. Complications observed were two humeral head necroses, one partial necrosis after a head-splitting fracture with nevertheless good clinical result, and a deep infection in two cases. Breakage of the plate was seen in one patient with an A3.3 fracture without medial buttress; no further surgery was necessary; the fracture healed after a short period of immobilization.
稳定固定不稳定的肱骨近端骨折直至骨愈合。早期进行肩关节活动及早期积极康复计划，以确保良好的功能结果及日常生活活动能力的良好恢复。
肱骨近端的不稳定二部分、三部分和四部分骨折（根据AO分类为：11-A2、A3、B1、B2、B3、C1、C2、C3）。肱骨近端不愈合，尤其是在颈部。肱骨近端病理性骨折。
老年患者的粉碎性肱骨头骨折，无法充分重建。未成熟患者的肱骨近端骨折。既往手术后局部感染。
三角肌胸大肌入路。钝性分离三角肌。通过缝线环穿过冈上肌腱、冈下肌腱和肩胛下肌腱，靠近其骨质附着处。小心间接复位骨折碎片，避免进一步损伤其血供。将锁定肱骨近端钢板（LPHP）正确放置在肱骨外侧，大结节尖端下方约5mm处。通过拧紧一枚插入干骺端骨折线远侧第一个孔的标准3.5mm皮质骨螺钉，将股骨头下骨折块间接靠近钢板。用1.8mm克氏针临时固定钢板。使用锁定螺钉将钢板与骨进行角稳定固定。用缝线环将结节进一步稳定至钢板。
1997年1月1日至2002年4月30日期间，格拉茨医科大学医院对64例急性肱骨近端骨折患者采用角稳定钢板固定治疗。36例符合纳入标准（即创伤后14天内以标准化方式进行初次手术稳定，最短随访期12个月）的患者在术后平均31个月时，使用Constant评分和DASH评分进行评估。22名女性和14名男性的平均年龄为57.5岁（21-78岁）。根据AO分类，8例骨折为11-A3，1例骨折为B1，5例骨折为B2，3例骨折为B3，1例骨折为C1，16例骨折为C2，2例骨折为C3。平均Constant评分为62.6分，平均年龄相关Constant评分为80.7%，DASH评分为18.0分，四分之三的患者结果令人满意。观察到的并发症有2例肱骨头坏死，1例劈裂骨折后部分坏死但临床结果良好，2例深部感染。1例A3.3骨折且无内侧支撑的患者出现钢板断裂；无需进一步手术；骨折在短期固定后愈合。
