Lögters Tim Tobias, Wild Michael, Windolf Joachim, Linhart Wolfgang
Department of Trauma and Hand Surgery, University Hospital Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
Arch Orthop Trauma Surg. 2008 Dec;128(12):1431-5. doi: 10.1007/s00402-008-0607-9. Epub 2008 Mar 6.
Locked antegrade or retrograde nailing of humeral shaft and proximal humerus fractures is a well established treatment option. Anatomic-morphological studies revealed a potential high risk of axillary nerve injury within proximal interlocking screw insertion. However, clinical experiences do not seem to confirm this, as there is a lack of interlocking screw insertion associated axillary lesions in literature.
We report about a 69-year-old man with a humeral shaft fracture (AO-type 12-A3) stabilized by a retrograde implanted interlocking nail. Proximal interlocking screw insertion was performed in a posterior-to-anterior direction. The fracture healed uneventfully. In a follow-up examination 2 years later, an atrophy and paralysis of the deltoid muscle were visible. Electrophysiological evaluation confirmed an isolated axillary nerve injury. Nevertheless, the patient showed good functional recovery with almost free range of motion.
Even for clinical practise proximal interlocking screw insertion is associated with a substantial risk of axillary nerve injury. Particularly for posterior-to-anterior screw insertion anatomic conditions should be considered. In spite of axillary nerve lesion, recovery of almost full shoulder function is possible by compensating the loss of deltoid function by rotator cuff muscles.
肱骨骨干和近端肱骨骨折的锁定顺行或逆行髓内钉固定是一种成熟的治疗选择。解剖形态学研究表明，在近端锁定螺钉置入过程中，腋神经损伤风险较高。然而，临床经验似乎并未证实这一点，因为文献中缺乏与锁定螺钉置入相关的腋部损伤病例。
我们报告一例69岁男性肱骨骨干骨折（AO 12-A3型），采用逆行植入锁定髓内钉固定。近端锁定螺钉从后向前置入。骨折顺利愈合。2年后的随访检查中，可见三角肌萎缩和麻痹。电生理评估证实为孤立性腋神经损伤。尽管如此，患者功能恢复良好，活动范围几乎正常。
即使在临床实践中，近端锁定螺钉置入也存在较高的腋神经损伤风险。特别是从后向前置入螺钉时，应考虑解剖条件。尽管存在腋神经损伤，但通过肩袖肌肉代偿三角肌功能丧失，仍有可能实现几乎完全的肩部功能恢复。
