肱骨近端NeerIV型骨折latest

肱骨近端NeerIV型骨折：

切腹內(nèi)固定vs關(guān)節(jié)置換

ProximalHumeralFracture:

IncidenceandMechanismProximalhumerusfracture:accountfor4-5%ofallfracturesIncidence:Female>maleIncreaseswithage;especiallyafterage50CausebydirectorindirectforcesVascularAnatomyofHumeralHeadAmajorroleintheoutcomeDevascularisedheadcollapseandbecomeincongruentsecondaryarthritisArteriaarcuataCirculateswithinthehumeralhead4Origins:themetaphyseaslarterybranchofanteriorcirucumflexarteryarteryfromrotatorcuffmedialbranchofposteriorcircumflexarteryAxillarynerveAtriskinthesefracturesSuppliesthedeltoidandteresminormusclesformotorandsensoryfunctiononthelateralaspectoftheshoulderShouldbetestedbeforemanipulationAtoperationShouldbevisualizedoratleastpalpatedLiesanteriorlytosubsapularisClassificationoftheFracturesCodmansuggestedthatthenumberandtypeoffragmentfoundineachfracturemayplayanimportantrole.NeerandBrienetalrefinedthisconcept

amountofdisplacement,ifmorethan1cmlinearand45°angularfragmentandthenumberoffragmentsinvolved.ThepresenceorabsenceofdislocationRelevantAnatomyNeer’sClssificationNeerIVClassificationoftheFracturesThesesystemsofclassificationhavetheirshortcomings:Inter-andintraobserverreliability.Nonetakesintoaccountthequalityoftheboneorsofttissues.RelevantAnatomyRadiologicalInvestigationTrueAPofthescapula,alateralscapulaview,axillaryviewand600anteriorobliqueviewTheglenohumeraljointline:completelyopenwithnooverlapRadiologicalInvestigationCTscan:

EvaluateintraarticularfractureAssessjointsurfaceEvaluatefracturedisplacement3DreconstructionIndicationsandMethodsofTreatmentIndecisionmaking—FracturepatternandclassificationPatient’sgeneralhealth,age,occupationandavocationsAlso,additionalbenefitsfromsurgicalstabilizationTreatmentinChoice(Traditional)Three-part:Sufficientbonestock:ORIFPoorbonestock:treatedwithhemiarthroplasty.Four-part:Youngpatients(secondtofourthdecades):maytryORIFAllothersaretreatedwithhemiarthroplastyortotalshoulderarthroplasty.OverviewofSurgicalTechniquePlatefixationOsteosutrueExtramedullarypinningIntramedullarynailingProstheticreplacementOsteosutureFor3and4partfractureInolderindiviualwithfragileosteopenicboneUseofwire,cableorheavysutureThesesuturesarethenfixedtometaphsisbetween1and2cmbelowthemetaphysealfractureline

ExtramedullaryPinningManytechniqueshavebeendescribedClosereductionandpercutaneouspinningusingimageintensifierPinsleftprotrudingthroughtheskinandcanberemoved6to8weekslaterReservedforOpensurgeryisnotpossibleQualityofboneissufficienttoholdpin

IntramedullaryNailingTransdeltoidsplitapproachRotatorcuffexposedpassedthroughtheheadattheinterferencebetweentendonandcartilageFragmentsoftheheadheldtogetherwithlockingscrewsCaretoavoiddamageof:axillarynerveandtendonoflongheadofbicepsProstheticReplacementIncasesoffour-partfractureVascularizationoftheheadiscompromisedwithintra-articularhead-splittingfractureSurgeryTreatmentforProximalHumeralFractureKeytosuccess:ameticuloustechniquewithminimalsoft-tissuetraumaandarigidfixationwiththeleastamountofhardwareTuberosityRepairInadequatetuberosityrepairisoneofthemostcommonanddevastatingcausesoffailure.FixationofStem:

Press-fitorCementedHarris…inacadaverstudy:micromotionwassignificantlylesswithproximalcementthanwithpress-fit;nodifferencebetweenproximalcementationandfullcementation.72uncementedNeerIIprostheses,40(55.6%)wereatriskforlooseningatanaverage4-yearfollow-up,andonly1(2%)of43cementedprosthesiswasatriskatover6years'follow-upClinicallysignificantlooseningofthehumeralcomponentisrare,regardlessoffixationmethods.Four-PartFractureofProximalHumerusRetroversion,heightandheadsizetorecreateproximalhumeralanatomy.Treatmentalgorithm

ORIForHemiarthroplastyAvascularNecrosisPrevalenceofproximalfour-parthumeralfractures:21%~75%Incadavericperfusionstudy,LaingandGerberetalshowedthemainarterialsupplyisant.humeralcircumflexartery.AdditionaldevascularizationthroughsurgicalexposureandimplantinsertionToavoidit,minimaldissectionandosteosynthesisOpenReductionandInternalFixationofThreeandFour-PartFracturesoftheProximalPartoftheHumerus

A.J.WijgmanetalJ.BoneJointSurg.Am.84:1919-1925,2002Method:~Totreatallthreeandfour-partfractureswithminimalinvasiveORIF~Averageof10yearsoffollow-up~AllfracturesfitNeer’scriteriaandindication~Male/Female:29/31,Average48y/o~ORIFwithin48hours

MaterialsandMethodsMaterialsandMethodsP.E.Visualanalogscale(0~10)Constantscoreassignspointsformusclestrength,ADL,painAPandaxillaryX-rayResultsConstantscore:Good:87%/Poor:13%Avascularnecrosis:37%But64%oftheavascularnecrosis:>90degreeshoulderabductionTheaverageVASwas2pointsConclusionsORIFofproximalhumeralthreeorfour-partfractureyieldsgoodfunctionalresultinmost.Fracture-dislocationassociateswithahighriskforavascularnecrosis.Eventhat,itdidnotprecludeagoodresult.PrimaryHemiarthroplastyforTreatmentofProximalHumeralFracturesC.MichaelRobinsonetalJ.BoneJointSurg.Am.85:1215-1223,2003Methods:AllpatientshadnormalshoulderfunctionpriortotheinjuryFromJan.1998toDec.2000,total138patients112/138four-partfractures

OutcomeMeasuresConstantscoreassessedoneyearlaterMusclepowerFunctionalresultX-ray(APandmodifiedlateralview):ProstheticsurvivaltorevisionResultsTheaveragedurationoffollow-up:6.3yearsTheoverallprostheticsurvivalrateOneyear:96.9%Fiveyears:95.3%Tenyears:93.9%FunctionalResultsConclusionsPainfreeusuallyOverallfunctionalresults(ROM.M.P.,function)weredisappointingWhenthehumeralheadcanbereconstructed,ORIFisrecommendedIfthehumeralheadisdevoidofsoft-tissueattachmentsorunreconstructable,hemiarthroplastycanbeperformedinmedicallyfit,cooperativepatientsHemiarthroplastyasalatereconstructiveprocedureafterinitialtreatmentfailedSupplementedwithCalciumPhosphateCement

BiomechanicalEvaluationofProximalHumeralFractureFixation

BrianK.KwonetalJ.BoneJointSurg.Am.84:951-961,2002.Methods:~Cadavericthree-partproximalhumeralosteotomymodel~Threetypesofdevices:cloverleafplate,anangledblade-plate,andKirschnerwires~TheeffectofsupplementingwithSRS(SkeletalRepairSystem)calciumphosphatecementwasevaluated.MaterialsandMethods

Eighteenpairsoffresh-frozenhumeriBMDwasmeasuredTestedcyclicallyinabductionandinexternalrotationfor250cyclestoevaluateinterfragmentarymotion.ExternalrotationtomeasuretorsionalloadtofailureandtorsionalstiffnessResultsNosignificantdifferencesbetweenthespecimenstreatedwiththebladeandcloverleafplatesThespecimenstreatedwithKirschnerwiresdemonstratedmoreinterfragmentarymotion,less