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Injury:新型肱骨顺行髓内钉治疗肱骨近端骨折易损伤腋神经

2014-07-24 林超文 丁香园

肱骨近端骨折是第三常见的骨折,其中大部分经保守治疗后可获得良好的临床预后,特别是老年人的肱骨近端骨折。而切开复位后各种内固定方法也可用于治疗肱骨近端骨折。 有研究证明钢板内固定术和髓内钉固定术治疗肱骨近端骨折均可获得稳固的内固定。而Zhu等的研究结果显示钢板内固定术的术后并发症发生率明显高于髓内针固定(31%比4%),但是术后第三年两种手术方法的临床预后并无明显差异。 还有研究指出

肱骨近端骨折是第三常见的骨折,其中大部分经保守治疗后可获得良好的临床预后,特别是老年人的肱骨近端骨折。而切开复位后各种内固定方法也可用于治疗肱骨近端骨折。

有研究证明钢板内固定术和髓内钉固定术治疗肱骨近端骨折均可获得稳固的内固定。而Zhu等的研究结果显示钢板内固定术的术后并发症发生率明显高于髓内针固定(31%比4%),但是术后第三年两种手术方法的临床预后并无明显差异。

还有研究指出前内侧的骨距螺钉(calcar screw)可有效防止骨折块内翻移位和肱骨头缺血性坏死,尤其是在钢板内固定术中。因此,新一代的顺行髓内钉通过把螺钉打在肱骨大结节远端来增加了内侧骨距的支撑力。但是,螺钉打入的地方是腋神经前支所分布的区域,可能会损伤到腋神经及其分支。

因此,本文作者Ben G.I. Spiegelberg医生的研究结果显示,采用刀头固定的肱骨顺行髓内钉治疗肱骨近端骨折时,打入锁定螺钉容易损伤腋神经的前支,文章最近发表在Injury上。

研究纳入了13具完整的尸体(26例肩关节),肉眼检查均未见骨折的迹象。

肱骨近端顺行锁定刀头髓内针装置是由一根直的髓内针和一枚向头方向穿过髓内针的刀头(图1,A点),后者是由两枚刀头锁定螺钉固定在髓内针上(图1,B点和C点),还有两枚螺钉打入髓内针分别固定肱骨大小结节。这个刀头的作用原理是通过像钢板内固定术中骨距螺钉那样增加肱骨内侧支撑力,可有效减少发生股骨头缺血性坏死和骨折块内翻畸形。另外,螺钉头处还有直径1cm的垫圈可分散螺钉作用于肱骨头的力。

图1:肱骨近端刀头固定的髓内针

手术采取三角肌劈开入路(deltoid split approach)。在肩缝的外侧界向远端作一长4cm的切口,钝性分离三角肌,顺着肩袖的肌纤维方向作一长2cm的切口,暴露肱骨头。

髓内针的入点选在肱骨头顶端的外侧,依次为肱骨的骨髓通道和肩袖切口的内侧。髓内针打入方法与传统的一致,术者还需通过特定的夹具(jig)把髓内针在关节软骨下方压入预定的0、2或4mm左右。再通过夹具打入引导针保证上肢在合适的旋转位置。

首先,先打入固定肱骨大结节的螺钉预防髓内针发生旋转,再打入刀头。接着,分别打入固定刀头的近端和远端螺钉。

以上装置的打入都是在导航系统的引导下完成的,打入点的切口主要是通过皮肤的保护套管标记的,作一2cm长的切口后,在水平方向(平行于腋神经)用剪刀钝性分离至肱骨。钻孔和打入螺钉时,需要先打入保护套管避免损伤周围组织,而刀头可通过套管打入。

成功打入髓内针后,把尸体改成仰卧位,向前臂方向反折皮肤和皮下组织以便暴露肱骨干上的三角肌止点。这样,三角肌平面和冈上肌和小圆肌上面可得到完全暴露。

然后,把三角肌从肩胛冈向前外侧的肩缝分离,并从内侧向外侧折叠。在小圆肌下方的四边孔即可见腋神经穿过,再把三角肌向近端肱骨翻折,可见腋神经前支走形在肱骨颈上。

最后,在臂中立位测量腋神经前支与锁定螺钉之间的距离。

研究结果显示,腋神经前支到肩峰前外侧的平均距离为62mm(45-82mm),而且,大部分腋神经前支横穿肱骨外科颈在肱骨纵轴上走于远端刀头固定螺钉与刀头之间(图2)。其中,腋神经前支到远端刀头固定螺钉的平均距离为4.9mm(0-19mm)。其中有三例的腋神经前支在螺钉的垫圈下,而且都有肉眼可见的神经损伤。


图2:腋神经前支横穿肱骨外科颈在肱骨纵轴上走于远端刀头固定螺钉与刀头之间

因此,采用刀头固定的肱骨顺行髓内钉治疗肱骨近端骨折时,打入锁定螺钉容易损伤腋神经的前支。

作者建议使用Gardener教授提出的肩峰前外侧入路:在肩峰前外侧向远端作一长8-10cm的切口,打开三角肌前束和中间束的间隙后,术者可以伸入手指探查并分离腋神经前支,这样就可安全打入锁定螺钉,避免发生腋神经前支损伤(图3)。


图3:经延长的肩峰前外侧入路,可见腋神经前支的神经血管束穿过刀头的固定螺钉(B点和C点)


原始出处:

Spiegelberg BG1, Riley ND2, Taylor GJ2.Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation - An anatomical study.Injury. 2014 Aug;45(8):1185-9. doi: 10.1016/j.injury.2014.05.006. Epub 2014 May 17.

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    2015-04-30 xuqianhua
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    2014-07-26 shalley68
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  5. [GetPortalCommentsPageByObjectIdResponse(id=1877891, encodeId=13a718e78916d, content=<a href='/topic/show?id=d21b9864ab' target=_blank style='color:#2F92EE;'>#Injury#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9864, encryptionId=d21b9864ab, topicName=Injury)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8ba7103, createdName=xuqianhua, createdTime=Thu Apr 30 22:49:00 CST 2015, time=2015-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396853, encodeId=24711396853fc, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Sat Jul 26 00:49:00 CST 2014, time=2014-07-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1460629, encodeId=92b31460629e9, content=<a href='/topic/show?id=b08e81986a8' target=_blank style='color:#2F92EE;'>#肱骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81986, encryptionId=b08e81986a8, topicName=肱骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=70e46352899, createdName=shalley68, createdTime=Sat Jul 26 00:49:00 CST 2014, time=2014-07-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1506461, encodeId=81731506461a8, content=<a href='/topic/show?id=05c010210252' target=_blank style='color:#2F92EE;'>#髓内钉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=102102, encryptionId=05c010210252, topicName=髓内钉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4cfc9759058, createdName=hanhaisha2011, createdTime=Sat Jul 26 00:49:00 CST 2014, time=2014-07-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579477, encodeId=9ad615e94779e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Jul 26 00:49:00 CST 2014, time=2014-07-26, status=1, ipAttribution=)]
    2014-07-26 hittouch

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