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作为临床骨科中常见的骨折,肱骨骨折的患病率约为5%[1]。目前临床上主要采用内固定术治疗骨折块移位>1 cm或者成角>45°的肱骨近端移位骨折,然而肱骨近端骨折病人在内固定术后可能发生肱骨头坏死、螺钉穿出肱骨头、肱骨头不愈合或者畸形愈合等并发症[2]。相关研究[3]显示肱骨近端骨折病人术后螺钉穿出肱骨的发生率为10%~30%,严重影响病人的术后治疗效果及生命质量,增加病人再次手术的概率。因此,探讨肱骨近端骨折病人内固定术后螺钉穿出的影响因素逐渐受到临床研究的关注。本研究观察肱骨近端骨折内固定术病人术后螺钉穿出肱骨头的发生情况及其影响因素,为临床上减少病人术后螺钉穿出的发生及改善预后提供依据。
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125例肱骨近端骨折病人内固定术后螺钉穿出的发生率为14.4%(18/125),随访时间为8~70个月(中位数19个月)。肱骨近端骨折内固定术后正常组病人与螺钉穿出组病人植骨、骨密度差异均无统计学意义(P>0.05)。单因素分析显示,存在内侧柱粉碎、Neer分型较高、内侧柱支撑、螺钉数目较少及复位程度较差的肱骨近端骨折病人内固定术后发生螺钉穿出的概率较高(P < 0.05~P < 0.01)(见表 1)。
特征 n 螺钉穿出 χ2 P 植骨 否
是93
3216(17.20)
2(6.25)2.17 >0.05 内侧柱粉碎 否
是77
487(9.09)
11(22.92)4.59 < 0.05 Neer分型/型 Ⅱ 12 2(16.67) Ⅲ 101 12(11.88) 7.40 < 0.05 Ⅳ 12 5(41.67) 骨密度/cm < -2.5
≥-2.544
815(11.36)
13(16.05)0.51 >0.05 内侧柱支撑 无 97 7(7.22) 1枚
2枚11
106(54.55)
2(20.00)23.30 < 0.01 皮质支撑 7 3(42.86) 螺钉数目/枚 < 5
≥527
988(29.63)
10(10.20)6.48 < 0.05 复位程度 差
优12
11310(83.33)
8(7.08)51.17 < 0.01 表 1 影响肱骨近端骨折病人内固定术后发生螺钉穿出发生的单因素分析[n;百分率(%)]
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以是否发生螺钉穿出肱骨头为因变量(未发生组为参照组),将年龄(< 65岁组为参照组)、性别(男性组为参照组)及单因素分析中有意义的变量纳入多因素分析[内侧柱粉碎(无为参照组)、Neer分型较高(Ⅱ型为参照组)、内侧柱支撑(无为参照组)、螺钉数目(< 5枚为参照组)及复位程度(优为参照组)]。多因素logistic回归分析显示,Neer分型、内侧柱粉碎及复位程度较差是肱骨近端骨折病人内固定术后发生螺钉穿出的独立影响因素(P < 0.01)(见表 2)。
变量 β SE Waldχ2 P OR(95%CI) Neer分型(对照=Ⅱ型) Ⅲ 0.64 0.95 2.08 < 0.01 1.86(1.21~2.88) Ⅳ 1.26 0.43 8.63 < 0.01 3.53(1.52~8.19) 内侧柱粉碎(对照=无) 有 0.98 0.19 25.46 < 0.01 2.66(1.82~3.89) 复位程度(对照=优) 差 0.40 0.14 8.86 < 0.01 1.49(1.15~1.94) 表 2 125例肱骨近端骨折病人内固定术后发生螺钉穿出的多因素logistic回归分析
125例肱骨近端骨折病人内固定术后螺钉穿出肱骨头的危险因素分析
Analysis of the risk factors of screw perforating humerus head after internal fixation in 125 patients with proximal humerus fractures
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摘要:
目的探讨肱骨近端骨折病人内固定术后螺钉穿出肱骨头的发生情况及其影响因素。 方法选择125例行切开复位锁定钢板内固定治疗的病人为研究对象,根据病人术后螺钉穿出肱骨头的发生情况分为2组,其中发生螺钉穿出的病人18例,无螺钉穿出的病人107例。分析肱骨近端骨折内固定术后发生螺钉穿出的影响因素。 结果125例肱骨近端骨折病人内固定术后螺钉穿出的发生率为14.4%(18/125)。单因素分析显示,存在内侧柱粉碎、Neer分型较高、内侧柱支撑、螺钉数目较少及复位程度较差的肱骨近端骨折病人内固定术后发生螺钉穿出的概率较高(P < 0.05~P < 0.01)。多因素logistic回归分析显示,Neer分型、内侧柱粉碎及复位程度较差是肱骨近端骨折病人内固定术后发生螺钉穿出的独立影响因素(P < 0.01)。 结论Neer分型较高、内侧柱粉碎及复位程度差的肱骨近端骨折病人术后发生螺钉穿出的风险较高。临床上应采取一定的措施加强骨折稳定性及增加肱骨头支撑,从而降低螺钉穿出的发生风险,提高病人治疗效果。 Abstract:ObjectiveTo analyze the incidence and risk factors of screw perforating humeru after internal fixation in patients with proximal humerus fractures. MethodsThe clinical data of 125 patients treated with open reduction-internal fixation with locking plates were analyzed.The patients were divided into two groups according to whether screw perforation.Among 125 cases, 18 patients with screw perforation and 107 patients without screw perforation were found.The risk factors of screw perforation in patients with proximal humerus fractures after internal fixation were analyzed. ResultsThe incidence rate of screw perforation in patients with proximal humeral fractures after internal fixation was 14.4%(18/125).The results of univariate analysis showed that the probability of screw perforation in patients with proximal humerus fractures complicated with medial column crushing, higher Neer type, medial column support, fewer screws and poor reduction after internal fixation were higher(P < 0.05 to P < 0.01).The results of multivariate logistic regression analysis showed that the Neer type, medial column crushing and poor reduction were the independent influencing factors of screw perforation after internal fixation in patients with proximal humeral fractures(P < 0.01). ConclusionsThe probability of screw perforation in patients with proximal humerus fractures complicated with medial column crushing, high Neer type and poor reduction is high.Clinically, some measures should be taken to strengthen the fracture stability and increase the humeral head support, so as to reduce the risk of screw perforation and improve the treatment effect of patients. -
Key words:
- proximal humerus fracture /
- internal fixation /
- screw perforation /
- risk factor
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表 1 影响肱骨近端骨折病人内固定术后发生螺钉穿出发生的单因素分析[n;百分率(%)]
特征 n 螺钉穿出 χ2 P 植骨 否
是93
3216(17.20)
2(6.25)2.17 >0.05 内侧柱粉碎 否
是77
487(9.09)
11(22.92)4.59 < 0.05 Neer分型/型 Ⅱ 12 2(16.67) Ⅲ 101 12(11.88) 7.40 < 0.05 Ⅳ 12 5(41.67) 骨密度/cm < -2.5
≥-2.544
815(11.36)
13(16.05)0.51 >0.05 内侧柱支撑 无 97 7(7.22) 1枚
2枚11
106(54.55)
2(20.00)23.30 < 0.01 皮质支撑 7 3(42.86) 螺钉数目/枚 < 5
≥527
988(29.63)
10(10.20)6.48 < 0.05 复位程度 差
优12
11310(83.33)
8(7.08)51.17 < 0.01 表 2 125例肱骨近端骨折病人内固定术后发生螺钉穿出的多因素logistic回归分析
变量 β SE Waldχ2 P OR(95%CI) Neer分型(对照=Ⅱ型) Ⅲ 0.64 0.95 2.08 < 0.01 1.86(1.21~2.88) Ⅳ 1.26 0.43 8.63 < 0.01 3.53(1.52~8.19) 内侧柱粉碎(对照=无) 有 0.98 0.19 25.46 < 0.01 2.66(1.82~3.89) 复位程度(对照=优) 差 0.40 0.14 8.86 < 0.01 1.49(1.15~1.94) -
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