| BackgroundProximal humeral fracture refers to the fracture of the upper arm humerus adjacent to the glenoid of shoulder joint.The incidence of proximal humeral fractures accounts for about 5.03%of total fractures,and most of them are adults over 60 years old.With the acceleration of global aging,the incidence of proximal humeral fractures in the elderly population has increased significantly year by year.At present,there is no unified guideline to explicitly indicate th-at a certain scheme is the" gold standard" for the treatment of proximal humeral fractures.It has been reported that about 4/5 fractures of proximal humerus can be treated conservatively.Conservative treatments of proximal humeral fractures mainly include triangle towel suspension,plaster external fixation,small splint external fixation,shoulder throwing therapy and shoulder and chest bandage therapy.Among them,the small splint therapy is a systematic therapy developed and popularized by predecessors represented by Fang Xianzhi and Shang Tianyu in the 1950s-1970s,which combines willow boards,bandages and paper pressure pads to fix fractures.It is the wisdom crystallization of treating fractures with integrated traditional Chinese and Western medicine,and is deeply recognized by peers at home and abroad.In the small splint therapy,the raw materials are cheap,the materials are convenient,and different types of splints are designed for fractures in different parts of limbs,which makes the small splint simple,convenient,effective and cheap in clinical application.However,the small splints used for fracture fixation in some parts are not satisfactory in clinical application.For example,the small splints used for proximal humeral fractures often have the phenomena of rhombic knot easy to deform,loose band fixation,easy lateral displacement and longitudinal sliding between plates,etc.Cheng Hao,chief physician of our hospital,has a lot of experience in conservative treatment of proximal humeral fractures,and has added new elements to the traditional small splint used in the treatment of proximal humeral fractures,and invented a new type of small splint(Patent number:ZL201320216756.0).After the subject verification of" Clinical Research on Bone-setting Manipulation Combined with New Small Splint in Treating Humeral Surgical Neck Fracture"(2014 Capital Characteristic Project,Subject number:Z141107002514093),the new small splint can solve some problems in the use of traditional small splint,and expand the application scope of small splint in treating proximal humeral fracture with remarkable curative effect.Manipulative reduction,also known as manipulative reduction,refers to the process in which the operator alone or with the assistance of assistant reconstructs the dislocated fracture ends to the satisfaction of alignment and alignment and even close to anatomical reduction by means of bone-setting techniques such as stretching,unfolding and swinging,which is the first step in treating fractures.Ancient Chinese physicians realized the importance of manipulative reduction in fracture treatment,and put forward corresponding manipulative reduction according to different fracture types.In Qing Dynasty,Wu Qian and others studied the bone injury techniques of the past dynasties,and summarized the eight methods of bone setting,namely touching,ending,connecting,pushing,lifting,taking,pressing and rubbing,and systematically described the operation steps.In the late 1950s,Fang Xianzhi,Shang Tianyu and other predecessors brought together the advantages of various traditional Chinese medicines in treating fractures with integrated traditional Chinese and Western medicine,and gradually opened up a set of new therapies featuring internal dominance,manipulative reduction and small splint fixation and functional exercise.In the methods of fracture reduction,the predecessors summarized ten bone-setting techniques,such as touching the heart with hands,flexing and stretching,stretching and pulling,folding the top at an angle,pinching and separating bones.These manipulations are still of great guiding significance for the conservative treatment of fractures in orthopedics and traumatology of traditional Chinese medicine.The reduction technique of proximal humeral fracture is the flexible application of ten bone-setting techniques,such as hand touching,stretching and traction.According to the degree of fracture displacement on X-ray film of shoulder joint,the traditional method of treating proximal humeral fracture with small splint is to fix the affected limb with small splint.However,when a new type of small splint external fixation was used to treat proximal humeral fractures,we found that more than half of the elderly patients were not suitable or did not accept manual reduction because of systemic medical diseases such as heart disease,hypertension,diabetes,moderate and severe osteoporosis,or the pain when they were afraid of reduction.In this case,we can only directly give patients a new type of small splint external fixation treatment without manual reduction.Follow-up shows that most of these patients can get satisfactory clinical effect.This phenomenon aroused our interest.ObjectiveTo collect the related data of the treatment of proximal humeral fractures with new small splint external fixation and make a retrospective analysis.To design a control study scheme for the treatment of proximal humeral fractures with new splint external fixation without manual reduction and new splint external fixation with manual reduction,and to discuss the differences of shoulder joint function and imaging between the two groups according to the research results.MethodsTaking patients with proximal humeral fractures treated with new small splint external fixation as the research object,according to whether or not they received manual reduction before the new small splint external fixation treatment,the patients were divided into two groups:non-manual reduction group and manual reduction group.Allogeneic matching design was adopted between groups to ensure the balance of baseline data(P>0.05).Firstly,the data of age,sex,fracture classification of proximal humerus,appearance photos,shoulder X-ray film,shoulder joint function scale and so on were collected and summarized.Two groups of patients were matched 1:1 according to three basic conditions:fracture type(Neer classification and TCM classification),age and sex.According to the inclusion and exclusion criteria and the estimation results of sample size,30 pairs(60 cases)of patients were selected.Among them,there were 36 Neer Ⅲ fractures,22 Neer Ⅳ fractures and 2 Neer v fractures.All patients were followed up to the 12th week after treatment.The X-ray films of shoulder joint and the shoulder joint function evaluation scale filled in the last follow-up were summarized,and the imaging evaluation and shoulder joint function evaluation of the two groups were compared between groups and within groups.ResultsAt the 12th week after treatment,the scores of shoulders joint function of the two groups were as follows:in pain score,it was 27.67±3.14 in the non-manual reduction group and 28.17±3.08 in the manual reduction group,with no significant difference(P>0.05);In the range of motion score,it was 15.37±3.05 in the non-manual reduction group and 16.00±1.39 in the manual reduction group,with no significant difference(P>0.05).On the score of muscle strength,it was 4.50±0.51 in the group without manual reduction and 4.63±0.49 in the group with manual reduction,with no significant difference(P>0.05).In the score of daily living ability,it was 28.93±6.31 in the group without manual reduction and 31.13±2.97 in the group with manual reduction,with no significant difference(P>0.05).The scores of local morphologies were 4.83±0.38 in the non-manual reduction group and 4.87±0.35 in the manual reduction group,with no significant difference(P>0.05).In the total score,it was 81.30±10.00 in the non-manual reduction group and 84.80±4.68 in the manual reduction group,with no significant difference(P>0.05).When comparing before and after treatment,the axial distance(the distance from the axis of humeral shaft to the midpoint of anatomical neck of humerus on X-ray film of shoulder joint,in mm)in the group without manual reduction was 6.84±2.22 and 5.81±1.03,respectively,with significant difference(P<0.05).The discrete distance(the distance between two parallel lines tangent to the axis of humeral shaft and the anterior and posterior lateral edges of proximal humerus in mm)was 46.55±6.36 and 45.70±5.04 respectively,with no significant difference(P>0.05).The axial distance before and after treatment was 6.76±1.51 and 5.30±2.03,the difference was statistically significant(P<0.05),and the discrete distance was 46.16±5.74 and 45.95±5.82,the difference was statistically significant(P<0.05).When compared between the groups,the axial distance between the group without manual reduction and the group with manual reduction before treatment was 6.84±2.22 and 6.76±1.51,respectively,with no significant difference(P>0.05).Before treatment,the discrete distances of the non-manual reduction group and the manual reduction group were 46.55±6.36 and 46.16±5.74,respectively,with no significant difference(P>0.05).At the 12th week after treatment,the axial distance between the manual reduction group and the manual reduction group was 5.81±1.03 and 5.30±2.03,respectively,and the difference was statistically significant(P<0.05).At the 12th week after treatment,the discrete distances of the manual reduction group and the manual reduction group were 45.70±5.04 and 45.95±5.82,respectively,with no significant difference(P>0.05).ConclusionAt the 12th week after treatment,the imaging evaluation of the non-manipulative reduction group was inferior to that of the manipulative reduction group,but there was no significant difference in shoulder joint function score between the two groups.Therefore,we believe that it is also one of the optional treatment schemes for patients who are not suitable for or do not accept manual reduction due to systemic medical diseases such as heart disease,hypertension,diabetes and moderate to severe osteoporosis,or who are afraid of pain during reduction.The imaging evaluation of the non-manual reduction group at the 12th week was significantly improved compared with that before treatment.Therefore,we believe that small splint,as an elastic fixation method,can play a certain role in chronic reduction of fracture end in the treatment of proximal humerus fracture. |
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