鎖定鋼板治療老年肱骨近端三部分、四部分骨折的療效分析

唐詩添 劉剛 王軍 石波 王陶 楊衡 康斌 張定偉

·論著·

鎖定鋼板治療老年肱骨近端三部分、四部分骨折的療效分析

唐詩添 劉剛 王軍 石波 王陶 楊衡 康斌 張定偉

目的探討鎖定鋼板治療老年肱骨近端三部分、四部分骨折療效。方法回顧性分析2005年1月至2012年1月綿陽市中心醫(yī)院收治的年齡＞60歲，Neer三部分、四部分肱骨近端骨折患者45例，其中男13例，女32例；年齡60～84歲，平均71歲；左側(cè)22例，右側(cè)23例，優(yōu)勢側(cè)受傷者24例；受傷至手術(shù)時(shí)間3～10 d，平均5.8 d；骨折類型（Neer分型）：三部分骨折24例，四部分骨折21例，其中四部分嵌插型10例，肱骨近端內(nèi)側(cè)柱骨折6例，合并肩胛盂骨折5例，無四部分解剖頸骨折。均采用切開復(fù)位鎖定接骨板手術(shù)治療，術(shù)后隨訪根據(jù)肩關(guān)節(jié)簡明測試（simple shoulder test，SST）問卷和Constant-Mudey評(píng)分對(duì)肩關(guān)節(jié)功能進(jìn)行評(píng)估。結(jié)果43例患者獲得門診隨訪，平均隨訪時(shí)間為18個(gè)月（12～48個(gè)月）。本組患者Constant評(píng)分平均為72分。6例（14.0%）患者需翻修手術(shù)。術(shù)后再移位發(fā)生率為9.3%（4例）、不愈合7.0%（3例）、肩峰撞擊7.0%（3例）、肱骨頭壞死14.0%（6例）、螺釘進(jìn)入肩關(guān)節(jié)11.6%（5例）。結(jié)論雖然鎖定接骨板治療老年肱骨近端三部分、四部分骨折肩關(guān)節(jié)功能恢復(fù)較好，但并發(fā)癥多，醫(yī)師應(yīng)根據(jù)患者實(shí)際情況、骨折分型以及醫(yī)師自身情況選擇治療方案。手術(shù)治療需注重肱骨近端骨折的解剖復(fù)位、螺釘及鋼板位置、螺釘長度、內(nèi)側(cè)柱支撐及穩(wěn)定性，這是獲得良好功能、降低并發(fā)癥的關(guān)鍵因素。

肱骨近端骨折； 鎖定鋼板； 療效

Palvanen等[1］報(bào)道3/4的肱骨近端骨折發(fā)生于60歲以上老年人，女性的發(fā)病率是男性的3倍，以肱骨近端三部分、四部分骨折較為常見。大多數(shù)肱骨近端骨折患者因存在骨質(zhì)量不佳以及嚴(yán)重的骨質(zhì)疏松癥，為肱骨近端骨折的治療帶來了嚴(yán)峻的挑戰(zhàn)。近年來，隨著鎖定鋼板治療肱骨近端骨折的廣泛應(yīng)用，年輕患者獲得良好的臨床效果，但老年患者并發(fā)癥發(fā)生率仍較高[1-2］。本研究對(duì)45例鎖定鋼板內(nèi)固定治療肱骨近端三部分、四部分骨折老年患者的療效進(jìn)行了總結(jié)分析，以便了解鎖定鋼板治療肱骨近端嚴(yán)重粉碎性骨折的并發(fā)癥及風(fēng)險(xiǎn)，現(xiàn)報(bào)道如下。

資料與方法

一、一般資料

2005年1月至2012年1月，本院共收治326例肱骨近端骨折患者，納入年齡＞60歲，Neer三部分、四部分肱骨近端骨折患者共45例，均采用肱骨近端鎖定鋼板治療。男13例，女32例；年齡60～84歲，平均71歲；左側(cè)22例，右側(cè)23例，優(yōu)勢側(cè)受傷者24例；受傷至手術(shù)時(shí)間3～10 d，平均5.8 d；骨折類型（Neer分型）：三部分骨折24例，四部分骨折21例，其中四部分嵌插型10例，肱骨近端內(nèi)側(cè)柱骨折6例，合并肩胛盂骨折5例，無四部分解剖頸骨折。

二、治療方法

全身麻醉，采取仰臥位，三角肌胸大肌間溝入路。強(qiáng)生2號(hào)縫線牽拉大小結(jié)節(jié)輔助復(fù)位骨折，恢復(fù)正常頸干角、肱骨頭后傾角以及大小結(jié)節(jié)解剖位置，以l枚直徑為2.0 mm螺紋針臨時(shí)固定。透視骨折復(fù)位滿意后，根據(jù)骨折的情況選擇不同長短肱骨近端鎖定鋼板進(jìn)行固定，隨后將大小結(jié)節(jié)通過強(qiáng)生2號(hào)縫線固定于鎖定板。合并肩胛盂骨折病例，先行肩胛盂骨折錨定或空心釘固定，再行同前方法固定。術(shù)后腕頸吊帶保護(hù)患肢2周，開始功能鍛煉。

三、療效評(píng)價(jià)

術(shù)后1、3、6、12個(gè)月以及末次隨訪時(shí)攝肩關(guān)節(jié)創(chuàng)傷系列X線片，判斷骨折愈合情況及內(nèi)固定物的位置。本組患者術(shù)前未記錄肩關(guān)節(jié)活動(dòng)度的具體數(shù)據(jù)，因此隨訪時(shí)患側(cè)肩關(guān)節(jié)活動(dòng)度的數(shù)據(jù)與健側(cè)進(jìn)行比較。末次隨訪時(shí)通過Constant-Mudey評(píng)分對(duì)肩關(guān)節(jié)功能進(jìn)行評(píng)估[3］，＞75分為優(yōu)，50～75分為良，＜50分為差。主觀功能根據(jù)SST問卷進(jìn)行評(píng)定。記錄相關(guān)并發(fā)癥并分析Constant評(píng)分的影響因素。

四、統(tǒng)計(jì)學(xué)方法

結(jié) 果

本組40例患者獲得門診隨訪，3例患者電話隨訪，2例患者因無法取得聯(lián)系失訪。隨訪時(shí)間12～48個(gè)月，平均18個(gè)月。

一、末次隨訪時(shí)患者肩關(guān)節(jié)活動(dòng)度和Constant功能評(píng)分

肩關(guān)節(jié)活動(dòng)度：患側(cè)前屈上舉60°～100°，平均 85°；健 側(cè) 130°～180°， 平 均 155°。 患 側(cè) 外 展50°～150°，平均 100°；健側(cè) 90°～170°，平均 145°?；紓?cè)Constant功能評(píng)分為50～85分，平均72.3分；健側(cè)為70～100分，平均96.2分。末次隨訪時(shí)，肩關(guān)節(jié)Constant功能評(píng)分為優(yōu)15例，良20例，可3例，差5例，優(yōu)良率81.4%，有6例（14.0%）需要接受翻修手術(shù)。

骨折類型與Constant功能評(píng)分有關(guān)：Neer三部分骨折Constant評(píng)分為（77.5±6.5）分，高于Neer四部分骨折Constant功能評(píng)分[（66.9±9.3）分］，差異有統(tǒng)計(jì)學(xué)意義（P ＜0.01）。外翻型骨折Constant評(píng)分為（75.9±7.7）分，高于內(nèi)翻型骨折Constant功能評(píng)分[（68.6±10.0）分］，差異有統(tǒng)計(jì)學(xué)意義（P=0.01）。

二、末次隨訪時(shí)患者主觀功能評(píng)價(jià)

主觀功能評(píng)價(jià)采用有10個(gè)問題的問卷，回答“是”的問題平均為6.7個(gè)（1～10個(gè)）。20例（46.5%）患者認(rèn)為術(shù)后生活與傷前無明顯變化。

三、術(shù)后并發(fā)癥

再移位4例（9.3%），其中Neer三部分骨折1例，Neer四部分骨折3例；不愈合3例（7.0%），均為Neer四部分骨折；撞擊3例（7.0%），均為Neer四部分骨折；肱骨頭壞死6例（14.0%），其中Neer三部分骨折2例，Neer四部分骨折4例；螺釘進(jìn)入肩關(guān)節(jié)5例（11.6%），其中Neer三部分骨折2例，Neer四部分骨折3例。

本組6例有肱骨近端內(nèi)側(cè)柱損傷的患者中，3例發(fā)生骨折再移位，2例骨折不愈合（其中1例合并螺釘進(jìn)入關(guān)節(jié)腔），1例肱骨頭壞死合并螺釘進(jìn)入關(guān)節(jié)腔。末次隨訪4例患者需翻修手術(shù)治療，占翻修患者的2/3（圖1）。

討 論

老年肱骨近端骨折常常是低能量損傷所致，80%的患者可以采用保守治療，但對(duì)于Neer三部分、四部分骨折大部分患者需要手術(shù)治療。目前手術(shù)治療方法較多，鎖定接骨板螺釘依然是治療肱骨近端復(fù)雜骨折的主流方向，但其治療結(jié)果受多種因素影響，甚至出現(xiàn)嚴(yán)重的并發(fā)癥[4］。

圖1 患者男，35歲，肱骨近端骨折切開復(fù)位鋼板螺釘內(nèi)固定術(shù)（Neer三部分骨折）。圖A 術(shù)前X線片；圖B CT三維重建；圖C 術(shù)后X線片；圖D 術(shù)后3個(gè)月肱骨近端骨折畸形愈合，肱骨頭密度不均勻，內(nèi)固定失效；圖E 術(shù)后1年X線片提示肱骨頭缺血壞死，肱骨大結(jié)節(jié)吸收改變

肱骨近端骨折的預(yù)后取決于骨塊的移位程度和肱骨頭血液循環(huán)的損傷程度[5］，本組肱骨近端三部分、四部分骨折患者手術(shù)治療后肩關(guān)節(jié)功能恢復(fù)較好，但部分患者出現(xiàn)了嚴(yán)重并發(fā)癥[6］，6例肱骨近端骨折合并內(nèi)側(cè)柱損傷患者中發(fā)生3例骨折再移位、2例骨折不愈合和2例螺釘進(jìn)入關(guān)節(jié)腔，末次隨訪4例患者需翻修手術(shù)治療，占翻修患者的2/3。作者認(rèn)為肱骨近端內(nèi)側(cè)柱完整性是預(yù)測肱骨頭血液循環(huán)破壞程度的重要因素之一[7-10］，雖然本組隨訪發(fā)現(xiàn)外翻型骨折療效較內(nèi)翻型骨折好[8］。然而，如外翻型骨折合并肱骨近端內(nèi)側(cè)皮質(zhì)（內(nèi)側(cè)柱）損傷，預(yù)后較差，這可能與缺乏內(nèi)側(cè)壁支撐、骨折端內(nèi)側(cè)柱穩(wěn)定欠佳有關(guān)，是導(dǎo)致內(nèi)固定失敗、肱骨頭壞死的主要原因。Foruria等[9］發(fā)現(xiàn)采用保守治療的內(nèi)翻型骨折療效較外翻型骨折效果好，分析是內(nèi)翻型骨折內(nèi)側(cè)鉸鏈完整的原因。Hertel等[10］認(rèn)為干骺端-頭延伸區(qū)＜8 mm是缺血較好的預(yù)測因素（精確度為0.84），預(yù)測缺血的另一因素是內(nèi)側(cè)鉸鏈區(qū)的斷裂＞2 mm（精確度為0.79，圖1B）。除了解剖頸骨折，合并干骺端-頭延伸區(qū)＜8 mm與內(nèi)側(cè)鉸鏈區(qū)的斷裂＞2 mm，肱骨頭缺血的陽性預(yù)測值可達(dá)97%。因此，作者對(duì)于肱骨近端骨折合并內(nèi)側(cè)柱損傷患者手術(shù)治療應(yīng)注重于內(nèi)側(cè)柱的穩(wěn)定，肱骨近端前外側(cè)鋼板的多枚螺釘置入內(nèi)側(cè)皮質(zhì)區(qū)，必要時(shí)需進(jìn)行內(nèi)側(cè)鋼板支撐固定聯(lián)合植骨治療。曾浪清等[11］對(duì)130例鎖定鋼板螺釘治療肱骨近端骨折患者進(jìn)行隨訪，發(fā)現(xiàn)與單枚螺釘置入組及無支撐重建組比較，多枚螺釘置入組在肩關(guān)節(jié)功能、疼痛視覺模擬評(píng)分及內(nèi)翻角度比較上差異有統(tǒng)計(jì)學(xué)意義，而并發(fā)癥及翻修率比較差異無統(tǒng)計(jì)學(xué)意義，建議采用內(nèi)側(cè)骨皮質(zhì)支撐重建肱骨近端內(nèi)側(cè)柱支撐具有較佳的固定效果。此外，骨折類型也是預(yù)測術(shù)后并發(fā)癥的重要原因之一。本組術(shù)后并發(fā)癥發(fā)生情況表明：4例再移位患者中3例為Neer四部分骨折，占3/4；發(fā)生不愈合、撞擊的均為Neer四部分骨折患者；發(fā)生肱骨頭壞死的患者Neer四部分骨折占2/3，螺釘進(jìn)入肩關(guān)節(jié)占3/5。黃強(qiáng)等[12］對(duì)28例Neer三部分、四部分肱骨近端骨折患者進(jìn)行隨訪平均25個(gè)月，發(fā)現(xiàn)Neer三部分骨折脫位優(yōu)良率為71%，無差的病例，肱骨頭壞死發(fā)生率為17%，Neer四部分骨折脫位優(yōu)良率為58%，差為25%，肱骨頭壞死率達(dá)67%，認(rèn)為復(fù)雜的肱骨近端骨折術(shù)后發(fā)生肱骨頭壞死可能性高。因此，作者認(rèn)為內(nèi)側(cè)柱完整性、穩(wěn)定性以及肱骨近端骨折類型是影響治療效果的重要因素。

目前，對(duì)于老年Neer三部分、四部分骨折治療方法的選擇仍沒有定論。本組患者均采用鎖定接骨板螺釘內(nèi)固定手術(shù)治療，隨訪顯示肩關(guān)節(jié)功能恢復(fù)較好。但也有文獻(xiàn)報(bào)道與保守治療相比，手術(shù)治療對(duì)患者肩關(guān)節(jié)功能恢復(fù)無明顯改善。Misra等[13］認(rèn)為老年Neer三部分、四部分骨折手術(shù)治療僅在疼痛方面較保守治療有所緩解，而在功能及其他方面無差別。Iyengar等[14］通過隨機(jī)對(duì)照研究發(fā)現(xiàn)，老年患者肱骨近端三部分、四部分骨折保守治療與手術(shù)治療的功能結(jié)果差異無統(tǒng)計(jì)學(xué)意義。因此，作者認(rèn)為在一些特定的情況下對(duì)于老年患者肱骨近端粉碎性骨折采取保守治療也是合理的。治療方案的選擇應(yīng)根據(jù)患者實(shí)際情況、功能訴求、骨折分型及醫(yī)師自身情況綜合考慮。

關(guān)于鎖定鋼板固定治療老年Neer三部分、四部分骨折的臨床并發(fā)癥報(bào)道較多，最高達(dá)59%，包括再移位、不愈合、肩峰撞擊、肱骨頭壞死、螺釘進(jìn)入肩關(guān)節(jié)以及感染等，翻修比例也較高。多數(shù)學(xué)者認(rèn)為并發(fā)癥與骨折類型、手術(shù)復(fù)位情況、骨質(zhì)疏松、術(shù)中操作、內(nèi)側(cè)柱是否完整有關(guān)[15］。在本組也出現(xiàn)了相似的結(jié)果，肱骨頭壞死及螺釘進(jìn)入肩關(guān)節(jié)發(fā)生率最高，分別高達(dá)14.0%（6例）、11.6%（5例），除了與骨折類型有關(guān)外，復(fù)位不良可能是導(dǎo)致肱骨頭壞死等并發(fā)癥的重要原因之一。Gerber等[16］將25例肱骨近端骨折手術(shù)后出現(xiàn)肱骨頭壞死的患者分成2組，一組為解剖或接近解剖復(fù)位（13例），另一組至少有1個(gè)部位畸形愈合（12例）。結(jié)果發(fā)現(xiàn)復(fù)位良好的一組雖然肱骨頭壞死、塌陷，但肩關(guān)節(jié)功能同一期肱骨頭置換相似。認(rèn)為即使發(fā)生肱骨頭部分壞死，良好的復(fù)位仍然能夠獲得滿意臨床結(jié)果。因此，特別注意術(shù)中復(fù)位，尤其強(qiáng)調(diào)后內(nèi)側(cè)肱骨距的支撐。對(duì)于外科頸粉碎無法實(shí)現(xiàn)良好支撐的骨折，可先去除粉碎的骨折塊，短縮骨折端，肱骨干嵌插入肱骨頭，后再用去除的碎骨塊植骨。而外翻嵌插的骨折復(fù)位時(shí)應(yīng)注意保護(hù)內(nèi)側(cè)鉸鏈結(jié)構(gòu)和血供。復(fù)位時(shí)通過肩袖縫線，間接控制肱骨頭骨折塊，如大結(jié)節(jié)與肱骨頭分離的骨折，復(fù)位大結(jié)節(jié)與肱骨頭后先用克氏針固定，作為把手，輔助復(fù)位。對(duì)于四部分骨折、頭劈裂型骨折這類血液供應(yīng)遭到嚴(yán)重破壞的骨折，則應(yīng)在術(shù)中高度注意殘留血運(yùn)的保護(hù)，必要時(shí)應(yīng)予以植骨以促進(jìn)愈合。

綜上所述，對(duì)于老年肱骨近端骨折患者的治療方案仍存在較大爭議，醫(yī)師應(yīng)根據(jù)其實(shí)際情況、骨折類型及醫(yī)師自身情況選擇治療方案。在鎖定接骨板螺釘治療時(shí)，需注意肱骨近端骨折的解剖復(fù)位、螺釘及鋼板位置、螺釘長度、內(nèi)側(cè)柱支撐及穩(wěn)定性，這是獲得良好功能、降低并發(fā)癥的關(guān)鍵因素。

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Therapeutic effect analysis of locking plate fixation for the treatment of 3-part and 4-part proximal humeral factures in the elderly

Tang Shitian, Liu Gang, Wang Jun, Shi Bo, Wang Tao, Yang Heng, Kang Bin, Zhang Dingwei. Department of Orthopaedics, Mianyang Central Hospital,Mianyang 621000, China

Tang Shitian, Email: 15984682088@163.com

BackgroundPalvanen reported that 3/4 of the proximal humerus fractures occurs s in the elderly patient over 60 years with 3-part and 4-part fractures as common types,and the incidence rate in women is 3 times higher than that of men. Formost patients with proximal humeral fractures, poor bone quality and severe osteoporosis bring great challenges to the treatment. Recently, young patients with proximal humeral fractures have

good therapeutic outcome with the extensive use of locking plates. However, the complication rate in elderly patients maintains a high level. In this study, we analyzed and summarized the therapeutic effects of locking plates fixation in treating 45 cases of proximal humeral fractures occurred in elderly patients to explore the corresponding clinical effects, complications and risks.MethodsI. General data. From January 2005 to January 2012, 326 patients with proximal humerus fractures were treated in our hospitals.45 patients （13 males and 32 females） over 60 years with Neer 3-part and Neer 4-part fractures were included in our study and treated with locking plates fixation, The age of patients ranged from 60 to 84 withan average of 71 years. The positions of affect armincludedtwenty-two cases ofleft side and twenty-three cases of right side, and 24 cases had the affected armon the dominant sides.The time from injury to operation spanned from 3 to 10 days with an average of 5.8 days. According to the Neer classification, the group was comprised oftwenty-four cases of 3-part fractures and twenty-one cases of 4-part fractures, which included 10 cases of 4-part impacted fractures,6 cases of medial column fractures of proximal humerus, 5 cases of combinedglenoid cavity fractures. No 4-part anatomical neck fractures of proximal humerus was reported.II. Treatment methods. The patient was put with the supine positionafter successful general anesthesia, and the deltopectoral interval approach was applied for exposure. The fracture was reduced withNo.2 Ethicon sutures by pulling the greater tuberosity and the lesser tuberosity to restore the normal neck-shaft angle, the retroversion angle of humeral head,and anatomical positions of greater tuberosity and lesser tuberosity, which was temporarilyfixed with a 2.0 mm thread Kirsch wire. After satisfactory fracture reduction under fluoroscopy, the proximal humeral locking plate of proper length was selected for fixation based on the fracture condition. Then, both the greater tuberosity and the lesser tuberosity werefixed on the plate with No.2 Ethicon sutures. If the case wascombined with glenoid cavity fractures, the fixation should be conducted with suture anchors or hollow screws before treated with the former method. The affected arm was in forearm sling for 2 weeks before functional rehabilitation. III. Efficacy evaluation.The fracture healing and internal fixator positions were assessed with shoulder joint X-ray films oftraumatic series at the time points of 1, 3, 6, 12 months and the last follow-up.Since thespecific index of preoperative range of motion was not recorded for the group, the range of motion of the affected shoulder was compared with that of the contralateral side.During the last follow-up, the shoulder joint function was evaluated by the Constant-Murley score:＞75 points as excellent; 50-75 points as good; ＜50 points as poor. The subjective functional evaluation was conducted according to the SST questionnaire.Complications were documented,and influencing factors of the Constant-Murley score were analyzed. IV. Statistical methods. The SPSS 17.0 software was used for statistical processing. The measurement data were expressed as mean±standard deviation, and the paired t-test was performed to examine the comparison between the contralateral side and the affected side. Similarly, the differencebetween fracture types were verified by the group t-test. The test level α=0.05, P ＜0.05 was considered as statistical difference.ResultsThe followup conditions: 40 patients were followed-up in the outpatient clinic; 3 patients were followed-up via telephone; 2 patients were lost to follow-up. The follow-up time ranged from 12 months to 48 months with an average of 18 months.I. The range of motion of shoulder and Constant score for the last followup.Shoulder range of motion: forward flexion and elevation of the affected shoulder joint was 60°-100°with an average of 85°; forward flexion and elevation of the contralateral shoulder joint was 130°-180°with an average of 155°. Abduction of the affected shoulder joint was 50°-150° with an average of 100°; abduction of the contralateral shoulder joint was90°-170° with an average of 145°. Constant score of the affected shoulder was 50-85 with an average of 72.3; Constant score of the contralateral shoulder was 70-100 with an average of 96.2. According to the Constant scores of the last follow-up, there were 15 cases of excellent, 20 cases of good, 3 cases of tolerable and 5 cases of poor. The good and excellent rate was 81.4%, and 6 cases （14.0%） requiredsurgical revision.The type of fracture was related to the Constant score. The Constant score of Neer 3-part fractures （77.5±6.5） was higher than that of Neer 4-part fractures （66.9±9.3）, and there was statistical difference （P ＜0.01）.The Constant score of valgus fracture was 75.9±7.7, which was higher than that of varus fracture （68.6±10.0）, and there was statistical difference（P=0.01）.II. Subjective functional evaluation for the last follow-up.A questionnaire with 10 questions were adopted for the subjective functional evaluation. The average number of the questions replied with “Yes” as the answer was 6.7 （1-10）. Twentypatients （46.5%）believed that there was no obvious change of life quality before and after operation.III. Postoperative complications. 4 cases （9.3%） had fracture redisplacement, including 1 case of Neer 3-part fractures and 3 cases of Neer 4-part fractures; 3 cases （7.0%） had fracture nonunion, which were all Neer 4-part fractures; 3 cases （7.0%） had impingement syndrome, which were all Neer 4-part fractures;6 cases（14.0%） had humeral head necrosis, whichincluded 2 cases of Neer 3-part fractures and 4 cases ofNeer 4-part fractures. 5 cases （11.6%） had screws into the shoulder joint, including 2 cases of Neer 3-part fractures and 3 cases of Neer 4-part fractures. Among the 6 in-group patients who had proximal humeral medial column fractures, there were 3 cases of fracture redisplacement, 2 cases of fracture nonunion and 2 cases of screws into shoulder joint. In the last follow-up, 4 cases required surgical revision, which accounted for 2/3 of the patients who needed revision.ConclusionsCurrently,there is still no final conclusion about the treatment selection of the 3-part and 4-part proximal humeral fractures of Neer classification in elderly patients.The treatment plan selected by doctors should be based on practical situations, fracture types and doctor's own situations. During the treatment with locking plates and screws, attentions should be paid to anatomic reduction, position of screws and plates, screw length, medial column support and its stability.These are the key factors of obtaining good functions and reducing complications.

Proximal humerus fractures; Locking plate; Therapeutic effect

2016-07-19）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10.3877/cma.j.issn.2095-5790.2017.02.004

東莞市醫(yī)療衛(wèi)生基金項(xiàng)目（201610515000302）

621000 綿陽市中心醫(yī)院骨科

唐詩添，Email:15984682088@163.com

唐詩添,劉剛,王軍,等. 鎖定鋼板治療老年肱骨近端三部分、四部分骨折的療效分析[J/CD］.中華肩肘外科電子雜志,2017,5（2）：96-101.