合并结节骨折的肩关节脱位，在急诊室直接复位安全吗？
16%的肩关节脱位合并肱骨结节骨折，既往研究表明，在急诊室手法复位合并肱骨结节脱位的肩关节脱位，可能有较大的肱骨近端骨折风险。
对此，有研究者对在急诊室复位的合并结节骨折的肩关节脱位患者进行了研究，比较其医源性骨折风险及安全性。
Aim（目的）
本研究的目的是确定急诊肩关节脱位伴结节骨折复位的安全性。
[Aim: A fracture of the tuberosity is associated with 16% of glenohumeral dislocations. Extension of the fracture into the humeral neck can occur during closed manipulation, leading some to suggest that all such injures should be managed under general anaesthesia in the operating theatre. The purpose of this study was to establish the safety of reduction of glenohumeral dislocations with tuberosity fractures in the emergency department (ED).]
Patients and Methods（病例与方法）
我们回顾了从数据库中识别的连续188例肩关节脱位伴结节骨折患者。记录患者人口统计、损伤细节、急诊科管理和并发症。记录复位方法、镇静方式、临床医生级别和结果。
图1 病例挑选与治疗方法流程图。
Results（结果）
平均年龄为61岁(18-96岁)，其中男性79人，女性109人。大多数损伤(146，78%)发生在从站立高度跌落之后。162例(86%)急诊患者在镇静下成功完成闭合复位。其余患者中，22例(11%)在镇静下闭合复位失败，随后去了手术室，6例(3%)被认为不适合急诊室操作。操作过程中35名(19%)患者出现神经损伤，其中29名(90%)患者自行痊愈。两例医源性骨折发生在闭合复位过程中，一个在急诊室，另一个在手术室。因此，如果在急诊进行复位，骨折医源性累及到肱骨近端颈部的风险为0.5%，总的来说为1%。两次以上的尝试性复位预测急诊室复位的失败(P = 0.001)。
[Results: The mean age was 61 years (range 18–96 years) with 79 males and 109 females. The majority of injuries (146, 78%) occurred after a fall from standing height. Closed reduction under sedation in the ED was successful in 162 (86%) cases. Of the remainder, 22 (11%) failed closed reduction under sedation and subsequently went to theatre and 6 (3%) were deemed not suitable for ED manipulation. At presentation 35 (19%) patients had a nerve injury, of which 29 (90%) resolved spontaneously. Two iatrogenic fractures occurred during close manipulation, one in the ED and the other in the operating theatre. Therefore, the risk of iatrogenic propagation of the fracture into the proximal humerus neck was 0.5% if the reduction was performed in the ED, and 1% over-all. More than two attempted reductions predicted a failed ED reduction (P = 0.001).]
病例 一例合并肱骨大结节骨折的肩关节脱位患者，在急诊室行复位后出现肱骨近端骨折，予以肩关节置换。
Conclusion（结论）
在急诊室中行闭合复位伴有结节骨折的肩关节脱位是安全的，医源性骨折的发生率为1%。这些损伤应该由有适当经验的人在两次充分的X光透视后处理。如果肱骨颈的完整性不明确，应推迟复位，直到获得多平面CT成像。
[Conclusion: Closed reduction of glenohumeral dislocations with associated tuberosity fractures in the ED is safe, with a rate of iatrogenic fracture of 1%. These injuries should be managed by those with appropriate experience only after two adequate radiographic views. In cases where there is ambiguity over the integrity of the humeral neck, reduction should be delayed until multiplanar CT imaging has been obtained.]
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