肩胛骨骨折（英文）课件

Scapula Fractures Thomas P. Goss, MD Robert V. Cantu, MD University of Massachusetts Medical Center Scapulothoracic Dissociation Andrew H. Schmidt, MD Created March 2004 Outline 1. Incidence and Mechanisms 2. Diagnosis and Nonoperative Treatment 3. Fractures of the Glenoid Process 4. Isolated Fractures of the Coracoid Process Outline Continued 5. Isolated Fractures of the Acromial Process 6. Double Disruptions of the Superior Shoulder Suspensory Complex 7. Scapulothoracic Dissociation 8. Complications Incidence of Scapula Fractures 1% of all fractures 3% of injuries to shoulder girdle 5% of shoulder fractures Location of Scapula Fractures Diagnosis History typically high energy injury (80- 95% incidence other injury) Mechanism often direct but can be indirect Diagnosis ultimately radiographic Radiographs “Scapula trauma series”: AP and Lat of scapula, true glenohumeral axillary view CT scanning for complex injuries with 3D reconstructions Stress AP projection if injury to the clavicular-scapular linkage suspected Nonoperative Treatment 90% scapular fractures minimally displaced Treatment in sling and swathe with gradual increase of functional use for first 6 weeks x-rays at 2 week intervals until 6 weeks Nonoperative Tx Continued At 6 weeks osseous union usually present and sling/swathe discontinued Full recovery may take 6 months to 1 year Operative Indications 1. Significantly displaced (5-10mm) fractures of glenoid cavity (rim and fossa) 2. Significantly displaced (10mm or 40 degrees rotation) fractures of the glenoid neck 3. Double Disruptions of the superior suspensory shoulder complex with displacement of one or more elements Glenoid Process Glenoid process includes glenoid cavity (rim and fossa) and glenoid neck Fractures of the Glenoid Cavity (Rim and Fossa) 10% of scapula fractures of which no more than 10% are significantly displaced Classification Glenoid Cavity Fractures Ia= anterior rim fracture Ib=posterior rim fracture Classification Glenoid Cavity Fractures II= fracture line through glenoid fossa exiting at lateral border of scapula Classification Glenoid Cavity Fractures III= fracture line through glenoid fossa exiting at superior border of the scapula Classification Glenoid Cavity Fractures IV= fracture line through glenoid fossa exiting at the medial border of the scapula Classification Glenoid Cavity Fractures Va= combination types II and IV Vb= combination types III and IV Vc= combination types II,III, and IV Classification Glenoid Cavity Fractures VI= comminuted fracture Glenoid Rim Fractures Instability anticipated if fracture displaced 10mm and involves one fourth anterior aspect or one third posterior aspect glenoid cavity Fractures of anterior rim approached anteriorly and posterior rim posteriorly Fractures of the Glenoid Fossa Surgery if articular step-off 5-10mm or displacement causes subluxation humeral head out of glenoid cavity All glenoid fossa fractures approached posteriorly Glenoid Neck Fractures 25% of scapula fractures of which 10% or less are significantly displaced Mechanism can be direct blow, fall on outstretched arm, or fall on superior aspect shoulder Classification Glenoid Neck Fractures Type I: non and minimally displaced ( 10 mm 5 of 20 scapular fxs displaced 5 mm Treated with sling or immobilizer Evaluated by 3 different shoulder scores, strength compared to uninjured shoulder. Edwards SG, et al. JBJS 82B: 774-80, 2000 Results 1 clavicle nonunion (segmental bone loss at injury) Strength = to opposite arm in all Constant score 96, Rowe score 95 17-18 patients excellent results depending on evaluation system Edwards SG, et al. JBJS 82B: 774-80, 2000 Summary - Floating Shoulder Nonoperative treatment sufficient for many of these injuries. Each component of the injury should be separately evaluated for indications for surgery, but the combination itself does not mandate operative intervention Scapulothoracic Dissociation Traumatic disruption of scapula from posterior chest wall Neurovascular injury common Scapulothoracic Dissociation = Closed Forequarter Amputation Scapulothoracic Dissociation Left scapulothoracic dissociation with brachial artery disruption Scapulothoracic Dissociation Rare, life-threatening injury First described in 1984 (Oreck, JBJS 66A:758). Hallmark: Severe neurovascular injury to the upper extremity, associated with lateral displacement of the scapula. Sometimes associated with obvious fracture or dislocation about the shoulder Sometimes without obvious bone injury Scapulothoracic Dissociation Caused by Blunt Trauma Review of 4 personal cases and 54 described in the literature Broad spectrum of injuries: Neurologic injuries in 94% Vascular injuries in 88% Poor Outcome Flail extremity in 52% Early amputation in 21% Death in 10%, 8% due to this injury Damschen et al, J Trauma 42:537, 1997. Musculoskeletal Injuries Damschen et al, J Trauma 42:537, 1997. Clavicle Injury: 47% Sternoclavicular Sternoclavicular separation: 28%separation: 28% Acromioclavicular separation: 25% Brachial Plexus Injury Complete brachial plexopathy: 81% Partial plexopathy: 13% None: 6% Damschen et al, J Trauma 42:537, 1997. Neurologic Injury in Scapulothoracic Dissociation If deficit present EMG done at 3 weeks to determine extent and assess recovery if any Cervical myelography can be performed at 6 weeks Nerve root avulsions and complete deficits have a poor prognosis Partial plexus injuries have good prognosis and functional use extremity often regained Vascular Injury Subclavian or axillary artery: 88% None: 12% Damschen et al, J Trauma 42:537, 1997. Diagnosis Massive swelling of shoulder region Pulseless arm Complete or partial neurologic deficit Lateral displacement of scapula on a non- rotated chest radiograph is diagnostic 37 year old male, found lying on ground, intoxicated. Paramedics noted broken branches above. Patient later found to have fallen from 2nd story balcony Intoxicated Pale In acute distress Bilateral breath sounds present Left shoulder swelling Absent pulses left arm Unable to move left arm Distal Clavicle Fracture Chest Radiography Ratio of distance between medial border of scapula and spinous process on non- rotated CXR (A/B)= 1.07 Chest Radiography has many pitfalls: Absence of bony injury Patient position Bilateral injuries A B Kelbel et al, CORR 209:210, 1986. CT Scan Subclavicular swelling Arteriogram Axillary Artery Avulsion Classification Type I: Musculoskeletal injury alone Type IIA: Musculoskeletal injury with vascular disruption Type IIB: Musculoskeletal injury with neurologic impairment Type III: Musculoskeletal injury with both neurologic and vascular injury Damschen et al, J Trauma 42:537, 1997. Initial Treatment Patients often polytraumatized ATLS protocols must be followed. Angiography of limb. Vascular repair, with exploration of brachial plexus. Case Example To OR immediately Revascularization of Left Arm with Goretex graft. Musculocutaneous nerve avulsion ? What can the orthopedist do? Stabilize associated bone or joint injury Clavicle fractures are most common. Benefits of Skeletal Stabilization Avoid delayed or nonunion Stabilize shoulder girdle Protect vascular and/or neurologic repairs ORIF Clavicle Complications of Revascularization Graft thrombosis Compartment syndrome Hyperkalemia Rhabdomyolysis, myoglobinuria Case Example CPK levels: 9579 IU/L just after admission Hb: 13.7 admission to 8.1 4 hrs later Treated with iv fluids and alkalinization of urine, no renal failure seen. Deep Vein Thrombosis Severe swelling of arm 2 weeks later DVT L cephalic and brachial veins Later Treatment 3 weeks: EMG 6 weeks: cervical myelography Shoulder arthrodesis and/or above-elbow amputation may be necessary if the limb is flail. Prognosis Nerve avulsion or complete neurologic deficit: poor Partial neurologic deficit: good Case Example Cervical myelogram: no root avulsion EMG 4 months: severe, widespread brachial plexopathy, complete denervation. Repeat EMG 7 months: no change. To OR for exploration, neurolysis. 2.5 years, arm remains paralyzed. Limb Salvage If initial exploration of the brachial plexus reveals a severe injury, primary above- elbow amputation should be considered . If cervical myelography reveals 3 or more pseudomeningoceles, the prognosis is similarly poor. Summary - Scapulotho