肩胛骨骨折.ppt

肩胛骨 Scapula 骨折的诊治 戚剑 AnatomyReview 1 Borders1 medial 内侧缘 2 lateral 外侧缘 3 superior 上缘 coracoidprocess 喙突 scapularnotch 肩胛切迹 2 Angles1 superior 上角 2 inferior 下角 3 lateral 外侧角 glenoidcavity 关节盂 neckofscapula 肩胛颈 3 Surfaces1 Anteriorsubscapularfossa 肩胛下窝 2 Posteriorspineofscapula 肩胛冈 supraspinousfossa 冈上窝 infraspinousfossa 冈下窝 RAntview RPostview FunctionsoftheScapula 肩胛骨对稳定上肢及发挥上肢功能起重要作用肩胛骨主要通过肌肉与躯干形成软组织连接 因此肩胛骨的稳定主要由肌肉连接来完成上臂上举时1 3的活动发生于肩胛胸壁间 ShoulderEvaluation Observation ScapulohumeralRhythmMovementofscapularelativetothehumerusInitial30degreesofglenohumeralabductiondoesnotincorporatescapularmotion settingphase 30to90degreesthescapulaabductsandupwardlyrotates1degreeforevery2degreesofhumeralelevationAbove90degreesthescapulaandhumerusmovein1 1ratio IncidenceofScapulaFractures 1 ofallfractures3 ofinjuriestoshouldergirdle5 ofshoulderfractures ScapulaFractures Classification BodyNeckGlenoidAcromionCoracoidSpine Classification 稳定的关节外骨折 肩胛体 肩胛骨突 单纯肩胛颈不稳定的关节外骨折 肩胛颈合并骨突或锁骨骨折关节内骨折 肩盂的横行骨折 或大块盂缘骨折 Zdravkovic DamholtClassification 肩胛体部骨折骨突部位的骨折肩胛骨的外上部骨折 肩胛颈和肩盂骨折 IdebergClassification 盂缘骨折盂窝至肩胛体外缘骨折盂窝外上部分骨折盂窝中心至肩胛内缘的横行骨折 组合损伤盂窝严重粉碎骨折 EyresClassification 喙突顶端或骺的损伤喙突中部骨折喙突基底骨折波及肩胛体上部的骨折延及肩盂的骨折 Diagnosis Historytypicallyhighenergyinjury 80 95 incidenceotherinjury MechanismoftendirectbutcanbeindirectDiagnosisultimatelyradiographic Radiographs Scapulatraumaseries APandLatofscapula trueglenohumeralaxillaryviewCTscanningforcomplexinjurieswith3DreconstructionsStressAPprojectionifinjurytotheclavicular scapularlinkagesuspected 假性肩袖损伤体征喙突骨折和体部骨折 深吸气时 疼痛加剧肩胛颈和肩峰骨折时 肩外形变扁注意检查肋骨 脊柱和胸部损伤 NonoperativeTreatment 90 scapularfracturesminimallydisplacedTreatmentinslingandswathewithgradualincreaseoffunctionaluseforfirst6weeksx raysat2weekintervalsuntil6weeks NonoperativeTxContinued At6weeksosseousunionusuallypresentandsling swathediscontinuedFullrecoverymaytake6monthsto1year OperativeIndications 1 Significantlydisplaced 5 10mm fracturesofglenoidcavity rimandfossa 2 Significantlydisplaced 10mmor40degreesrotation fracturesoftheglenoidneck3 DoubleDisruptionsofthesuperiorsuspensoryshouldercomplex 上方悬吊复合体 withdisplacementofoneormoreelements GlenoidProcess Glenoidprocessincludesglenoidcavity rimandfossa andglenoidneck FracturesoftheGlenoidCavity RimandFossa 10 ofscapulafracturesofwhichnomorethan10 aresignificantlydisplaced ClassificationGlenoidCavityFractures Ia anteriorrimfractureIb posteriorrimfracture ClassificationGlenoidCavityFractures II fracturelinethroughglenoidfossaexitingatlateralborderofscapula ClassificationGlenoidCavityFractures III fracturelinethroughglenoidfossaexitingatsuperiorborderofthescapula ClassificationGlenoidCavityFractures IV fracturelinethroughglenoidfossaexitingatthemedialborderofthescapula ClassificationGlenoidCavityFractures Va combinationtypesIIandIVVb combinationtypesIIIandIVVc combinationtypesII III andIV ClassificationGlenoidCavityFractures VI comminutedfracture GlenoidRimFractures Instabilityanticipatediffracturedisplaced10mmandinvolvesonefourthanterioraspectoronethirdposterioraspectglenoidcavityFracturesofanteriorrimapproachedanteriorlyandposteriorrimposteriorly 肱骨头复位后 三角巾或吊带保护3 4周 FracturesoftheGlenoidFossa Surgeryifarticularstep off5 10mmordisplacementcausessubluxationhumeralheadoutofglenoidcavityAllglenoidfossafracturesapproachedposteriorlyNonoperativetreatmentto GlenoidNeckFractures 25 ofscapulafracturesofwhich10 orlessaresignificantlydisplacedMechanismcanbedirectblow fallonoutstretchedarm orfallonsuperioraspectshoulder ClassificationGlenoidNeckFractures TypeI nonandminimallydisplaced 10mm TypeII translationaldisplacement1cmormoreorangulatorydisplacement40degreesormore GlenoidNeckFracturesContinued SurgeryfortypeIIfracturesPosteriorapproachbetweeninfraspinatusandteresminorFixationwith3 5mmreconplate andpossiblyk wiresorinterfragmentaryscrews IsolatedFracturesoftheCoracoidProcess Fracturecanbeatbaseofcoracoid betweenCAandCCligaments orattip avulsion DiagnosisoftenonplainfilmsbutCTscanmaybeneededtobetterdefinefractureFracturesattipofcoracoidtypicallytreatednon operatively athletesandmanuallaborersmaybeexceptions CoracoidFracturesCon t SurgicaloptionsincludeORIF cannulated3 5or4 0mmscrew orexcisionfragmentandsuturefixationconjoinedtendontoremainingcoracoidprocessFracturesbetweenCAandCCligamentscanoftenbetreatednon operativelyunlesshighphysicaldemandpatientFracturesatbasecoracoidgenerallyminimallydisplacedandtreatednon operatively Fibrousunionmayoccurbutrarelysourcediscomfort 合并有臂丛或肩胛上神经损伤时合并肩锁关节 度脱位时 IsolatedFracturesoftheAcromialProcess ScapulaseriesdetectsmostacromialfracturesMostarenondisplacedorminimallydisplacedandtreatedsymptomatically FixationofAcromialFractures IfORIFundertakentensionbandconstructforfracturesatdistalportionand3 5mmreconplateformoreproximalfractures DoubleDisruptionsoftheSuperiorSuspensoryShoulderComplex SSSC SSSCisabone softtissueringattheendofasuperiorandinferiorbonestrutRingincludesglenoidprocess coracoidprocess CCligaments distalclavicle ACjoint acromialprocessSuperiorstrutismiddlethirdclavicleInferiorstrutislateralscapularbodyandspine SuperiorShoulderSuspensoryComplex DoubleDisruptionofSSSC Traumaticdisruption2ormorecomponentsSSSCusuallysecondarytohighenergyinjuryandfrequentlyrequiresurgicalmanagementFrequentlydescribedas FloatingShoulder Potentiallongtermconsequencesnon operativetreatmentinclude nonunion malunion impingement alteredshouldermechanics DJD neurovascularcompromise FloatingShoulder Operativemanagementrecommendedbecauseofpotentialinstability displacementofglenoidRecentseriesoffloatingshoulderstreatednonoperativelyshowsgoodresultswithconservativecare NonoperativeManagementofIpsilateralFracturesoftheScapulaandClavicle Retrospectivereviewof20cases11of20claviclefx sdisplaced 10mm5of20scapularfx sdisplaced 5mmTreatedwithslingorimmobilizerEvaluatedby3differentshoulderscores strengthcomparedtouninjuredshoulder EdwardsSG etal JBJS82B 774 80 2000 Results 1claviclenonunion segmentalbonelossatinjury Strength tooppositearminallConstantscore96 Rowescore9517 18patientsexcellentresultsdependingonevaluationsystem EdwardsSG etal JBJS82B 774 80 2000 Summary FloatingShoulder Nonoperativetreatmentsufficientformanyoftheseinjuries Eachcomponentoftheinjuryshouldbeseparatelyevaluatedforindicationsforsurgery butthecombinationitselfdoesnotmandateoperativeintervention ScapulothoracicDissociation TraumaticdisruptionofscapulafromposteriorchestwallNeurovascularinjurycommon ScapulothoracicDissociation ClosedForequarterAmputation ScapulothoracicDissociation Leftscapulothoracicdissociationwithbrachialarterydisruption ScapulothoracicDissociation Rare life threateninginjuryFirstdescribedin1984 Oreck JBJS66A 758 Hallmark Severeneurovascularinjurytotheupperextremity associatedwithlateraldisplacementofthescapula SometimesassociatedwithobviousfractureordislocationabouttheshoulderSometimeswithoutobviousboneinjury ScapulothoracicDissociationCausedbyBluntTrauma Reviewof4personalcasesand54describedintheliteratureBroadspectrumofinjuries Neurologicinjuriesin94 Vascularinjuriesin88 PoorOutcomeFlailextremityin52 Earlyamputationin21 Deathin10 8 duetothisinjury Damschenetal JTrauma42 537 1997 MusculoskeletalInjuries Damschenetal JTrauma42 537 1997 ClavicleInjury 47 Sternoclavicularseparation 28 Acromioclavicularseparation 25 BrachialPlexusInjury Completebrachialplexopathy 81 Partialplexopathy 13 None 6 Damschenetal JTrauma42 537 1997 NeurologicInjuryinScapulothoracicDissociation IfdeficitpresentEMGdoneat3weekstodetermineextentandassessrecoveryifanyCervicalmyelographycanbeperformedat6weeksNerverootavulsionsandcompletedeficitshaveapoorprognosisPartialplexusinjurieshavegoodprognosisandfunctionaluseextremityoftenregained VascularInjury Subclavianoraxillaryartery 88 None 12 Damschenetal JTrauma42 537 1997 Diagnosis MassiveswellingofshoulderregionPulselessarmCompleteorpartialneurologicdeficitLateraldisplacementofscapulaonanon rotatedchestradiographisdiagnostic 37yearoldmale foundlyingonground intoxicated Paramedicsnotedbrokenbranchesabove Patientlaterfoundtohavefallenfrom2ndstorybalcony IntoxicatedPaleInacutedistressBilateralbreathsoundspresentLeftshoulderswellingAbsentpulsesleftarmUnabletomoveleftarm DistalClavicleFracture ChestRadiography Ratioofdistancebetweenmedialborderofscapulaandspinousprocessonnon rotatedCXR A B 1 07 ChestRadiographyhasmanypitfalls AbsenceofbonyinjuryPatientpositionBilateralinjuries Kelbeletal CORR209 210 1986 CTScan Subclavicularswelling Arteriogram Classification TypeI MusculoskeletalinjuryaloneTypeIIA MusculoskeletalinjurywithvasculardisruptionTypeIIB MusculoskeletalinjurywithneurologicimpairmentTypeIII Musculoskeletalinjurywithbothneurologicandvascularinjury Damschenetal JTrauma42 537 1997 InitialTreatment PatientsoftenpolytraumatizedATLSprotocolsmustbefollowed Angiographyoflimb Vascularrepair withexplorationofbrachialplexus CaseExample ToORimmediatelyRevascularizationofLeftArmwithGoretexgraft Musculocutaneousnerveavulsion Whatcantheorthopedistdo StabilizeassociatedboneorjointinjuryClaviclefracturesaremostcommon BenefitsofSkeletalStabilization AvoiddelayedornonunionStabilizeshouldergirdleProtectvascularand orneurologicrepairs ORIFClavicle ComplicationsofRevascularization GraftthrombosisCompartmentsyndromeHyperkalemiaRhabdomyolysis myoglobinuria CaseExample CPKlevels 9579IU LjustafteradmissionHb 13 7 admissionto8 14hrslaterTreatedwithivfluidsandalkalinizationofurine norenalfailureseen DeepVeinThrombosis Severeswellingofarm2weekslaterDVTLcephalicandbrachialveins LaterTreatment 3weeks EMG6weeks cervicalmyelographyShoulderarthrodesisand orabove elbowamputationmaybenecessaryifthelimbisflail Prognosis Nerveavulsionorcompleteneurologicdeficit poorPartialneurologicdeficit good CaseExample Cervicalmyelogram norootavulsionEMG4months severe widespreadbrachialplexopathy completedenervation RepeatEMG7months nochange ToORforexploration neurolysis 2 5years armremainsparalyzed LimbSalvage Ifinitialexplorationofthebrachialplexusrevealsasevereinjury primaryabove elbowamputationshouldbeconsidered Ifce