肩胛骨骨折課件

肩胛骨骨折

scapulafracture流行病學(xué)受傷機(jī)制及影像學(xué)檢查骨折分型及治療解剖手術(shù)入路EpidemiologyEpidemiology25%to45%ofpatientshaveaccompanyingribfractures,15%to40%havefracturesoftheclavicle,15%to55%havepulmonaryinjuries(e.g.,hemopneumotho-rax,pulmonarycontusion),12%havehumeralfractures,and5%to10%sustaininjuriestothebrachialplexusandperipheralnerves.Fracturesoftheskullarefoundinapproximately25%ofpatients,cerebralcontusionsin10%to40%,centralneurologicde?citsin5%,tibiaand?bulafracturesin11%,majorvascularinjuriesin11%,andinjuriesthatresultinsplenectomyin8%.Harris發(fā)現(xiàn)100列肩胛骨骨折病人中僅有57%的骨折可在胸片上識(shí)別受傷機(jī)制外展上肢軸向負(fù)荷的間接損傷（肩胛頸-關(guān)節(jié)盂，關(guān)節(jié)內(nèi)）直接打擊或身體跌倒直接作用于肩峰喙突的創(chuàng)傷肌肉或韌帶的牽拉影像學(xué)檢查肩胛骨前后位(負(fù)重/正常)和腋窩位，或側(cè)位X線檢查。肩關(guān)節(jié)三維CT檢查骨折分型Zdravkovic和Damholt肩胛骨骨折分型Ideberg關(guān)節(jié)盂分型Kuhn的肩峰骨折分型Eyres喙突骨折分型FracturesoftheScapularBody

Thevastmajorityoffracturesofthescapularbodyandinsignificantlydisplacedfractures(>90%ofglenoid,coracoid,acromial,andavulsionfractures)aremanagednonoperatively.Fracturesofthescapularbodyandspine,aswellasinsignificantlydisplacedfracturesoftheglenoid,acromial,andcoracoidprocesses,aremanagednonoperatively.Theliteraturedoesmentionafractureofthescapularbodywithalateralspike

enteringtheglenohumeraljointasanindication(albeitextremelyuncommon)forsurgicalmanagement,andasimilarrecommendationwasmadeintwocasesinvolvingpatientswithfracturesofthescapularbodyandintrathoracic

penetrationbyoneofthefragments.

Bowenandcolleaguesreportedacaseofasignificantlyangulatedgreenstick

fractureofthescapularbodythatrequiredaclosedreduction.

Onrareoccasions,malunionofascapularbodyfracturecanresultinscapulothoracic

painandcrepitusrequiringsurgicalexposureofitsventralsurfaceandremovaloftheresponsiblebonyprominenceorprominences.Nonunion

ofascapularbodyfracturerequiringsurgicalmanagementhasbeendescribed.NordqvistandPetersson報(bào)道：當(dāng)肩胛骨骨折移位大于1cm時(shí)，7例患者中僅有3例患者恢復(fù)滿意；當(dāng)移位小于1cm時(shí)，34例患者中29例恢復(fù)滿意。當(dāng)肩胛骨骨折碎片向下后方移位，建議手術(shù)治療，切除碎片。IsolatedAcromialFracturesTheacromialprocessisformedfromtwoossificationcenters:oneforitsmostanteriorendandoneforitsposterolateraltip(itsbaseisactuallyanextensionofthescapularbodyandspine).

Theacromialprocesshasfourbasicfunctions:1.Itprovidesonesideoftheacromioclaviculararticulation.2.Itservesasapointofattachmentforvariousmusculotendinousandligamentousstructures.3.Itlendsposterosuperiorstabilitytotheglenohumeraljoint.4.ItisanimportantcomponentoftheSSSC(thescapular–clavicularlinkage).Kuhn肩峰骨折分型Ｉ型是指肩峰骨折無移位，或僅有輕度移位。ＩＩ型肩峰骨折是指骨折塊向外側(cè)或上方移位，肩峰下間隙無狹窄。ＩＩＩ型肩峰骨折是指肩峰骨折移位造成肩峰下間隙狹窄。Kuhnandcolleaguesproposedaclassificationschemethatdrewsomediscussion.

TheyemphasizedtheneedforORIFifanacromialfragmentisdisplacedinferiorlybythepullofthedeltoidmuscleandiscompromisingthesubacromialspace,therebyresultinginimpingementsymptomsandinterferingwithrotatorcufffunction.Symptomatic,nonoperativecaregenerallyleadstounionandagoodtoexcellentfunctionalresult.Ifunacceptabledisplacementispresent,however,surgicalreductionandstabilizationmustbeconsidered.IsolatedCoracoidFracturesThecoracoidprocessdevelopsfromtwoconstantossificationcenters:oneatitsbase,andonethatbecomesitsmainbody.

Inaddition,ithasatleasttwoinconstantcenters:oneatitsanglewherethecoracoclavicularligamentattachesandoneatitstipwheretheconjoinedtendonislocated.Theregionsatwhichthecentersfinallyunitearerelativelyweak,especiallyinyoungadults,thusmakingfracturesmorelikelytooccurwhendirectorindirectforcesareapplied.Theseinjuriescanbeanatomicallydividedintothefollowingcategories:1.Fracturesofthetipofthecoracoid2.Fracturesofthecoracoidbetweenthecoracoclavicularandcoracoacromialligaments3.FracturesatthebaseofthecoracoidprocessEyresTypeIFracturesofthecoracoidtipareavulsioninjuries—theresultofanindirectforceappliedthroughtheconjoinedtendonandconcentratedoveritsattachmenttothecoracoidprocess.Displacementmaybequitemarked,butnonsurgicaltreatmentisusuallyinorder.Opensurgicalreductionplusinternal?xationhasbeenadvocatedinathletes,especiallythoseparticipatinginsportsthatrequireoptimalupperextremityfunction,andinpersonswhoperformheavymanuallabor.TypeIIFracturesbetweenthecoracoclavicularandthecoracoacromialligamentsmaybetheresultofeitheradirectoranindirectforce.Treatmentmaybenonsurgicalorsurgical,followingthesamereasoningdescribedforsignificantlydisplacedavulsionfracturesofthecoracoidtip.Becausethefragmentislarger,however,symptomaticirritationofthelocalsofttissuesismorecommonandlatesurgicalmanagementismorelikely.TypeIII

Fracturesatthebaseofthecoracoidprocessarethemostcommoncoracoidfractures.Theymaybecausedbyadirectblowfromtheoutsideorbyadislocatinghumeralhead.Avulsionfracturescausedbystrongtractionforcesarealsopossible.Theseinjuriesaregenerallyminimallydisplacedduetothestabilizingeffectofthesurroundingsofttissues,inparticularthecoracoclavicularligament.Symptomaticnonsurgicalcareisusuallysufficient,andunionoccurswithin6weeks.FIGURE1.Cadavericdissectiondemonstratingthelandmarksfortheincision(A)anddissection(B)throughLanger’slineinthe

anteriorapproachtothecoracoid.Wepreferascrewlengthbetween30and45mmwith15°medialangulationand30–40°posteriorangulationtoensurethatthescrewremainsenclosedinthebone.Withfracturesoccurringbetweenthecoracoclavicularandcoracoacromial

ligaments,thefragmentislargerandsymptomaticirritationoflocalsofttissuesismorelikely.Consequently,surgicalmanagement(acuteorlate)ismorelikely.Withfracturesofthebaseofthecoracoidprocess,nonoperativecareisusuallysufficient.However,intheeventofsymptomaticnonunion,bonegraftingandcompressionscrewfixationmustbeconsidered.

Glenoid

neck

fracture

TypeIfracturesincludeallinsignificantlydisplaced

injuriesandconstitutemorethan90%ofthetotal.Management

isnonoperative,andagoodtoexcellentfunctional

resultcanbeexpected.

TypeIIfracturesinclude

allsignificantlydisplacedinjuries;significantdisplacement

isdefinedastranslationaldisplacementofthe

glenoidfragmentof1cmormoreorangulardisplacement

ofthefragmentofatleast40degrees。GlenoidCavity(Intra-articular)FracturesFracturesoftheglenoidcavitymakeup10%ofscapula

fractures.Themajority(>90%)areinsignificantlydisplaced

andaremanagednonoperatively。

Significantlydisplacedfracturesrequiresurgical

treatmentoratleastmeritsurgicalconsideration.idebergTypeISurgicalmanagementoffracturesoftheglenoidrimisindicatedifthefractureresultsinpersistentsubluxationofthehumeralhead(failureofthehumeralheadtolieconcentricallywithintheglenoidcavity)orifthefractureorhumeralheadisunstableafterreduction.

DePalma

statedthatinstabilitycouldbeexpectedifthefractureis

displaced10mmormoreandifaquarterormore

ofthe

glenoidcavityanteriorlyorathirdormoreoftheglenoidcavityposteriorlyisinvolved.TypeIIWithtypeIIglenoidfossafractures,thehumeralheadis

driveninferiorlyandaninferiorglenoidfragmentis

created.Surgeryisindicatedifanarticularstep-offof

5mmormoreispresentorifthefragmentisdisplaced

inferiorlyandcarriesthehumeralheadwithitsuchthat

thehumeralheadfailstolieinthecenteroftheglenoidcavity.Theseinjuriescanresultinposttraumaticdegenerativejointdiseaseorglenohumeralinstability,orboth.TypeIII(glenoidfossa)fracturesoccurwhentheforceofthehumeralheadisdirectedsuperiorlyandcausesthetransversedisruptiontopropagateupward,generallyexitingthroughthesuperiorscapularmargininthevicinityofthesuprascapularnotch.Displacementisusuallyminimal,withthefragmentlyingmedially.Consequently,aswithbaseofthecoracoidfractures,theseinjuriesaregenerallytreatednonoperativelyandhealuneventfully.Anyglenoidcavityfracturemaybeassociatedwithneurovascularinjuryduetotheproximityofthebrachialplexusandaxillaryvessels,aswellastheconsiderableviolenceinvolved.SurgicalmanagementoftypeIIIfracturesisindicatedifthefracturehasanarticularstep-offof5mmormorewithlateraldisplacementofthesuperiorfragmentorifasignificantlydisplacedadditionaldisruptionoftheSSSCispresent(adoubledisruptioninjury).ExamplesincludeanassociateddisruptionoftheC-4linkageoroftheclavicular–acromioclavicularjoint–acromialstrut.Theseinjuriescanresultinpost-traumaticdegenerativejointdiseaseandseverefunctionalimpairmentTypeIVTypeIV(glenoidfossa)injuriesoccurwhenthehumeralheadisdrivendirectlyintothecenteroftheglenoidCavity.

Thefracturecoursestransverselyacrosstheentirescapulaandexitsalongitsvertebralborder.Ifthereisanunacceptablearticularstep-off(≥5mm)withthesuperiorfragmentdisplacedlaterally,orifthesuperiorandinferiorglenoscapularsegmentsareseverelyseparated,ORIFisindicatedtopreventsymptomaticdegenerativejointdisease,nonunionatthefracturesite.FerrazandcolleaguesdescribedaTypeIVglenoidfossafracturethatprogressedtoanonunion.TypeVTheseglenoidfossainjuriesarecombinationsoftypeII,III,andIVinjuriesandarecausedbymoreviolentandcomplexforces.ThesameclinicalconcernsandoperativeindicationsdetailedforthetypeII,III,andIVfracturesapplytotypeVfracturesTypeVITypeVIglenoidcavityfracturesarecausedbythemostviolentforcesandincludealldisruptionsinwhichtwoormorearticularfragmentsarepresent.

Operativetreatmentiscontraindicatedbecauseexposingtheseinjuriessurgicallydoeslittlemorethandisruptwhateversofttissuesupportremains,renderingthefragmentsevenmoreunstableandmakingabadsituationworse.DoubleDisruptionsoftheSuperior

ShoulderSuspensoryComplex(SSSC)肩關(guān)節(jié)懸吊復(fù)合體superiorshouldersuspensorycomplex（SSSC）包括骨性結(jié)構(gòu)和軟組織結(jié)構(gòu)（肩胛盂，喙突，喙鎖韌帶，鎖骨外側(cè)端，肩鎖關(guān)節(jié)和肩峰），上方骨性結(jié)構(gòu)（鎖骨干），以及下方骨結(jié)構(gòu)（肩胛骨外側(cè)部和肩胛岡）。懸吊復(fù)合體中有2個(gè)部位（或以上）的損傷，才會(huì)造成不穩(wěn)定，導(dǎo)致漂浮肩。SingletraumaticdisruptionsoftheSSSCarecommon.Theseareanatomicallystablesituationsbecausetheoverallintegrityofthecomplexisnotsigni?cantlyviolated,andnonoperativemanagementgenerallyyieldsagoodtoexcellentresult.Whenthecomplexisdisruptedintwo(ormore)places(adoubledisruption),however,theintegrityoftheSSSCiscompromisedandapotentiallyunstableanatomicsituationiscreated.Signi?cantdisplacementcanoccurateitherorbothsitesandresultinbonyhealingproblems(delayedunion,malunion,andnonunion),aswellasadverselong-termfunctionaldif?culties(subacromialimpingement,decreasedstrength,musclefatiguediscomfort,neurovascularcompromisefromadroopingshoulder,anddegenerativejointdisease),dependingupontheparticularinjury.TheFloatingShoulder(IpsilateralFractures

oftheMidshaftClavicleandtheGlenoidNeck)The?oatingshoulderrepresentsadoubledisruptionoftheSSSC.Inisolation,eachfractureisgenerallyminimallydisplacedandmanagednonoperatively.Incombination,however,eachdisruptionhasthepotentialtomaketheotherunstable(theglenoidneckfractureallowingseveredisplacementtooccurattheclavicularsite,andviceversa)Thesituationisrenderedevenmoreunstableifanadditionaldisruptionoftheclavicular–acromioclavicularjoint–acromialstrutispresentoriftheC-4linkageisviolatedwithorwithoutinvolvementofthecoracoacromialligament.Hardeggerandcolleaguesstatedthattheseinjuriesrepresenteda“functionalimbalance”asaresultof“alteredglenohumeral–acromialrelationships.”BoththeyandButtersrecommendedsurgerytoreduceandstabilizetheinjury.Surgicalreductionplusstabilizationoftheclavicular

fracturesite(mostcommonlywithplatefixation)isadvisableifdisplacementisunacceptableinordertoavoidnonunion,alleviatetensileforcesonthebrachialplexus,restorenormalanatomicrelationships,andensurerestorationofnormalshoulderfunction.

Theglenoidneckfracturecanreducesatisfactorilywithstabilizationoftheclavi