115-肩胛骨骨折（英文）

nullScapula Fractures Thomas P. Goss, MD Robert V. Cantu, MD University of Massachusetts Medical Center Scapulothoracic Dissociation Andrew H. Schmidt, MD Created March 2004Scapula Fractures Thomas P. Goss, MD Robert V. Cantu, MD University of Massachusetts Medical Center Scapulothoracic Dissociation Andrew H. Schmidt, MD Created March 2004Outline Outline 1. Incidence and Mechanisms 2. Diagnosis and Nonoperative Treatment 3. Fractures of the Glenoid Process 4. Isolated Fractures of the Coracoid Process Outline ContinuedOutline Continued5. Isolated Fractures of the Acromial Process 6. Double Disruptions of the Superior Shoulder Suspensory Complex 7. Scapulothoracic Dissociation 8. ComplicationsIncidence of Scapula FracturesIncidence of Scapula Fractures 1% of all fractures 3% of injuries to shoulder girdle 5% of shoulder fractures Location of Scapula FracturesLocation of Scapula FracturesDiagnosisDiagnosisHistory typically high energy injury (80-95% incidence other injury) Mechanism often direct but can be indirect Diagnosis ultimately radiographicRadiographsRadiographs“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 suspectedNonoperative TreatmentNonoperative 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 weeksNonoperative Tx ContinuedNonoperative Tx ContinuedAt 6 weeks osseous union usually present and sling/swathe discontinued Full recovery may take 6 months to 1 yearOperative IndicationsOperative Indications1. 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 Glenoid process includes glenoid cavity (rim and fossa) and glenoid neck Fractures of the Glenoid Cavity (Rim and Fossa)Fractures of the Glenoid Cavity (Rim and Fossa) 10% of scapula fractures of which no more than 10% are significantly displaced Classification Glenoid Cavity FracturesClassification Glenoid Cavity FracturesIa= anterior rim fracture Ib=posterior rim fractureClassification Glenoid Cavity FracturesClassification Glenoid Cavity FracturesII= fracture line through glenoid fossa exiting at lateral border of scapulaClassification Glenoid Cavity FracturesClassification Glenoid Cavity FracturesIII= fracture line through glenoid fossa exiting at superior border of the scapulaClassification Glenoid Cavity FracturesClassification Glenoid Cavity FracturesIV= fracture line through glenoid fossa exiting at the medial border of the scapulaClassification Glenoid Cavity FracturesClassification Glenoid Cavity FracturesVa= combination types II and IV Vb= combination types III and IV Vc= combination types II,III, and IVClassification Glenoid Cavity FracturesClassification Glenoid Cavity Fractures VI= comminuted fractureGlenoid Rim FracturesGlenoid Rim FracturesInstability 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 posteriorlyFractures of the Glenoid FossaFractures of the Glenoid FossaSurgery if articular step-off 5-10mm or displacement causes subluxation humeral head out of glenoid cavity All glenoid fossa fractures approached posteriorlyGlenoid Neck FracturesGlenoid Neck Fractures25% 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 FracturesClassification Glenoid Neck FracturesType I: non and minimally displaced (<10mm) Type II: translational displacement 1cm or more or angulatory displacement 40 degrees or moreGlenoid Neck Fractures ContinuedGlenoid Neck Fractures ContinuedSurgery for type II fractures Posterior approach between infraspinatus and teres minor Fixation with 3.5mm recon plate, and possibly k-wires or interfragmentary screwsIsolated Fractures of the Coracoid ProcessIsolated Fractures of the Coracoid ProcessFracture can be at base of coracoid, between CA and CC ligaments, or at tip (avulsion) Diagnosis often on plain films but CT scan may be needed to better define fracture Fractures at tip of coracoid typically treated non-operatively (athletes and manual laborers may be exceptions)Coracoid Fractures Con’tCoracoid Fractures Con’tSurgical options include ORIF (cannulated 3.5 or 4.0mm screw) or excision fragment and suture fixation conjoined tendon to remaining coracoid process Fractures between CA and CC ligaments can often be treated non-operatively unless high physical demand patient Fractures at base coracoid generally minimally displaced and treated non-operatively. Fibrous union may occur but rarely source discomfortIsolated Fractures of the Acromial ProcessIsolated Fractures of the Acromial ProcessScapula series detects most acromial fractures Os acromionale may complicate evaluation Most are nondisplaced or minimally displaced and treated symptomatically Fixation of Acromial FracturesFixation of Acromial FracturesIf ORIF undertaken tension band construct for fractures at distal portion and 3.5mm recon plate for more proximal fracturesDouble Disruptions of the Superior Suspensory Shoulder Complex (SSSC)Double Disruptions of the Superior Suspensory Shoulder Complex (SSSC)SSSC is a bone-soft tissue ring at the end of a superior and inferior bone strut Ring includes glenoid process, coracoid process, CC ligaments, distal clavicle, AC joint, acromial process Superior strut is middle third clavicle Inferior strut is lateral scapular body and spineSuperior Shoulder Suspensory ComplexSuperior Shoulder Suspensory ComplexDouble Disruption of SSSCDouble Disruption of SSSCTraumatic disruption 2 or more components SSSC usually secondary to high energy injury and frequently require surgical management Frequently described as “Floating Shoulder” Potential long term consequences non-operative treatment include: nonunion, malunion, impingement, altered shoulder mechanics, DJD, neurovascular compromiseFloating ShoulderFloating ShoulderOperative management recommended because of potential instability, displacement of glenoid Recent series of floating shoulders treated nonoperatively shows good results with conservative care.Nonoperative Management of Ipsilateral Fractures of the Scapula and ClavicleNonoperative Management of Ipsilateral Fractures of the Scapula and ClavicleRetrospective review of 20 cases 11 of 20 clavicle fx’s displaced > 10 mm 5 of 20 scapular fx’s 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, 2000ResultsResults1 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 systemEdwards SG, et al. JBJS 82B: 774-80, 2000Summary - Floating ShoulderSummary - Floating ShoulderNonoperative 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 interventionScapulothoracic Dissociation Scapulothoracic Dissociation Traumatic disruption of scapula from posterior chest wall Neurovascular injury common Scapulothoracic Dissociation = Closed Forequarter AmputationScapulothoracic Dissociation = Closed Forequarter AmputationScapulothoracic DissociationScapulothoracic DissociationLeft scapulothoracic dissociation with brachial artery disruptionScapulothoracic DissociationScapulothoracic DissociationRare, 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 TraumaScapulothoracic Dissociation Caused by Blunt TraumaReview 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 injuryDamschen et al, J Trauma 42:537, 1997.Musculoskeletal InjuriesMusculoskeletal InjuriesDamschen et al, J Trauma 42:537, 1997.Clavicle Injury: 47%Sternoclavicular separation: 28%Acromioclavicular separation: 25%Brachial Plexus InjuryBrachial Plexus InjuryComplete brachial plexopathy: 81% Partial plexopathy: 13% None: 6%Damschen et al, J Trauma 42:537, 1997.Neurologic Injury in Scapulothoracic DissociationNeurologic Injury in Scapulothoracic DissociationIf 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 regainedVascular InjuryVascular InjurySubclavian or axillary artery: 88% None: 12%Damschen et al, J Trauma 42:537, 1997.DiagnosisDiagnosisMassive swelling of shoulder region Pulseless arm Complete or partial neurologic deficit Lateral displacement of scapula on a non-rotated chest radiograph is diagnosticnull37 year old male, found lying on ground, intoxicated. Paramedics noted broken branches above. Patient later found to have fallen from 2nd story balconyIntoxicated Pale In acute distress Bilateral breath sounds present Left shoulder swelling Absent pulses left arm Unable to move left arm nullDistal Clavicle FractureChest RadiographyChest RadiographyRatio of distance between medial border of scapula and spinous process on non-rotated CXR (A/B)= 1.07Chest Radiography has many pitfalls: Absence of bony injury Patient position Bilateral injuriesKelbel et al, CORR 209:210, 1986.CT ScanCT ScanSubclavicular swellingArteriogramArteriogramClassificationClassificationType 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 TreatmentInitial TreatmentPatients often polytraumatized ATLS protocols must be followed. Angiography of limb. Vascular repair, with exploration of brachial plexus.Case ExampleCase ExampleTo OR immediately Revascularization of Left Arm with Goretex graft. Musculocutaneous nerve avulsion ???What can the orthopedist do?What can the orthopedist do?Stabilize associated bone or joint injury Clavicle fractures are most common.Benefits of Skeletal StabilizationBenefits of Skeletal StabilizationAvoid delayed or nonunion Stabilize shoulder girdle Protect vascular and/or neurologic repairsORIF ClavicleORIF ClavicleComplications of RevascularizationComplications of RevascularizationGraft thrombosis Compartment syndrome Hyperkalemia Rhabdomyolysis, myoglobinuria Case ExampleCase ExampleCPK 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 ThrombosisDeep Vein ThrombosisSevere swelling of arm 2 weeks later DVT L cephalic and brachial veinsLater TreatmentLater Treatment3 weeks: EMG 6 weeks: cervical myelography Shoulder arthrodesis and/or above-elbow amputation may be necessary if the limb is flail.PrognosisPrognosisNerve avulsion or complete neurologic deficit: poor Partial neurologic deficit: goodCase ExampleCase ExampleCervical 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 SalvageLimb SalvageIf 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 - Scapulothoracic DissociationSummary - Scapulothoracic DissociationScapulothoracic dissociation may be a life or limb-threatening injury If revascularization is necessary, try to explore the brachial plexus at the same time - if it is “shredded” amputation may be considered Orthopedic stabilization of any skeletal injury is warranted - although the outcome remains poor in most cases.Intrathoracic Dislocation of the ScapulaIntrathoracic Dislocation of the Scapula Extremely rare Inferior angle scapula locked in intercostal space Chest CT may be needed to confirm diagnosis Intrathoracic Dislocation of the Scapula ContinuedIntrathoracic Dislocation of the Scapula Continued Treatment is closed reduction and immobilization with sling and swathe and tape for 2 weeks followed by progressive functional use of shoulder and armComplications of Scapula FracturesComplications of Scapula FracturesNonunion (rare) Malunion more common DJD glenohumeral joint Shoulder instability Glenohumeral pain and dysfunction Infection, neurovascular injury, loss of fixationReturn to Upper Extremity Index