锁骨骨折的诊疗与手术_精品文档.ppt

锁骨骨折的诊疗与手术_精品文档.ppt

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InjuriesoftheClavicle,AcromioclavicularJointandSternoclavicularJointAndrewH.Schmidt,MDT.J.McElroyCreatedMarch2004“S”-shapedboneMedial-sternoclavicularjointLateral-acromioclavicularjointandcoracoclavicularligamentsMuscleattachments:

Medial:

sternocleidomastoidLateral:

Trapezius,pectoralismajorClavicleDiarthrodialjointbetweenmedialfacetofacromionandthelateral（distal）clavicle.Containsintra-articulardiskofvariablesize.Thincapsulestabilizedbyligamentsonallsides:

ACligamentscontrolhorizontal（anteroposterior）displacementSuperiorACligamentmostimportantACJointCoracoclavicularligaments“Suspensoryligamentsoftheupperextremity”Twocomponents:

TrapezoidConoidStrongerthanACligamentsProvideverticalstabilitytoACjointDistalClavicleMechanismofInjuryModerateorhigh-energytraumaticimpactstotheshoulder1.Fallfromheight2.Motorvehicleaccident3.Sportsinjury4.Blowtothepointoftheshoulder5.RarelyadirectinjurytotheclaviclePhysicalExaminationInspectionEvaluatedeformityand/ordisplacementBewareofrareinferiororposteriordisplacementofdistalormedialendsofclavicleComparetooppositeside.PhysicalExaminationPalpationEvaluatepainLookforinstabilitywithstressPhysicalExaminationNeurovascularexaminationEvaluateupperextremitymotorandsensationMeasureshoulderrange-of-motionRadiographicEvaluationoftheClavicleAnteroposteriorView30-degreeCephalicTiltViewRadiographicEvaluationoftheClavicleQuesana45-degreeanglesuperiorlyanda45-degreeangleinferiorlyProvidebetterassessmentoftheextentofdisplacementRadiographicEvaluationoftheACJointZancaViewAPviewcenteredatACjointwith10degreecephalictiltLessvoltagethanusedforAPshoulderStressViewsoftheDistalClavicle&ACJointRationale:

willdemonstrateinstabilityanddifferentiategradeIIIACseparationsfrompartialGradeI-IIinjuriesPerformedbyhavingpatienthold10#weightwithinjuredarmRarelyusedtoday,sincemostACjointinjuriestreatedthesame,andmanagementofdistalclaviclefracturesdependsoninitialdisplacementandlocationoffracture.RadiographicEvaluationoftheMedialOneThirdX-ray:

Cephalictiltviewof40to45degreesCTscanusuallyindicatedtobestassessdegreeanddirectionofdisplacementClassificationofClavicleFracturesGroupI:

MiddlethirdMostcommon（80%ofclaviclefractures）GroupII:

Distalthird10-15%ofclavicleinjuriesGroupIII:

MedialthirdLeastcommon（approx.5%）TreatmentOptionsNonoperativeSlingBraceSurgicalPlateFixationScreworPinFixationNonoperativeTreatment“StandardofCare”formostclaviclefractures.Continuedquestionsabouttheneedtowearaspecializedbrace.SimpleSlingvs.Figure-of-8BandageProspectiverandomizedtrialof61patientsSimpleslingLessdiscomfortFunctionalandcosmeticresultsidenticalAlignmentofhealedfracturesunchangedfromtheinitialdisplacementinbothgroupsAndersenetal.,ActaOrthopScand58:

71-4,1987.NonoperativeTreatmentItisdifficulttoreduceclaviclefracturesbyclosedmeans.MostclaviclefracturesuniterapidlydespitedisplacementSignificantlydisplacedmid-shaftanddistal-thirdinjurieshaveahigherincidenceofnonunion,butmanyoftheseareminimallysymptomatic.DefiniteIndicationsforSurgicalTreatmentofClavicleFractures1）Openfractures2）AssociatedneurovascularinjuryRelativeIndicationsforAcuteTreatmentofClavicleFractures1）Widelydisplacedfractures2）Multipletrauma3）Displaceddistal-thirdfracturesRelativeIndicationsforAcuteTreatmentofClavicleFractures4）Floatingshoulder5）Seizuredisorder6）Cosmeticdeformity7）Earlierreturntowork.ClavicularDisplacement20mmshorteningassociatedwithincreasedriskofnonunionandpoorfunctionaloutcomeat3years（Hilletal,JBJS79B:

537-9）PlateFixationTraditionalmeansofORIFPlateappliedsuperiorlyorinferiorlyInferiorplatingassociatedwithlowerriskofhardwareprominenceUsedforacutedisplacedfracturesandnonunions.IntramedullaryFixationLargethreadedcannulatedscrewsFlexibleelasticnailsK-wiresAssociatedwithriskofmigrationUsefulwhenplatefixationcontra-indicatedBadskinSevereosteopeniaFixationlesssecureComplicationsofClavicularFracturesanditsTreatmentNonunionMalunionNeurovascularSequelaePost-TraumaticArthritisRiskFactorsfortheDevelopmentofClavicularNonunionsLocationofFracture（outerthird）DegreeofDisplacement（markeddisplacement）PrimaryOpenReductionPrinciplesfortheTreatmentofClavicularNonunionsRestorelengthofclavicleMayneedintercalarybonegraftRigidinternalfixation,usuallywithaplateIliaccrestbonegraftRoleofbone-graftsubstitutesnotyetdefined.ClavicularMalunionSymptomsofpain,fatigue,cosmeticdeformity.Initiallytreatwithstrengthening,especiallyofscapulothoracicstabilizers.Considerosteotomy,internalfixationinrarecasesinwhichnonoperativetreatmentfails.NeurologicSequelaeOccasionally,fracturefragmentsorabundantcallus