锁骨骨折的诊疗与手术_精品文档.ppt

1、Injuries of the Clavicle,Acromioclavicular Joint and Sternoclavicular JointAndrew H.Schmidt,MDT.J.McElroyCreated March 2004“S”-shaped bone Medial-sternoclavicular jointLateral-acromioclavicular joint and coracoclavicular ligamentsMuscle attachments:Medial:sternocleidomastoidLateral:Trapezius,pectora

2、lis majorClavicleDiarthrodial joint between medial facet of acromion and the lateral(distal)clavicle.Contains intra-articular disk of variable size.Thin capsule stabilized by ligaments on all sides:AC ligaments control horizontal(anteroposterior)displacementSuperior AC ligament most importantAC Join

3、tCoracoclavicular ligaments“Suspensory ligaments of the upper extremity”Two components:TrapezoidConoidStronger than AC ligamentsProvide vertical stability to AC jointDistal ClavicleMechanism of InjuryModerate or high-energy traumatic impacts to the shoulder1.Fall from height2.Motor vehicle accident3

4、.Sports injury4.Blow to the point of the shoulder5.Rarely a direct injury to the claviclePhysical ExaminationInspectionEvaluate deformity and/or displacementBeware of rare inferior or posterior displacement of distal or medial ends of clavicleCompare to opposite side.Physical ExaminationPalpationEva

5、luate painLook for instability with stressPhysical ExaminationNeurovascular examinationEvaluate upper extremity motor and sensationMeasure shoulder range-of-motionRadiographic Evaluationof the ClavicleAnteroposterior View30-degree Cephalic Tilt ViewRadiographic Evaluation of the ClavicleQuesana45-de

6、gree angle superiorly and a 45-degree angle inferiorly Provide better assessment of the extent of displacementRadiographic Evaluation of the AC Joint Zanca ViewAP view centered at AC joint with 10 degree cephalic tiltLess voltage than used for AP shoulderStress Views of the Distal Clavicle&AC JointR

7、ationale:will demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuriesPerformed by having patient hold 10#weight with injured armRarely used today,since most AC joint injuries treated the same,and management of distal clavicle fractures depends on initial d

8、isplacement and location of fracture.Radiographic Evaluation of the Medial One ThirdX-ray:Cephalic tilt view of 40 to 45 degreesCT scan usually indicated to best assess degree and direction of displacementClassification of Clavicle FracturesGroup I:Middle thirdMost common(80%of clavicle fractures)Gr

9、oup II:Distal third10-15%of clavicle injuriesGroup III:Medial thirdLeast common(approx.5%)Treatment OptionsNonoperativeSlingBraceSurgicalPlate FixationScrew or Pin FixationNonoperative Treatment“Standard of Care”for most clavicle fractures.Continued questions about the need to wear a specialized bra

10、ce.Simple Sling vs.Figure-of-8 BandageProspective randomized trial of 61 patientsSimple slingLess discomfortFunctional and cosmetic results identicalAlignment of healed fractures unchanged from the initial displacement in both groupsAndersen et al.,Acta Orthop Scand 58:71-4,1987.Nonoperative Treatme

11、ntIt is difficult to reduce clavicle fractures by closed means.Most clavicle fractures unite rapidly despite displacementSignificantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion,but many of these are minimally symptomatic.Definite Indications for Surgical Treat

12、ment of Clavicle Fractures1)Open fractures2)Associated neurovascular injuryRelative Indications for Acute Treatment of Clavicle Fractures1)Widely displaced fractures2)Multiple trauma3)Displaced distal-third fracturesRelative Indications for Acute Treatment of Clavicle Fractures4)Floating shoulder5)S

13、eizure disorder6)Cosmetic deformity7)Earlier return to work.Clavicular Displacement 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years(Hill et al,JBJS 79B:537-9)Plate FixationTraditional means of ORIFPlate applied superiorly or inferiorlyInferior plati

14、ng associated with lower risk of hardware prominenceUsed for acute displaced fractures and nonunions.Intramedullary FixationLarge threaded cannulated screwsFlexible elastic nailsK-wiresAssociated with risk of migrationUseful when plate fixation contra-indicatedBad skinSevere osteopeniaFixation less

15、secureComplications of Clavicular Fractures and its TreatmentNonunionMalunion Neurovascular SequelaePost-Traumatic Arthritis Risk Factors for the Development of Clavicular NonunionsLocation of Fracture(outer third)Degree of Displacement(marked displacement)Primary Open ReductionPrinciples for the Tr

16、eatment of Clavicular NonunionsRestore length of clavicleMay need intercalary bone graftRigid internal fixation,usually with a plateIliac crest bone graftRole of bone-graft substitutes not yet defined.Clavicular MalunionSymptoms of pain,fatigue,cosmetic deformity.Initially treat with strengthening,especially of scapulothoracic stabilizers.Consider osteotomy,internal fixation in rare cases in which nonoperative treatment fails.Neurologic SequelaeOccasionally,fracture fragments or abundant callus