齊魯醫(yī)學(xué)鎖骨骨折的診療與手術(shù)

InjuriesoftheClavicle,AcromioclavicularJointandSternoclavicularJointAndrewH.Schmidt,MDT.J.McElroy

CreatedMarch2004鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第1頁!“S”-shapedboneMedial-sternoclavicularjointLateral-acromioclavicularjointandcoracoclavicularligamentsMuscleattachments:Medial:sternocleidomastoidLateral:Trapezius,pectoralismajorClavicle鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第2頁!Diarthrodialjointbetweenmedialfacetofacromionandthelateral(distal)clavicle.Containsintra-articulardiskofvariablesize.Thincapsulestabilizedbyligamentsonallsides:ACligamentscontrolhorizontal(anteroposterior)displacementSuperiorACligamentmostimportantACJoint鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第3頁!Coracoclavicularligaments“Suspensoryligamentsoftheupperextremity”Twoponents:TrapezoidConoidStrongerthanACligamentsProvideverticalstabilitytoACjointDistalClavicle鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第4頁!PhysicalExaminationInspectionEvaluatedeformityand/ordisplacementBewareofrareinferiororposteriordisplacementofdistalormedialendsofclavicleComparetooppositeside.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第5頁!PhysicalExaminationNeurovascularexaminationEvaluateupperextremitymotorandsensationMeasureshoulderrange-of-motion鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第6頁!RadiographicEvaluationoftheClavicleQuesana45-degreeanglesuperiorlyanda45-degreeangleinferiorlyProvidebetterassessmentoftheextentofdisplacement鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第7頁!StressViewsoftheDistalClavicle&ACJointRationale:willdemonstrateinstabilityanddifferentiategradeIIIACseparationsfrompartialGradeI-IIinjuriesPerformedbyhavingpatienthold10#weightwithinjuredarmRarelyusedtoday,sincemostACjointinjuriestreatedthesame,andmanagementofdistalclaviclefracturesdependsoninitialdisplacementandlocationoffracture.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第8頁!ClassificationofClavicleFracturesGroupI:MiddlethirdMostmon(80%ofclaviclefractures)GroupII:Distalthird10-15%ofclavicleinjuriesGroupIII:MedialthirdLeastmon(approx.5%)鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第9頁!NonoperativeTreatment“StandardofCare”formostclaviclefractures.Continuedquestionsabouttheneedtowearaspecializedbrace.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第10頁!NonoperativeTreatmentItisdifficulttoreduceclaviclefracturesbyclosedmeans.MostclaviclefracturesuniterapidlydespitedisplacementSignificantlydisplacedmid-shaftanddistal-thirdinjurieshaveahigherincidenceofnonunion,butmanyoftheseareminimallysymptomatic.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第11頁!RelativeIndicationsforAcuteTreatmentofClavicleFractures1)Widelydisplacedfractures2)Multipletrauma3)Displaceddistal-thirdfractures鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第12頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第13頁!PlateFixationTraditionalmeansofORIFPlateappliedsuperiorlyorinferiorlyInferiorplatingassociatedwithlowerriskofhardwareprominenceUsedforacutedisplacedfracturesandnonunions.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第14頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第15頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第16頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第17頁!ComplicationsofClavicularFracturesanditsTreatmentNonunionMalunionNeurovascularSequelaePost-TraumaticArthritis鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第18頁!PrinciplesfortheTreatmentofClavicularNonunionsRestorelengthofclavicleMayneedintercalarybonegraftRigidinternalfixation,usuallywithaplateIliaccrestbonegraftRoleofbone-graftsubstitutesnotyetdefined.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第19頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第20頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第21頁!NeurologicSequelaeOccasionally,fracturefragmentsorabundantcalluscancausebrachialplexussymptoms.Treatmentisreductionandfixationofthefracture,orresectionofcalluswithorwithoutosteotomyandfixationformalunions.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第22頁!ClassificationofDistalClavicularFractures

(GroupIIClavicleFractures)TypeI-nondisplacedBetweentheCCandACligamentswithligamentstillintactFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第23頁!TypeIIAA.ConoidandtrapezoidattachedtodistalfragmentFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第24頁!ClassificationofDistalClavicularFracturesTypeIII:articularfracturesFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第25頁!DisplacedTypeIIfracturesofthedistalclavicleareoftentreatedmoreaggressivelybecauseoftheincreasedriskofnonunionwithnonoperativetreatment鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第26頁!Regardlessofthetechniqueofclavicularfixation,coracoclavicularfixationisalsoneededtopreventredisplacementofthemedialclavicle.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第27頁!IndicationsForLateSurgeryForDistalClavicleFracturesPainWeaknessDeformity鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第28頁!CaseExample鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第29頁!CaseExampleCoracoclavicularfixationnotvisible鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第30頁!RadiographicEvaluationoftheAcromioclavicularJointProperexposureoftheACjointrequiresone-thirdtoone-halfthex-raypenetrationofroutineshoulderviewsInitialViews:AnteroposteriorviewZancaview(15degreecephalictilt)Otherviews:Axillary:demonstratesanterior-posteriordisplacementStressviews:notgenerallyrelevantfortreatmentdecisions.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第31頁!TypeISprainofacromioclavicularligamentACjointintactCoracoclavicularligamentsintactDeltoidandtrapeziusmusclesintactFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第32頁!ACligamentsandCCligamentsalldisruptedACjointdislocatedandtheshoulderplexdisplacedinferiorlyCCinterspacegreaterthanthenormalshoulder(25-100%)DeltoidandtrapeziusmusclesusuallydetachedfromthedistalclavicleTypeIIIFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第33頁!ACandCCligamentsdisruptedACjointdislocatedandclavicledisplacedposteriorlyintoorthroughthetrapeziusmuscleDeltoidandtrapeziusmusclesdetachedfromthedistalclavicleTypeIVFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第34頁!ACjointdislocatedandclavicledisplacedinferiortotheacromionorthecoracoidprocessACandCCligamentsdisruptedDeltoidandtrapeziusmusclesdetachedfromthedistalclavicleTypeVIFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第35頁!TypeIIoperativetreatmentGenerallyreservedonlyforthepatientwithchronicpain.Treatmentisresectionofthedistalclavicleandreconstructionofthecoracoclavicularligaments.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第36頁!TypeIIIInjuries:Needforacutesurgicaltreatmentremainsverycontroversial.Mostsurgeonsremendconservativetreatmentexceptinthethrowingathleteoroverheadworker.Repairgenerallyavoidedincontactathletesbecauseoftheriskofreinjury.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第37頁!SurgicalOptionsforACJointInstabilityCoracoidprocesstransfertodistaltransfer(Dynamicmuscletransfer)PrimaryACjointfixationPrimaryCoracoclavicularFixationDistalClavicleExcisionwithCCligamentreconstruction.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第38頁!IndicationsforLateSurgicalTreatmentofAcromioclavicularInjuriesPainWeaknessDeformity鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第39頁!CaseExampleAPViewZancaView鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第40頁!SternoclavicularJointFromWirthMAandRockwoodCA,JAAOS,4:268,1996鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第41頁!Interclavicularligament-ConnectsthesuperomedialaspectsofeachclaviclewiththecapsularligamentsandtheuppersternumCapsularligament-Coverstheanteriorandposterioraspectsofthejointandrepresentsthickeningsofthejointcapsule.Theanteriorportionoftheligamentisheavierandstrongerthantheposteriorportion.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第42頁!RadiographicTechniquesforAssessingSternoclavicularInjuries40-degreecephalictiltviewCTscan-BesttechniqueforsternoclavicularjointproblemsFromWirthMAandRockwoodCA,JAAOS,4:268,1996鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第43頁!TreatmentofAnteriorSternoclavicularDislocationsNonoperativetreatmentAnalgesicsandimmobilizationFunctionalouteusuallygoodClosedreductionOftennotsuccessfulDirectpressureoverthemedialendoftheclaviclemayreducethejoint鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第44頁!AbductiontractionAdductiontraction“TowelClip”-anteriorforceappliedtoclaviclebypercutaneouslyappliedtowelclipClosedReductionTechniques鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第45頁!MechanismofInjuryModerateorhigh-energytraumaticimpactstotheshoulderFallfromheightMotorvehicleaccidentSportsinjuryBlowtothepointoftheshoulderRarelyadirectinjurytotheclavicle鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第46頁!PhysicalExaminationPalpationEvaluatepainLookforinstabilitywithstress鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第47頁!RadiographicEvaluation

oftheClavicleAnteroposteriorView30-degreeCephalicTiltView鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第48頁!RadiographicEvaluationoftheACJointZancaViewAPviewcenteredatACjointwith10degreecephalictiltLessvoltagethanusedforAPshoulder鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第49頁!RadiographicEvaluationoftheMedialOneThirdX-ray:Cephalictiltviewof40to45degreesCTscanusuallyindicatedtobestassessdegreeanddirectionofdisplacement鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第50頁!TreatmentOptionsNonoperativeSlingBraceSurgicalPlateFixationScreworPinFixation鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第51頁!SimpleSlingvs.Figure-of-8BandageProspectiverandomizedtrialof61patientsSimpleslingLessdisfortFunctionalandcosmeticresultsidenticalAlignmentofhealedfracturesunchangedfromtheinitialdisplacementinbothgroupsAndersenetal.,ActaOrthopScand58:71-4,1987.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第52頁!DefiniteIndicationsforSurgicalTreatmentofClavicleFractures1)Openfractures2)Associatedneurovascularinjury鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第53頁!RelativeIndicationsforAcuteTreatmentofClavicleFractures4)Floatingshoulder5)Seizuredisorder6)Cosmeticdeformity7)Earlierreturntowork.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第54頁!ClavicularDisplacement<5mmshortening:acceptableresultsat5years(Nordqvistetal,ActaOrthopScand1997;68:349-51.>20mmshorteningassociatedwithincreasedriskofnonunionandpoorfunctionalouteat3years(Hilletal,JBJS79B:537-9)鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第55頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第56頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第57頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第58頁!IntramedullaryFixationLargethreadedcannulatedscrewsFlexibleelasticnailsK-wiresAssociatedwithriskofmigrationUsefulwhenplatefixationcontra-indicatedBadskinSevereosteopeniaFixationlesssecure鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第59頁!RiskFactorsfortheDevelopmentofClavicularNonunionsLocationofFracture(outerthird)DegreeofDisplacement(markeddisplacement)PrimaryOpenReduction鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第60頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第61頁!鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第62頁!ClavicularMalunionSymptomsofpain,fatigue,cosmeticdeformity.Initiallytreatwithstrengthening,especiallyofscapulothoracicstabilizers.Considerosteotomy,internalfixationinrarecasesinwhichnonoperativetreatmentfails.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第63頁!DistalThirdClavicleFractures鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第64頁!ClassificationofDistalClavicularFracturesTypeIITypicallydisplacedsecondarytoafracturemedialtothecoracoclavicularligaments,keepingthedistalfragmentreducedwhileallowingthemedialfragmetntodisplacesuperiorlyHighestrateofnonunion(upto30%)TwoTypes鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第65頁!TypeIIBTypeIIB:Conoidtorn,trapezoidattachedFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第66頁!TreatmentofDistal-Third(TypeII)ClavicleFracturesNonoperativetreatment22to33%failedtounite45to67%tookmorethanthreemonthstohealOperativetreatment100%offractureshealedwithin6to10weeksaftersurgery鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第67頁!TechniquesforAcuteOperativeTreatmentofDistalClavicleFracturesKirschnerwiresinsertedintothedistalfragmentDorsalplatefixationCCscrewfixationTension-bandwireorsutureTransferofcoracoidprocesstotheclavicle鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第68頁!PreferredtechniqueforfixationofacutedistalthirdclaviclefracturesHorizontalincisionManualreductionoffractureDorsaltensionbandsutureandreconstruction/augmentationofcoracoclavicularligaments.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第69頁!TechniquesForLateSurgeryForDistalClavicleFracturesExcisionofdistalclavicleWithorwithoutreconstructionofcoracoclavicularligamentsReductionandfixationoffracture鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第70頁!CaseExample鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第71頁!AcromioclavicularJoint鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第72頁!ClassificationForAcromioclavicularJointInjuriesInitiallyclassifiedbybothAllmanandTothreetypes(I,II,andIII).RockwoodlateraddedtypesIV,V,andVI,sothatnowsixtypesarerecognized.Classifieddependingonthedegreeanddirectionofdisplacementofthedistalclavicle.AllmanFLJr.Fracturesandligamentousinjuriesoftheclavicleanditsarticulation.JBJS49A:774-784,1967.RockwoodCAJrandYoungDC.Disordersoftheacromioclavicularjoint,InRockwoodCA,MatsenFAIII:TheShoulder,Philadelphia,WBSaunders,1990,pp.413-476.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第73頁!ACjointdisrupted<50%VerticaldisplacementSprainofthecoracoclavicularligamentsCCligamentsintactDeltoidandtrapeziusmusclesintactTypeIIFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第74頁!“Pseudodislocation”throughanintactperiostealsleevePhysealinjuryCoracoidprocessfractureTypeIIIVariants鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第75頁!ACligamentsdisruptedCCligamentsdisruptedACjointdislocatedandgrossdisparitybetweentheclavicleandthescapula(100-300%)DeltoidandtrapeziusmusclesdetachedfromthedistalhalfofclavicleTypeVFromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第76頁!TreatmentOptionsForTypesI-IIAcromioclavicularJointInjuriesNonoperative:Iceandprotectionuntilpainsubsides(7to10days).Returntosportsaspainallows(1-2weeks)Noapparentbenefittotheuseofspecializedbraces.鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第77頁!TreatmentOptionsForTypeIII-VIAcromioclavicularJointInjuriesNonoperativetreatmentClosedreductionandapplicationofaslingandharnesstomaintainreductionoftheclavicleShort-termslingandearlyrangeofmotionOperativetreatmentPrimaryACjointfixationPrimaryCCligamentfixationExcisionofthedistalclavicleDynamicmuscletransfers鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第78頁!IndicationsforAcuteSurgicalTreatmentofAcromioclavicularInjuriesTypeIIIinjuriesinhighlyactivepatientsTypeIV,V,andVIinjuries鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第79頁!Weaver-DunnProcedureThedistalclavicleisexcised.TheCAligamentistransferredtothedistalclavicle.TheCCligamentsarerepairedand/oraugmentedwithacoracoclavicularscreworsuture.Repairofdeltotrapezialfascia

FromNuberGWandBowenMK,JAAOS,5:11,1997鎖骨骨折的診療與手術(shù)共87頁，您現(xiàn)在瀏覽的是第80頁!TechniquesforLateSurgicalTreatmentof