手舟骨骨折分析解析

1、手舟骨骨折第1页手舟骨解剖特点第2页英文名“Scaphoid”起源于希腊词汇“skaphos”，意思为“小船”，将其翻译为“舟状骨” 或又称之为“手舟骨”。第3页与桡骨、月骨、头骨、大多角骨相关联；表面为透明软骨覆盖；血供较少，缺乏骨膜： 1.骨折一期愈合，难以形成骨痂。 2.背侧支桡动脉分支提供70%-80%血供，主要包含近极；掌侧支提供20%-30%血供，主要包含远极。第4页发病机制 跌倒时腕部撑地 腰部70%-80%，近极10%-20%，远极及舟状骨结节占5%儿童骨折多以远极为多第5页Type A (acute stable fractures)A 1 : fractures of th

2、e tubercleA2 : undisplaced “crack” fracture of waistType B (acute unstable fractures)Bl : oblique fractures of distal thirdB2 : displaced or mobile fractures of waistB3 : proximal pole fractures B4: fracture dislocations of carpusB5 : comminuted fracturesType C (delayed union)Type D (established non

3、-union)Dl : fibrous non-unionD2 : pseudarthrosisD3: Sclerotic pseudarthrosisD4: Avascular Necrosis骨折分型第6页病史及体格检验外伤史，跌倒时手撑地 腕关节桡侧肿胀、疼痛，活动受限，尤其为背伸活动受限 鼻烟窝压痛舟状骨远端结节压痛舟骨挤压试验（+）第7页辅助检验 蝶侧位X片 不稳定骨折诊疗标准： 1.移位超出1mm 2.成角大于10 3.粉碎性 4.桡月角大于15 5.舟月角大于60 6.舟骨内角大于35第8页辅助检验 腕关节CT：评定骨折程度及不易发觉骨折。腕关节MRI：用于诊疗隐匿性骨折，结合造

4、影剂用于判断血供及有没有缺血坏死发生。第9页判别诊疗 舟月损伤腕关节扭伤腕关节软组织挫伤其它腕骨骨折桡骨远端骨折第10页治 疗 非手术治疗-石膏固定手术治疗-切开复位内固定 闭合复位内固定 关节镜辅助下内固定 第11页Steven J Rhemrev, Daan Ootes, Frank JP Beeres, Sven AG Meylaerts, Inger B Schipper. Rhemrev et al. International Journal of Emergency Medicine , 4:4第12页治 疗 非手术治疗-石膏固定 适应症：急性、远极无位移（无位移腰部骨折仍存争议

5、） 通常固定时间为6-12周，依据 复查情况而定 Colles-type cast with the wrist in slight extensionJ. E. Hambidge, V. V. Desai, P. J. Schranz, J. P. Compson, T. R. C. Davis, N. J. Barton. TREATMENT BY CAST IMMOBILISATION WITH THE WRIST IN FLEXION OR EXTENSION? J Bone Joint Surg Br 1999;81-B:91-2.第13页治 疗手术治疗-断端加压螺钉固定 闭合 OR

6、 切开 OR 其它 ？ 第14页切开复位内固定第15页 切开复位内固定 431 patients, Scaphoid fracture, ORIF, over a 13-year period by T. J. HERBERT S. L. FILAN, T. J. HERBERT HERBERT SCREW FIXATION OF SCAPHOID FRACTURES J Bone Joint Surg Br 1996;78-B:519-29.第16页Table III. Rate of union related to type of fracture forpatients with at

7、 least 6 months follow-upFracture type Union Nonunion % UnionDistal oblique B1 9 1 90Waist B2 29 4 88Proximal pole B3 11 2 85Fibrous union D1 65 9 88Pseudarthrosis D2 73 37 66Sclerotic D3 25 25 50pseudarthrosisS. L. FILAN, T. J. HERBERT HERBERT SCREW FIXATION OF SCAPHOID FRACTURES J Bone Joint Surg

8、Br 1996;78-B:519-29.第17页闭合复位内固定40 patients, Scaphoid fracture, A1，B1，B2， semi-closed method of Herbert screw fixation G. INOUE, K. SHIONOYA . HERBERT SCREW FIXATION BY LIMITED ACCESS FOR ACUTE FRACTURES OF THE SCAPHOID J Bone Joint Surg Br 1997;79-B:418-21.第18页闭合复位内固定 Conservative SurgicalScaphoid u

9、nion 38 of 39 40 of 40Mean time for union(weeks) 9.7 4.0* 6 2.1Mean time for union intype-B fracture (weeks) 12.2 4.6 6.5 2.4Mean time to return tomanual work (weeks) 10.2 3.9* 5.8 2.2* p 0.001 p 0.0001G. INOUE, K. SHIONOYA . HERBERT SCREW FIXATION BY LIMITED ACCESS FOR ACUTE FRACTURES OF THE SCAPHO

10、ID J Bone Joint Surg Br 1997;79-B:418-21.第19页闭合复位内固定32 patients, Scaphoid fracture, B1, B2 and C types， percutaneous fixation of scaphoid fractures via a dorsal approach第20页闭合复位内固定All fractures united over an average of nine weeks. There was no avascular necrosisSameer Naranje & P. P. Kotwal & P. Sh

11、amshery &Vikas Gupta & H. L. Nag. Percutaneous fixation of selected scaphoid fractures by dorsal approach.International Orthopaedics (SICOT) () 34:9971003第21页关节镜辅助下内固定234 scaphoid fractures and nonunions 126 acute injuries;65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid

12、 perilunate dislocations including four trans-scaphoid trans-capitate fractures;10 combined scaphoid and distal radius fractures. 99% union rate by CT scan in 12 weeksArthroscopy with the dorsal percutaneous implantation of a headless compression screwSlade JF 3rd, Gillon T. Retrospective review of 234 scaphoi