齐鲁医学锁骨骨折的诊疗与手术

InjuriesoftheClavicle,AcromioclavicularJointandSternoclavicularJointAndrewH.Schmidt,MDT.J.McElroy

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

(GroupIIClavicleFractures)TypeI-nondisplacedBetweentheCCandACligamentswithligamentstillintactFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第23页!TypeIIAA.ConoidandtrapezoidattachedtodistalfragmentFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第24页!ClassificationofDistalClavicularFracturesTypeIII:articularfracturesFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第25页!DisplacedTypeIIfracturesofthedistalclavicleareoftentreatedmoreaggressivelybecauseoftheincreasedriskofnonunionwithnonoperativetreatment锁骨骨折的诊疗与手术共87页，您现在浏览的是第26页!Regardlessofthetechniqueofclavicularfixation,coracoclavicularfixationisalsoneededtopreventredisplacementofthemedialclavicle.锁骨骨折的诊疗与手术共87页，您现在浏览的是第27页!IndicationsForLateSurgeryForDistalClavicleFracturesPainWeaknessDeformity锁骨骨折的诊疗与手术共87页，您现在浏览的是第28页!CaseExample锁骨骨折的诊疗与手术共87页，您现在浏览的是第29页!CaseExampleCoracoclavicularfixationnotvisible锁骨骨折的诊疗与手术共87页，您现在浏览的是第30页!RadiographicEvaluationoftheAcromioclavicularJointProperexposureoftheACjointrequiresone-thirdtoone-halfthex-raypenetrationofroutineshoulderviewsInitialViews:AnteroposteriorviewZancaview(15degreecephalictilt)Otherviews:Axillary:demonstratesanterior-posteriordisplacementStressviews:notgenerallyrelevantfortreatmentdecisions.锁骨骨折的诊疗与手术共87页，您现在浏览的是第31页!TypeISprainofacromioclavicularligamentACjointintactCoracoclavicularligamentsintactDeltoidandtrapeziusmusclesintactFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第32页!ACligamentsandCCligamentsalldisruptedACjointdislocatedandtheshoulderplexdisplacedinferiorlyCCinterspacegreaterthanthenormalshoulder(25-100%)DeltoidandtrapeziusmusclesusuallydetachedfromthedistalclavicleTypeIIIFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第33页!ACandCCligamentsdisruptedACjointdislocatedandclavicledisplacedposteriorlyintoorthroughthetrapeziusmuscleDeltoidandtrapeziusmusclesdetachedfromthedistalclavicleTypeIVFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第34页!ACjointdislocatedandclavicledisplacedinferiortotheacromionorthecoracoidprocessACandCCligamentsdisruptedDeltoidandtrapeziusmusclesdetachedfromthedistalclavicleTypeVIFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第35页!TypeIIoperativetreatmentGenerallyreservedonlyforthepatientwithchronicpain.Treatmentisresectionofthedistalclavicleandreconstructionofthecoracoclavicularligaments.锁骨骨折的诊疗与手术共87页，您现在浏览的是第36页!TypeIIIInjuries:Needforacutesurgicaltreatmentremainsverycontroversial.Mostsurgeonsremendconservativetreatmentexceptinthethrowingathleteoroverheadworker.Repairgenerallyavoidedincontactathletesbecauseoftheriskofreinjury.锁骨骨折的诊疗与手术共87页，您现在浏览的是第37页!SurgicalOptionsforACJointInstabilityCoracoidprocesstransfertodistaltransfer(Dynamicmuscletransfer)PrimaryACjointfixationPrimaryCoracoclavicularFixationDistalClavicleExcisionwithCCligamentreconstruction.锁骨骨折的诊疗与手术共87页，您现在浏览的是第38页!IndicationsforLateSurgicalTreatmentofAcromioclavicularInjuriesPainWeaknessDeformity锁骨骨折的诊疗与手术共87页，您现在浏览的是第39页!CaseExampleAPViewZancaView锁骨骨折的诊疗与手术共87页，您现在浏览的是第40页!SternoclavicularJointFromWirthMAandRockwoodCA,JAAOS,4:268,1996锁骨骨折的诊疗与手术共87页，您现在浏览的是第41页!Interclavicularligament-ConnectsthesuperomedialaspectsofeachclaviclewiththecapsularligamentsandtheuppersternumCapsularligament-Coverstheanteriorandposterioraspectsofthejointandrepresentsthickeningsofthejointcapsule.Theanteriorportionoftheligamentisheavierandstrongerthantheposteriorportion.锁骨骨折的诊疗与手术共87页，您现在浏览的是第42页!RadiographicTechniquesforAssessingSternoclavicularInjuries40-degreecephalictiltviewCTscan-BesttechniqueforsternoclavicularjointproblemsFromWirthMAandRockwoodCA,JAAOS,4:268,1996锁骨骨折的诊疗与手术共87页，您现在浏览的是第43页!TreatmentofAnteriorSternoclavicularDislocationsNonoperativetreatmentAnalgesicsandimmobilizationFunctionalouteusuallygoodClosedreductionOftennotsuccessfulDirectpressureoverthemedialendoftheclaviclemayreducethejoint锁骨骨折的诊疗与手术共87页，您现在浏览的是第44页!AbductiontractionAdductiontraction“TowelClip”-anteriorforceappliedtoclaviclebypercutaneouslyappliedtowelclipClosedReductionTechniques锁骨骨折的诊疗与手术共87页，您现在浏览的是第45页!MechanismofInjuryModerateorhigh-energytraumaticimpactstotheshoulderFallfromheightMotorvehicleaccidentSportsinjuryBlowtothepointoftheshoulderRarelyadirectinjurytotheclavicle锁骨骨折的诊疗与手术共87页，您现在浏览的是第46页!PhysicalExaminationPalpationEvaluatepainLookforinstabilitywithstress锁骨骨折的诊疗与手术共87页，您现在浏览的是第47页!RadiographicEvaluation

oftheClavicleAnteroposteriorView30-degreeCephalicTiltView锁骨骨折的诊疗与手术共87页，您现在浏览的是第48页!RadiographicEvaluationoftheACJointZancaViewAPviewcenteredatACjointwith10degreecephalictiltLessvoltagethanusedforAPshoulder锁骨骨折的诊疗与手术共87页，您现在浏览的是第49页!RadiographicEvaluationoftheMedialOneThirdX-ray:Cephalictiltviewof40to45degreesCTscanusuallyindicatedtobestassessdegreeanddirectionofdisplacement锁骨骨折的诊疗与手术共87页，您现在浏览的是第50页!TreatmentOptionsNonoperativeSlingBraceSurgicalPlateFixationScreworPinFixation锁骨骨折的诊疗与手术共87页，您现在浏览的是第51页!SimpleSlingvs.Figure-of-8BandageProspectiverandomizedtrialof61patientsSimpleslingLessdisfortFunctionalandcosmeticresultsidenticalAlignmentofhealedfracturesunchangedfromtheinitialdisplacementinbothgroupsAndersenetal.,ActaOrthopScand58:71-4,1987.锁骨骨折的诊疗与手术共87页，您现在浏览的是第52页!DefiniteIndicationsforSurgicalTreatmentofClavicleFractures1)Openfractures2)Associatedneurovascularinjury锁骨骨折的诊疗与手术共87页，您现在浏览的是第53页!RelativeIndicationsforAcuteTreatmentofClavicleFractures4)Floatingshoulder5)Seizuredisorder6)Cosmeticdeformity7)Earlierreturntowork.锁骨骨折的诊疗与手术共87页，您现在浏览的是第54页!ClavicularDisplacement<5mmshortening:acceptableresultsat5years(Nordqvistetal,ActaOrthopScand1997;68:349-51.>20mmshorteningassociatedwithincreasedriskofnonunionandpoorfunctionalouteat3years(Hilletal,JBJS79B:537-9)锁骨骨折的诊疗与手术共87页，您现在浏览的是第55页!锁骨骨折的诊疗与手术共87页，您现在浏览的是第56页!锁骨骨折的诊疗与手术共87页，您现在浏览的是第57页!锁骨骨折的诊疗与手术共87页，您现在浏览的是第58页!IntramedullaryFixationLargethreadedcannulatedscrewsFlexibleelasticnailsK-wiresAssociatedwithriskofmigrationUsefulwhenplatefixationcontra-indicatedBadskinSevereosteopeniaFixationlesssecure锁骨骨折的诊疗与手术共87页，您现在浏览的是第59页!RiskFactorsfortheDevelopmentofClavicularNonunionsLocationofFracture(outerthird)DegreeofDisplacement(markeddisplacement)PrimaryOpenReduction锁骨骨折的诊疗与手术共87页，您现在浏览的是第60页!锁骨骨折的诊疗与手术共87页，您现在浏览的是第61页!锁骨骨折的诊疗与手术共87页，您现在浏览的是第62页!ClavicularMalunionSymptomsofpain,fatigue,cosmeticdeformity.Initiallytreatwithstrengthening,especiallyofscapulothoracicstabilizers.Considerosteotomy,internalfixationinrarecasesinwhichnonoperativetreatmentfails.锁骨骨折的诊疗与手术共87页，您现在浏览的是第63页!DistalThirdClavicleFractures锁骨骨折的诊疗与手术共87页，您现在浏览的是第64页!ClassificationofDistalClavicularFracturesTypeIITypicallydisplacedsecondarytoafracturemedialtothecoracoclavicularligaments,keepingthedistalfragmentreducedwhileallowingthemedialfragmetntodisplacesuperiorlyHighestrateofnonunion(upto30%)TwoTypes锁骨骨折的诊疗与手术共87页，您现在浏览的是第65页!TypeIIBTypeIIB:Conoidtorn,trapezoidattachedFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第66页!TreatmentofDistal-Third(TypeII)ClavicleFracturesNonoperativetreatment22to33%failedtounite45to67%tookmorethanthreemonthstohealOperativetreatment100%offractureshealedwithin6to10weeksaftersurgery锁骨骨折的诊疗与手术共87页，您现在浏览的是第67页!TechniquesforAcuteOperativeTreatmentofDistalClavicleFracturesKirschnerwiresinsertedintothedistalfragmentDorsalplatefixationCCscrewfixationTension-bandwireorsutureTransferofcoracoidprocesstotheclavicle锁骨骨折的诊疗与手术共87页，您现在浏览的是第68页!PreferredtechniqueforfixationofacutedistalthirdclaviclefracturesHorizontalincisionManualreductionoffractureDorsaltensionbandsutureandreconstruction/augmentationofcoracoclavicularligaments.锁骨骨折的诊疗与手术共87页，您现在浏览的是第69页!TechniquesForLateSurgeryForDistalClavicleFracturesExcisionofdistalclavicleWithorwithoutreconstructionofcoracoclavicularligamentsReductionandfixationoffracture锁骨骨折的诊疗与手术共87页，您现在浏览的是第70页!CaseExample锁骨骨折的诊疗与手术共87页，您现在浏览的是第71页!AcromioclavicularJoint锁骨骨折的诊疗与手术共87页，您现在浏览的是第72页!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.锁骨骨折的诊疗与手术共87页，您现在浏览的是第73页!ACjointdisrupted<50%VerticaldisplacementSprainofthecoracoclavicularligamentsCCligamentsintactDeltoidandtrapeziusmusclesintactTypeIIFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第74页!“Pseudodislocation”throughanintactperiostealsleevePhysealinjuryCoracoidprocessfractureTypeIIIVariants锁骨骨折的诊疗与手术共87页，您现在浏览的是第75页!ACligamentsdisruptedCCligamentsdisruptedACjointdislocatedandgrossdisparitybetweentheclavicleandthescapula(100-300%)DeltoidandtrapeziusmusclesdetachedfromthedistalhalfofclavicleTypeVFromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第76页!TreatmentOptionsForTypesI-IIAcromioclavicularJointInjuriesNonoperative:Iceandprotectionuntilpainsubsides(7to10days).Returntosportsaspainallows(1-2weeks)Noapparentbenefittotheuseofspecializedbraces.锁骨骨折的诊疗与手术共87页，您现在浏览的是第77页!TreatmentOptionsForTypeIII-VIAcromioclavicularJointInjuriesNonoperativetreatmentClosedreductionandapplicationofaslingandharnesstomaintainreductionoftheclavicleShort-termslingandearlyrangeofmotionOperativetreatmentPrimaryACjointfixationPrimaryCCligamentfixationExcisionofthedistalclavicleDynamicmuscletransfers锁骨骨折的诊疗与手术共87页，您现在浏览的是第78页!IndicationsforAcuteSurgicalTreatmentofAcromioclavicularInjuriesTypeIIIinjuriesinhighlyactivepatientsTypeIV,V,andVIinjuries锁骨骨折的诊疗与手术共87页，您现在浏览的是第79页!Weaver-DunnProcedureThedistalclavicleisexcised.TheCAligamentistransferredtothedistalclavicle.TheCCligamentsarerepairedand/oraugmentedwithacoracoclavicularscreworsuture.Repairofdeltotrapezialfascia

FromNuberGWandBowenMK,JAAOS,5:11,1997锁骨骨折的诊疗与手术共87页，您现在浏览的是第80页!TechniquesforLateSurgicalTreatmentof