锁骨骨折的诊疗与手术.ppt

Injuries of the Clavicle,Acromioclavicular Joint and Sternoclavicular Joint Andrew H.Schmidt,MD T.J.McElroy Created March 2004 “S”-shaped bone Medial-sternoclavicular joint Lateral-acromioclavicular joint and coracoclavicular ligaments Muscle attachments:Medial:sternocleidomastoid Lateral:Trapezius,pectoralis major Clavicle Diarthrodial 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)displacement Superior AC ligament most important AC Joint Coracoclavicular ligaments “Suspensory ligaments of the upper extremity”Two components:Trapezoid Conoid Stronger than AC ligaments Provide vertical stability to AC joint Distal Clavicle Mechanism of Injury Moderate or high-energy traumatic impacts to the shoulder 1.Fall from height 2.Motor vehicle accident 3.Sports injury 4.Blow to the point of the shoulder 5.Rarely a direct injury to the clavicle Physical Examination Inspection Evaluate deformity and/or displacement Beware of rare inferior or posterior displacement of distal or medial ends of clavicle Compare to opposite side.Physical Examination Palpation Evaluate pain Look for instability with stress Physical Examination Neurovascular examination Evaluate upper extremity motor and sensation Measure shoulder range-of-motion Radiographic Evaluation of the Clavicle Anteroposterior View 30-degree Cephalic Tilt View Radiographic Evaluation of the Clavicle Quesana 45-degree angle superiorly and a 45-degree angle inferiorly Provide better assessment of the extent of displacement Radiographic Evaluation of the AC Joint Zanca View AP view centered at AC joint with 10 degree cephalic tilt Less voltage than used for AP shoulder Stress Views of the Distal Clavicle&AC Joint Rationale:will demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuries Performed by having patient hold 10#weight with injured arm Rarely used today,since most AC joint injuries treated the same,and management of distal clavicle fractures depends on initial displacement and location of fracture.Radiographic Evaluation of the Medial One Third X-ray:Cephalic tilt view of 40 to 45 degrees CT scan usually indicated to best assess degree and direction of displacement Classification of Clavicle Fractures Group I:Middle third Most common(80%of clavicle fractures)Group II:Distal third 10-15%of clavicle injuries Group III:Medial third Least common(approx.5%)Treatment Options Nonoperative Sling Brace Surgical Plate Fixation Screw or Pin Fixation Nonoperative Treatment “Standard of Care”for most clavicle fractures.Continued questions about the need to wear a specialized brace.Simple Sling vs.Figure-of-8 Bandage Prospective randomized trial of 61 patients Simple sling Less discomfort Functional and cosmetic results identical Alignment of healed fractures unchanged from the initial displacement in both groups Andersen et al.,Acta Orthop Scand 58:71-4,1987.Nonoperative Treatment It is difficult to reduce clavicle fractures by closed means.Most clavicle fractures unite rapidly despite displacement Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion,but many of these are minimally symptomatic.Definite Indications for Surgical Treatment of Clavicle Fractures 1)Open fractures 2)Associated neurovascular injury Relative Indications for Acute Treatment of Clavicle Fractures 1)Widely displaced fractures 2)Multiple trauma 3)Displaced distal-third fractures Relative Indications for Acute Treatment of Clavicle Fractures 4)Floating shoulder 5)Seizure disorder 6)Cosmetic deformity 7)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 Fixation Traditional means of ORIF Plate applied superiorly or inferiorly Inferior plating associated with lower risk of hardware prominence Used for acute displaced fractures and nonunions.Intramedullary Fixation Large threaded cannulated screws Flexible elastic nails K-wires Associated with risk of migration Useful when plate fixation contra-indicated Bad skin Severe osteopenia Fixation less secure Complications of Clavicular Fractures and its Treatment Nonunion Malunion Neurovascular Sequelae Post-Traumatic Arthritis Risk Factors for the Development of Clavicular Nonunions Location of Fracture(outer third)Degree of Displacement(marked displacement)Primary Open Reduction Principles for the Treatment of Clavicular Nonunions Restore length of clavicle May need intercalary bone graft Rigid internal fixation,usually with a plate Iliac crest bone graft Role of bone-graft substitutes not yet defined.Clavicular Malunion Symptoms of pain,fatigue,cosmetic deformity.Initially treat with strengthening,especially of scapulothoracic stabilizers.Consider osteotomy,internal fixation in rare cases