锁骨骨折的诊疗与手术

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,锁骨骨折的诊疗与手术,锁骨骨折的诊疗与手术锁骨骨折的诊疗与手术,“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,Fall from height,Motor vehicle accident,Sports injury,Blow to the point of the shoulder,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 Evaluationof 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 in which nonoperative treatment fails.,Neurologic Sequelae,Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms.,Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.,Distal Third Clavicle Fractures,Classification of Distal Clavicular Fractures(Group II Clavicle Fractures),Type I-nondisplaced,Between the CC and AC ligaments with ligament still intact,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,Classification of Distal Clavicular Fractures,Type II,Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace superiorly,Highest rate of nonunion (up to 30%),Two Types,Type IIA,A. Conoid and trapezoid attached to distal fragment,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,Type IIB,Type IIB: Conoid torn, trapezoid attached,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,Classification of Distal Clavicular Fractures,Type III:articular fractures,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,Treatment of Distal-Third (Type II) Clavicle Fractures,Nonoperative treatment,22 to 33% failed to unite,45 to 67% took more than three months to heal,Operative treatment,100% of fractures healed within 6 to 10 weeks after surgery,Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatment,Techniques for Acute Operative Treatment of Distal Clavicle Fractures,Kirschner wires inserted into the distal fragment,Dorsal plate fixation,CC screw fixation,Tension-band wire or suture,Transfer of coracoid process to the clavicle,Regardless of the technique of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.,Preferred technique for fixation of acute distal third clavicle fractures,Horizontal incision,Manual reduction of fracture,Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.,Indications For Late Surgery For Distal Clavicle Fractures,Pain,Weakness,Deformity,Techniques For Late Surgery For Distal Clavicle Fractures,Excision of distal clavicle,With or without reconstruction of coracoclavicular ligaments,Reduction and fixation of fracture,Case Example,Case Example,Case Example,Coracoclavicular fixation not visible,Acromioclavicular Joint,Radiographic Evaluation of the Acromioclavicular Joint,Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder views,Initial Views:,Anteroposterior view,Zanca view (15 degree cephalic tilt),Other views:,Axillary: demonstrates anterior-posterior displacement,Stress views: not generally relevant for treatment decisions.,Classification For Acromioclavicular Joint Injuries,Initially classified by both Allman and Tossy et al. into three types (I, II, and III).,Rockwood later added types IV, V, and VI, so that now six types are recognized.,Classified depending on the degree and direction of displacement of the distal clavicle.,Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. JBJS 49A: 774-784, 1967.,Rockwood CA Jr and Young DC. Disorders of the acromioclavicular joint, In Rockwood CA, Matsen FA III: The Shoulder, Philadelphia, WB Saunders, 1990, pp. 413-476.,Type I,Sprain of acromioclavicular ligament,AC joint intact,Coracoclavicular ligaments intact,Deltoid and trapezius muscles intact,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,AC joint disrupted, 50% Vertical displacement,Sprain of the coracoclavicular ligaments,CC ligaments intact,Deltoid and trapezius muscles intact,Type II,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,AC ligaments and CC ligaments all disrupted,AC joint dislocated and the shoulder complex displaced inferiorly,CC interspace greater than the normal shoulder(25-100%),Deltoid and trapezius muscles usually detached from the distal clavicle,Type III,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,“Pseudodislocation” through an intact periosteal sleeve,Physeal injury,Coracoid process fracture,Type III Variants,AC and CC ligaments disrupted,AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle,Deltoid and trapezius muscles detached from the distal clavicle,Type IV,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,AC ligaments disrupted,CC ligaments disrupted,AC joint dislocated and gross disparity between the clavicle and the scapula (100-300%),Deltoid and trapezius muscles detached from the distal half of clavicle,Type V,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process,AC and CC ligaments disrupted,Deltoid and trapezius muscles detached from the distal clavicle,Type VI,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,Treatment Options For Types I - II Acromioclavicular Joint Injuries,Nonoperative: Ice and protection until pain subsides (7 to 10 days).,Return to sports as pain allows (1-2 weeks),No apparent benefit to the use of specialized braces.,Type II operative treatment,Generally reserved only for the patient with chronic pain.,Treatment is resection of the distal clavicle and reconstruction of the coracoclavicular ligaments.,Treatment Options For Type III-VI Acromioclavicular Joint Injuries,Nonoperative treatment,Closed reduction and application of a sling and harness to maintain reduction of the clavicle,Short-term sling and early range of motion,Operative treatment,Primary AC joint fixation,Primary CC ligament fixation,Excision of the distal clavicle,Dynamic muscle transfers,Type III Injuries: Need for acute surgical treatment remains very controversial.,Most surgeons recommend conservative treatment except in the throwing athlete or overhead worker.,Repair generally avoided in contact athletes because of the risk of reinjury.,Indications for Acute Surgical Treatment of Acromioclavicular Injuries,Type III injuries in highly active patients,Type IV, V, and VI injuries,Surgical Options for AC Joint Instability,Coracoid process transfer to distal transfer (Dynamic muscle transfer),Primary AC joint fixation,Primary Coracoclavicular Fixation,Distal Clavicle Excision with CC ligament reconstruction.,Weaver-Dunn Procedure,The distal clavicle is excised.,The CA ligament is transferred to the distal clavicle.,The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture.,Repair of deltotrapezial fascia,From Nuber GW and Bowen MK, JAAOS, 5:11, 1997,Indications for Late Surgical Treatment of Acromioclavicular Injuries,Pain,Weakness,Deformity,Techniques for Late Surgical Treatment of Acromioclavicular Injuries,Reduction of AC joint and repair of AC and CC ligaments,Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure),Case Example,AP View,Zanca View,Case Example,After Weaver-Dunn,procedure,Sternoclavicular Joint,From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996,The Anatomy of the Sternoclavicular Joint,Diarthrodial Joint,“Saddle shaped”,Poor congruence,Intra-articular disc ligament. Divides SC joint into two separate joint spaces.,Costoclavicular ligament- (rhomboid ligament) Short and strong and consist of an anterior and posterior fasciculus,Interclavicular ligament-,Connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum,Capsular ligament-,Covers the anterior and posterior aspects of the joint and represents thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger than the posterior portion.,Epiphysis of the Medial Clavicle,Medial Physis- Last of the ossification centers to appear in the body and the last epiphysis to close.,Does not ossify until 18th to 20th year,Does not unite with the clavicle until the 23rd to 25th year,Radiographic Techniques for Assessing Sternoclavicular Injuries,40-degree cephalic tilt view,CT scan- Best technique for sternoclavicular joint problems,From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996,Injuries Associated with Sternoclavicular Joint Dislocations,Mediastinal Compression,Pneumothorax,Laceration of the superior vena cava,Tracheal erosion,From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996,Treatment of Anterior Sternoclavicular Dislocations,Nonoperative treatment,Analgesics and immobilization,Functional outcome usually good,Closed reduction,Often not successful,Direct pressure over the medial end of the clavicle may reduce the joint,Treatment of Posterior Sternoclavicular Dislocations,Careful examination of the patient is extremely important to rule out vascular compromise.,Consider CT to rule out mediastinal compression,Attempt closed reduction - it is often successful and remains stable.,Abduction traction,Adduction traction,“Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip,Closed Reduction Techniques,汇报结束,谢谢大家,!,请各位批评指正,