1、肩锁关节脱位 病例讨论,西安红会医院创伤骨科 张 堃 马腾 吕敏,病例,张某，男,23岁，摔伤致右肩疼痛活动受限数小时，无血管神经症状。,诊断？分型？,脱位如何处理？,治疗方案,肩锁关节脱位 保守？ 切开复位内固定？ 韧带重建？ 锁骨远端切除？ 肩锁关节融合？,治疗方案,复位脱位 内固定方式克氏针？钢丝？螺钉？钩钢板？肌腱转位？袢钢板？ 肩锁关节稳定性维持 康复治疗,术中情况,喙突,肩峰,锁骨,切口,三角肌,喙突,锁骨,克氏针建立工作通道,4.5mm空心钻扩大工作通道,放置导丝,导丝,从喙突下抽出导丝一端,导丝穿引袢钢板,导丝,袢钢板一端穿过喙突,术前术后X线片对照,术后3个月复查X线及肩关节
2、功能像,肩锁关节脱位分型,AllmanTossyRockwood,Mazzocca AD，Arciero RA，Bicos J Evaluation and treatment of acromioclavicular joint injuries Am J Sports Med 2007， 35：316329,讨论,Rockwood,I型：肩部遭受轻度暴力，肩锁关节韧带轻微扭伤。韧带保持完整，肩锁关节仍稳定。,II型：肩部遭受中度暴力，肩锁关节韧带断裂。锁骨远端在水平面上不稳定，在垂直方向上仍稳定。,III型：肩部遭受严重暴力，肩锁和喙锁韧带撕裂。与对侧放射学表现相比，喙锁间隙增加25%-1
3、00%。,IV型：锁骨远端向后脱位，锁骨向后脱入或穿透斜方肌。,V型：类似III型但软组织损伤程度更重，肩锁韧带、喙锁韧带、三角肌斜方肌附着点均被撕脱。与对侧放射学表现相比，喙锁间隙增加100%以上。,VI型：锁骨向下脱位至肩峰下或喙突下。此类损伤常常是严重创伤结果，还往往伴有多发伤。,Schwarz N, Kuderna H. Infrior acromioclavicular separation: report of an unusual case. Clin orthop 1988;234:28-30,合并损伤,肩胸分离骨折Wurtz LD, Lyons FA, Rockwood CA
4、 Tr. Fracture of the middle third of the clavicle and dislocation of the acromioclavicular jiont. A report of four cases. J Bone Joint Surg (Am) 1992;74:133-137 臂丛神经功能异常Meislin RJ, Zuckerman JD, Nainzadeh N. Type III acromioclavicular Jiont separation associated with late brachial plexus neurapraxia
5、. J Orthop Trauma 1992;6:370-372,讨 论,喙锁骨化Urist MR. Complete dislocation of the acromioclavicular Jiont:the nature of the traumatic lesion and effective methods of treatment with an analysis of 41 cases. J Bone Joint Surg 1946;28:813-83 锁骨远端骨溶解Madsen B. Osteolysis of the acromial end of the clavicle
6、following trauma. Br J Raiol 1963;36:822,应用解剖,肩锁韧带：肩锁关节被一层细薄的关节囊包绕，在其上下前后分别由肩锁关节上下前后韧带加强。其中肩锁关节上韧带最强韧。,Renfree KJ, Riley MK, Wheeler D, et al. Ligamentous anatomy of the distal clavicle. J Shoulder Elbow Surg 2003;12(4) :355-359,喙锁韧带：锥状韧带：长0.7-2.5cm，宽0.4-0.95cm；位于斜方韧带内侧，呈锥形，其尖端附着于喙突基底部后内侧面，基底部位于锁骨锥状
7、结节。,Salter EG, Nasca RJ, Shelley BS, Anatomical observations on the acromioclavicular joint and supporting ligaments. Am J Sports Med 1987;15:199-206,斜方韧带：长0.8-2.5cm，宽0.8-2.5cm，起于喙突与锥状韧带着点的前外侧，止于锁骨下面的粗线。,韧带稳定性：Urist及Fukuda等试验得出：肩锁韧带控制水平方向稳定性；喙锁韧带控制垂直方向稳定性。,Klimkiewicz JJ, Williams GR, Sher JS, et al
8、. The acromioclavicular capsule as a restraint to posterior translation of the clavicle: a biomechanical analysis. J Shoulder Elbow Surg 1999;8:119-124,功能：喙锁韧带能协助耦合两关节运动，即盂肱关节的外展、屈曲和肩胛骨在胸壁上的旋转。,Rockwood CA, Williams GR, Young CD. Injures to the acromioclavicular joint.In: Rockwood CA.Green DP,Buchol
9、z RW, Heckman JD,eds. Fractures in adults, vol 2, 4th ed,Philadelphia: Lippincott-Raven,1996:1341-1414,运动：Rockwood证实：随着肩部上抬锁骨向上旋转40-50，但锁骨相对于肩峰只有5-8的旋转。,Flatow EL. The biomechanics of the acromioclavicular,stemoclavicular,and scapulothoracic joints.AAOS Instr Course Lect 1993;42:237-245Rockwood CA,
10、Williams GR, Young CD. Injures to the acromioclavicular joint.In: Rockwood CA.Green DP,Bucholz RW, Heckman JD,eds. Fractures in adults, vol 2, 4th ed,Philadelphia: Lippincott-Raven,1996:1341-1414,治疗方法的选择,I型损伤：无需手术治疗。 II型损伤：非手术治疗：所有急性II型损伤；手术治疗：有症状的慢性II型损伤（单纯半月板清理术、锁骨远端切除术、肩锁关节重建术）。,Moushine E, Garof
11、alo R,Crevoisier X, et al. Grade I and II acromioclavicular dislocation: results of conservative treatment. J Shoulder Elbow Surg 2003;12(6):599-602,锁骨远端切除,讨 论,III 型损伤：非手术治疗：宽胶布固定、吊带悬吊、绷带固定、支具、牵引、加压包扎、石膏管型。,Schlegal TF, Burks RT, Marcus RL, et al. A prospective evaluation of untreated acute grade II
12、I acromioclavicula separations. Am J Sports Med 2001;29(6):699-703,手术治疗：肩锁关节修补、喙锁韧带修补、肩锁和喙锁联合修补、喙锁融合、利用联合腱及其附着的喙突尖端所动的肌肉动力转位。,Sloan SM, Budogg JE, Hipp JA, et al. Corcacolavicular ligament reconstruction using the lateral half of the conjoined tendon. J Shoulder Elbow Surg 2004;13(2):186-190,IV、V、VI
13、型损伤：手术治疗。,Talbert TW, Green JR 3rd , Mukherjee DP, et al. Bioabsorbable screw fixation in coracoclavicular liagament reconstruction. J Long Term Eff Med Implants 2003;13(4):317-323Sloan SM, Budogg JE, Hipp JA, et al. Corcacolavicular ligament reconstruction using the lateral half of the conjoined te
14、ndon. J Shoulder Elbow Surg 2004;13(2):186-190Lee SJ,Akizuki KH,Kremenic IJ. Reconstruction of the coracoclavicular liagament with tendon grafts. Am J Sports Med 2003;31:648-655,切开复位内固定内植物种类,克氏针,讨 论,钢丝,镙钉,钩钢板,骨锚,袢钢板,Lim Yw. Triple Endobutton technique in acromioclavicular joint reduction and reconst
15、ruction Ann Acad Med Singapore，2008 37：294299,并发症,骨圆针游移,Lyons FA,Rockwood CA.Migration of pins used in operations on the shoulder. J Bone Joint Surg (Am) 1990;72:1262-1267,讨 论,喙突镙钉固定失败,Sander JO, Lyons FA, Rockwood CA. Management of dislocations of both ends of the clavicle. J Bone Joint Surg (Am) 1
16、990;72:399-402,锁骨钩肩峰骨质溶解肩峰下撞击甚至应力性骨折脱钩翼状肩,ElMaraghy Aw.Devereaux Mw，Ravichandiran K，et a1subacromial morphometric asscessment of the clavicle hook plate Injury，20104l：613-619,讨论,利用Endobutton技术使用双袢钢板完全符合目前提倡的非刚性、弹性方式固定，通过它可以分别对锥形韧带和斜方韧带进行解剖重建。,袢钢板重建喙锁韧带,Steven struhl MDDouble Endobutton technique for
17、 repair of complete acromioclavicular joint dislocationTechn Shouder Elbow Surg，2007 8(4)：175179,术后constant评分和SSV评分均优于术前，疗效明显。,肩胛悬吊复合体损伤,肩胛悬吊复合体（ SSSC ）中有两个部位（或以上）的损伤，会造成不稳定，导致“飘浮肩”。,Goss TP. Double disruptions of the superior shoulder suspensory complexJ OrthopTrauma;1993,7(2):99-106Peter C. Lapner. Scapula Fractures. Orthop Clin N Am (2008) 39 459474,肩胛盂,喙突,肩峰,锁骨,肩锁韧带,喙锁韧带,两处及以上的肩胛悬吊复合体损伤破坏其稳定性而致肩关节不稳，需手术治疗,小 结,Endobutton技术优点：解剖复位；持续稳定固定；符合生物力学要求；创伤小；术后并发症少；无需二次手术取出等。,谢 谢,
