锁骨骨折的诊疗与手术VIP免费

InjuriesoftheClavicle,AcromioclavicularJointandSternoclavicularJointAndrewH.Schmidt,MDT.J.McElroyCreatedMarch2004•“S”-shapedbone•Medial-sternoclavicularjoint•Lateral-acromioclavicularjointandcoracoclavicularligaments•Muscleattachments:–Medial:sternocleidomastoid–Lateral:Trapezius,pectoralismajorClavicle•Diarthrodialjointbetweenmedialfacetofacromionandthelateral(distal)clavicle.•Containsintra-articulardiskofvariablesize.•Thincapsulestabilizedbyligamentsonallsides:–ACligamentscontrolhorizontal(anteroposterior)displacement–SuperiorACligamentmostimportantACJoint•Coracoclavicularligaments–“Suspensoryligamentsoftheupperextremity”–Twocomponents:•Trapezoid•Conoid–StrongerthanACligaments–ProvideverticalstabilitytoACjointDistalClavicleMechanismofInjuryModerateorhigh-energytraumaticimpactstotheshoulder1.Fallfromheight2.Motorvehicleaccident3.Sportsinjury4.Blowtothepointoftheshoulder5.RarelyadirectinjurytotheclaviclePhysicalExamination•Inspection–Evaluatedeformityand/ordisplacement–Bewareofrareinferiororposteriordisplacementofdistalormedialendsofclavicle–Comparetooppositeside.PhysicalExamination•Palpation–Evaluatepain–LookforinstabilitywithstressPhysicalExamination•Neurovascularexamination•Evaluateupperextremitymotorandsensation•Measureshoulderrange-of-motionRadiographicEvaluationoftheClavicle•AnteroposteriorView•30-degreeCephalicTiltViewRadiographicEvaluationoftheClavicle•Quesana–45-degreeanglesuperiorlyanda45-degreeangleinferiorly–ProvidebetterassessmentoftheextentofdisplacementRadiographicEvaluationoftheACJoint•ZancaView–APviewcenteredatACjointwith10degreecephalictilt–LessvoltagethanusedforAPshoulderStressViewsoftheDistalClavicle&ACJoint•Rationale:willdemonstrateinstabilityanddifferentiategradeIIIACseparationsfrompartialGradeI-IIinjuries•Performedbyhavingpatienthold10#weightwithinjuredarm•Rarelyusedtoday,sincemostACjointinjuriestreatedthesame,andmanagementofdistalclaviclefracturesdependsoninitialdisplacementandlocationoffracture.RadiographicEvaluationoftheMedialOneThird•X-ray:Cephalictiltviewof40to45degrees•CTscanusuallyindicatedtobestassessdegreeanddirectionofdisplacementClassificationofClavicleFractures•GroupI:Middlethird–Mostcommon(80%ofclaviclefractures)•GroupII:Distalthird–10-15%ofclavicleinjuries•GroupIII:Medialthird–Leastcommon(approx.5%)TreatmentOptions•Nonoperative–Sling–Brace•Surgical–PlateFixation–ScreworPinFixationNonoperativeTreatment•“StandardofCare”formostclaviclefractures.•Continuedquestionsabouttheneedtowearaspecializedbrace.SimpleSlingvs.Figure-of-8Bandage•Prospectiverandomizedtrialof61patients•Simplesling–Lessdiscomfort•Functionalandcosmeticresultsidentical•AlignmentofhealedfracturesunchangedfromtheinitialdisplacementinbothgroupsAndersenetal.,ActaOrthopScand58:71-4,1987.NonoperativeTreatment•Itisdifficulttoreduceclaviclefracturesbyclosedmeans.•Mostclaviclefracturesuniterapidlydespitedisplacement•Significantlydisplacedmid-shaftanddistal-thirdinjurieshaveahigherincidenceofnonunion,butmanyoftheseareminimallysymptomatic.DefiniteIndicationsforSurgicalTreatmentofClavicleFractures•1)Openfractures•2)AssociatedneurovascularinjuryRelativeIndicationsforAcuteTreatmentofClavicleFractures•1)Widelydisplacedfractures•2)Multipletrauma•3)Displaceddistal-thirdfracturesRelativeIndicationsforAcuteTreatmentofC...