CT在预防肩关节脱位伴肱骨大结节骨折手法复位致医源性骨折中的作用

The role of CT in preventing iatrogenic fractures caused by manual reduction of shoulder dislocation associated with greater tuberosity fractures of the humerus

目的分析肩关节脱位伴肱骨大结节骨折患者的CT数据,提出以横断位上CT是否越过结节间沟作为患者是否能进行手法复位的标准。方法回顾性分析2015年1月至2020年12月上海长海医院急诊骨科治疗的肩关节脱位病例。共统计患者828例,其中单纯脱位532例、复杂外科颈骨折伴肩关节脱位35例、肩关节脱位合并肱骨大结节骨折共261例,另外无复位资料28例、手法复位病例230例。手法复位前患者均进行X线片检查及肩关节CT平扫,获得230例患者的复位前X线片及CT资料。认真判读复位后的X线片后,确定复位后盂肱关节对位良好、无骨折加重、无半脱位等情况,统计复位医师及复位方法,在横断位CT图像上认真判读骨折线走向。根据CT图像上骨折线的走向,将230例手法复位病例分为A、B两组,A组为肩关节前侧骨折线越过结节间沟;B组为骨折线未越过结节间沟,分别统计两组病例在手法复位过程中发生医源性骨折的病例数量,计算两组病例的RR值。同时,获得35例肩关节脱位伴肱骨外科颈骨折患者的CT图像,观察其骨折线走向。结果在手法复位的230例患者中,急诊局麻下手法复位222例,复位方法为足蹬法或Milch手法,全麻下手法复位8例。手术切开复位3例,1例臂丛神经损伤行切开复位、2例难复性肩关节脱位行切开复位。3例急诊室手法复位致医源性骨折,1例全麻手法复位致医源性骨折,手法复位致医源性骨折的发生率为1.8%。对CT资料进行分析后,A组病例数为4例、B组病例为226例,其中A组病例中发生医源性骨折为4例,盂肱关节对合不良,肱骨解剖颈骨折;B组病例中无医源性骨折发生,盂肱关节对应良好,骨折无加重。对两组病例进行统计学分析,计算RR值为0。在对肩关节脱位伴复杂肱骨近端骨折的病例进行分析时发现,35例病例中,CT图像均出现肩关节前侧骨折线通过肱骨结节间沟。结论肩关节脱位伴肱骨大结节骨折在急诊室进行手法复位发生医源性骨折的风险低,肩关节CT平扫是一种有效的手段,在不进行三维重建的情况下就可以快速识别易发生医源性骨折的病例,减少了医源性损伤。

Background Shoulder joint dislocation is a common disease in the emergency department.Since the shoulder joint is flexible and unstable,the shoulder joint is the joint most prone to dislocation in the human body.Anterior shoulder dislocation is often associated with greater tuberosity fracture,and posterior dislocation of the shoulder is often associated with lesser tuberosity fracture.According to statistics,the incidence of anterior shoulder dislocation associated with greater tuberosity fracture is about 15%-30%.As with simple shoulder dislocation,shoulder dislocation with greater tuberosity fracture should be reduced immediately.Closed reduction of this kind of injury in the emergency room is still controversial,and there is a distinct possibility during the reduction process.Sex can lead to aggravated fracture displacement.Ehud Atoun et al.proposed that when the greater tuberosity fracture of the humerus is combined,the probability of iatrogenic humeral neck fractures due to manual shoulder dislocation reduction is significantly increased,shoulder dislocation combined with greater tuberosity fracture can be manually reduced under sedation in the emergency room.Mackenzie et al.found in their statistical cases that 188 conservatively treated shoulder dislocations combined with greater tuberosity fractures.Only two cases of iatrogenic fractures occurred among the patients who underwent a closed manual reduction in the emergency room.Reducing such fractures and dislocations in the emergency room was considered safe.Guo Junfei et al.proposed using the ratio of the size of the humerus's greater tuberosity to the humeral head’s size on the anterior view of the shoulder joint as an index to measure the risk of manual reduction.When the ratio is greater than 0.4,the risk of iatrogenic fractures increases significantly.However,this method is not accurate in clinical applications.Based on the above studies,it can be seen that manual reduction of shoulder dislocation with greater tuberosity fracture in the emergency room is still controversial,and there is still a lack of reliable methods.Objective Anterior dislocation of the shoulder joint with fracture of the greater tuberosity of the humerus is a common disease in the emergency department.There are still many controversies in its treatment.If an iatrogenic fracture occurs during manual reduction,it will increase the difficulty of treatment and affect the prognosis of patients.This paper analyzes the dislocation of the shoulder joint with humerus fracture based on the CT data of patients with greater tuberosity fractures.It was proposed that whether the CT crossed the intertuberous sulcus on the transverse plane was the criterion for whether the patients could perform the manual reduction.Methods The cases of shoulder dislocation treated in the emergency orthopedic department of Shanghai Changhai Hospital from 2015 to 2020 were retrospectively analyzed.A total of 828 patients were counted,including 532 cases of simple dislocation,35 cases of complex surgical neck fracture with shoulder dislocation,261 cases of shoulder dislocation combined with fracture of the greater tuberosity of the humerus,28 cases without reduction data,and 230 cases of manual reduction.Before manual reduction,all patients underwent an X-ray examination and shoulder CT scan.The X-ray and CT data of 230 cases before reduction were obtained.Carefully interpret the X-ray images after reduction,confirm that the glenohumeral joint is well aligned and there is no aggravation of fractures,no subluxation,etc.,count the reduction physicians and reduction methods,and carefully interpret the direction of the fracture line on the transverse CT image.According to the direction of the fracture line on the CT image,230 manual reduction cases were divided into groups:A and B.There were 4 cases in group A,226 cases in group B,and 4 cases of iatrogenic fractures in group A.Group A was when the anterior shoulder fracture line crossed the intertuberous groove.Group B was when the fracture line did not cross the intertuberous groove.The number of cases of iatrogenic fractures in the two groups of patients during manual reduction was counted,and the RR values of the two cases were calculated.At the same time,CT images of 35 patients with a shoulder dislocation and surgical neck fracture of the humerus were obtained,and the direction of the fracture line was observed.Results Among the 230 patients who underwent manual reduction,222 patients underwent manual reduction under anesthesia in the emergency department,and the reduction methods were the foot pedal or Milch maneuver.Eight patients underwent manual reduction under general anesthesia,three underwent open reduction,and one had a brachial plexus injury.Open reduction was performed,2 cases of refractory shoulder dislocation received open reduction,3 cases of iatrogenic fractures caused by manual reduction in the emergency room,1 case of iatrogenic fractures caused by manual reduction under general anesthesia,and 1 case of iatrogenic fractures caused by manual reduction.The incidence rate was 1.8%.After analyzing the CT data,there were 4 cases of iatrogenic fractures in group A,with malalignment of the glenohumeral joint and fracture of the anatomical neck of the humerus.The fracture did not worsen.Statistical analysis was performed on the two groups of cases,and the RR value was calculated as 0.In an analysis of shoulder dislocation cases with complex proximal humerus fractures,it was found that in all 35 cases,the anterior shoulder fracture line passed through the intertuberous groove of the humerus on CT images.Conclusion The risk of iatrogenic fracture of shoulder dislocation with fracture of the greater tubercle of the humerus in the emergency room is low.CT scan of the shoulder joint is an effective method that can quickly identify cases of the iatrogenic fracture without three-dimensional reconstruction and reduce iatrogenic injury.