移位肩胛颈骨折的手术方法研究

Surgery for scapular neck displaced fracture

目的探讨手术治疗肩胛颈骨折的入路和固定方法。方法对14例肩盂下缘向内严重重叠移位的肩胛颈骨折患者，采用府卧位后入路施术，置入钢板螺钉分别固定肩胛冈和腋缘的方法治疗。本组左侧肢体9例，右5例；均为新鲜的肩胛颈骨折，骨折线走向：起于肩胛上切迹，经过肩胛冈，止于腋缘盂下2—4cm，平均3cm；肩盂下缘向内重叠移位的程度2—4cm，平均3cm。按Miller等的分型：均为Ⅱ-B型肩胛骨骨折。手术指征为肩盂下缘向内重叠移位的程度大于1cm。伤后至手术的时间：3—10d。结果14例手术过程顺利，无神经血管损伤的病例，术后伤口一期愈合，拍X线平片，显示骨折达解剖复位或接近解剖复位标准，肩盂倾斜角度正常。全部病例骨折愈合，骨折临床愈合时间：术后4周-8周，平均6周。全部病例得到随访，随访时间：术后1—7年，平均3．5年。未见肩关节创伤性关节炎、异位骨化、肩峰撞击征等并发症。按Hardegger的评定标准评价：优8例，良4例，可2例。结论肩盂下缘向内严重重叠移位的肩胛颈骨折，直接影响上肢的功能，应手术治疗。肩胛冈和腋缘形态规整骨质较坚硬，适合放置植入物。俯卧位后入路施术容易复位和固定骨折，钢板螺钉应分别固定肩胛冈和腋缘，手术既恢复了肩胛骨解剖学形态和三角形的力学结构，又固定牢靠，是治疗肩胛颈骨折较佳的固定方法。可早期行肩关节功能煅炼，利于肩关节功能恢复。

Objective To study the appropriate approach and method of fixation in the surgery for scapular neck displaced fracture. Methods Fourteen patients with serious step-off displacement of glenoid rim, with a distance of 3 cm （2 -4 cm） involving fresh scapular neck fracture, all located from the superior scapular notch to glenoid armpit rim and passing through the mesoscapula, all of the type Ⅱ according to the Miller＇s system, 10 males and 4 females, aged 33 （21-60）. The surgical indications included a distance of step-off displacement exceeding 1 cm and a time between the injury and operation of 3-10 days. Results All operations were successful without injury of nerve and blood vessels. All the wounds obtained primary healing within 6 weeks （4-8 weeks）. X-ray plain films showed that all cases obtained complete or nearly complete anatomical reduction. Follow-up carried out for 1-7 years showed no complication. According to the Hardegger＇s evaluation, 8 cases showed excellent prognosis, 4 showed good prognosis, and 2 showed fair prognosis. Conclusion Operation is necessary for step-off displacement of glenoid rim involving scapular neck fracture. Hard and with regular shape, the mesoscapula and armpit rim suits for fixation. Open reduction through posterior approach and internal fixation in prone position help recover the morphology and biomechanics characteristic of scapula. Propitious to functional recovery, dirigation should begin early.