浮肩损伤手术治疗的内固定策略

Internal fixation for floating shoulder

目的探讨手术治疗浮肩损伤的适应证、复位顺序、内固定方法及其疗效。方法2000年1月至2008年1月，采用切开复位内固定治疗浮肩损伤患者19例，男13例，女6例，平均年龄31．6（18-62）岁；肩胛颈骨折合并锁骨骨折18例，肩胛颈骨折合并肩锁关节脱位1例。全部采用内固定治疗。取浮动侧卧位，先将患者体位向后浮动，变为侧仰卧位，复位固定锁骨后，X线透视检查锁骨及肩胛骨，如果此时肩胛骨也已复位，可以考虑仅固定锁骨即可而不必再内固定肩胛骨。如果肩胛骨未复位，或复位后不稳定，则将体位向前旋转变为侧俯卧位，取后路复位并固定肩胛颈，若存在肩胛冈等其他部位的肩胛骨骨折，应考虑同时复位固定。如果锁骨骨折无明显移位，则仅采用后入路复位固定肩胛骨。本组中肩胛骨与锁骨同时固定13例，单纯肩胛骨固定2例，单纯锁骨固定3例，1例合并肩锁关节脱位者采用张力带固定并行韧带修复。结果17例患者获得随访，随访时间10个月-4年，平均26个月。骨折均获得临床愈合，平均愈合时间11．8（8-16）周。肩关节功能根据Rowe疗效评价标准，优11例，良4例，可2例，优良率为88．2％。结论切开复位内固定是治疗浮肩损伤的有效方法，但应根据骨折类型及移位程度选择复位顺序与固定方法。浮肩损伤大多须将两处骨折同时固定，以便于早期进行功能锻炼。手术时先复位固定锁骨后复位固定肩胛骨有利于手术完成，减小手术创伤。

Objective To investigate the effect of operative treatment of floating shoulder and the methods of its internal fixation. Methods From January 2000 to January 2008, 19 patients of floating shoulder were treated by open reduction and internal fixation. There were 13 males and 6 females with an average age of 31.6 years. The patient was placed in the ＂floppy lateral＂ position where the patients could be placed anteriorly and posteriorly in operation. The patient was tilted posteriorly first, the clavicle fracture was reduced and fixed through the anterior approach, then both the fractures of clavicle and the scapular were of checked the with C-arm X-ray, if the scapular fractures was also reduced and stable, no more operation were needed. Otherwise, the patient should be tilted anteriorly, and the scapular neck fractures were reduced and fixed. In some cases, open reduction and internal fixation can be performed only for the scapular fracture if the clavicular fracture was undisplaced and stable. In this study, 13 cases were fixed both scapula and clavicle, 2 cases were fixed only scapula, 3 cases were fixed only clavicle, 1 case who had acromioclavicular joint dislocation accompanied with scapular neck fracture were fixed with tension band and plate. Results Seventeen patients were followed np; the mean follow-up time was 26 （10-48） months. The fractures were clinically healed at 11.8 （8-16） weeks. According to Rowe scores system, 11 patients showed excellent, 4 good and 2 fair. Conclusion Open reduction and internal fixation was effective method for floating shoulder. The fixation strategy should be decided according to fracture type and the stability of the shoulder. Both of the scapula and clavicle should be fixed in most cases. During the operation, the clavicular fractures should be reduced and fixed prior to the scapular neck fractures in most cases.