肩袖损伤合并臂丛损伤的诊治

DIAGNOSIS AND TREATMENT OF ROTATOR CUFF TEAR AND BRACHIAL PLEXUS INJURY

目的探讨肩袖损伤合并臂丛损伤的诊断、治疗方法选择以及疗效。方法回顾分析2006年7月-2012年6月收治的7例肩袖损伤合并臂丛损伤患者临床资料,其中男3例,女4例;年龄37~72岁,平均47.3岁。致伤原因：高处坠落伤1例,外伤性肩关节前脱位6例。受伤至就诊时间5-31 d,平均17 d。肩关节功能根据美国肩肘外科协会（ASES）评分为（55.86±9.42）分,疼痛视觉模拟评分（VAS）为（7.14±1.35）分。根据Gerber分型：大型肩袖撕裂（〉3 cm）3例,巨大型肩袖撕裂（〉5 cm）4例;根据顾玉东提出的臂丛损伤分型标准：上干型损伤1例,束支型损伤6例。臂丛功能参考中华医学会手外科学会上肢部分功能评定试用标准为（7.43±1.27）分。患者均于关节镜下行肩袖修补术及营养神经、物理治疗,1例联合臂丛探查、神经外膜松解术。结果术后切口均Ⅰ期愈合,无手术相关并发症发生。7例均获随访,随访时间18-25个月,平均20.4个月。患者肩关节功能明显恢复,肌力及感觉均较治疗前显著改善。末次随访时,患者肩关节功能ASES评分为（84.71±8.06）分,与治疗前比较差异有统计学意义（t=—8.194,P=0.000）;VAS评分为（2.71±1.50）分,与治疗前比较差异有统计学意义（t=7.750,P=0.000）;臂丛功能评分为（14.00±1.16）分,与治疗前比较差异有统计学意义（t=—11.500,P=0.000）。结论肩袖损伤合并臂丛损伤诊断较为困难,易漏诊和误诊,应引起重视;治疗时应在积极修复肩袖损伤的同时行理疗及营养神经治疗,可获满意疗效。

Objective To investigate the mechanisms, diagnosis, and surgical procedures of simultaneous lesions of the rotator cuf and the brachial plexus. Methods Between July 2006 and June 2012, 7 patients with rotator cuf tear associated with brachial plexus injury were treated. There were 3 males and 4 females with a mean age of 47.3 years（range, 37-72 years）. The reasons of injury were traumatic shoulder dislocation in 6 cases and falling injury from height in 1 case, with a mean disease duration of 17 days（range, 5-31 days）. The average American Shoulder and Elbow Surgeons（ASES） score was 55.86 ± 9.42, and visual analogue scale（VAS） score was 7.14 ± 1.35. There were 3 cases of large rotator cuf tears（ 3 cm） and 4 cases of massive rotator cuf tears（〉 5 cm） according to Gerber standard; 1 case had upper trunk injury of the brachial plexus and 6 cases had bundle branch injury of the brachial plexus according to GU Yudong＇s classii cation. The functional score of brachial plexus score was 7.43 ± 1.27 according to the functional assessment standard by Hand Surgery Branch of Chinese Medical Association. All patients accepted arthroscopic rotator cuf repairing, and 1 case received surgical neurolysis of brachial plexus. Results All incisions healed by first intention without complication. All the 7 patients were followed up 18 to 25 months（mean, 20.4 months）. The function, muscle strength, and sensation of the shoulder were improved obviously. The shoulder ASES score was 84.71 ± 8.06 and was signii cantly better than preoperative score（t= —8.194, P=0.000）. The VAS score was 2.71 ± 1.50 and was signii cantly better than preoperative score（t=7.750, P=0.000）. The functional score of brachial plexus was 14.00 ± 1.16 and was signii cantly better than preoperative score（t= —11.500, P=0.000）. Conclusion It is dii cult to simultaneously diagnose lesions of the rotator cuf and the brachial plexus; orthopedists should pay attention to possible patients to avoid missed diagnosis and diagnostic errors. Nerve nutrition, physical therapy, and arthroscopic rotator cuf repair can achieve good ef ectiveness.