手术治疗创伤致神经源性单纯肩外展功能障碍

The diagnosis and treatment of suprascapular nerve combined with axillary nerve injuries following the shoulder trauma

目的 探讨手术治疗肩部创伤致肩胛上神经与腋神经同时损伤的疗效.方法 回顾性分析2003年7月至2011年9月,手术治疗13例男性肩部创伤后诊断为肩胛上神经与腋神经同时损伤的患者资料,年龄8～59岁,平均28岁;受伤至手术时间为2～7个月,平均3.7个月.其中肩胛颈和锁骨同时骨折2例,浮肩损伤3例,肱骨颈及关节盂骨折1例,锁骨骨折3例,肩峰骨折1例,肩胛骨骨折2例,寰枢椎骨折1例.13例临床检查均示单纯肩外展、外旋功能完全丧失,三角肌及冈上、下肌肌力均为0级.电生理检查示腋神经、肩胛上神经完全失神经支配.肩胛上神经断裂10例,其中6例通过1股腓肠神经移植修复,1例通过1股颈丛浅支移植修复,3例因远端撕脱而放弃神经修复;另3例肩胛上神经仅进行松解.腋神经断裂12例,其中10例采用2～3股腓肠神经移植修复,2例采用正中神经束支移位修复;另1例腋神经于四边孔处进行松解.13例患者中,10例患者的肩胛上神经及腋神经同时断裂.结果 13例患者随访时间36～134个月,平均85个月;7例肩关节上举恢复正常达180＆#176;,该7例的三角肌力均为4级,肩外旋40＆#176;～70＆#176;,平均56＆#176;;5例肩外展达30＆#176;～50＆#176;,平均38＆#176;;该5例肩外旋为-40＆#176;～30＆#176;,平均10＆#176;,三角肌肌力4级1例,3级2例,2级2例;另1例无恢复.结论 对于肩部创伤后出现的单纯肩关节外展、外旋功能完全丧失,应考虑肩胛上神经与腋神经同时损伤的可能.此种类型的神经损伤修复后的效果满意,应尽早进行神经移植修复.

Objective To expore the effect of nerve repair for patients with traumatic suprascapular nerve combined with axillary nerve injuries.Methods Data of 13 cases with traumatic suprascapular nerve combined axillary nerve injuries treated by surgery from June 2003 to September 2011 were retrospectively analyzed.All the cases were males,and the average age was 28 years old.There were 2 cases of neck of scapula fracture combined with clavicle fracture,3 of floating shoulder injury,1 of humerus neck fracture combined with glenoid cavity fracture,3 of clavicle fracture,1 of acromion fracture,2 of shoulder blade fracture and 1 of atlanto-axial vertebral fractures.All the 13 cases performed isolated lost of the function of shoulder abduction and external rotation completely,and the muscle strength of deltoid,the supraspinatus and infraspinatus was M0.The electrophysiological examination showed complete denervation of axillary nerve and suprascapular nerve.The suprascapular nerve was broken in 10 cases in which 6 cases were repaired by 1 band sural nerve graft and 1 case was repaired by 1 band superficial cervical plexus,and 3 cases were irreparable because of the distal avulsion injury from the target muscle,and 3 cases were performed with neurolysis.The axillary nerve ruptured in 12 cases,in which 10 cases was repaired by 2-3 bands sural nerve graft,and fascicles selected from the median nerve were used to neurotize axillary nerve in 2 cases.The neurolysis of axillary nerve was performed at the quadrilateral space in 1 case.10 of the 13 cases had both the suprascapular nerve and axillary nerve ruptured.Results 13 cases were followed up,the follow up period was 36 to 134 months.In 7 cases,the functional recovery of shoulder abduction were 180＆#176; and the average external rotation was 56＆#176; and the muscle strength of deltoid attained M4.In 5 cases,the average shoulder abduction was 38＆#176;;the range of external rotation was-40＆#176;-30＆#176;,and the muscle strength of deltoid achieved M4 in 1 case,M3 in 2,M2 in 2.There was no improvement in 1 case.Conclusion The suprascapular nerve associated axillary nerve injury should be suspected in the patients with isolated lost the function of shoulder abduction and extemal rotation completely.Repair of axillary nerve and suprascapular nerve by nerve graft simultaneously could achieve good outcome,and early surgery should be conducted.