肩关节恐怖三联征的诊断

Report on diagonsis of two cases of terrible triad of shoulder

目的分析肩关节恐怖三联征的临床诊断方法,避免误诊、漏诊。方法对收治的2例肩关节脱位后肩袖撕裂合并腋神经损伤(肩关节恐怖三联征)的病例进行回顾性分析,分析肩关节恐怖三联征的诊断规律及容易误诊漏诊的原因。结果 2例患者均临床证实为肩关节脱位后腋神经损伤合并肩袖撕裂。病例1,一期行腋神经探查松解术,二期行关节镜下肩袖修补术。病例2,同期行腋神经探查取腓肠神经桥接修复术与肩袖断裂缝合修补术。两病例术后症状均缓解。结论肩关节脱位可合并肩袖、腋神经损伤。当肩脱位后肩关节外展功能受限,肩部外侧感觉障碍应考虑腋神经损伤的可能;但当患者,尤其是老年患者同时合并有肩袖撕裂及肩关节冻结后会表现为肩外展功能丧失,表现为肩胛上神经、腋神经损伤的上臂丛神经损伤后的表现,应进行临床详细检查仔细鉴别。肩关节MRI检查有助于了解有无肩袖撕裂,从而避免误诊、漏诊。

Objective To discuss the diagnosis of terrible triad of the shoulder in order to avoid misdiagnosis and missed diagnosis. Methods Two cases of concurrent rotator cuff tear and axillary nerve palsy resulting from anterior dislocation of the shoulder were analyzed retrospectively. Both the distinguishing features of the disease and the reasons of misdiagnosis or missed diagnosis were discussed.Results Both the two cases were proved rotator cuff tear associated with axillary nerve injury resulting from anterior dislocation of the shoulder. Both the cases were treated by operation. One-stage neurolysis of the axillary nerve and two-stage arthroscopic repair of the rotator cuff were performed in one case. The other case underwent axillary nerve repair with sural nerve graft and the rotator cuff repair at the same time. Both the two cases were improved after the operations. Conclusions Concurrent rotator cuff tear and axillary nerve injury may happen after traumatic anterior dislocation of the shoulder. Axillary nerve injury should be considered when the shoulder abduction is limited with upper lateral arm paresthesia. For the elder patients with stiff shoulders and rotator cuff tears who present the similar symptoms of upper plexus injury,careful physical examination should be performed to check the rotator cuff and MRI is useful for a clear diagnosis.