经改良肩后方入路治疗肩胛骨骨折

Operative treatment of scapular fractures through modified posterior shoulder approach

背景:肩胛骨骨折多见于高能量损伤。由于肩胛骨位置深在,周围有丰富肌肉、血管、神经等软组织包绕,手术显露、复位及内固定较为棘手。目的:探讨经改良肩后方入路治疗肩胛骨骨折的疗效。方法:2011年12月至2017年6月,采用改良肩后方入路治疗肩胛骨骨折患者24例,男21例,女3例,年龄20～78岁,平均46.7岁。按照Hardegger肩胛骨骨折分型,肩胛颈累及肩胛冈或肩胛骨体部骨折17例,肩盂骨折7例。记录手术时间、出血量、骨折愈合时间及并发症,采用Neer评分评定肩关节功能。结果:所有患者均获得良好骨折复位及内固定。术后随访8个月至5年,平均30.6个月;骨折均愈合,愈合时间6～20周,平均10.8周;术后合并切口浅表感染2例,经口服抗生素切口愈合;无深部感染、医源性血管神经损伤、内固定物失效及骨折不愈合。Neer肩关节功能评定:优17例,良4例,可2例,差1例,优良率87.5%(21/24)。结论:经改良肩后方入路允许同时显露肩胛骨腋缘、肩胛颈、肩盂关节面、肩胛冈及肩胛骨脊柱缘,骨折显露充分、安全,复位、内固定方便,创伤小,患者功能恢复满意,治疗复杂肩胛骨骨折效果良好。

Background： Scapular fractures are frequently resulted from high-energy injuries. These fractures present unique challenges for surgical approaches and reduction and fixation strategies because of the complex anatomy of the bony and neurovascular structures. Objective： To evaluate the clinical outcomes of operative treatment of scapular fractures through a modified posterior shoulder approach. Methods： From December 2011 to June 2017, 24 patients with complex scapular fractures were treated through a modified posterior shoulder approach. There were 21 males and 3 females with a mean age of 46.7 years（range, 20 to 78 years）. According to the Hardegger classification system, there were 17 cases of scapular neck fractures associated with scapular body or spine fractures, and 7 cases of glenoid fossa fractures. Operation time, blood loss, bone healing time, and intraoperative and postoperative complications were recorded. The shoulder functions were evaluated according to the Neer scoring system. Results： Postoperative X-ray photography confirmed satisfactory fracture reduction and internal fixation in all the patients. All were followed up in the outpatient clinic with a mean duration of 30.6 months（range, 8 months to 5 years）. The bone union was observed in all patients after the mean period of 10.8 weeks（range, 6 to 20 weeks）. Two cases developed superficial infection, which was resolved with oral antibiotics. No implant failure, deep infection, nonunion, or iatrogenic neurovascular injury were observed in all cases. According to the Neer scoring system, 17 cases showed excellent, 4 cases showed good, 2 cases showed fair, and 1 case showed poor results. Function recovery rate was 87.5%（21/24）. Conclusions：The modified posterior shoulder approach allows for the simultaneous exposure of the medial/lateral border of the scapula,scapular neck, scapular spine, and glenoid articular surface. Through this approach, it is possible to obtain perfect reduction and internal fixation of complex scapular fractures as well as satisfactory functional recovery with minimal trauma.