肩关节后脱位的诊断与治疗

目的 探讨肩关节后脱位相关诊断方法的意义和治疗效果。方法 对5例漏珍的肩关节后脱闰进行创伤系列X线检查和CT扫描检查。根据伤后延误时间、临床症状和影像学检查结果选择治疗方法。3例行早期闭合复位,2例陈旧脱位中,1例行切开复位内固定,1例放弃复位。结果 CT、MRI和肩关节侧位、腋窝位、Velpeau腋窝位X线片分别显示5例、1例、2例、5例肩关节后脱位;CT和腋位X线检查同时显示伴随骨折。随访2－5年,闭合复位者UCLA评分32－35分;切开复位者UCLA评分14分;未予复位者UCLA评分22分。结论 临床上对该症认识不足是造成漏诊的主要原因,早期闭合复位可取得良好功能恢复。     

陈旧性交锁肩关节后脱位手术治疗

目的 评价肱骨关节面复位加大块植骨治疗陈旧性交锁肩关节后脱位的疗效及结果.方法 2002年3月-2008年4月,对18例陈旧性交锁肩关节后脱位的患者,采用肱骨关节面复位加大块植骨进行手术治疗.全部患者受伤至接受手术时间平均为5个月,术前CT检查证实为陈旧性交锁肩关节后脱位,其中8例肱骨头前缘缺损(反Hill～Sachs征)在20%～25%之间,10例在25%～45%之间.结果 术后随访1～4年,平均2.6年.肩关节功能采用Constant评分:优7例,良9例,中1例,差1例;优良率为88.8%.1例患者术后肩关节僵直,但未有复发脱位.UCLA评分最高35分,最低13分,平均30分.结论 采用肱骨关节面复位加大块植骨治疗创伤导致陈旧性交锁肩关节后脱位,疗效肯定,肩关节功能恢复良好.     

手术治疗肩关节后脱位合并反Hill-Sachs损伤与文献复习

目的探讨肩关节后脱位合并反Hill-Sachs损伤的手术治疗方法及效果。方法回顾性分析自2010-01—2016-01手术治疗的6例肩关节后脱位合并反Hill-Sachs损伤,4例切开后撬顶法复位、植骨、螺钉内固定,2例切开后将肩胛下肌-肌腱-骨块复合体切除后移植到缺损处并锚钉缝合固定。结果 6例均获得随访,随访时间14.6(12～25)个月。末次随访时肩关节功能较术前均有改善,肩关节功能UCLA评分平均27.8(21～34)分;优1例,良4例,差1例。效果为差的1例为陈旧性后脱位合并肱骨头反Hill-Sachs损伤,伤后第9周手术,末次随访时肩关节活动受限仍较为明显。1例随访期间X线片显示存在创伤性关节炎改变。结论肩关节后脱位合并反Hill-Sachs损伤临床少见,容易漏诊。目前对于反Hill-Sachs损伤范围≥20%及闭合复位失败者多主张手术治疗,手术方法有多种,术者应根据具体情况采取不同手术方法,越早治疗效果越好。     

肩关节后脱位的诊断与处理(附五例报告)

目的 分析肩关节后脱位的诊疗情况,提高对该病的认识.方法 对5例肩关节后脱位进行分析,指出其X线、CT等影像学特点,并进行随访观察,使用Constant评分法进行评分.结果 患者均获得明确诊断,并成功复位.随访1年以上,无再脱位,功能良好,Constant评分84～92分.结论 肩关节后脱位容易漏诊,对可疑患者应行肩部CT检查,以明确诊断,早期复位可获得良好功能.     

切开复位带线锚钉内固定治疗陈旧性肩关节前脱位

目的探讨切开复位带线锚钉内固定治疗陈旧性肩关节前脱位的临床疗效。方法回顾性分析自2013-04—2017-09采用三角肌与胸大肌前侧入路切开复位带线锚钉内固定治疗9例陈旧性肩关节前脱位,根据合并不同的损伤采用不同方式稳定肩关节。结果 9例均获得随访,随访时间平均7.6(3～12)个月。1例术中发生腋静脉撕裂损伤,术中紧急作腋下新切口显露腋静脉损伤部位并缝合处理;1例复位时发生肱骨外科颈骨折,行肱骨近端解剖钢板内固定,术后4个月骨折临床愈合。末次随访时肩关节功能Constant-Murley评分为57～79分,平均67.5分。结论切开复位带线锚钉内固定治疗陈旧性肩关节前脱位可以获得满意的复位并维持良好的肩关节稳定性,明显改善了肩关节功能。     

髋关节后脱位并髋臼后壁（柱）骨折手术治疗结果分析

目的探讨髋臼后壁（柱）骨折伴髋关节脱位手术治疗的中远期疗效。方法回顾性分析21例髋关节脱位伴髋臼骨折患者临床资料,其中20例髋臼脱位行闭合复位,1例行急诊切开复位内固定;所有合并的髋臼骨折均采用开放复位内固定术治疗。结果完整随访19例,失访2例,随访时间29～86个月。按髋关节功能恢复情况评分：优13例,良3例,可2例,差1例,优良率84．2％。结论髋关节脱位伴髋臼骨折应尽早诊断,应尽快行髋关节复位,骨折应尽早开放复位内固定,早期功能锻炼,避免过早负重。     

肩关节后脱位3例报告及其诊断治疗策略

目的分析肩关节后脱位及其合并伤的发病率、治疗策略、预后情况,提高对该病的认识。方法回顾分析山东中医药大学附属医院2015年8月至2017年4月收入院的3例肩关节后脱位病例并结合相关文献一并进行分析讨论,3例患者中,病例1为28岁女性,摔伤后致左肩关节后脱位合并大结节骨折,腋神经损伤,伤后12 h行闭合复位切开内固定术。病例2为61岁男性,电击伤致右肩关节后脱位合并反Hill-Sachs损伤及肱骨外科颈骨折,肩袖损伤,在外院漏诊,伤后1 d于我院明确诊断,行关节镜联合切开手术治疗。病例3为60岁男性,电击伤致左肩关节后脱位伴反Hill-Sachs损伤,反向骨性Bankart损伤及小结节骨折,肩袖损伤,外院漏诊,伤后45 d于我院明确诊断,行左侧肱骨头切除术。3例患者术后随访,使用Constant评分系统对疗效进行评估。结果病例1随访15个月,无复发性脱位,Constant评分从术前33分提高到术后的97分。病例2随访12个月,无复发性脱位,Constant评分从术前22分提高到术后的95分。病例3随访31个月,Constant评分从术前14分提高到术后的51分。3例患者对其治疗效果满意。结论肩关节后脱位易漏诊,同时应注意合并损伤,早期确诊及治疗可获得良好的临床疗效。     

初次肩关节脱位伴肱骨大结节骨折的关节镜治疗

[目的]探讨关节镜治疗初次肩关节脱位合并肱骨大结节骨折的手术方法及近期临床效果。[方法]2013年5月~2015年6月,收治21例初次肩关节脱位合并肱骨大结节骨折患者。21例均为首次脱位,急症行肩关节闭合手法复位,复位后2~7 d,平均4 d,行肩关节镜下探查,其中肩袖损伤7例,Bankart损伤3例,SLAP损伤1例,均以缝合锚钉固定修复。肱骨大结节骨折块行镜下复位,根据骨折块大小、粉碎情况选择空心螺钉或双排缝线桥固定手术治疗。术后随访肩关节活动度、骨折愈合情况,并进行VAS疼痛评分,美国加州大学洛杉矶分校评分(UCLA)评分,评估临床疗效。[结果]术后切口均Ⅰ期愈合,无感染等相关并发症发生。21例患者均获随访,随访时间6~24个月,平均12个月。患者肩关节稳定,未出现再次脱位。术后6个月随访3例出现肩关节外展活动轻度受限;2例前屈时疼痛。术后2~6个月肱骨大结节骨折愈合,平均3.4个月。术后6个月根据美国加州大学洛杉矶分校评分标准(UCLA)评分为(32.6±6.8)分,较术前明显改善。VAS疼痛评分由术前的(7.2±2.1)降至术后的(1.7±1.02)分。[结论]肩关节镜下治疗肩关节脱位合并肱骨大结节骨折手术创伤小,术后恢复快。可做到早期全面诊断,一期处理肩关节其他合并伤,有效降低术后并发症,近期疗效满意,但对外科医师的要求较高。     

切开复位联合Latarjet手术治疗陈旧性肩关节前脱位

目的评估切开复位联合Latarjet手术治疗陈旧性肩关节前脱位的临床疗效。 方法自2012年1月至2018年1月共14例陈旧性肩关节前脱位患者（16个肩关节）纳入本研究,其中男8例、女6例;年龄30~70岁,平均51.2岁;脱位时间为8~22周,平均10.2周。受伤原因为：摔伤10例,车祸伤4例。合并Hill-Sachs损伤12例,缺损占肱骨头的比例平均为32%。合并骨性Bankart损伤11例,缺损占肩胛盂的比例平均为13%。合并肩袖损伤9例,合并肱骨近端骨折6例,无一例合并神经血管损伤。术前检查肩关节活动度（前屈、外展、内旋、外旋）并记录视觉模拟评分法（visual analogue scale,VAS）、美国肩肘外科（American shoulder elbow surgeons’form,ASES）评分、美国加州大学肩关节系统（University of California at Los Angeles,UCLA）评分。术中均采用胸大肌三角肌间沟入路,彻底松解挛缩的关节囊和周围软组织,清除盂窝内的瘢痕组织后复位,再行Latarjet术重建肩胛盂弧度维持复位,同时依据损伤情况处理伴随的Hill-Sachs损伤、肩袖损伤和肱骨近端骨折等。 结果14例患者均获随访,随访时间10~22个月,平均18个月。随访期间肩关节均未出现再脱位。1例患者术后出现肩部麻木,考虑腋神经损伤,1个月后恢复正常。无感染、医源性骨折及其他血管神经损伤等并发症。与术前相比,末次随访时平均前屈角度由（65.9±10.4）°升至（112.1±13.3）°（P=0.000）,平均外展角度由（41.1±9.7）°升至（63.3±13.6）°（P=0.000）,平均内收位外旋角度由（10.7±4.3）°升至（22.1±5.1）°（P=0.000）,平均内收位内旋角度由（52.6±5.3）°升至（54.0±6.0）°（P=0.081）,VAS评分由（5.4±1.4）分降至（1.7±1.1）分（P=0.000）,ASES评分由（34.1±10.6）分升至（70.8±12.3）分（P=0.000）,UCLA评分由（10.1±3.2）分升至（22.6±4.6）分（P=0.000）。除内旋外,手术前后肩关节活动度和功能评分的差异均有统计学意义。 结论对于陈旧性肩关节前脱位,切开复位联合Latarjet手术可有效重建肩关节前方稳定性。同时术中正确处理伴随损伤及术后早期规范康复锻炼也是提高手术疗效的重要因素。     

肩关节镜治疗复发性肩关节前脱位

目的 对关节镜治疗复发性肩关节前脱位的疗效进行评价.方法 2001年1月至2006年3月关节镜治疗复发性肩关节前脱位患者52例,其中44例获得随访,随访时间12～54个月,平均26个月.对获得随访的44例患者的临床资料进行回顾性研究.采用美国加州洛杉矶大学肩关节评分系统(UCLA)、肩关节简明测试(SST)、Dawson评分对术后效果进行评价.采用Dawson评分对患者年龄、是否存在松弛、术前脱位频率、复位情况和病程长短等因素对术后疗效的影响进行评价.结果 获得随访的44位患者的脱位复发率为4.5%.术后UCLA、SST、Dawson评分与术前比较差异具有统计学意义,肩关节镜治疗术后优良率在91%以上.患者年龄、病程长短、术前脱位频率、是否伴有关节松弛、复位方法对治疗效果无明显影响.结论 关节镜治疗复发性肩关节前脱位手术效果较好,术后肩关节功能改善明显.     

创伤性肩关节后脱位合并肱骨头反向Hill-Sachs损伤的治疗策略

目的探讨创伤性肩关节后脱位合并肱骨头反向Hill-Sachs(R-HS)损伤的治疗策略。方法回顾性分析2015年7月至2018年6月治疗8例创伤性肩关节后脱位合并肱骨头前内侧压缩,即关节盂后缘撞击肱骨头前侧形成R-HS损伤患者资料。男7例,女1例;年龄(44.5±12.3)岁(范围,30~70岁);左侧2例,右侧6例;急性损伤7例,陈旧性损伤1例;4例合并肩袖损伤,包括全层撕裂1例和部分撕裂3例。1例肱骨头R-HS损伤缺失面积<20%,且未合并肩关节其他损伤者,在臂丛麻醉下行闭合复位,肩关节外展枕制动;7例肱骨头R-HS损伤缺失面积在20%~40%者,行手术治疗,其中2例选择胸大肌三角肌间隙入路(1例经前入路修复后盂肱关节仍有后脱位趋势,加用改良Judet入路);4例因复位困难选择改良胸大肌三角肌间隙入路;1例因合并肩胛盂后下方骨折而选择改良Judet入路。7例手术患者中,4例采用同种异体骨植骨联合PHILOS钢板固定,2例采用单纯空心螺钉固定,1例采用同种异体骨植骨联合McLaughlin手术锚钉修复。末次随访时,分别采用肩关节Constant-Murley评分和视觉模拟评分(visual analogue scale,VAS)对患者治疗后的肩关节功能及疼痛进行评价。结果7例手术患者中,6例切口均一期愈合,术后3个月随访肱骨近端骨折均骨性愈合;1例于术后2周确诊肩关节感染,行肱骨头切除及抗生素骨水泥旷置,等待行肩关节置换,切口二期愈合。8例患者均获得随访,随访时间(20.6±8.4)个月(范围,9~36个月)。末次随访时,肩关节前屈123.8°±30.1°(范围,90°~180°),外展124.4°±34.2°(范围,80°~180°),外旋(中立位)36.9°±20.9°(范围,0°~70°),内旋(中立位)58.8°±10.9°(范围,50°~80°)。末次随访时,肩关节Constant-Murley评分(83.5±12.1)分(范围,70~95分);VAS评分,其中7例为0~3分,1例为4~6分。1例手术患者术后9个月随访时CT检查虽显示肱骨头部分缺血性坏死征象,但肩关节活动良好,故未予以处理。8例患者无一例发生血管及神经损伤、肩关节再脱位等并发症。结论对于创伤性肩关节后脱位合并肱骨头R-HS损伤的患者应根据肱骨头R-HS损伤缺失面积采取相应治疗方式,对缺失面积<20%者可采用麻醉下闭合复位治疗,对缺失面积20%~40%者应采用手术治疗。     

Missed posterior shoulder dislocation and McLaughlin lesion after an electrocution accident

Posterior shoulder dislocation is a rare event that may occur after a direct trauma, an epileptic seizure, electric shock or electroconvulsive therapy. In more than 50% of the cases, posterior dislocations are missed on initial evaluation and often misdiagnosed as frozen shoulders with unfortunate consequences. We present the case of a missed posterior subluxation and reverse Hill Sachs lesion (McLaughlin lesion) in a 40-year-old woman caused by anelectric shock of 240 V. The patient underwent surgery in our institute two weeks after the injury. The humeral head was reduced and the reverse Hill Sachs lesion was filled by demineralized bone matrix allograft with osteoinductive factors. Tendons were repaired and a temporaneous artrodesis was performed. At the final follow up of 12 months, we obtained a Costant Score of 93 and the patient returned to her previous daily activities.     

Missed posterior shoulder dislocation with malunited proximal humerus fracture

Posterior dislocation of the shoulder may be missed or neglected at initial presentation especially in developing countries.We present a case of 40-year-old Indian man who had 3-month missed posterior dislocation of the right shoulder along with malunited fracture of the anatomical neck of the humerus.Open reduction and stabilization with modified McLaughlin procedure was performed.Rotational osteotomy of proximal humerus had to be performed as supplementary procedure to keep the humeral head stable in glenoid cavity during functional range of movements.The patient had excellent result of the shoulder at 3 years follow-up.     

Simultaneous bilateral anterior shoulder dislocation: report of two cases and review of the literature

Bilateral shoulder dislocations are rare and almost always occur in the posterior direction. Simultaneous bilateral anterior shoulder dislocation is even rarer and only a few cases are stated in the literature. The most interesting part of a bilateral shoulder dislocation is about its injury mechanism as a synchronous and simultaneous force is needed to result in it. In cases of epilepsy or electrocution, the mechanism is different and the forceful contractions of the selective group of muscles result in the dislocation. This article reports two cases of bilateral simultaneous anterior shoulder joint dislocation that occurred after a road side accident and after an episode of convulsion in an epileptic patient. The dislocations were diagnosed early and reduced immediately with a proper postreduction rehabilitation. During their follow-up, both patients had satisfactory functional outcome. This article emphasizes on the importance of shoulder examination in road side accident victims and epileptic patients. All orthopedic surgeons and emergency physicians should be aware of such unusual possibilities to have an early diagnosis and treatment.An early reduction and appropriate rehabilitation can provide satisfactory functional outcome. This article also briefly discusses the injury mechanisms, diagnoses and treatments of bilateral shoulder dislocation as reported in the literature.     

Locked posterior shoulder dislocation treated by arthroscopic tenodesis of the subscapularis in the reversed Hill-Sachs lesion

Report of a case of locked posterior shoulder dislocation, diagnosed after 3 weeks with an impression fracture involving almost 30% of the humeral head. Closed reduction was not stable. Shoulder arthroscopy confirmed the fracture and the unstable character of the dislocation. The subscapularis tendon was attached in this lesion using two suture anchors. Immediate shoulder stability was obtained. The 6-month follow-up was good, and the shoulder became stable and pain free. Arthroscopic tenodesis of the subscapularis may be an alternative to the McLaughlin technique in locked posterior shoulder dislocations involving 20–40% of the humeral head in cases presenting within 6 months after the initial episode.     

Traumatic posterior shoulder dislocation: a case with modification of Gerber procedure for humeral head reconstruction at 10-year follow-up

We report a case of acute traumatic posterior shoulder dislocation in a 41-year-old patient, which we treated surgically by a modification of the procedure described by Gerber for humeral head reconstruction in such cases. The diagnosis was confirmed by CT scan, which also helped us to assess the size of the antero-medial humeral head defect or impaction secondary to the dislocation; the size of this defect being a determinant element for the indication. Because the shoulder was unstable after closed reduction and almost 50% of the humeral head was impacted, we carried out a surgical treatment using an original technique as mentioned above. Radiologic and surgical features of acute traumatic posterior shoulder dislocation are discussed with special emphasis on diagnosis, indications and surgical aspects of this rare lesion, which represent 2–4% of acute traumatic shoulder dislocations.     

Die dorsal verhakte Schulterluxation

Posterior dislocation of the shoulder is a rare injury and is often misdiagnosed at initial presentation. Shoulder function improves over the course of time with the joint still in locked dislocation. Misdiagnosis is due to a lack of clear clinical signs compared to anterior dislocation; thus, appropriate x-rays (i.e., true anterior-posterior and axial views) are indispensible. However, posterior dislocation frequently becomes chronic and closed reduction is not successful any more. In contrast to anterior dislocations, the humeral head defect accounts for recurrent instability. Depending on the size of the defect and the duration of the dislocation, there are different treatment options, including elevation of the defect, bone grafting, McLaughlin procedure, rotation osteotomy, and arthroplasty. The patient’s outcome strongly depends on the size of the humeral head defect and the interval between trauma and definite diagnosis. The smaller the defect and the quicker the diagnosis is made, the better the results. Recurrent dislocations rarely occur in comparison to traumatic anterior instability.     

距骨后突内侧结节骨折

目的分析讨论距骨后突内侧结节骨折的早期诊断及治疗。方法 利用ＣＴ确诊５例距骨后突内侧结节骨折病例。对胃及距下关节面的３例患者,２例采用切开复位内固定术,１例因拒绝手术而行保守治疗。另外２例,１例给予石膏固定６周,１例行骨块切除术。结果 本初诊确诊４例,漏诊１例,平均随访２４个月。１例漏诊患者因６个月后骨折不愈合伴疼痛、足底麻木而行骨块切除,术后疗效满意;其余４例中３例疗效满意,１例接受保守治疗者