肩胛颈骨折和漂浮肩的手术治疗

关于肩胛颈骨折和漂浮肩较少见，文献报道为0．2％-13％。肩胛骨骨折多发生在肩胛骨体部和颈部，而肩胛颈骨折往往为高能量损伤，造成肩胛盂及肩关节移位不稳定。漂浮肩为同侧肩胛颈骨折合并锁骨骨折或肩锁脱位，多数情况下被认为是需要手术的不稳定性损伤，肩胛颈骨折又为漂浮肩的一部分。肩胛骨骨折和漂浮肩又往往为高能量致多发骨折的一部分，     

Assessment of scapulohumeral rhythm for scapular plane shoulder elevation using a modified digital inclinometer

AIM: To develop a better understanding of scapulohumeral rhythm during scapular plane shoulder elevation.METHODS: Thirteen healthy, college-aged subjects participated in this study. Subjects were free from any upper extremity, neck or back pathology. A modified digital inclinometer was utilized to measure scapular upward rotation of the subject’s dominant shoulder. Upward rotation was measured statically as subjects performed clinically relevant amounts of shoulder elevation in the scapular plane. Testing order was randomized by arm position. Scapular upward rotation was assessed over the entire arc of motion and over a series of increments. The percent contributions to shoulder elevation for the scapula and glenohumeral joint were calculated. Scapulohumeral rhythm was assessed and represented the ratio of glenohumeral motion to scapulothoracic motion (glenohumeral elevation: scapular upward rotation). A one-way ANOVA was used to compare scapular upward rotation between elevation increments.RESULTS: Scapulohumeral rhythm for the entire arc of shoulder elevation was equal to a ratio of 2.34 :1 and ranged from 40.01:1 to 0.90:1 when assessed across the different increments of humeral elevation. Total scapular motion increased over the arc of shoulder elevation. The scapula contributed 2.53% of total motion for the first 30 degrees of shoulder elevation, between 20.87% and 37.53% for 30^o-90^o of shoulder elevation, and 52.73% for 90^o-120^o of shoulder elevation. Statistically significant differences in scapular upward rotation were identified across the shoulder elevation increments [F_(3,48) = 12.63, P = 0.0001].CONCLUSION: Clinically, we must recognize the usefulness of the inclinometer in documenting the variable nature of scapulohumeral rhythm in healthy and injured shoulders.     

肩胛骨骨折与其合并伤关系的探讨

目的 分析115例肩胛骨骨折病例的临床资料,探讨肩胛骨骨折粉碎程度和涉及部位与合并伤之间的关系.方法 回顾性分析2006年8月至2008年3月115例肩胛骨骨折患者的病史及其影像学资料,分为单部分骨折组(83例)和多部分骨折组(32例),比较两组合并伤的发生率及特点.将单部分肩胛骨骨折组按Nordqvist与Petersson方法分成3组:肌肉覆盖部分(64例)、骨突起部分(11例)及肩胛盂部分(8例),并比较3组合并伤的发生率及特点.结果 绝大部分肩胛骨骨折是严重多发伤的一部分,致伤原因与高能量损伤有关.最常见的致伤原因是车祸伤(70.4%).损伤严重程度评分值(injury severity Scale,ISS)平均14.0,42例(36.5%)患者ISS>16.98例(85.2%)患者伴有不同程度和类型的合并伤,其中又以胸部合并伤的发生率最高(85/115,73.9%).多部分肩胛骨骨折组胸部简明损伤定级法评分值(abbreviated injury score,AIS)和总体ISS值均高于单部分肩胛骨骨折组.在单部分肩胛骨骨折组中,肌肉覆盖部骨折组较骨突起部和肩胛盂部骨折组的胸部AIS值和总体ISS值更高.结论 肩胛骨骨折尤其是骨折涉及多部分或肌肉覆盖部时更容易并发严重的胸部损伤.多部分肩胛骨骨折致伤原因多为高能量损伤,常伴发严重的胸部合并伤,可作为胸部严重损伤存在的一项骨性指标.     

Morphometric analysis of the association of primary shoulder reconstruction procedures with scapular growth in obstetric brachial plexus paralysis patients

Background

Obstetric brachial plexus paralysis (OBPP) has been associated with shoulder deformities, scapular growth, and shoulder function impairment. The absence of balanced muscular forces acting on the scapula has been considered responsible for scapula dysplasia and impaired growth as compared with the normal side. Scapula growth impairment may also lead to shoulder and upper extremity dysfunction. This study aims at showing the association of primary nerve reconstruction with the restoration of scapular bone growth potential.

Methods

This is a retrospective review of 73 patients with OBPP who underwent primary shoulder reconstruction. Patients were categorized for assessment and analysis into group A, global paralysis; group B, Erb’s palsy; and group C, Erb’s palsy with C7 root involvement. Scapular posteroanterior and lateral X-rays were obtained in which four scapula dimensions were manually measured. The growth discrepancy depending on the applied treatment was investigated.

Results

The highest improvement was noted in scapular height in the Erb’s palsy group who underwent simultaneous neurotization of the suprascapular and axillary nerves. The oblique axis was more improved in the Erb’s palsy group while both big and small widths were more improved in the Erb’s palsy with C7 root involvement group in patients who underwent concomitant neurotization of the suprascapular and the axillary nerves. Functional improvement correlated positively with growth improvement in all groups and scapular dimensions.

Conclusion

Scapula growth and shoulder function improvement were higher in patients with Erb’s palsy. Simultaneous axillary and suprascapular nerve neurotization provided the best outcome in both functional and growth restoration.     

不稳定性肩胛骨骨折的手术治疗与入路选择分析

目的探讨不稳定性肩胛骨骨折的手术治疗及手术入路选择。方法2004年7月-2009年7月治疗不稳定性肩胛骨骨折患者25例,其中开放性骨折取原伤口入路,闭合性骨折分别取肩关节前侧、肩胛骨后侧、肩胛骨外侧缘入路,骨折复位后运用重建钢板、螺钉、钢丝等进行固定。结果所有患者均获随访,随访时间3～20个月,平均11个月。术后复查x线片显示复位满意。根据Hardegger功能评定标准,优18例,良6例,可1例,优良率为96％。结论对不稳定性肩胛骨骨折选择合适的手术入路和固定方法,辅以早期功能锻炼,疗效满意。     

Prosthetic design of reverse shoulder arthroplasty contributes to scapular notching and instability

AIM To evaluate whether implant design, glenoid positioning, and other factors influenced instability and scapular notching in reverse total shoulder arthroplasty.METHODS We retrospectively reviewed records of patients who had undergone reverse total shoulder arthroplasty by the senior author from July 2004 through October 2011 and who had at least 24 mo of follow-up. The 58 patients who met the criteria had 65 arthroplasties: 18 with a Grammont-type prosthesis(Grammont group) and 47 with a lateral-based prosthesis(lateral-design group). We compared the groups by rates of scapular notching and instability and by radiographic markers of glenoid position and tilt. We also compared glenoid sphere sizes and the number of subscapularis tendon repairs between the groups. Rates were compared using the Fisher exact test. Notching severity distribution was compared using the χ2 test of association. Significance was set at P 0.05.RESULTS The Grammont group had a higher incidence of scapular notching(13 of 18; 72%) than the lateral-design group(11 of 47; 23%)(P 0.001) and a higher incidence of instability(3 of 18; 17%) than the lateral-design group(0 of 47; 0%)(P = 0.019). Glenoid position, glenoid sphere size, and subscapularis tendon repair were not predictive of scapular notching or instability, independent of implantdesign. With the lateral-based prosthesis, each degree of inferior tilt of the baseplate was associated with a 7.3% reduction in the odds of developing notching(odds ratio 0.937, 95%CI: 0.894-0.983). CONCLUSION The lateral-based prosthesis was associated with less instability and notching compared with the Grammonttype prosthesis. Prosthesis design appears to be more important than glenoid positioning.     

Radiographic assessment of scapular rotational tilt in chronic shoulder impingement syndrome

This study presents an objective evaluation of both scapular upward and axial rotational tilts in shoulder impingement syndrome, using a scapular spine line defined on antero-posterior (AP) radiographs of the shoulder as the referential line. Twenty-seven patients with unilateral shoulder motion pain, who were diagnosed as having chronic shoulder impingement syndrome, were enrolled in the study. Scapular upward and axial rotational tilts were compared between the affected and contralateral shoulders. AP radiographs were obtained at shoulder abduction angles of 0°, 45°, and 90°, and the X-ray films were digitized by computer. The upward and axial rotational tilts of the scapula were then evaluated on the digital images. In shoulder impingement syndrome, both upward and axial external rotations of the scapula were impaired at the painful arc angle of abduction. This tended to be more apparent for the axial rotation of the scapula than for the upward rotation. These reductions in scapular rotations reduce available clearance for the rotator cuff and humeral greater tuberosity as the shoulder is abducted. Received: January 13, 2000 / Accepted: October 2, 2000     

CT三维重建技术对肩胛骨骨折的诊断价值

目的：探讨螺旋CT三维表面遮盖法重建(surface shaded display，SSD)及容积重建技术(volume rendering technique，VRT)对肩胛骨骨折的诊断应用价值。方法：使用SIEMENS PLUS4螺旋CT机对20例肩胛骨骨折患者进行扫描，全部数据输入工作站进行SSD及VRT处理，并与X线、二维CT(2D CT)检查结果进行对照分析。结果：2D CT扫描的结果经临床与手术证实为临床诊断的重要依据，经统计学分析，X线检查及SSD的诊断准确率分别为94．44％和97．78％，假阴性率分别为17．65％和7．84％，X线检查的假阳性率为0．76％；VRT诊断正确率为100％。SSD、VRT检出骨折创伤的数量与X线、2D CT的结果差异无显著性意义，但是显示损伤的质量优于X线和2D CT。术后对8例进行3D CT复查，VRT能立体显示术后肩胛骨骨质及内固定物的形态与结构。结论：螺旋3DCT是诊断肩胛骨骨折的有效手段，可指导手术计划的制定和内固定物的选择，应作为诊断复杂性肩部骨折的首选方法。VRT对骨折术后内固定物的位置及复位效果的判断有较高的应用价值。     

Proximal humeral fractures treated with arthroplasty

P74ro50x%iyme aaolrfs h houulmdm.eer raAalfl t effrrraa cactgtuuerr ee5ss0,ainc wc oopumanteiten nf othsra vomeldo reaer m tthhucaanhnhigher incidence of proximal humeral fractures thanmen.In patients younger than50years old,high-energy trauma is the most common cause of proximalhumeral fractures,and after age50,minimal-to-moderate trauma is the most common cause.1Neer s classification,the most popularclassification system for proximal humeral fractures,isbased on the anatomical relationship o…     

肩胛骨骨折的分类及手术治疗

目的 探讨肩胛骨骨折（scapular fracture,SF)的分类及手术治疗。方法 回顾分析自1996年1月-2001年1月收治的经手术治疗的16例SF的临床资料。其中行前后位X线检查者16例,侧位及腋窝位X线检查者5例,螺旋CT三维重建检查者12例。根据Hardegger的分型方法,体部骨折9处,肩胛颈骨折7处,盂缘骨折2处,盂窝骨折1处,肩胛冈骨折5处,肩峰骨折3处,喙突骨折2处。其中混合型骨折11例（68.8%)。伴有合并损伤者14例（87.5%)。通过前方入路,后方入路,后上入路及前后联合入路分别对不同类型的SF使用重建钢板或拉力螺钉等固定。结果 16例患者全部获得随访,随访时间12-60个月。平均18.6个月,根据Rowe的疗效评价标准,优11例,良2例,可1例,差2例,优良率为81%。术后主要并发症包括创伤性关节炎2例,异位骨化1例,肩关节不稳定1例。结论 （1）SF多由高能暴力所致,常伴有合并损伤。三维CT重建有助于明确骨折类型和选择治疗方法;（2）盂窝骨折台阶样移位在3-5mm以上,盂缘骨折合并肱骨头半脱位,某些体部爆裂骨折,肩胛颈骨折失稳及浮肩损伤等应行手术治疗;（3）手术治疗是一种安全有效的方法。严重SF至少需随访1年,才能确定功能预后。     

Effects of trapezius kinesio taping on scapular kinematics and associated muscular activation in subjects with scapular dyskinesis

Study DesignCrossover repeated-measure design.IntroductionScapular dyskinesis rehabilitation programs that focus on inhibiting upper trapezius (UT) and activating the lower trapezius (LT) may assist in restoring scapular movements. We hypothesized that taping may be able to normalize scapular movements and associated muscular recruitment.Purpose of the StudyThe purpose of this study was to investigate the immediate effects of kinesio taping over trapezius on scapular kinematics and muscular activation in different dyskinesis patterns. We expected that taping can improve scapular kinematics and muscular activation in subjects with dyskinesis.MethodsFifty-four participants with inferior angle prominence (pattern I), medial border prominence (pattern II), and mixed pattern (pattern I + II) were recruited. Kinesio taping was applied over 3 parts of trapezius muscles, including UT, middle trapezius (MT), and LT. The scapular kinematics and electromyographic data of trapezius and serratus anterior were collected during scapular plane elevation without taping and after each taping application.ResultsUT taping decreased UT activity (5%-7%; P = .001-.003) in 72% of participants with pattern II and pattern I + II dyskinesis, with increased posterior tipping (2.2°-2.5°; P = .003) in pattern II dyskinesis. MT taping increased UT activity (3%; P = .003) in 48% of participants with pattern II dyskinesis.DiscussionThe taping over the trapezius muscle may help to restore coordinated scapular muscle balance and increased upward rotation of the scapula, especially in pattern II dyskinesis. Although no electromyography or kinematic difference was found with LT taping in each dyskinesis pattern, methods of applying LT taping need to be further investigated.ConclusionReduced UT muscle activity and scapular posterior tipping are appropriate when applying taping over UT muscle in patterns II and I + II dyskinesis. Caution should be taken when applying taping over MT and LT muscles in terms of increased UT activity, especially in pattern II dyskinesis.     

双入路双重建钛板内固定治疗不稳定型肩胛颈骨折

目的 探讨双入路切开复位双重建钛板内固定治疗不稳定型肩胛颈骨折的近期疗效.方法 回顾性分析2005年9月至2010年9月采用双入路切开复位内固定治疗并获完整随访的13例肩胛颈骨折患者资料,男10例,女3例;年龄19 ～52岁,平均35.3岁.按Euler等分型方法将肩胛颈骨折分为:解剖颈骨折3例,外科颈骨折10例(A型7例,B型3例).所有患者均使用3.5 mm重建钛板和螺钉固定.通过肩胛骨前位X线片测量肩胛盂成角和盂极角(GPA).末次随访时根据Constant-Murley评分和Herscovici功能评分评定肩关节功能. 结果 13例患者术后获6～ 37个月(平均16.2个月)随访.骨折复位质量:解剖复位11例,接近解剖复位2例.术后7～9d切口均一期愈合.术后平均肩胛盂成角(27.1°)与GPA(36.2°)均较术前(55.1°、17.1°)有所改善.骨折临床愈合时间为6～12周,平均8周.末次随访时Constant-Murley评分平均为79.6分(54 ～ 95分),其中优9例,良3例,差1例;Herscovici功能评分平均为14.7分(12～16分):优8例,良2例,可2例,差1例.无肩胛上动脉神经损伤、感染、血肿形成等并发症发生. 结论 双入路切开复位双重建钛板内固定治疗不稳定型肩胛颈骨折可达到解剖复位、稳定内固定和满意的近期疗效.     

The Glenoid Vault Outer Cortex (GVOC) radiological reference for shoulder arthroplasty evaluated in aging scapulae

BackgroundAccurate glenoid component positioning is an important determinant of outcome in a shoulder arthroplasty surgery. Optimal glenoid placement is determined using bony landmarks of the scapula. The Glenoid Vault Outer Cortex (GVOC) has been recently described as a new, more accurate radiological reference. This has, however, only been evaluated against current standard references in young patients. Further investigation of the GVOC in older patients is therefore warranted. We, therefore, evaluated the effect of aging on the accuracy and stability of the GVOC, in determining glenoid anatomy as compared to the commonly used Scapular Border (SB) plane.MethodsComputed tomography imaging of 129 individual scapulae was obtained retrospectively from a cohort of patients who had undergone either total body or region-specific computed tomography imaging which included the shoulder region. This comprised of 35 males and 33 females (64 and 65 scapulae respectively) who were aged from 30 to 92 years. Imaging of 54 scapulae was from patients aged ≥60 years. The accuracy of the GVOC plane was then assessed against the SB plane.ResultsIn all patients, the mean difference between estimates using the GVOC plane and the GR (actual) was 2.2° (standard deviation [SD], 4.2) for version, and 1.8° (SD, 4.9) for inclination (P < .001). This contrasted with values of 7.6° (SD, 7.6) for version, and 22.9° (SD, 10.8) for inclination when using the SB reference plane (P < .001). Within the group aged ≥60 years, the mean difference between estimates using the GVOC plane and the glenoid rim (actual) was 3.2° (SD, 4.7) for version and 1.9° (SD, 3.1) for inclination, (P < .001). This contrasted to 10.0° (SD, 7.2) for version, and 23.4° (SD, 10.7) for inclination when using the SB plane (P < .001).Separately it was noted that the GVOC’s relationship to the glenoid rim remained constant throughout aging as opposed to the SB which changed significantly over time effecting estimates of glenoid retroversion.ConclusionsThe GVOC is a new plane of reference developed specifically for the use in shoulder arthroplasty. It is shown to be more accurate and stable in the aging scapulae than the currently used SB plane. The future development of guides and planning softwares that utilize the GVOC may provide an important opportunity for improved accuracy and outcome in shoulder arthroplasty.     

3D打印技术在肩关节骨性关节炎全肩关节置换术中的应用研究

目的探讨3D打印技术在全肩关节置换术治疗肩关节骨性关节炎的应用价值。 方法2014年5月至2016年5月四川省人民医院骨科收治的肩关节骨关节炎患者12例,其中男4例,女8例;年龄48~81岁,平均（58.5±13.2）岁。累及侧别：左5例,右7例。其中原发性盂肱关节骨关节炎5例,肱骨头缺血性坏死继发盂肱关节骨关节炎4例,创伤性盂肱关节骨关节炎3例。术前应用3D打印技术制备患者双侧肩关节模型,在健侧模型上测定相关解剖学参数,用于假体型号的选择与置入。在患侧模型上观察病变情况,模拟手术过程。记录并与术中情况比较。比较末次随访与术前的肩关节活动度、Constant评分和视觉模拟评分（visual analogue scale,VAS）。采用SPSS 17.0软件对数据进行t检验分析。 结果12例患者均顺利完成人工全肩关节置换术手术,术中选取的假体型号、截骨平面均与模拟手术完全一致。术后影像学资料证实假体组件均按计划精确置入。12例患者术后获随访（16.0±3.8）个月,13~25个月,末次随访Constant评分和VAS与术前对比均有改善,差异具有统计学意义（P <0.05）。末次随访无神经血管损伤,无感染、假体松动,无假体肱骨头上移等严重并发症。 结论3D打印技术用于人工全肩关节置换术治疗原发性和继发性盂肱关节骨关节炎,有助于术前制定手术计划并模拟手术操作,降低手术难度,提高手术质量。     

高龄股骨颈基底部粉碎性骨折人工股骨头置换术

随着人们生活水平的提高,高龄人群增多,发生股骨颈及粗隆间骨折呈逐年上升趋势。由于高龄股骨颈基底部粉碎性骨折,常伴有严重骨质疏松、骨折块复杂,处理十分棘手。近3年我科处理16例此类病例,报告如下。1临床资料16例中女13例,男3例;年龄76～101岁,平均84.5岁。骨折粉碎块:3块9     

肱骨近端骨折的治疗与肩关节功能预后因素分析

目的 探讨肱骨近端骨折的治疗方法及影响肩关节功能的预后因素.方法 2002年1月至2005年7月收治51例肱骨近端骨折患者且获得随访.按Neer分型:一部分骨折2例,二部分骨折30例,三部分骨折13例,四部分骨折6例.采用保守治疗7例,切开复位内固定42例,人工肱骨头置换2例.应用ASES评分评估治疗结果.对患者年龄、性别、合并伤、合并症、受伤至治疗时间、骨折类型及治疗方法等7个可能的相关因素进行多因素分析.结果 51例患者术后获平均37.2个月(19-67个月)随访.ASES评分平均82.1分(36.7-100分).单因素Logistic回归分析发现年龄、合并症和骨折类型的差异有统计学意义(P值、OR值及95%C1分别为0.005、0.513、0.404-0.651,0.021、0.129、0.053-0.312,0.005、0.267、0.167-0.427).多因素Logistic逐步回归分析发现仅年龄和骨折类型的差异有统计学意义(P值、OR值及95%C1分别为0.007、0.494、0.379-0.642,0.006、0.240、0.142-0.405).结论 影响肱骨近端骨折后肩关节功能的主要预后因素是年龄和骨折类型,应主要根据这两个因素采用个体化的治疗方法.     

移位性肱骨近端四部分骨折人工肱骨头置换及术后早期个体化康复治疗

目的探讨人工肱骨头置换结合术后个体化康复手段治疗移位性肱骨近端四部分骨折的临床疗效,为基层医院开展肱骨近端复杂骨折治疗提供临床经验。方法对9例移位性肱骨近端四部分骨折患者施行人工肱骨头置换,并于术后给予个体化康复治疗,采用Constant评分进行临床效果评估。结果术后随访5～24个月,平均15.4个月。手术前和末次随访时的Constant评分分别为（14.5±6.5）分和（80.5±5.6）分。结论人工肱骨头置换是治疗移位性肱骨近端四部分骨折的有效方法,正确选择适应证、术中精细操作、术后进行个体化康复锻炼是减少并发症和取得满意疗效的关键。     

The effects of exercise type and elbow angle on vertical ground reaction force and muscle activity during a push-up plus exercise

Background

Proper alignment of the scapula during upper extremity motion is important in maintaining shoulder joint function and health. Push-up plus exercise is considered as one of the best exercise to strengthen the muscles that stabilize the scapula. The purpose of the study is to examine the effects of push-up plus variants and elbow position on vertical ground reaction force and electromyographical activity of four shoulder muscles during concentric contraction.

Methods

A total of 22 healthy subjects volunteered for the study. Each of the subjects performed both modified and traditional push-up plus. Modified push-up plus was performed with both knees and hands touching the ground while the traditional push-up plus was executed with hands and feet contacting the ground. Electromyography (EMG) of the upper trapezius (UT), lower trapezius (LT), infraspinatus (INFRA), and serratus anterior (SA), and vertical ground reaction forces (vGRF) were collected.

Results

The traditional push-up plus exhibited higher EMG activity in all muscles tested (P < .05) and vertical ground reaction force (P < .001) compared to modified push-up plus. The highest difference in EMG activity between the two exercises was observed with the Serratus Anterior muscle (22%). Additionally, the traditional push-up plus presented a higher vGRF compared to the modified push-up plus (P < .001) by 17%. The SA had the greatest EMG activity compared to the other muscles tested during the concentric phase of the traditional push-up plus, and this did not occur during the plus phase of the exercise.

Conclusion

The highest activity of the serratus anterior occurred at 55° of elbow extension during the concentric phase of the traditional PUP and not at the plus phase of the exercise. This suggests that when prescribing an exercise to target the serratus anterior, a traditional push-up is adequate and the plus-phase is not necessary. However, for patients that cannot perform a traditional push-up, the modified push-up plus would be a great alternative to strengthen their serratus anterior.     

外侧切口入路桥接组合式内固定治疗肩胛骨骨折

目的:探讨采用外侧切口入路桥接组合式内固定系统治疗肩胛骨骨折的临床效果。方法:2012年10月至2016年12月,采用外侧切口入路桥接组合式内固定系统治疗20例肩胛骨骨折,男15例,女5例;年龄21~52岁,平均31.6岁。肩胛体骨折14处,肩胛颈骨折10处,肩胛冈骨折6处,肩峰骨折1处,喙突骨折1处,盂缘骨折4处,盂窝骨折3处。手术时间为伤后4~15 d,平均10 d。结果:所有患者获得随访,时间3~24个月,平均15个月。术后2例发生伤口感染,经伤口清创、换药后愈合,无骨髓炎、医源性神经损伤、内固定松动断裂、骨折再移位、关节僵硬等并发症发生。术后3个月骨折部位可见骨痂生长,骨折愈合时间为4~7个月,骨折愈合良好,无延迟愈合或畸形愈合。肩关节功能评定采用Hardegger评定标准:优12例,良6例,可2例。结论:肩胛骨外侧切口入路术中操作方便,显露清楚,该切口可任意向两边延长,能为骨折的复位固定提供有利条件。桥接组合式内固定系统术中操作灵活,固定强度可靠,是一种治疗肩胛骨骨折的良好选择。