手舟骨骨折分析解析

1、手舟骨骨折,手舟骨解剖特點(diǎn),英文名“Scaphoid”起源于希臘詞匯“skaphos”，意思為“小船”，將其翻譯為“舟狀骨” 或又稱之為“手舟骨”。,,與橈骨、月骨、頭骨、大多角骨相關(guān)聯(lián)；表面為透明軟骨覆蓋；血供較少，缺乏骨膜： 1.骨折一期愈合，難以形成骨痂。 2.背側(cè)支橈動(dòng)脈分支提供70%-80%血供，主要包含近極；掌側(cè)支提供20%-30%血供，主要包含遠(yuǎn)極。,發(fā)病機(jī)制,跌倒時(shí)腕部撐地 腰部70%-8

2、0%，近極10%-20%，遠(yuǎn)極及舟狀骨結(jié)節(jié)占5%兒童骨折多以遠(yuǎn)極為多,Type A (acute stable fractures)A 1 : fractures of the tubercleA2 : undisplaced “crack” fracture of waistType B (acute unstable fractures)Bl : oblique fractures of distal thirdB2

3、: displaced or mobile fractures of waistB3 : proximal pole fractures B4: fracture dislocations of carpusB5 : comminuted fracturesType C (delayed union)Type D (established non-union)Dl : fibrous non-unionD2 : ps

4、eudarthrosisD3: Sclerotic pseudarthrosisD4: Avascular Necrosis,骨折分型,病史及體格檢查,外傷史，跌倒時(shí)手撐地 腕關(guān)節(jié)橈側(cè)腫脹、疼痛，活動(dòng)受限，尤其為背伸活動(dòng)受限 鼻煙窩壓痛舟狀骨遠(yuǎn)端結(jié)節(jié)壓痛舟骨擠壓實(shí)驗(yàn)（+）,輔助檢查,蝶側(cè)位X片 不穩(wěn)定骨折的診斷標(biāo)準(zhǔn)： 1.移位超過(guò)1mm 2.成角大于10° 3.粉碎性

5、 4.橈月角大于15° 5.舟月角大于60° 6.舟骨內(nèi)角大于35°,輔助檢查,腕關(guān)節(jié)CT：評(píng)估骨折程度及不易發(fā)現(xiàn)的骨折。腕關(guān)節(jié)MRI：用于診斷隱匿性骨折，結(jié)合造影劑用于判斷血供及有無(wú)缺血壞死的發(fā)生。,鑒別診斷,舟月?lián)p傷腕關(guān)節(jié)扭傷腕關(guān)節(jié)軟組織挫傷其他腕骨骨折橈骨遠(yuǎn)端骨折,治 療,非手術(shù)治療---石膏固定手術(shù)治療---切開復(fù)位內(nèi)固定

6、 閉合復(fù)位內(nèi)固定 關(guān)節(jié)鏡輔助下內(nèi)固定,Steven J Rhemrev, Daan Ootes, Frank JP Beeres, Sven AG Meylaerts, Inger B Schipper. Rhemrev et al. International Journal of Emergency Medicine 2011, 4:4,治 療,非手術(shù)治療

7、---石膏固定 適應(yīng)癥：急性、遠(yuǎn)極無(wú)位移（無(wú)位移腰部骨折仍存爭(zhēng)議） 通常固定時(shí)間為6-12周，根據(jù) 復(fù)查情況而定,Colles’-type cast with the wrist in slight extension,J. E. Hambidge, V. V. Desai, P. J. Schranz, J. P. Compson, T. R. C. Davis, N. J. Barton. TREATMENT B

8、Y CAST IMMOBILISATION WITH THE WRIST IN FLEXION OR EXTENSION? J Bone Joint Surg [Br] 1999;81-B:91-2.,,治 療,手術(shù)治療---斷端加壓螺釘固定 閉合 OR 切開 OR 其他 ？,切開復(fù)位內(nèi)固定,,切開復(fù)位內(nèi)固定,,431 patients, Scaphoid fracture, ORIF, over a 13-ye

9、ar period by T. J. HERBERT,S. L. FILAN, T. J. HERBERT HERBERT SCREW FIXATION OF SCAPHOID FRACTURES J Bone Joint Surg [Br] 1996;78-B:519-29.,,Table III. Rate of union related to type of fracture forpatients with at leas

10、t 6 months’ follow-upFracture type Union Nonunion % UnionDistal oblique B1 9 1 90Waist B2 29 4

11、 88Proximal pole B3 11 2 85Fibrous union D1 65 9 88Pseudarthrosis D2 73 37 66Sclerotic

12、 D3 25 25 50pseudarthrosis,S. L. FILAN, T. J. HERBERT HERBERT SCREW FIXATION OF SCAPHOID FRACTURES J Bone Joint Surg [Br] 1996;78-B:519-29.,閉合復(fù)位內(nèi)固定,40 patients, Scaphoid fracture,

13、A1，B1，B2， semi-closed method of Herbert screw fixation,G. INOUE, K. SHIONOYA . HERBERT SCREW FIXATION BY LIMITED ACCESS FOR ACUTE FRACTURES OF THE SCAPHOID J Bone Joint Surg [Br] 1997;79-B:418-21.,閉合復(fù)位內(nèi)固定,Conservative

14、 SurgicalScaphoid union 38 of 39 40 of 40Mean time for union(weeks) 9.7 ± 4.0* 6 ±

15、 2.1Mean time for union intype-B fracture (weeks) 12.2 ± 4.6? 6.5 ± 2.4Mean time to return tomanual work (weeks) 10.2 ± 3.9* 5.8 ± 2.

16、2* p < 0.001 ? p < 0.0001,G. INOUE, K. SHIONOYA . HERBERT SCREW FIXATION BY LIMITED ACCESS FOR ACUTE FRACTURES OF THE SCAPHOID J Bone Joint Surg [Br] 1997;79-B:418-21.,閉合復(fù)位內(nèi)固定,32 patients, Scaphoid fracture, B

17、1, B2 and C types， percutaneous fixation of scaphoid fractures via a dorsal approach,閉合復(fù)位內(nèi)固定,All fractures united over an average of nine weeks. There was no avascular necrosis,Sameer Naranje & P. P. Kotwal & P.

18、Shamshery &Vikas Gupta & H. L. Nag. Percutaneous fixation of selected scaphoid fractures by dorsal approach.International Orthopaedics (SICOT) (2010) 34:997–1003,關(guān)節(jié)鏡輔助下內(nèi)固定,234 scaphoid fractures and nonunions 1

19、26 acute injuries;65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid perilunate dislocations including four trans-scaphoid trans-capitate fractures;10 combined scaphoid and distal radius fr

20、actures. 99% union rate by CT scan in 12 weeksArthroscopy with the dorsal percutaneous implantation of a headless compression screw,Slade JF 3rd, Gillon T. Retrospective review of 234 scaphoid fractures and nonunions