手舟骨骨折.ppt
手舟骨骨折,手舟骨解剖特点,英文名“Scaphoid”起源于希腊词汇“skaphos”，意思为“小船”，将其翻译为“舟状骨”或又称之为“手舟骨”。,与桡骨、月骨、头骨、大多角骨相关联；表面为透明软骨覆盖；血供较少，缺乏骨膜：1.骨折一期愈合，难以形成骨痂。2.背侧支桡动脉分支提供70%-80%血供，主要包含近极；掌侧支提供20%-30%血供，主要包含远极。,发病机制,跌倒时腕部撑地 腰部70%-80%，近极10%-20%，远极及舟状骨结节占5%儿童骨折多以远极为多,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: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:pseudarthrosisD3:Sclerotic pseudarthrosisD4:Avascular Necrosis,骨折分型,病史及体格检查,外伤史，跌倒时手撑地 腕关节桡侧肿胀、疼痛，活动受限，尤其为背伸活动受限 鼻烟窝压痛舟状骨远端结节压痛舟骨挤压实验（+）,辅助检查,蝶侧位X片 不稳定骨折的诊断标准：1.移位超过1mm 2.成角大于10 3.粉碎性 4.桡月角大于15 5.舟月角大于60 6.舟骨内角大于35,辅助检查,腕关节CT：评估骨折程度及不易发现的骨折。腕关节MRI：用于诊断隐匿性骨折，结合造影剂用于判断血供及有无缺血坏死的发生。,鉴别诊断,舟月损伤腕关节扭伤腕关节软组织挫伤其他腕骨骨折桡骨远端骨折,治 疗,非手术治疗-石膏固定手术治疗-切开复位内固定 闭合复位内固定 关节镜辅助下内固定,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 疗,非手术治疗-石膏固定 适应症：急性、远极无位移（无位移腰部骨折仍存争议）通常固定时间为6-12周，根据 复查情况而定,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 BY CAST IMMOBILISATION WITH THE WRIST IN FLEXION OR EXTENSION?J Bone Joint Surg Br 1999;81-B:91-2.,治 疗,手术治疗-断端加压螺钉固定 闭合 OR 切开 OR 其他？,切开复位内固定,切开复位内固定,431 patients,Scaphoid fracture,ORIF,over a 13-year 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 least 6 months follow-upFracture type Union Nonunion%UnionDistal oblique B1 9 1 90Waist B2 29 4 88Proximal pole B3 11 2 85Fibrous union D1 65 9 88Pseudarthrosis D2 73 37 66Sclerotic 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.,闭合复位内固定,40 patients,Scaphoid fracture,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.,闭合复位内固定,Conservative SurgicalScaphoid union 38 of 39 40 of 40Mean time for union(weeks)9.7 4.0*6 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 2.2*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.,闭合复位内固定,32 patients,Scaphoid fracture,B1,B2 and C types，percutaneous fixation of scaphoid fractures via a dorsal approach,闭合复位内固定,All fractures united over an average of nine weeks.There was no avascular necrosis,Sameer Naranje&P.P.Kotwal&P.Shamshery&Vikas Gupta&H.L.Nag.Percutaneous fixation of selected scaphoid fractures by dorsal approach.International Orthopaedics(SICOT)(2010)34:9971003,关节镜辅助下内固定,234 scaphoid fractures and nonunions 126 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 fractures.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 treated with arthroscopy for union and complications.Scand J Surg.2008;97(4):280-9.,总 结,易骨折 骨膜少，血供差 需一期愈合石膏 or 手术？取决于是否移位及稳定切开 or 闭合 or 关节镜？解剖复位是关键,谢谢!,
