手舟骨骨折分析解析

Arthroscopy 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.
Scaphoid union 38 of 39
Surgical
40 of 40
Mean time for union (weeks)
Mean time for union in type-B fracture (weeks) Mean time to return to manual work (weeks)
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
治
闭合 OR 切开 OR 其他 ？
疗
手术治疗---断端加压螺钉固定
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.
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
总
易骨折 骨膜少，血供差 需一期愈合
结
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
治
非手术治疗---石膏固定
疗
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.
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 transscaphoid trans-capitate fractures; 10 combined scaphoid and distal radius fractures. 99% union rate by CT scan in 12 weeks
Table III. Rate of union related to type of fracture for patients with at least 6 months’ follow-up Fracture type Union Nonunion % Union Distal oblique B1 9 1 90 Waist B2 29 4 88 Proximal pole B3 11 2 85 Fibrous union D1 65 9 88 Pseudarthrosis D2 73 37 66 Sclerotic D3 25 25 50 pseudarthrosis
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) 34:997–1003
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
9.7 ± 4.0* 12.2 ± 4.6†
6 ±来自百度文库2.1 6.5 ± 2.4
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.
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
骨折分型
Type A (acute stable fractures) A 1 : fractures of the tubercle A2 : undisplaced “crack” fracture of waist Type B (acute unstable fractures) Bl : oblique fractures of distal third B2 : displaced or mobile fractures of waist B3 : proximal pole fractures B4: fracture dislocations of carpus B5 : comminuted fractures Type C (delayed union) Type D (established non-union) Dl : fibrous non-union D2 : pseudarthrosis D3: Sclerotic pseudarthrosis D4: Avascular Necrosis
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
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
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。