手舟骨骨折.ppt
手舟骨骨折手舟骨骨折手舟骨解剖特点手舟骨解剖特点英文名英文名“Scaphoid”起源于希腊词汇起源于希腊词汇“skaphos”，意思为，意思为“小船小船”，将其翻，将其翻译为译为“舟状骨舟状骨”或又称之为或又称之为“手舟骨手舟骨”。与桡骨、月骨、头骨、大与桡骨、月骨、头骨、大多角骨相关联；多角骨相关联；表面为透明软骨覆盖；表面为透明软骨覆盖；血供较少，缺乏骨膜：血供较少，缺乏骨膜：1.骨折一期愈合，难以形骨折一期愈合，难以形成骨痂。成骨痂。2.背侧支桡动脉分支提供背侧支桡动脉分支提供70%-80%血供，主要包含血供，主要包含近极；掌侧支提供近极；掌侧支提供20%-30%血供，主要包含远极。血供，主要包含远极。发病机制发病机制 跌倒时腕部撑地跌倒时腕部撑地 腰部腰部70%-80%，近极，近极10%-20%，远极及舟状骨结节占远极及舟状骨结节占5%儿童骨折多以远极为多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骨折分型骨折分型病史及体格检查病史及体格检查外伤史，跌倒时手撑地外伤史，跌倒时手撑地 腕关节桡侧肿胀、疼痛，活动受限，腕关节桡侧肿胀、疼痛，活动受限，尤其为尤其为背伸活动受限背伸活动受限 鼻烟窝压痛鼻烟窝压痛舟状骨远端结节压痛舟状骨远端结节压痛舟骨挤压实验（舟骨挤压实验（+）辅助检查辅助检查 蝶侧位蝶侧位X片片 不稳定骨折的诊断标准：不稳定骨折的诊断标准：1.移位超过移位超过1mm 2.成角大于成角大于10 3.粉碎性粉碎性 4.桡月角大于桡月角大于15 5.舟月角大于舟月角大于60 6.舟骨内角大于舟骨内角大于35辅助检查辅助检查 腕关节腕关节CT：评估骨折程度及不易发现的骨折。：评估骨折程度及不易发现的骨折。腕关节腕关节MRI：用于诊断隐匿性骨折，结合造影剂用：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。于判断血供及有无缺血坏死的发生。鉴别诊断鉴别诊断 舟月损伤舟月损伤腕关节扭伤腕关节扭伤腕关节软组织挫伤腕关节软组织挫伤其他腕骨骨折其他腕骨骨折桡骨远端骨折桡骨远端骨折治治 疗疗 非手术治疗非手术治疗-石膏固定石膏固定手术治疗手术治疗-切开复位内固定切开复位内固定 闭合复位内固定闭合复位内固定 关节镜辅助下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治治 疗疗 非手术治疗非手术治疗-石膏固定石膏固定 适应症：急性、远极无位移适应症：急性、远极无位移（无位移腰部骨折仍存争议）（无位移腰部骨折仍存争议）通常固定时间为通常固定时间为6-12周，根据周，根据 复查情况而定复查情况而定 Colles-type cast with the wrist in slight extensionJ.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.治治 疗疗手术治疗手术治疗-断端加压螺钉固定断端加压螺钉固定 闭合闭合 OR 切开切开 OR 其他其他？切开复位内固定切开复位内固定 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.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 50pseudarthrosisS.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 0.0001G.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闭合复位内固定闭合复位内固定All fractures united over an average of nine weeks.There was no avascular necrosisSameer 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 screwSlade 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.总总 结结 易骨折易骨折 骨膜少，血供差骨膜少，血供差 需一期愈合需一期愈合石膏石膏 or 手术？手术？取决于是否移位及稳定取决于是否移位及稳定切开切开 or 闭合闭合 or 关节镜？关节镜？解剖复位是关键解剖复位是关键
