趙良瑜 陳愛民 李永川

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經(jīng)改良Judet入路手術(shù)治療肩胛骨骨折的療效

趙良瑜 陳愛民 李永川

目的 介紹改良Judet入路的概念，經(jīng)該入路治療部分復雜肩胛骨骨折的手術(shù)方法，并經(jīng)臨床隨訪，分析該方法手術(shù)療效和意義。方法 17例肩胛骨骨折患者進行了改良Judet入路。手術(shù)采用Judet切口，從肩胛岡掀起三角肌下緣。自肩胛骨背面和肩胛岡剝離部分岡下肌，向外側(cè)在岡下肌和小圓肌的間隙進行分離，形成兩個“窗口”，顯露肩胛岡、肩胛頸、肩胛盂背側(cè)、肩胛骨內(nèi)、外側(cè)緣。對骨折進行復位和充分固定。術(shù)后6周、12周、6個月分別進行臨床和影像學隨訪，末次隨訪時采用美國肩肘外科協(xié)會(ASES)評分。結(jié)果 17例患者均在6個月的隨訪期內(nèi)骨折愈合。并發(fā)癥包括肺部感染3例、切口皮膚邊緣壞死1例、切口淺表感染1例，均治愈，1例患者提前取出內(nèi)固定材料。ASES評分56～100分，平均為85.9分。結(jié)論 改良Judet入路顯露充分、易于復位固定、保護肩胛上神經(jīng)，對于部分復雜肩胛骨骨折具有良好療效。

改良Judet入路；肩胛骨；骨折；內(nèi)固定

肩胛骨位于胸廓后面，是一塊三角形的不規(guī)則骨，通過肩峰、喙突、肩胛盂等結(jié)構(gòu)，與鎖骨和肱骨相連接，是上肢和軀干相結(jié)合的重要結(jié)構(gòu)。肩胛骨經(jīng)常由于各種外傷因素造成損傷形成骨折，對上肢的運動造成障礙。以往肩胛骨骨折經(jīng)常進行保守治療，近年來，隨著外科條件的改善、相關(guān)器械和器材的研發(fā)和手術(shù)技術(shù)的改進，越來越多的肩胛骨患者經(jīng)過手術(shù)治療取得了良好的效果[1]。肩胛骨骨折的手術(shù)入路種類較多，包括前方入路、后方直切口入路、Judet入路等，本文重點總結(jié)了經(jīng)改良Judet入路行肩胛骨骨折手術(shù)的情況。

對 象 與 方 法

一、一般資料

自2004年7月至2014年7月，本組共進行肩胛骨骨折手術(shù)患者71例。其中，有17例患者進行了改良Judet入路，男性16例、女性1例，年齡29～62歲，平均47.1歲。致傷原因：車禍受傷8例，高處墜落摔傷6例，摔倒、運動損傷和其他原因3例。按照部位分型，包括肩胛頸累及肩胛岡或肩胛骨內(nèi)側(cè)緣骨折13例，累及肩胛盂的骨折3例，肩胛骨合并同側(cè)鎖骨骨折1例。41%(7/17)合并有其他部位的各類損傷，包括肋骨骨折6例，顱腦損傷1例，肺挫傷和胸腔積液3例，脊柱骨折5例，頸椎過伸傷1例，上頜竇骨折1例，肱骨近端骨折1例，第一掌骨基底部骨折1例，臂叢神經(jīng)損傷1例。肩胛骨骨折為雙側(cè)者1例。受傷至手術(shù)時間2～15 d，平均7.1 d。

二、手術(shù)方法

患者取全麻或者臂叢阻滯麻醉。手術(shù)采取后方改良Judet入路，切口起自肩胛盂背側(cè)沿肩胛岡向內(nèi)，經(jīng)肩胛骨內(nèi)上角轉(zhuǎn)向下方，沿肩胛骨內(nèi)緣至肩胛骨下角。分離皮膚皮瓣后，從肩胛岡掀起三角肌下緣。自肩胛骨背面和肩胛岡剝離部分岡下肌，向外側(cè)在岡下肌和小圓肌的間隙進行分離，保留岡下肌在肩胛骨內(nèi)側(cè)緣和背面的附著，形成兩個“窗口”，顯露肩胛岡、肩胛頸和肩胛盂背側(cè)、肩胛骨內(nèi)、外側(cè)緣。注意避免肩胛上神經(jīng)、腋神經(jīng)損傷，有時為擴大顯露需結(jié)扎旋肩胛動脈。切開骨膜顯露骨折線，將骨折復位，以克氏針臨時固定骨折，透視確認復位良好后，以空心釘、普通實心螺釘或2.7～3.5 mm內(nèi)固定板進行內(nèi)固定。復位固定完成后透視確認螺釘沒有誤穿破肩胛盂關(guān)節(jié)面，手術(shù)臺上檢查肩關(guān)節(jié)活動，逐層縫合。

三、手術(shù)后治療

術(shù)后早期即可開始主、被動肩關(guān)節(jié)圓周活動，并逐漸加大活動范圍。術(shù)后6周內(nèi)患肢不得持重。術(shù)后6周、12周、6個月分別來院復查，拍攝X線檢查骨折愈合情況，并指導進一步加強功能鍛煉。待骨折端可見有骨痂生長通過骨折線時可逐步進行上肢持重。末次隨訪時進行肩關(guān)節(jié)功能評定，以影像學顯示骨折線消失，連續(xù)性骨痂通過骨折線為骨折愈合標準。功能評定采用美國肩肘外科協(xié)會(ASES)評分系統(tǒng)[2]，滿分為100分。

結(jié) 果

17例患者完成18側(cè)肩胛骨骨折手術(shù)，采用改良Judet入路17側(cè)(1例雙側(cè)肩胛骨骨折患者，單側(cè)采取了本入路)，占同期肩胛骨手術(shù)的24%(17/71)。17側(cè)全部達到解剖復位，12例采用2塊內(nèi)固定板，2例使用3塊內(nèi)固定板，3例經(jīng)雙窗口復位后1塊內(nèi)固定板即達到固定效果。本組17例患者完成全程隨訪，在6個月的隨訪期內(nèi)骨折愈合，未出現(xiàn)骨不連病例。6例患者圍手術(shù)期發(fā)生并發(fā)癥。其中肺部感染3例，經(jīng)抗生素治療痊愈，切口皮膚邊緣壞死1例，切口淺表感染1例，經(jīng)切口換藥獲得愈合，有1例患者因內(nèi)固定物突出不適，于骨折出現(xiàn)愈合跡象后提前取出內(nèi)固定材料。全部病例未發(fā)生骨折再移位、內(nèi)固定裝置斷裂或者移位、內(nèi)固定螺釘穿破肩胛盂關(guān)節(jié)面、神經(jīng)損傷等并發(fā)癥。

肩關(guān)節(jié)功能評分：ASES評分56～100分，平均為85.9分，其中10例未合并其他損傷，單純肩胛骨骨折患者術(shù)后平均評分較高，達90.8分。在評分不足70分的患者中，未按醫(yī)師指導進行充分的肩關(guān)節(jié)功能鍛煉、肩胛盂粉碎性骨折、合并損傷多、并發(fā)癥發(fā)生導致延長治療時間是主要影響因素。

討 論

肩胛骨與鎖骨一起，形成了將人體上肢懸吊于身體軀干兩側(cè)的懸臂，并通過肩胛盂關(guān)節(jié)面，與肱骨頭構(gòu)成了肩關(guān)節(jié)的主要部分，肩胛骨類似上肢的“骨盆”。既往多采取保守治療[3]，然而，單純采取保守治療，肩關(guān)節(jié)不能及時進行功能鍛煉，容易發(fā)生粘連和僵硬，導致肩關(guān)節(jié)活動障礙，移位的肩胛骨骨折如果發(fā)生畸形愈合，將發(fā)生肩胛頸短縮、肩胛盂關(guān)節(jié)面角度改變從而喪失與肱骨頭的正常對合關(guān)系。愈合不良的肩胛岡、喙突等部位也會產(chǎn)生癥狀影響肩關(guān)節(jié)的活動[4-5]。因此手術(shù)主要針對重建肩關(guān)節(jié)的正?；顒优c穩(wěn)定性，手術(shù)指征主要包括：(1)累及肩胛盂關(guān)節(jié)面的骨折；(2)肩胛頸骨折短縮移位超過1 cm或者成角超過40°，肩胛骨體部或者突起部粉碎性骨折和移位較大的骨折；(3)以及肩胛骨合并同側(cè)鎖骨骨折，經(jīng)鎖骨骨折切開復位內(nèi)固定仍不能達到肩關(guān)節(jié)穩(wěn)定以及肩胛頸恢復良好角度者。

肩胛骨形狀不規(guī)則，相關(guān)解剖復雜。經(jīng)典Judet入路(圖1)需將岡下肌自起點切開剝離，向外側(cè)掀開，形成以肩胛上神經(jīng)血管為蒂的肌瓣，對肩胛骨背面、肩胛頸、肩胛盂背側(cè)進行充分顯露。此種方法雖然顯露較為充分和廣泛，然而對肌肉組織剝離多，創(chuàng)傷面積大，不利于術(shù)后及時進行功能鍛煉。

2000年Braun 等[6]學者對Judet入路嘗試進行改良，然而他們的方法對岡下肌的剝離仍然較大，具有一定損傷。2004年Obremskey等[7]學者對Judet入路進行了較為科學的改良，即在岡下肌與小圓肌之間、以及在岡下肌在肩胛岡的附著點進行分離，治療了部分肩胛骨骨折，發(fā)現(xiàn)可減少肌肉組織的剝離，尤其對肩袖的功能增加保護。然而他們并未闡述該入路的適應證范圍以及結(jié)果評價。2006年周東生等[8]學者對Judet入路進行了不同的變化，進行了多種手術(shù)入路的組合，取得了良好的臨床效果。本組對17例復雜肩胛骨骨折患者進行了單一的、標準化的改良Judet入路，即不剝離岡下肌在肩胛骨背面內(nèi)側(cè)緣的起點，僅僅剝離岡下肌在肩胛岡上的部分起點，以及在外側(cè)的岡下肌和小圓肌間隙進行分離，進而形成岡下肌上緣與肩胛岡、岡下肌外下緣與小圓肌兩個“窗口”。兩者可以在岡下肌深面連通，同樣可對肩胛岡、肩胛頸和肩胛盂背側(cè)進行充分顯露(圖2～4)。對岡下肌、三角肌起點進行剝離時應做好標記，手術(shù)縫合切口時應將其重建于肩胛骨岡下窩以及肩胛岡。本組17例患者均為肩胛頸/肩胛盂/肩胛骨外側(cè)緣+肩胛岡骨折，單純采用外側(cè)直切口，無法對肩胛頸和肩胛盂背側(cè)尤其是肩胛岡外緣進行充分顯露，無法對肩胛上神經(jīng)進行顯露和松解，損傷該神經(jīng)的風險較大，采用改良Judet入路則均達到了對復雜骨折的充分顯露，實現(xiàn)了良好復位和內(nèi)固定，并保護了肩胛上神經(jīng)。本組患者隨訪時均未發(fā)現(xiàn)肩胛上神經(jīng)醫(yī)源性損傷。

外側(cè)直切口是肩胛骨后側(cè)另一個常用重要入路，該入路經(jīng)岡下肌和小圓肌間隙進行顯露，這個切口損傷范圍相對較小，因此與Jones等[9]不同，我們對于發(fā)生于后側(cè)的骨折，包括大部分肩胛骨體部、外側(cè)緣、肩胛頸和肩胛盂后、下方以及肩胛岡骨折，并不需要進行改良Judet入路，僅僅進行外側(cè)直切口入路即可。而對于骨折范圍較廣、需廣泛顯露的病例，可采用Judet入路，即采用后側(cè)弧形切口，剝離三角肌后側(cè)以及部分乃至全部岡下肌。這些病例包括肩胛岡合并肩胛骨外緣和肩胛頸骨折、肩胛頸和肩胛骨外緣骨折，單純外側(cè)固定無法穩(wěn)定肩胛頸者，以及肩胛岡、肩胛頸骨折損傷肩胛上神經(jīng)，需要充分顯露和松解者。

肩胛骨骨折的復位，應以點狀復位鉗小心夾持，配合克氏針臨時固定，必要時在肩胛骨背面鉆孔，容納點狀復位鉗的尖端。固定器材可采用空心釘、2.7～3.5 mm板等。對于骨質(zhì)條件好的患者，普通板足以完成固定，而骨質(zhì)疏松患者，可采用鎖定板，對粉碎的骨折塊可采用2.7 mm螺釘和板等小型內(nèi)固定器材固定[9]。3.5 mm空心釘在固定喙突、肩胛盂等部位的骨折時，有使用方便的優(yōu)點，但應注意防止較細的導針在骨內(nèi)彎折，空心鉆擴孔時導致導針折斷。采用經(jīng)典或者改良Judet入路，可以在肩胛骨外側(cè)及肩胛盂/肩胛頸背側(cè)、或者肩胛岡安放內(nèi)固定板，放置內(nèi)固定的空間較為充分，一般均可放置至少2塊內(nèi)固定板(圖5)。本組患者中14例使用2塊及以上內(nèi)固定板，固定充分，術(shù)后均達到早期功能鍛煉的效果。

肩胛骨骨折術(shù)后的隨訪和功能鍛煉極為重要，其目標是在骨折愈合的同時，獲得活動良好、無痛、穩(wěn)定的肩關(guān)節(jié)。手術(shù)完成復位和固定后，醫(yī)師需“個體化”地指導患者，在康復訓練師的協(xié)助下循序漸進地進行功能鍛煉以達到最大的功能效果[10]。一方面應防止過度鍛煉引起骨折和內(nèi)固定移位；另一方面需防止大多數(shù)患者的畏懼鍛煉引起肩關(guān)節(jié)僵硬。一般來講，經(jīng)良好復位固定的患者，6周內(nèi)應在不持重狀態(tài)下進行肩關(guān)節(jié)活動范圍的鍛煉；6～12周達到肩關(guān)節(jié)最大范圍的活動；12周后，經(jīng)拍片發(fā)現(xiàn)骨折愈合跡象后，逐步增加上肢持重?；颊咦罱K的肩關(guān)節(jié)功能評分，主要受到骨折的類型和復雜程度、手術(shù)復位和固定的質(zhì)量以及有無并發(fā)癥、功能鍛煉的依從性的影響。

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圖1 尸體解剖圖，示經(jīng)典Judet入路，右肩。A.肩胛岡；B.肩胛上神經(jīng)；C.岡下??；D.肩胛骨外緣；E.肩胛骨內(nèi)緣 圖2 尸體解剖圖，示改良Judet入路，右肩。A.肩胛岡外側(cè)份；B .從肩胛岡掀起的三角??；C .岡下??；D .岡下肌與肩胛岡之間的間隙；E.上下兩個間隙可在岡下肌深面連通 圖3 術(shù)中圖片，改良Judet入路，右肩。A.剝離岡下肌與肩胛岡之間的間隙；B .岡下肌 圖4 術(shù)中圖片，改良Judet入路，右肩。A.岡下肌；B.岡下肌與小圓肌之間的間隙 圖5 術(shù)中透視，顯示復位后用3塊板內(nèi)固定

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(本文編輯：李靜)

趙良瑜，陳愛民，李永川.經(jīng)改良Judet入路手術(shù)治療肩胛骨骨折的療效[J/CD].中華肩肘外科電子雜志,2015,3(1):30-34.

Evaluation of modified Judet approach in the treatment of scapula fractures

ZhaoLiangyu,ChenAimin,LiYongchuan.

DepartmentofOrthopedicTrauma,ChangzhengHospital,SecondMilitaryMedicalUniversity,Shanghai200433,China

ChenAimin，Email：orthopsurgery@smmu.edu.cn

Background The scapula locates in the posterior wall of chest.It is an irregular bone with a triangular shape.The scapula connects clavicle and humerus with its structure including the acromion,coracoid and scapular glenoid,forming an important combination of upper limbs and trunk.Various injury factors can cause fracture damage to the scapula,leading to obstacles to the movement of the upper limb.In history,scapular fractures used to be treated conservatively.While in recent years,with the improvement of operative techniques and development of surgical conditions and related devices and equipment,more and more scapular fracture patients accepted surgical treatments and achieved good results.There are different approaches to scapular fractures including anterior approach,the lateral straight incision approach,Judet approach and so on.In this study,modified Judet approach was evaluated as the treatment of some subgroup of scapular fracture cases.Methods From July,2004 to July 2014,71 cases of scapular fractures accepted surgical treatment,with 17 cases underwent Judet approach.The age of the 16 males and 1 female case ranged 29-62 years with the mean age 47.1 years old.The causes of injury included automobile accident in 8 cases,falls from height in 6 cases,fall,sports injuries and other causes of 3 cases.There were scapular neck fracture involving scapular spine or medial border of scapula in 13 cases,fracture involving the scapula glenoid fractures in 3 cases,combined fracture of scapular and ipsilateral clavicle in 1 case.41% (7 out of 17 cases) patients had associate injuries,including 6 cases of rib fracture,1 case of craniocerebral injury,3 cases of contusion of lung and pleural effusion,5 cases of spine fractures,1 case of cervical spinal cord hyperextension injury,1 cases of maxillary sinus fracture,1 case of proximal humerus fracture,1 case of first metacarpal fracture,and 1 case of brachial plexus injury.Bilateral scapular fractures occurred in 1 case.The time interval between injury and operation was 2-15 days,averaging 7.1 days.Operation method:Operations were done under general anesthesia or brachial plexus block anesthesia.The posterior modified Judet approach was performed.The incision started from the projection of scapular glenoid in the dorsal side of scapula,running medial along with the scapula spine,and turned downward in the superior medial corner of scapula,along with the medial edge of the scapula to the inferior corner of scapula.Skin and subcutaneous tissues were dissected.The posterior part of deltoid was dissected from scapula spine.The infraspinatus underneath was partly released from the scapula spine,dorsal surface of scapula,and between infraspinatus and teres minor,remaining attachment of the infraspinatus muscle in the medial border of scapula.Thus two "windows" was made,and scapula spine,dorsal side of scapula neck and glenoid,dorsal side of scapula body and the lateral and medial borders of scapula were exposed.The suprascapular and axillary nerves were carefully protected.Circumflex scapular artery was occasionally ligated for the purpose of expansion of exposure.Periosteotomy was performed nearing the fracture line.Then fractures were reduced and fixed temporarily by K-wires.After X-ray confirmation,final stabilization was done with cannulated screws,2.7- 3.5 mm cortical screws and plates.Reduction and fixation along with exclusion of screws penetrating the glenoid articular surface was confirmed by fluoroscopy,and range of motion of the shoulder joint was examined.Then wound was closed layer by layer.Postoperative treatments:active and passive shoulder circumferential motion was initiated early after operation and range of motion was gradually increased.The injured upper limb was kept without weight lifting within 6 weeks after surgery.Patients were asked to return to the hospital at 6 weeks,12 weeks and 6 months postoperatively.X-ray films were taken for fracture healing evaluation,and further instructions for functional rehabilitation were given by the surgeons.Weight lifting was not permitted until callus growth through the fracture line can be seen on the x-ray film.The shoulder joint function was assessed at the time of the latest follow-up.The standards for radiographic fracture healing were disappearance of fracture line and continuous callus through the fracture line.America shoulder and elbow surgery (ASES) scoring system was used for functional evaluation,with full score of 100 points.Results Seventeen patients underwent 18 scapular surgeries.Modified Judet approach was performed in 17 sides (one patient with bilateral scapular fractures had this approach in one side),accounting for 24% (17/71) scapula fracture operations of the corresponding period.All the 17 cases achieved anatomical reduction.Fractures were fixed by 2 pieces of internal fixation plates in 12 cases,3 pieces of plates in 2 cases,and in 3 cases,rigid stabilization was achieved by one plate.All 17 patients completed follow-up and all fractures healed during the follow-up period of 6 months,with no nonunion case.Six patients had peri-operational complications,including pulmonary infection in 3 cases and cured by antibiotic therapy,incision edge necrosis in one case,superficial infection in 1 case and cured by dressing change and wound care.Implant prominence caused discomfort in one case,which had to be removed in advance after signs of fracture healing occurred in X-ray film.No fracture displacement,implant loosening or displacement,implant penetrating into glenoid articular surface or nerve injury occurred.ASES score of shoulder joints ranged 56-100 points with an average of 85.9 points.Of the 10 cases with scapula fracture alone without other damage,the ASES scores were higher,averaging up to 90.8.Among patients scored less than 70 points,bad compliance to the guidance of physician for functional rehabilitation of shoulder joints,comminution of glenoid fracture,associate injuries and complications leading to prolonged treatment time may be the main influence factors.Conclusion Modified Judet approach is indicated for complex scapula fractures,and it has the advantages of extensive exposure,protection of suprascapular nerve and preservation of infraspinatus.Anatomical reduction,rigid fixation,early postoperative motion and good functional recovery can be achieved.

Modified Judet approach;Scapula;Fracture; Internal fixation

10.3877/cma.j.issn.2095-5790.2015.01.007

上海市科委產(chǎn)學研合作項目(13DZ1940705)

200433上海，第二軍醫(yī)大學骨創(chuàng)傷外科

陳愛民，Email：orthopsurgery@smmu.edu.cn

2014-12-26)