1、手舟骨骨折第1頁手舟骨解剖特點第2頁英文名“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”。第3頁與橈骨、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，主要包含遠極。第4頁發(fā)病機制 跌倒時腕部撐地 腰部70%-80%，近極10%-20%，遠極及舟狀骨結(jié)節(jié)占5%兒童骨折多以遠極為多第5頁Type A (acute stable fractures)A 1 : fractures of th

2、e 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

3、-union)Dl : fibrous non-unionD2 : pseudarthrosisD3: Sclerotic pseudarthrosisD4: Avascular Necrosis骨折分型第6頁病史及體格檢驗外傷史，跌倒時手撐地 腕關(guān)節(jié)橈側(cè)腫脹、疼痛，活動受限，尤其為背伸活動受限 鼻煙窩壓痛舟狀骨遠端結(jié)節(jié)壓痛舟骨擠壓試驗（+）第7頁輔助檢驗 蝶側(cè)位X片 不穩(wěn)定骨折診療標準： 1.移位超出1mm 2.成角大于10 3.粉碎性 4.橈月角大于15 5.舟月角大于60 6.舟骨內(nèi)角大于35第8頁輔助檢驗 腕關(guān)節(jié)CT：評定骨折程度及不易發(fā)覺骨折。腕關(guān)節(jié)MRI：用于診療隱匿性骨折，結(jié)合造

4、影劑用于判斷血供及有沒有缺血壞死發(fā)生。第9頁判別診療 舟月?lián)p傷腕關(guān)節(jié)扭傷腕關(guān)節(jié)軟組織挫傷其它腕骨骨折橈骨遠端骨折第10頁治 療 非手術(shù)治療-石膏固定手術(shù)治療-切開復位內(nèi)固定 閉合復位內(nèi)固定 關(guān)節(jié)鏡輔助下內(nèi)固定 第11頁Steven J Rhemrev, Daan Ootes, Frank JP Beeres, Sven AG Meylaerts, Inger B Schipper. Rhemrev et al. International Journal of Emergency Medicine , 4:4第12頁治 療 非手術(shù)治療-石膏固定 適應癥：急性、遠極無位移（無位移腰部骨折仍存爭議

5、） 通常固定時間為6-12周，依據(jù) 復查情況而定 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.第13頁治 療手術(shù)治療-斷端加壓螺釘固定 閉合 OR

6、 切開 OR 其它 ？ 第14頁切開復位內(nèi)固定第15頁 切開復位內(nèi)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.第16頁Table III. Rate of union related to type of fracture forpatients with at

7、 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

8、Br 1996;78-B:519-29.第17頁閉合復位內(nèi)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.第18頁閉合復位內(nèi)固定 Conservative SurgicalScaphoid u

9、nion 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 SCAPHO

10、ID J Bone Joint Surg Br 1997;79-B:418-21.第19頁閉合復位內(nèi)固定32 patients, Scaphoid fracture, B1, B2 and C types， percutaneous fixation of scaphoid fractures via a dorsal approach第20頁閉合復位內(nèi)固定All fractures united over an average of nine weeks. There was no avascular necrosisSameer Naranje & P. P. Kotwal & P. Sh

11、amshery &Vikas Gupta & H. L. Nag. Percutaneous fixation of selected scaphoid fractures by dorsal approach.International Orthopaedics (SICOT) () 34:9971003第21頁關(guān)節(jié)鏡輔助下內(nèi)固定234 scaphoid fractures and nonunions 126 acute injuries;65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid

12、 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 scaphoi