手术治疗电击伤致肩关节脱位、肩袖损伤、盂唇撕裂及肩胛骨喙突骨折1例

2019-09-27 客帅帅 韩铭 世界最新医学信息文摘

肩关节前脱位合并肩袖损伤较为常见,而电击伤致肩关节前脱位合并严重的肩袖损伤、盂唇撕裂及肩胛骨喙突骨折临床少见,国内外文献报导很少,相关诊断和治疗也缺乏研究。我院近期收治电击伤致肩关节脱位、肩袖损伤、盂唇撕裂及肩胛骨喙突骨折1例,病情复杂,较易误诊,治疗难度非常大。通过此例病案的诊治,总结一些经验,现报告如下。 临床资料 患者男性,52岁,于2017年12月份在工地工作时

肩关节前脱位合并肩袖损伤较为常见,而电击伤致肩关节前脱位合并严重的肩袖损伤、盂唇撕裂及肩胛骨喙突骨折临床少见,国内外文献报导很少,相关诊断和治疗也缺乏研究。我院近期收治电击伤致肩关节脱位、肩袖损伤、盂唇撕裂及肩胛骨喙突骨折1例,病情复杂,较易误诊,治疗难度非常大。通过此例病案的诊治,总结一些经验,现报告如下。

临床资料

患者男性,52岁,于2017年12月份在工地工作时,不慎触电,导致右上肢痉挛,极度上举后摆致伤,即右肩疼痛,活动受限,遂由家人搀扶至我院就诊。

方法

检查方法   临床检查 患者神清、查体合作,生命体征平稳,右侧肩部肿胀、疼痛,肩部活动明显受限,右肩外观呈方肩畸形、肩峰突出,关节盂空虚,肱骨头位于关节盂前下方。Dugas征(+)、直尺试验(+),患者指端感觉麻木。

辅助检查 X-ray:右肱骨头位于关节盂及喙突前方,肱骨头内侧可见游离骨折块,右肩关节向前脱位(如图1所示)。CT:右肩关节脱位,向内移位至关节盂及喙突前方,肱骨头前方可见游离骨折块,喙突骨质不连续,局部缺损(如图2所示)。MRI:右肩关节间隙消失,右肱骨头向前下方移位,肩胛下肌、冈上肌及冈下肌、三角肌形态欠佳,信号模糊欠均匀,肩胛下肌腱、冈上肌及冈下肌腱形态欠佳,连续性欠佳,信号模糊欠均匀,关节盂上盂唇、下盂唇结构欠清晰,可见条状略高信号,右侧喙突结构欠清晰。



治疗方法   完善相关检查,排除手术禁忌后在臂丛神经麻醉下行“右肩袖、右盂唇撕裂切开修补术+右肩胛骨喙突骨折切开复位内固定术”,手术操作如下:(1)麻醉成功后,患者取半仰卧位,常规消毒铺巾。(2)以右肩前侧为标志,做弧形切开,长约10cm,切开皮肤、皮下组织、深筋膜,显露头静脉,并加以保护,纵行分开三角肌,显露肱骨头、肩袖、喙突及盂唇,探查见:肱二头肌长头、肱二头肌短头部分撕裂,冈上肌、肩胛下肌、小圆肌、盂唇完全撕裂,喙突骨折,远端游离。被动牵开肱骨头,暴露关节盂,以带丝线铆钉3根打入关节盂,缝补撕裂盂唇,复位肱骨头。沿肩峰,取肩关节外侧切口5cm,切开皮肤、皮下组织,显露撕裂冈下肌,用3根铆钉打入肱骨大结节,将冈下肌固定于大结节。于前侧切口中分离暴露冈上肌,用2根铆钉打入肱骨大结节,将冈上肌固定于大结节。分离显露肩胛下肌,用1根铆钉打入肱骨小结节,将肩胛下肌固定于小结节。松解牵拉喙突远端游离骨折块,复位骨折断端,用2枚空心螺钉固定骨折断端(如图3、图4所示)。术后患者持续悬吊于胸前3周加以保护,患者定期门诊复查,右肩关节功能恢复良好。



讨论

肩关节是人体活动度最大的关节,其特点是头大盂小,周缘只有单纯的纤维软骨构成的盂唇来加深关节窝,肩关节可以完成前屈、后伸、旋前、旋后、内收、外展的等较复杂的大范围的活动。肩袖是由附着在肱骨大结节的小圆肌、冈下肌、冈上肌及在肩胛下肌附着的腱性组织组成,其主要负责关节盂及肱骨头维持、稳定、支持正常支点的功能。喙突是肩胛骨在肩前上方重要的骨突性结构,对喙肩弓和肩上方悬吊复合体起关键性作用,喙突从肩袖间隙中穿出,结构小巧且位置较深,喙锁韧带,喙肩韧带,喙肱韧带以及肱二头肌短头、喙肱肌、胸小肌等附着于喙突。单纯的肩关节前脱位合并肩袖损伤临床比较多见,但是像该患者这样因电击导致的肩关节前脱位合并严重的肩袖损伤、盂唇撕裂及肩胛骨喙突骨折临床非常少见。患者工作时突然遭受电击,通过反射弧的作用,即肩部外展肌群反射性极度收缩外展,使肱骨头冲破较薄弱的关节束前壁,向前下方滑脱,形成肩关节盂下脱位。脱位过程中,由于肱骨的极度牵拉,导致肩袖的小圆肌、冈下肌、冈上肌完全撕裂,肱骨大结节无任何肌腱附着。喙突骨折是由于喙锁韧带、肱二头肌短头及喙肱肌牵拉所致。

电击导致如此复杂的肩关节损伤临床非常少见,临床中也极易误诊漏诊。该患者来我院就诊时,因为未曾说明是因为电击导致,所以初诊时只认为是单纯的肩关节前脱位,入院后当天在麻醉下行手法复位,复位成功后患肩仍极其不稳定,活动后再次出现前脱位。给予患者CT及MRT检查后发现合并有严重的肩袖损伤、盂唇撕裂和喙突骨折,再次询问受伤机制,患者才说出电击的损伤。因为患者右侧肩关节失去了盂唇和肩袖的保护,所以极其不稳定,简单的肩外展、后伸伴外旋即可导致前脱位。肩袖损伤、盂唇撕裂病人进行手术,对患者临床效果及预后的影响具有重要的临床意义,自1911年Codman提出肩袖损伤以来,开放式肩袖修补术成为治疗肩袖损伤的“金标准”。该患者合并盂唇撕裂和喙突骨折,开放式手术是最佳治疗方案,所以在排除手术禁忌后给予患者“右肩袖、右盂唇撕裂切开修补术+右肩胛骨喙突骨折切开复位内固定术”。通过术后复查随访,患者右肩关节外展、后伸、屈曲等功能恢复良好,Neer评分88分。

通过此病例可以看出,电击是一种高能量损伤,可以对肩关节造成非常大的损害,不仅仅只有单纯的肩关节脱位,还有可能伴有复杂的韧带盂唇的损伤。因此临床中,遇到肩关节脱位时,必须要详细询问受伤机制,当有如电击等高能量损伤时,必须进一步结合临床检查,辅助X线照片和MRI作出明确诊断,避免出现误诊漏诊。对于伴有复杂的肩袖损伤、盂唇撕裂、喙突骨折的肩关节脱位,切开修补是最佳治疗方案。良好的切开修补术可以帮助患者重建肩关节功能,改善生活质量。

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    2019-09-29 gaoxiaoe
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