شكستگي و دررفتگي غيرقابل جاانداختن شانه گزارش يك مورد غيرمعمول
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1 شكستگي و دررفتگي غيرقابل جاانداختن شانه گزارش يك مورد غيرمعمول دكتر مجيد عيوض ضياي ي I چكيده شكستگي دررفتگي قدامي ٢ قطعهاي شانه ( ) را ميتوان با جااندازي بسته درمان كرد. در اين گزارش ١ مورد از اين نوع دررفتگي كه با جااندازي بسته جااندازي نشده بود معرفي ميگردد. در اين بيمار به علت گير تاندون عضله دوسربازويي و در كف مفصل گلنوي يد و ايجاد شكاف در طول الياف عضله ساب اسكاپولاريس( hole (Button درمان به صورت جراحي باز انجام شد. اين نوع گير( Interposition ) در كتابها و نوشتهها تا كنون گزارش نشده كليدواژهها: ١ شكستگي دررفتگي ٢ قطعهاي شانه ٢ عدم موفقيت در جااندازي با روش بسته ٣ گيركردن نسج بين دو جزء مفصل مقدمه شكستگي همراه با دررفتگي قدامي شانه در حدود ١٢% تا ١٥% گزارش شده اين شكستگي دررفتگي معمو لا با روش بسته جااندازي ميشود( ١ ). طبق نظر OMERA در مدت بيش از ٣٠ سال تنها ٨ مورد دررفتگي غيرقابل جااندازي با روش بسته در مقالات چاپ شده به زبان انگليسي گزارش شده اين دررفتگي بندرت احتياج به جااندازي باز و جراحي دارد. گاهي به علت پارگي تاندون طولي روتيتور كاف( ٢ و ٣) شكستگي بخوبي جانميافتد اما دررفتگي جا ميافتد. در موارد خيلي استثنايي دررفتگي با روش بسته جانميافتد كه علت آن گير عضله ساب اسكاپولاريس پاره شده( ٤ ) تاندون عضله دوسربازويي( ٥ ) گير لابروم در داخل حفره گلنوي يد و قطعه شكسته ( ٦ ) و پاره شدن عضلات روتيتور كاف از محل عضله و گير در داخل مفصل( ٢ ) ميباشد. در اين موارد دخالت جراحي براي درمان لازم و ضروري گير همزمان ٣ جزء از عوامل باز دارنده جا با روش بسته شامل تاندون دو سر بازويي قطعه شكسته و شكافته شدن عضله ساب اسكاپولاريس I) استاديار گروه ارتوپدي بيمارستان شفايحياييان دانشگاه علوم پزشكي و خدمات بهداشتي درماني ايران تهران. سال نهم/ شماره ٢٨/ بهار ١٣٨١ مجله دانشگاه علوم پزشكي ايران ٦٩
2 در طول الياف عضله و گيركردن سر در داخل hole) (Button تاكنون گزارش نشده موارد گزارش شده در جدول شماره ١ نشان داده شده چند روز بعد بيمار در مركز ديگري تحت بررسي مجدد با CTSCan قرار گرفت كه وجود قطعه شكسته را در داخل حفره تا ييد كرد(شكل شماره ١). چند روز بعد يعني حدود ٣ هفته بعد از اولين تلاش براي جااندازي بسته جدول شماره ١ موارد گزارش شده از عدم جااندازي شانه با روش بسته پيگيري جزء مانع براي شكستگي مكانيسم سمت جنس سن بيمار سال شماره جا همراه دررفتگي ١ ١٩٩٨ ٥٦ پارگي عضله زن ماه ٣ از تخت ٢ ١٩٩٠ ٥٥ پارگي عضله ماه ٦ ٣ ١٩٩٠ ٥٣ تاندون دو سر بازويي تصادف ماه ٢ ٤ ١٩٨٣ ٣٢ معلوم نيست ٥ ١٩٨٢ ٤٥ لابروم صرع ٦ ١٩٨٢ ٨٢ تاندون دو سر و ٧ ١٩٨٣ ٧٠ تاندون دو سر بازويي ٨ ١٩٧٩ ٩١ عضله زن ٩ ١٩٦٦ ٥٤ عضله تصادف ماه ٤ معرفيبيمار بيمار خانم ٣٨ سالهاي بود كه در سانحه رانندگي دچار شكستگي دررفتگي دوقطعهاي قدامي شانه شده بود. بيمار قبل از اين حادثه هيچگونه مشكلي در شانه نداشت. در يك مركز درماني پس از تصويربرداري ساده از شانه با تشخيص دررفتگي توسط يك متخصص ارتوپدي در زير بيهوشي عمومي تصميم به جااندازي بسته گرفته شد كه پزشك موفق به جااندازي نشد. پزشك ارتوپد بعدي سعي در جااندازي كرده بود كه متا سفانه اين تلاش هم با ناكامي روبرو گرديد. سرانجام ٢٧ روز بعد از اولين تلاش براي جااندازي بيمار توسط نويسنده مقاله تحت عمل جراحي باز شانه قرار گرفت. در الكتروميوگرافي كه قبل از عمل جراحي انجام شده بود بجز فشار روي شبكه عصبي بازويي مشكل ديگري وجود نداشت. ٧٠ مجله دانشگاه علوم پزشكي ايران سال نهم/ شماره ٢٨ / بهار ١٣٨١
3 بعد از جااندازي تاندون به داخل كانال و خارج كردن از داخل مفصل جااندازي صورت گرفت. لابروم قدامي و خلفي بررسي شدند كه سالم بودند. بقاياي ليگامان عرضي كانال دو سر با ايجاد ٢ سوراخ كوچك در لبه خارجي كانال و دوختن ليگامان به استخوان از طريق ٢ سوراخ تعبيه شده در لبه خارجي كانال تاندون دو سر در داخل كانال ثابت شد. شكستگي بعد از جااندازي با ٢ عدد پيچ ٣/٥ ميليمتر به محل اصلي متصل شد. عضله ساب اسكاپولاريس كه Z پلاستي شده بود به محل اصلي وصل گرديد. بازو در حالت خنثي (بدون چرخش خارجي و داخلي) قرار گرفت و عضله سينهاي و تاندون Conyoinet به محل اصلي دوخته و بدون ثابت كردن سخوان به حفره گلنوي يد پايداري مفصل امتحان شد. بعد از ترميم كامل زخم اندام به طريق بانداژ ولپوثابت گرديد و حركات مفصل شانه از هفته دوم شروع شد(شكل شماره ٢). شكل شماره ٢ CTاسكن شانه بعد از عمل جراحي باز شانه شكستگي و دررفتگي غيرقابل جاانداختن شانه شكل شماره ١ CT اسكن شانه كه در آن قطعه شكسته در حفره شانه مشخص جراحي باز با برش عضله دلتوپكتورال شروع شد و بعد از بازكردن فاشياي كلاوي پكتورال به علت سفتي بيش از اندازه در تاندون Z Conyoinet پلاستي در تاندون انجام گرديد. عصب موسكولوكوتاني وس بررسي و حفاظت شد. سپس ١ عضله سينهاي در بالايي محل اتصال به بازو ٢ بريده و آزاد گرديد. در بررسي عضله با كمال تعجب دريافتيم كه اين عضله از محل اتصال به ١ كوچك و حدود پاييني آن كنده شده و در زير گردن ٢ آناتوميك و پشت آن در داخل حفره گلنوي يد قرار گرفته متا سفانه پس از آزادكردن باقيمانده چسبندگي عضله از و بازكردن Button hole سخوان در داخل مفصل قرار نگرفت و جااندازي انجام شد. تاندون دو سر بازويي از كانال دو سر بازويي خارج و در داخل حفره گلنوي يد و پشت سخوان به همراه قرار گرفته بود. سال نهم/ شماره ٢٨/ بهار ١٣٨١ مجله دانشگاه علوم پزشكي ايران ٧١
4 در حال حاضر كه ٦ ماه از درمان بيمار سپري شده است حركات شانه به صورت فلكسيون پاسيو ١٧٠ درجه همراه با ابداكسيون پاسيو ١٦٠ درجه و چرخش داخلي ٧٠ درجه و چرخش خارجي ٤٥ درجه ميباشد. بيمار قادر است كارهاي روزمره خود را براحتي انجام دهد. راديوگرافي اخير نيز علاي مي از نكروز آسپتيك را نشان نداد(شكل شماره ٣). شكل شماره ٣ راديوگرافي شانه ٦ ماه بعد از جراحي باز شانه بحث به گفته Omer در بيش از ٣٠ سال گذشته فقط ٨ مورد دررفتگي غيرقابل جااندازي با روش بسته در نوشتههاي انگليسي زبان گزارش شده در جدول شماره ١ سه مورد از موارد گزارش شده همراه با شكستگي بودند و بيماري كه گزارش گرديد نيز چهارمين مورد از اين نوع بوده اگر چه اغلب جوانان در معرض دررفتگي شانه هستند اما همه موارد گزارش شده و نيز اين مورد از نظر سني در دهه چهارم بودند (٣٢ سال به بالا). موانعي كه سبب عدم موفقيت در جااندازي ميشوند شامل تاندون عضله دو سر عضله ساب اسكاپولاريس پاره شده لابروم گلنوي يد شكستگي و پاره شدن تاندونهاي روتيتوركاف از جسم تاندون و گير در فاصله مفصلي نام برده شده هستند. اما در بيماري كه معرفي شد ٣ عامل تاندون دو سر بازويي قسمتي از عضله ساب اسكاپولاريس بصورت ايجاد حالت جادگمهاي hole) (Button و قطعه شكسته در داخل مفصل با هم شكل جديدي از Interposition را ايجاد كرده بودند كه سبب عدم موفقيت در جااندازي بسته در مدت ٣ هفته از دررفتگي شده بود. از دست رفتن زمان عاملي است كه در نتايج درمان تا ثير منفي خواهد داشت( ٧ ). بنابراين توصيه ميشود در مواردي كه جاانداختن بسته در شرايط ايدهآل امكان ندارد جراحي بلافاصله و بدون از دست رفتن وقت انجام شود تا عوارض ناشي از كهنهشدن دررفتگي مانند محدوديت حركت شانه بعد از عمل يا بروز عارضه نكروز سر استخوان بازو و تشديد فشار روي شبكه عصبي اطراف شانه به حداقل رسانده شود. منابع 1 Omer A., Lliahi MD., Irreducible anterior dislocation of shoulder associated with Fr. Of G.T The american jurnal of orthopedic augest 1998, 27(8): Kuhnen & groves MD., Irreducible acute anterior dislocation of the shoulder, clinical orthopedic and related research 1979, 139: Tietjen R., Occult glenohumeral interposition of a torn rotator cuff, a case report J.B.J.S., 1982, 64A: ٧٢ مجله دانشگاه علوم پزشكي ايران سال نهم/ شماره ٢٨ / بهار ١٣٨١
5 4 Simonh Bridle. Barry ferris., Irreducible acute anterior dislocation of the shoulder interposed subscapularis. J.B.J.S. 1990, 72B: Sinao T., Hira YaMa Y. Take mitsu. Irreducible shoulder dislocation associated interposed biceps tendon. J.B.J.S. 1990, 72(6) november: Omi Ooa., Irreducible anterior dislocation of the shoulder due to loose fragment from an associated fracture of the greater tuberosity. injury 1983, 15: LAM S.J.S., Irreducible anterior dislocation of the shoulder. J.B.J.S., 1966, 48B: 132. سال نهم/ شماره ٢٨/ بهار ١٣٨١ مجله دانشگاه علوم پزشكي ايران ٧٣
6 IRREDUCIBLE ANTERIOR DISLOCATION OF THE SHOULDER AN UNUSUALL CASE REPORT I M. Eyvaz Ziaee, MD ABSTRACT The 2 part greater tuberosity fracture dislocation of shoulder can usually be reduced by close methods. We report a case of failed close reduction due to interposition of long head of biceps tendon and greater tuberosity and botton hole deformity of subscapularis musclue. Key Words: 1) 2 part fracture dislocation 2) Irreducible 3) Interposition I) Assistant professor of orthopedic surgery, Shafa yahyaian Hospital, Iran University of Medical Sciences and Health Services. ٧٤ مجله دانشگاه علوم پزشكي ايران سال نهم/ شماره ٢٨ / بهار ١٣٨١
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