The most commonly used surgical approach to the scapula is the posterior (Judet)approach. 18 Benefits of the Judet approach include adequate exposure for fractures of the inferior glenoid and those extending into the body. This approach allows for improved joint and scapular neck visualisation and can be extended to visualise the entire body, spine and acromion. Ebraheim conducted a cadaveric study of three variants of the Judet approach. Despite modifications, there were certain structures at risk with each approach. In 20 cadavers, the suprascapular nerve was found to lie 0.1~1.4cm from the glenoid rim. The circumflex scapular artery was 0.5~2. 8cm from the inferior glenoid margin. The axillary nerve was located beneath teres minor and had potential for injury if the teres minor muscle was retracted too vigorously. Thirteen studies were included in our analysis of operative approach to the scapula (Table 4).1,8,11,17,2,25,30,37 In the 166 cases,there were 4 glenoid rim fractures. 5,17 Three were treated through an anterior approach 5 and one was corrected through a posterior approach. 17 There were 105 glenoid fossa fractures. 5,8,11,17,19,24,27,34,37 A posterior approach was used in 82 (78.1%),an anterior approach was used in 19 (18.1%), and a combined anterior and posterior approach was used in 4 cases (3.8%) Thirty-eight of 39 neck fractures (97.4%)were treated using the posterior approach 1,5,8,11,17,19,23,25,27,30,34,37 and 1 with an anterior rapproach.5 Fractures of the apophyses were treated using an anterior approach in 7 of 10 cases (70%).5 One coracoid 17and one scapular spine fracture 37 were approached from the posterior approach. One combined coracoid and acromial fracture was approached through an incision directly over the site of injury. 5 One fracture of the body was internally fixed through a posterior approach.17Reports of time between injury and operation were variable. Patients were operated on a mean of 4,9days (range 0~38 days)after their injury . While one report noted that all operations were performed within 1 week of admission,34 another stated that all operations were done within 20 days( with the exception of one patient who was treated surgically 5 months post-injury for a painful nonunion with nonoperative treatment).1 Three authors reported that a significant number of patients were treated by secondary/ delayed operation to allow treatment of concomitant injuries.2,14,19 Kligman et al. 22 described a modified posterior approach for anterior glenoid fractures. A window was created posteromedially to the glenoid fossa after a plane had been developed between teres minor and infraspinatus. There was less soft tissue injury and a reduced possibility of axillary and suprascapular nerve palsy with this approach compared to the deltopectoral approach commonly used to treat anterior glenoid fractures.

                                                                                                              [J.Injury,2007;(10).1016]

參考譯文

肩胛骨手術(shù)最常用的外科入路方法是Judet的后路入路法。Judet入路法是能夠充分暴露盂下以及向肩胛體方向延長(zhǎng)的骨折段。這種入路方法增加了肩關(guān)節(jié)和肩胛頸的可視性,而且可以延長(zhǎng)切口直至暴露整個(gè)肩胛體、肩胛脊以及肩峰。Ebraheim曾經(jīng)在標(biāo)本上做了3個(gè)與Judet入路法相類似的方法。盡管都做了此改良,但是每種方法都在結(jié)構(gòu)上存在一定程度的風(fēng)險(xiǎn)。在20例標(biāo)本中發(fā)現(xiàn)，肩胛上伸進(jìn)位于肩胛骨邊緣的0.1~1.4cm處。旋肩胛動(dòng)脈離盂下界為0.5~2.8cm。腋神經(jīng)位于小圓肌下,如果小圓肌劇烈收縮時(shí),其存在損傷的隱患。在我們關(guān)于肩胛骨手術(shù)入路方法的分析中包括了13個(gè)方面的研究。在166個(gè)病例中,有4個(gè)盂緣骨折,其中3個(gè)采用前路入路治療，一個(gè)采用后路的方法校正。在105例關(guān)節(jié)窩骨折的病例中,有82例(78.1%)采用后路手術(shù)方法,有19例(18.1%)采用前路入路,有4例(3.8%)采用聯(lián)合入路,在39例肩胛骨頸骨折的病例中,有38例(97.4%)采用后路人路，只又1例采用前路手術(shù),在10例肩胛脊骨折的病例中,有7例(70%)采用前路人路,1例喙突骨折和1例肩胛岡骨折采用后路入路法。1例喙突和肩峰復(fù)合傷采用了從傷口直接入路的方法。1例肩胛骨體骨折采用后路入路內(nèi)固定的方法。在報(bào)道中,關(guān)于受傷和手術(shù)之間的間隔時(shí)間是不一樣的,病人平均在受傷后4.9d(0~38d)接受手術(shù)治療。其中一個(gè)報(bào)道聲稱,所有的手術(shù)都在人院后1周內(nèi)完成,而另一個(gè)報(bào)道則認(rèn)為所有的手術(shù)都在入院后 20d內(nèi)完成(除1例因?yàn)椴捎梅鞘中g(shù)治療導(dǎo)致骨不連性疼痛后5個(gè)月,采用手術(shù)治療的方法)。3位學(xué)者報(bào)道有相當(dāng)數(shù)量的患者為了治療伴發(fā)傷而選擇二期手術(shù)。Kligman等描述了一個(gè)改良的后中路入路治療關(guān)節(jié)窩前側(cè)骨折。在小圓肌和岡下肌之間暴露肩胛翼后，打開一個(gè)有后中向關(guān)節(jié)窩的窗口。在治療關(guān)節(jié)窩前側(cè)骨折中,與常用的三角肌入路法相比較,后中路入路法創(chuàng)傷更小,損傷腋神經(jīng)和肩胛上神經(jīng)的可能性更小。

責(zé)任編輯：admin