骨科英文书籍精读（63）｜肩锁关节损伤（2）
Treatment
Sprains and subluxations do not affect function and do not require any special treatment; the arm is rested in a sling until pain subsides (usually no more than a week) and shoulder exercises are then begun.
Dislocations are poorly controlled by padding and bandaging, yet the role of surgery is controversial. The large number of operations suggests that none is ideal. There is no convincing evidence that surgery provides a better functional result than conservative treatment for a straightforward Type III injury. Operative repair should be considered only for patients with extreme prominence of the clavicle, those with posterior or inferior dislocation of the clavicle and those who aim to resume strenuous overarm or overhead activities.
Whilst there is no consensus regarding the best surical solution, there are a number of underlying principles to consider if surgery is contemplated. Accurate reduction should be the goal. The ligamentous stability can be recreated either by transferring existing ligaments (the coracoacromial or conjoined tendons), or by using a free graft (e.g., autogenous semitendinosis or a synthetic ligament). This reconstruction must have sufficient stability to prevent re-dislocation during recovery. Any rigid implants which cross the joint will need to be removed at a later date to prevent loosening or fracture.
In the modified Weaver–Dunn procedure the lateral end of the clavicle is excised and the coracoacromial ligament is transferred to the outer end of the clavicle and attached by trans-osseous sutures. Tension on the repair can be reduced either by anchoring the clavicle to the coracoid with a Bosworth coracoclavicular screw (which has to be removed after 8 weeks) or by employing a Dacron sling – looped round the coracoid and the clavicle – for the same purpose. Great care is needed to avoid entrapment or damage to a nerve or vessel. Elbow and forearm exercises are begun on the day after operation and active-assisted shoulder movements 2 weeks later, increasing gradually to active movements at 4–6 weeks. Strenuous lifting movements are avoided for 4–6 months.
Recent advances in instrumentation have made it feasible to perform this type of reconstructive surgery arthroscopically (Snow and Funk, 2006).
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
controversial /ˌkɑːntrəˈvɜːrʃl/adj. 有争议的；有争论的
conservative treatment 保守疗法
prominence /ˈprɑːmɪnəns/n. 突出；显著；突出物；卓越
strenuous /ˈstrenjuəs/adj. 紧张的；费力的；奋发的；艰苦的；热烈的
overarm or overhead activities.手臂或头顶上的活动。
conjoined /kən'dʒɔɪn/v. 结合；联合（conjoin 的过去式和过去分词）adj. 结合的；联合的
autogenous /ɔ'tɑdʒənəs/adj. 自生的；自发的
synthetic /sɪnˈθetɪk/n. 合成物adj. 综合的；合成的，人造的
trans-osseous suture 经骨缝合
entrapment/ɪnˈtræpmənt/n. 诱捕；圈套；截留
Recent advances in instrumentation have made it feasible to perform this type of reconstructive surgery arthroscopically 近年来在器械方面的进展使得在关节镜下进行这种类型的重建手术成为可能。
arthroscopically经关节镜地
百度翻译：
治疗
扭伤和半脱位不会影响功能，也不需要任何特殊治疗；手臂放在吊带上，直到疼痛减轻（通常不超过一周），然后开始肩部锻炼。
通过填充和包扎对脱位的控制很差，但是手术的作用是有争议的。大量的手术表明没有一种是理想的。没有令人信服的证据表明外科手术能比保守治疗更有效地治疗直接的III型损伤。只有锁骨极度突出、锁骨后脱位或下脱位以及旨在恢复剧烈过度活动或头顶活动的患者才应考虑手术修复。
虽然目前还没有关于最佳手术解决方案的共识，但如果考虑手术，还有许多基本原则需要考虑。准确的减少应该是目标。韧带稳定性可通过转移现有韧带（喙肩胛肌腱或连体肌腱）或使用游离移植物（如自体半腱肌病或合成韧带）来重建。这种重建必须有足够的稳定性，以防止在恢复过程中再次脱位。任何穿过关节的刚性植入物以后需要取下，以防松动或断裂。
在改良的Weaver-Dunn手术中，锁骨外侧端被切除，喙肩胛韧带被转移到锁骨外侧端，并通过骨缝连接。为了同样的目的，可以用博斯沃思喙突螺钉（必须在8周后取出）将锁骨固定在喙突上，或者用涤纶吊带（环绕着喙突和锁骨）来减少修复的张力。需要非常小心，以避免神经或血管受到压迫或损坏。术后第二天开始肘和前臂运动，2周后开始主动辅助肩部运动，4-6周逐渐增加为主动运动。4-6个月内避免剧烈的举重运动。
最近在器械方面的进展使得在关节镜下进行这种重建手术成为可能（Snow and Funk，2006）。