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 The axillary nerve was located beneath teres minor and had potential for injury if the teres minor muscle was retracted too vigorously.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]

参考译文

肩胛骨手术最常用的外科入路方法是Judet的后路入路法。Judet入路法是能够充分暴露盂下以及向肩胛体方向延长的骨折段。这种入路方法增加了肩关节和肩胛颈的可视性,而且可以延长切口直至暴露整个肩胛体、肩胛脊以及肩峰。Ebraheim曾经在标本上做了3个与Judet入路法相类似的方法。尽管都做了此改良,但是每种方法都在结构上存在一定程度的风险。在20例标本中发现，肩胛上伸进位于肩胛骨边缘的0.1~1.4cm处。旋肩胛动脉离盂下界为0.5~2.8cm。腋神经位于小圆肌下,如果小圆肌剧烈收缩时,其存在损伤的隐患。在我们关于肩胛骨手术入路方法的分析中包括了13个方面的研究。在166个病例中,有4个盂缘骨折,其中3个采用前路入路治疗，一个采用后路的方法校正。在105例关节窝骨折的病例中,有82例(78.1%)采用后路手术方法,有19例(18.1%)采用前路入路,有4例(3.8%)采用联合入路,在39例肩胛骨颈骨折的病例中,有38例(97.4%)采用后路人路，只又1例采用前路手术,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例肩胛冈骨折采用后路入路法。1例喙突和肩峰复合伤采用了从伤口直接入路的方法。1例肩胛骨体骨折采用后路入路内固定的方法。在报道中,关于受伤和手术之间的间隔时间是不一样的,病人平均在受伤后4.9d(0~38d)接受手术治疗。其中一个报道声称,所有的手术都在人院后1周内完成,而另一个报道则认为所有的手术都在入院后 20d内完成(除1例因为采用非手术治疗导致骨不连性疼痛后5个月,采用手术治疗的方法)。3位学者报道有相当数量的患者为了治疗伴发伤而选择二期手术。Kligman等描述了一个改良的后中路入路治疗关节窝前侧骨折。在小圆肌和冈下肌之间暴露肩胛翼后，打开一个有后中向关节窝的窗口。在治疗关节窝前侧骨折中,与常用的三角肌入路法相比较,后中路入路法创伤更小,损伤腋神经和肩胛上神经的可能性更小。

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