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Fracturas de Escapula.pptx
- 1. R1 Carlos Ildelfonso Campaña Medina
- 2. Epidemiologia • 1% de todas las fracturas • 5% de las fracturas de hombros • 3% de la cintura escapular Acromion Cuello Glenoidea Cuerpo y espina Cavidad glenoidea Coracoides 70% 7% 8% 10% 5%
- 3. Como Diagnosticarla • Actitud de dessault • Dolor y deformidad del hombro • Limitación de abducción (pseudoparálisis) • Signo de Comolli / Escapula alada • Equimosis • Mecanismo de acción
- 4. Mecanismo de lesión • Edad 35 a 45 años • Traumatismo de alta energía • Motocicleta 11-25% • Automóvil 50% • Traumatismo indirecto • Caída sobre el brazo extendido • Fracturas o avulsiones
- 5. Lesión Neurovascular Lesiones Ipsilaterales 20% 76% 4% Lesión de columna Lesiones Asociadas Pero 80%-95% tienen una incidencia de lesiones oseas y de tejidos blandos 5-10% 25%-45% 15-40%
- 6. Anatomia • Glenoideo • Acromial • Espinoso Se extiende lateralmente desde el cuerpo compuesta de un borde y fosa glenoidea Se extiende lateralmente desde el proceso espinoso y finalmente anterior Sale posteriormente del cuerpo escapular y se extiende desde el borde escapular medial Se extiende superiormente desde la apófisis glenoidea y luego anterior y lateralmente. Coracoides Cuerpo escapular y procesos:
- 8. Musculos
- 12. Clasificacion por la AO Cuerpo Fosa Glenoidea Procesos A B F
- 13. Clasificacion por la AO Acromion Espina Coracoides 1 2 3 14A
- 14. Clasificacion por la AO 14B G zona lateral a la base de la coracoides Medial Lateral Superior L S M 1 2 Cuerpo
- 15. Clasificacion por la AO 14 F 0 Fx extraarticular que afecta el cuello 0 14F1.1 14F1.2 14F1.3 Anterior Posterior Transverso Fosa Glenoidea
- 16. Clasificacion por la AO
- 17. Evaluacion Radiografica Anteroposterior de hombro
- 18. Evaluacion Radiografica Proyeccion Axilar de la articulacion Glenohumeral
- 19. Evaluacion Radiografica Lateral verdaderas de Escapula Proyeccion AP en carga de hombro
- 20. Si el patron es complejo se solicita una TAC T A C TAC de reconstruccion TAC simple TAC Tridimensional
- 21. Fracturas del cuello glenoide Recuerda que el cuello tiene tres soportes : 1.- Ósea con el cuerpo de la escapular 2.- Ligamentos que se encuentran insertados 3.- Músculos que se encuentran insertados
- 22. Con Desplazamiento significativo 1.- ML desplazamiento >1cm 2.- AP desplazamiento angular >40 grados 3.- Disminucion de la glena Angulo no polar a 20 grados menos 90% con un desplazamiento NO Significativo
- 24. Fracturas de la Fosa Glenoidea Motivo por que la fractura es central: • 1.- La fuerza se conserva en el centro • 2.- Las traveculas sudcondrales son transversas • 3.- El centro es un área débil • Desplazamiento no significativo 90% tx conservador • Idenberg (fue el primero) y Goss Clasificación (agrego subcalificaciones) Siendo uno de las causas una fratura transversal que puede progresar a varias direcciones.
- 25. Clasificaciones de idenberg Tipo I Tipo II Tipo III Tipo IV • Fractura o avulsión del borde anterior • II A Fractura transversa que se extiende en dirección inferior • II B Fractura oblicua que se extiende en dirección inferior • Fractura Oblicua que se extiende de manera superior se asocia a lesión de la articulación acromioclavicular • Fractura transversa que se extiende al borde medial de la escapula
- 26. Clasificaciones de idenberg - Goss Tipo V Es una combinación de II,III y IV Tipo VI • Fractura conminuta de la glenoides
- 27. Tipo I • En caso de Subluxacion Persistente de la cabeza humeral • Articulación inestable Tipo V Criterios quirurgicos Tipo II • Cuando Tenemos un desplazamiento significativo provocando articulación inestable Fx desplazada mayor a 1cm ¼ anterior o 1/3 posterior de afectación en la fosa glenoidea Tipo III • Escalón articular de 5 mm con desplazamiento lateral del fragmento superior o si hay una rotura desplazada del SSSC • Complicaciones: Enfermedad degenerativa postraumática y disfunción grave de la articulacion Tipo IV • Si el trazo es transverso que discurre hasta el borde medial de la escapula con fragmento superior desplazado Tipo VI • Indicaciones previas Tx Qx contraindicado Podemos provocar: • Daño a Tejidos • Mayor inestabilidad Lesión neurovascular: Tipo II1 / Vb/Vc/VI mas frecuentes Mas si se compromete acromion, coracoides o cuello.
- 28. Fracturas de Coracoides Funciones de la coracoides .- Función de unión a musculotendinosas y ligamentos .- Proporciona estabilidad anterosuperior a la art glenohumeral .- Parte integral del SSSC
- 29. Clasificación de Ogawa .- Tipo I se localizan proximalmente al ligamento coracoclavicular .- Tipo II se localizan distalmente al ligamento coracoclavicular Clasificación de Eyres .- Tipo I Punta de la Apofisis .- Tipo II Fx de proceso medio .- Tipo III Fx Basal .- Tipo IV Fx con afectación del cuerpo escapular superior .- Tipo V Fx con extensión a la fosa glenoidea
- 30. Fracturas de Acromion Funciones del acromion 1. Proporciona un lado de la articulación acromioclavicular 2. Punto de unión musculotendinoasas y ligamentos 3. Da estabilidad posteroruperior 4. Componente de SSSSC
- 31. Tipo I • IA Avulsión • IB Fractura Real Tipo II • Desplazada sin reducción del espacio subacromial Tipo III • Desplazada con compromiso subacromial • Asociado a desplazamiento ipsilateral del cuello de la glenoides
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- 34. Fratura de cuello glenoidea
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Editor's Notes
- EL TX ACIDO BASE SUELE SER LA PISTA FUNDAMENTAL PARA IDENTIFICAR EL PROCESO CAUSAL INSOSPECHADO HASTA ENTONCES. ESTO SUELE PASAR EN PACIENTES HOSPITALIZADOS.
- articulación glenohumeral, articulación subdeltoidea, articulación escapulotorácica, articulación acromioclavicular y articulación esternoclavicular
- SISTEMA DE AMORTIGUACION DE LOS LIQUIDOS ORGANICOS ESTOS SE COMBINAN CON UN ACIDO O BASE DE MANERA INMEDIATA PARA REGULAR LA CONCENTRACION DE H+ EL SISTEMA DE HCO3, ES EL MAS IMPORTANTE A NIVEL EXTRACELULAR RELACION ESTRECHA CON LAS CONCENTRACIONES EXTRACELULARES TANTO DEL BICARBONATO COMO DEL CO2 LAS ALTERACIONES DE EL PROVOCAN TRASTORNOS DE ORIGEN METABOLICO SISTEMA DE AMORTIGUACION POR EL CENTRO RESPIRATORIO ELIMINA CO2 DEL LIQUIDO EXTRACELULAR, MEDIANTE EL INCREMENTO DE LA RESPIRACION - H+ LA FRECUENCIA RESPIRATORIA Y LA VELOCIDAD DE FORMACION DE CO2, ALTERAN LA FORMACION DE ESTE ULTIMO, REFLEJANDOSE EN LA PRESION DE CO2 (PCO2) DANDO LUGAR A TRASTORNOS ACIDO BASE DE ORIGEN RESPIRATORIO SISTEMA DE AMORTIGUACION RENAL SECRECION DE H+ REABSORCION DE BICARBONATO FILTRADO PRODUCCION DE BICARBONATO AMORTIGUADORES COMO EL FOSFATO Y EL ION AMONIO (ESTOS JUEGAN UN PAPEL IMPORTANTE EN LA EXCRECION DE H+ Y LA FORMACION DE HCOL3
- Desplazamiento ML afecta la dinámica musculotendinosa aun siendo desplazado antero o postero medial Debilidad muscular (abductores) Dolor Subacromial Disfuncion en el manguito rotador Angulacion excesiva: Provoca inestabilidad glenohumeral (anterior, posterior o inferior) La cabeza humeral pierde el soporte óseo provocando inestabilidad Malestar y disfunción del manguito de los rotadores y fuerza Complicaciones de pacientes no operados con desplazamientos manejados con tx conservador 20% rango de movimiento reducido 50% dolor subacromial 40% debilidad en abductor del hombro 25% noto estallidos Fx sin desplazamientos con tx conservador Pronostico de bueno a excelente Fx con tratamiento Qx ORIF temprano 80% resultados de bueno a excelentes ]A
- Fx en cuello anatomico Fx en cuello quirúrgico Fx que involucra el cuello hasta el borde medial (se manejan como fracturas de cuerpo) Fx que involucra el cuello y el borde superior (se manejan como fracturas de cuerpo)
- LA INTERPRETACION DE LOS TRASTORNOS ACIDO BASE SE REALIZA MEDIANTE EL ANALISIS DE GASES EN SANGRE ARTERIAL MEDIANTE LA GASOMETRIA HIPOCAPNIA SU MECANISMO ES LA HIPERVENTILACION ALVEOLAR HIPERCAPNIA HIPOVENTILACION ALVEOLAR LA SATURACION DE OXIGENO INDIRECTAMENTE PROPORCIONA INFORMACION DE LA PaO2, LOS NORMAL ES 95-98%
- LA INTERPRETACION DE LOS TRASTORNOS ACIDO BASE SE REALIZA MEDIANTE EL ANALISIS DE GASES EN SANGRE ARTERIAL MEDIANTE LA GASOMETRIA HIPOCAPNIA SU MECANISMO ES LA HIPERVENTILACION ALVEOLAR HIPERCAPNIA HIPOVENTILACION ALVEOLAR LA SATURACION DE OXIGENO INDIRECTAMENTE PROPORCIONA INFORMACION DE LA PaO2, LOS NORMAL ES 95-98%
- Pectoral menor Biceps Coracobraquial Anatomia: .- Centro de osificación constante En su base formando parte del tercio superior de la glenoides El cuerpo principal .- Centros inconstantes En su angulo donde se une el ligamento coracoclavicular En la Punta donde se une el tendón
- EL TX ACIDO BASE SUELE SER LA PISTA FUNDAMENTAL PARA IDENTIFICAR EL PROCESO CAUSAL INSOSPECHADO HASTA ENTONCES. ESTO SUELE PASAR EN PACIENTES HOSPITALIZADOS.