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Clavicle fracture, one of the commonest traumatic fractures, accounts for 5% to 10% of all fractures and 17.02% of upper extremities fractures, which normally happen to youth and children. Different types of clavicle fractures are often seen in different age groups. For instance, green stick fractures are often found in newborn babies and infants, while transverse fractures are often seen in teenagers and adults.
锁骨骨折是常见创伤骨折之一，其发生率占全身骨折的5%～10%，占上肢骨折的17.02%，多见于青壮年及儿童，不同年龄可发生不同类型锁骨骨折，如新生儿及幼儿以青枝骨折多见，青少年或成年人以横断型多见。
Both direct and indirect violence can attribute to clavicle fractures and the former one is more often. For example, landing on one’s hand, elbow or shoulder when falling down could cause clavicle fracture, usually in transverse or short-oblique type. While direct violence acts on the anterior or upper side of clavicle, leading to transverse or comminuted fractures.
间接暴力与直接暴力均可引起锁骨骨折，其中以间接暴力多见。如跌倒时，手掌、肘、肩先着地，暴力传导至锁骨引起锁骨骨折，骨折类型多为横行或短斜型。直接暴力通常可从锁骨前方或上方直接作用于锁骨，导致横断型或粉碎型骨折。
Clinically, clavicle fractures can be classified into three types according to the fracture site（Figure4-1-1）:
临床上常根据骨折部位（图4-1-1）分为：
Proximal fracture contributes 5% to 6% of clavicle fractures. Separation of epiphysis normally occurs in the inside of clavicle in youth which is easy to be misdiagnosed as sternocalvicular joint dislocations.
（1）近端骨折，占锁骨骨折的5%～6%，在青少年时期，锁骨内侧常发生骨骺分离，X线片诊断易误诊为胸锁关节脱位。
Medial fractures contribute 75% to 80% of clavicle fractures. The proximal end is shifted to the upper posterior owing to the stretching of sternocleidomastoid muscle while the distal end is shifted to the lower anterior owing to the stretching of pectoralis major, pectoralis minor and subscapularis muscle.
（2）中段骨折，占75%～80%，骨折后近端因胸锁乳突肌牵拉而向后上方移位，远端因胸大肌、胸小肌、肩胛下肌牵拉而向前下方移位。
Distal fracture contributes 12% to 15% of all clavicle fractures.
（3）远端骨折，占锁骨骨折的12%～15%。
图4-1-1 锁骨骨折X线片
Figure4-1-1 X-ray of clavicle fractures
Patients normally had traumatic history, localized swollen and abnormality with obvious tenderness,possible bony crepitus, sense of bone rubbing, and inability to lift and rear protraction. Generally speaking, a patient may lean his/her head toward the injured side to relieve stretching pain caused by sternocleidomastoid muscle, using the hand in the normal side to hold forearm and elbow in the injured side to relieve pain caused by the gravity and dislocations by nearby muscles. Some fractures even could damage the subclavian blood vessels and nerves or puncture the pleura, forming pneumothorax.Corresponding clinical symptoms may also be presented if combined with sternoclavicular joint dislocation, acromioclavicular joint dislocation, scapula fracture, first rib fracture, etc. A clear diagnosis can be made based on traumatic history, physical presentations and imaging results. Moreover, attention should be paid to its relevant complications and be distinguished from joint dislocations, separation of epiphysis and pathological fractures.
有明确外伤史，伤后局部通常可见肿胀、畸形，触之压痛明显，可有骨擦音和骨擦感。患肢不能自主上举和后伸，典型体征是患者头偏向患侧以缓解胸锁乳突肌的牵拉作用，患者健侧手托住患肢前臂及肘部以对抗上肢重力及相关肌群造成骨折移位引起的疼痛。部分骨折可损伤锁骨下血管及神经或刺破胸膜形成气胸，还可合并胸锁关节脱位、肩锁关节脱位、肩胛骨骨折、第一肋骨骨折等，从而引起相应临床症状。根据患者外伤史，体征及影像学检查，诊断通常不困难，但要注意检查相关并发症，同时要注意与关节脱位、骨骺分离及病理性骨折相鉴别。
Conservative treatment is strongly recommended to children with clavicle fractures. As most of them can recover with fine bone healing and even malunion can receive satisfactory results by remodelling（Figure4-1-2）. Clavicle fractures in adults are often the result of huge external forces with significant displacement and severe soft tissue injuries which are often difficult to receive bone-setting manipulation. And its external fixation is difficult to maintain even if the reduction is successful. In addition, surgery is another option for children as their bone healing and shaping capabilities are relatively weak.
儿童锁骨骨折即使无法获得良好的复位，骨折也鲜有不愈合，即使是畸形愈合的锁骨也可通过日后塑形获得良好的外形，所以治疗主要应以保守治疗为主（图4-1-2）。成人锁骨骨折常由较大外力引起，骨折常有明显移位且合并较重的软组织损伤，往往难以手法复位，即使手法复位成功，外固定也难以维持，加之骨的愈合能力及塑形能力较儿童弱，因此常建议手术治疗。
Bone-setting manipulation
1．整复方法
A patient sits with his/hers hands on the hips. Assistant A stands behind the patient, pulling his/hers shoulder outward, upper and posterior while using his knee against the patient’s spinous process of thoracic. Then the practitioner shall stand in front of the injured side, pressing the proximal end to inferior and lower side while pushing the distal end to upper posterior side as well as pressing the fractured end with the guidance of reverse traumatic mechanism. At the same time, assistant A shall loosen properly to maintain the shoulder for stable fixation（Figure4-1-3）. If what we have just mentioned is not effective, assistant B shall stretch patient’s arm outward and shall bandage across the armpit. Then assistant C stands at the patient’s normal side to against resistance by pulling inward and upward. In the end, assistant A shall loosen the distal end to reset.
图4-1-2 锁骨中段骨折复位前后X线片
Figure4-1-2 X-ray of medial clavicle fracture before and after bone-setting manipulation
伤者坐于凳子上，取两手叉腰挺胸位。一助手立于患者身后，两手握患者两肩两侧同时向外、向上、向后扳提，同时用一膝盖顶于伤者胸椎棘突，使锁骨两骨折端在挺胸时因杠杆作用及助手扳提作用力趋于同一轴线下，术者立于患肢前方，两手摸清骨折两端，利用逆创伤机制原理，结合骨折端端提挤压手法，将近侧骨折端向前下按压，将远侧骨折端向后上推顶，可使骨折复位。同时助手适当放松牵引，以利于骨折端相互嵌紧，保持相对稳定，以便固定（图4-1-3）。如若通过上述方法，骨折端仍不能有效牵开而影响复位，可嘱第二助手向外牵拉患肢上臂，嘱第三助手用一布带绕过患者患侧腋下胸壁，立于健侧做向内、向上作用力与第二助手对抗牵引，协助第一助手将远骨折端有效牵开，再行手法复位。
图4-1-3 左锁骨骨折整复示意图
Figure4-1-3 Bone-setting manipulationfor left clavicle fracture
Another plan is recommended to patients with distal clavicle fracture who did not received satisfactory results from above method. Firstly, the patient sits with elbow in 90°. Then Assistant A bandages crossing from axils, chest to back and stretches to the normal side while Assistant B holds the injured forearm, stretching upward and outward. In the end, the practitioner pushes the distal end up through armpit with one hand while presses the proximal end down with the other hand. Ordinarily,patients shall receive satisfactory results by stretching properly.
部分远端骨折患者经上述方法仍无法获得良好复位者，可采用腋下整复法，患者挺胸，上臂下垂，屈肘90°位。第一助手用一布带套过患侧腋下经胸前及背后于健侧牵引。第二助手扶患者患肢上臂向外上方牵引。术者一手经患者腋窝推压骨折远端向上，一手按压锁骨近端向下，通常骨折可达到满意复位，稍放松牵引，使骨折端嵌紧，以便进行外固定。
Fixation
2．固定方法
No extra measures are needed for clavicle fractures in newborn babies owing to their delicate skin and bone-healing abilities, as long as no pressure or any movements. Modified figure-of-eight bandage or clavicle support are recommended to children or adults without obvious displacement（Figure4-1-4）.
新生儿锁骨骨折，骨折愈合快，皮肤细嫩，不需特殊固定，只需避免压迫、活动锁骨即可。儿童及无明显移位的成人骨折可用改良“8”字绷带或锁骨固定带固定（图4-1-4）。
图4-1-4 左锁骨骨折改良“8”字绷带包扎固定
Figure4-1-4 Fixation of modified figure-of-eight bandage in left clavicle fracture
Conservative treatment is recommended to children with clavicle fractures（Figure4-1-5）. As most of them can recover with fine bone healing and remodelling is still effective for those in malunion.
小儿锁骨骨折后塑型能力强，治疗上主要以保守治疗为主（图4-1-5）。小儿锁骨骨折不用过分追求解剖对位，即使对位不佳骨折也鲜有不愈合或畸形愈合，即使畸形愈合的锁骨也可通过日后塑形获得良好的外形。
图4-1-5 锁骨骨折保守治疗X线片
Figure4-1-5 X-ray of clavicle fracture by conservative treatment
Scapula fracture refers to rare fractures in scapulas, scapular neck, scapular body, scapular spine,shoulder peak and coronoid process, contributing 3% to 5% of shoulder fractures and 0.4% to 1.0% of all fractures. Normally, these fractures are the results of high-energy direct violence as a part of multiple trauma and be associated with severe injuries in other parts.
肩胛骨骨折是指肩胛盂、颈部、体部、肩胛冈、肩峰、喙突的骨折，较为少见，约占肩部骨折发生率的3%～5%，占全身骨折发生率的0.4%～1.0%。骨折常由高能量直接暴力所致，通常为多发伤的一部分，常合并其他部位损伤，且合并伤通常较严重。
Scapular body fracture is the most common scapula fractures, contributing 50% of scapular fractures.
此为最常见的肩胛骨骨折之一，约占肩胛骨骨折的50%。
Scapular body fracture is mainly caused by direct violence such as heavy objects or firearms,leading to comminuted fracture, transverse fracture or oblique fracture without any obvious displacement owing to the protection of nearby muscles.
肩胛骨体部骨折主要由直接暴力引起，如重物或火器伤直接损伤肩胛骨体部，多为粉碎性骨折，亦有横形或斜形骨折，因肩胛骨前后均有肌肉保护，故骨折多无明显移位。
Patients usually had traumatic history caused by direct violence, localized swelling, ecchymosis,abrasions or bruises around the wound with obvious tenderness, limited lifting and outreaching in the injured side with symptoms as well as physical signs associated with rib fractures or organ injuries.Missed diagnosis may happen due to the obscure fracture line in anterior-posterior X-ray of the shoulder.Therefore, anterior-posterior, lateral-tangential and armpit X-ray of the scapula should be ordered for further diagnosis. CT scans and three-dimensional（3D）reconstruction are quite significant to the treatment of fractures thanks to their high-definition and quantification of displacements. A clear diagnosis can be made based on traumatic history, physical signs, X-ray and CT scan results（Figure4-1-6）.
多有直接暴力外伤史，致伤局部常有明显肿胀瘀斑及皮肤的擦伤或挫伤，以及明显压痛。患臂的上举、外展均受限。常可合并肋骨骨折或胸腔脏器伤出现相应症状及体征。X线常规肩关节前后位检查比较难辨明骨折线，导致漏诊，需加摄肩胛骨前后位、侧位切线位及腋窝位X线检查。CT扫描和三维重建可清晰显示肩胛骨骨折，并可对骨折块移位情况进行量化，对骨折治疗具有指导意义。根据外伤史、体征及X线、CT照片检查，诊断一般并不困难（图4-1-6）。
Figure4-1-6 X-ray of left scapular body fracture
图4-1-6 左肩胛骨体部骨折X线片
Surgery or internal fixation are rarely needed in scapular body fractures as those with little displacement could heal spontaneously under the protection of muscles. So triangular bandage is recommended for patients to hang the injured arm so as to begin functional exercises as soon as possible. Moreover, surgery is recommended to those who have obvious displacement and neuromuscular entrapment at the fractured end.
肩胛骨体部骨折极少需要切开复位和内固定。若骨折移位不大，因有肌肉保护，骨折多可自愈，不需特殊处理，一般用三角巾悬吊患肢，早日进行患肢功能锻炼。手术治疗适用于骨折移位明显，骨折端有神经肌肉卡压者。
Physical exercises shall be started one week after surgery or non-surgery treatments while functional exercises could begin in 2 to 3 weeks, including outreaching, adduction, lifting and rear protraction. Passive movements is given priority at first and active movements can be started in 2 weeks.
术后或非手术治疗1周后即可开始物理治疗。在2～3周开始进行肩的功能训练，包括外展、内收、上举及后伸。初始以被动运动为主，2周后做主动运动。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
按骨折三期辨证施治（见附录）。
Fractures of scapular neck and scapulas contribute 0.4% to 1% of the all fractures and just 10% of scapular fractures. Among them, only 10% to 15% of fractures of scapulas are accompanied by obvious displacement.
肩胛颈及肩胛盂骨折占全身各部位骨折发生率的0.4%～1%，占肩胛骨骨折发生率的10%，仅有10%～15%的肩胛盂骨折有明显移位。
Fractures of scapular neck and scapulas are mainly the results of indirect violence. For example,the lateral side of shoulder or one hand lands on the ground when falling down with impaction on the scapula and neck, resulting in compressed fracture, comminuted fracture of the scapula and oblique fracture of the scapula neck, or avulsion fracture of the lower or posterior-inferior edge of the scapula caused by strong contractions of the triceps.
该处骨折主要由间接暴力引起，如跌倒时肩部外侧着地，或手掌撑地，暴力经肱骨传导冲撞肩胛盂及颈部，导致肩胛盂的压缩骨折或粉碎性骨折及肩胛颈斜形骨折，又可因肱三头肌强烈收缩造成肩盂下缘或后下缘的撕脱骨折。
Scapulas fractures shall be classified into 6 types（Figure4-1-7）according to ideberg classification（1984）.
依据ideberg（1984）的分类法，肩盂骨折可分成6型（图4-1-7）。
Type Ⅰ: Anterior and posterior rim fractures account for 83% of scapulas fractures.
I型肩盂前缘或前下缘骨折，占肩盂骨折的83%。
Type Ⅱ: Transverse fracture through the glenoid fossa with the humeral head accounts for 2% to 3%of scapulas fractures.
Ⅱ型肩盂下缘包括部分肩盂颈嵴部的骨折，占2%～3%。
Type Ⅲ: Oblique fracture through the glenoid exiting at the mid-superior border of the scapula accounts for 2% to 3% of scapulas fractures which often involved with acromioclavicular fracture or dislocation.
Ⅲ型肩盂上部骨折，骨折线斜向内上，累及喙突的基底部，占2%～3%。
Type Ⅳ: Horizontal fracture exiting through the medial border of the scapula accounts for about 5%of scapulas fractures.
Ⅳ型肩盂上部的水平方向骨折，自肩盂经肩盂颈水平延伸至肩胛骨内缘，约占5%。
Type Ⅴ: Type Ⅳ plus fracture of separating the inferior half of the glenoid account for about 4% of scapulas fractures.
Ⅴ型在Ⅳ型骨折基础上合并肩盂下部及肩盂颈骨折，约占4%。
Type Ⅵ: Fracture of posterior edge of glenoid is often associated with posterior dislocation of glenohumeral joint.
Ⅵ型肩盂后缘骨折，通常是盂肱关节后方脱位的合并骨折。
Figure4-1-7 Six types of scapulas fractures
图4-1-7 肩盂骨折分6型
Patients had traumatic history, no abnormality and aggravated pain in shoulder, swelling and tenderness in armpit and shoulders movements. A clear diagnosis can be made by X-ray results to exclude the possibilities of dislocated shoulders without obvious displacement（Figure4-1-8）. As there is slight chance of missed diagnosed, this fracture can be easily diagnosed by traumatic history, clinical presentations, X-ray and CT results for further diagnosis.
有明显外伤史，肩胛盂外观多无明显畸形，检查肩部及腋窝部肿胀、压痛、活动肩关节时疼痛加重。X线片可排除肩关节脱位而确诊（图4-1-8），但对无明显移位的骨折有一定漏诊概率，可做CT扫描和三维重建以明确诊断。根据外伤史、体征及X线、CT照片检查即可明确诊断。
Figure4-1-8X-ray of Fractures of right scapular neck and scapulas
图4-1-8 右肩胛颈及肩胛盂骨折X线片
Bone-setting manipulation is not suitable for patients with little or small displacement. And triangular bandage shall be used to hang the injured arm and functional exercises shall be started as soon as possible. Moreover, manipulation could be performed in patients with severe displacement, and the fracture could be fixed by abduction splint for 4 weeks or by stretching skin or bone in outreaching and outward-rotating position for 3 to 4 weeks. Surgery is necessary when bone-setting manipulation or stretching is not effective. Open reduction and internal fixation should be performed when the fracture covering more than 1/4 of the all joint to prevent dislocated shoulders or subluxation. Non-surgery treatment, which as the same as that for dislocations, can be applied in patients with dislocation by using triangular bandage to hang on the injured arm and starting functional exercises as soon as possible.
一般无明显移位或移位不大的肩胛颈骨折，不需手法整复，可用三角巾悬吊患肢，尽早做患肢功能锻炼。严重移位的肩胛颈骨折，可行手法复位，再用外展架固定4周，或采用患肢外展外旋位置持续皮肤或骨牵引3～4周。手法整复或牵引无效时，可行手术治疗。盂缘骨折达到关节面1/4时应切开复位内固定，以防止肩关节脱位或半脱位。小的关节盂缘骨折伴有脱位者，也可按脱位方法采用非手术治疗，用三角巾悬吊患肢，尽早做患肢功能锻炼。
Fracture of shoulder peak is mostly seen in the youth, contributing 9% of scapular fractures. Severe fracture of shoulder peak could be associated with acromioclavicular dislocation, tendon injuries of supraspinatus muscle, even frozen shoulder and shoulder impingement syndrome.
肩峰骨折占肩胛骨骨折发生率的9%，多见于青壮年。严重的肩峰骨折常可合并肩锁关节脱位、冈上肌肌腱损伤，晚期形成冻结肩及肩部撞击征。
Fracture of shoulder peak are normally the result of top-down direct violence or sudden leverage impact,leading to transverse fracture or short-oblique fracture. Fractured segments in the distal end of shoulder peak are usually small with little displacement while those in the baseline end may affect outreaching movement of shoulder owing to the weight of its distal end and anterior-inferior stretching strength of deltoid.
多为自上而下的直接暴力打击，或由肱骨突然强烈的杠杆作用引起肩峰骨折，常为横断面或短斜面骨折。肩峰远端骨折，骨折块小，移位不大；而肩峰基底部骨折，远侧骨折端受上肢重量作用及三角肌的牵拉向前下移位，将影响肩关节外展活动。
It can be classified into three types according to the narrowest distance between the upper end of the humeral head and the lower end of the acromion fractured segment: mild, moderate and severe.
根据肱骨头上端与肩峰骨折块下端的最窄距离分为轻、中、重三型。
Mild : More than 7 mm.
轻度移位：骨折距离大于7 mm。
Moderate : Between 5 to 7 mm.
中度移位：骨折距离在5～7 mm。
Severe : Less than 5 mm.
重度移位：骨折距离小于5 mm。
Physical examination presents swelling and tenderness in shoulder, particularly in shoulder peak,and compromised shoulder functions such as outreaching to varied extent. A clear diagnosis could be made by traumatic history, X-ray results（Figure4-1-9）and clinical presentations.
患肩肿胀、疼痛，肩峰处压痛明显，肩关节不同程度功能障碍，以外展功能受限尤为明显。根据外伤史、X线照片检查（图4-1-9）及临床表现，诊断通常不困难。
Figure4-1-9 X-ray of fracture of right shoulder peak
图4-1-9 右肩峰骨折X线片
Conservative treatment is recommended for patients with no or little displacement, adopting eightshaped bandage and triangular bandage to hang on the injured arm for 4 to 6 weeks. Open reduction and internal fixation could be considered for patients with mild or severe displacement which often associated with retracted fractured segments into the space under shoulder peak, exerting impacts on the space and the function of deltoid muscle.
无移位或移位不明显的骨折可保守治疗，固定方法同锁骨外端骨折固定，“8”字绷带配合三角巾悬吊患肢4～6周。中、重度骨折移位明显，常伴有骨折块回缩并进入肩峰下间隙，肩峰下间隙受到明显影响或三角肌功能受到损害，造成肩关节外展肱骨大结节碰撞，需切开复位内固定。
It contributes 5% of the scapula fractures and most of them are caused by high-energy injuries.
肩胛骨喙突在肩部的位置较深，周围有肌肉和胸壁的保护，故骨折发生率低，仅占整个肩胛骨骨折发生率的5%，常为高能量损伤。
Isolated coracoid fracture is rare and usually caused by direct violence, such as squeezing, while indirect violence often leads to avulsion fractures accompanied with acromioclavicular dislocation or dislocated shoulders. The acromioclavicular dislocation is stretched by short head of the biceps and inferior displaced fractured segments while dislocated shoulders with upward displacement is stretched by coracoclavicular ligament.
单纯喙突骨折极其罕见，通常与直接挤压暴力有关。间接暴力多为撕脱性骨折，并发于肩锁关节脱位或肩关节脱位，前者受肱二头短肌和喙肱肌牵拉，骨折块向下移位，后者骨折块受喙锁韧带牵拉向上移位。
Localized pain and tenderness can be touched at the coracoid process as well as the moving bone mass sometimes. Joint abduction and anti-resistance adduction of shoulder, elbow flexion and increased pain during deep breathing are the most important clinical presentations of coracoid fractures. A clear diagnosis could be made by traumatic history, X-ray results（Figure4-1-10）and clinical presentations.
喙突解剖部位局部疼痛和压痛，有时可触及活动的骨块。肩关节外展、抗阻力内收肩或屈肘、深呼吸时引起疼痛加重是喙突骨折最主要的临床表现。根据外伤史、X线照片检查（图4-1-10）及临床表现即可诊断。
Figure4-1-10X-ray of coracoid process fracture in the left shoulder
图4-1-10 左肩胛骨喙突骨折X线片
For coracoid process fracture without any displacement, triangular bandage could be used for 3 to 4 weeks. Surgery is recommended to patients with avulsion fractures caused by dislocated shoulders and acromioclavicular dislocations, a kind of multitrauma of superior shoulder suspensory complex,leading to instability of shoulder. Furthermore, surgery shall be considered when nerves and vessels are oppressed by coracoid process fracture.
对无移位的喙突骨折，可用三角巾保护患肢3～4周。由肩关节脱位及肩锁关节脱位引起的撕脱性骨折，属于上肩胛悬吊带复合体多重损伤，严重影响肩关节的稳定性时，应予以手术治疗。喙突骨折压迫神经血管，也应手术治疗。
Proximal humerus fractures refer to a break of upper part of the bone of the arm（humerus）,including fractures of greater tubercle and anatomical neck of the humerus or separation of epiphysis and fracture of neck of surgical humerus which is more common in clinic. Proximal humerus fractures contributes 4% to 5% of all fractures and 26% of shoulder fractures. With higher incidence rate in the elderly, it contributes 1/3 of the all fractures in this group. And women are twice likely to occur than men.
肱骨近端骨折是指大结节基底部以上部位的骨折，包括肱骨大结节、肱骨解剖颈骨折或骨骺分离、肱骨外科颈骨折等，以肱骨外科颈骨折多见。该部位骨折约占全身骨折发生率的4%～5%，占肩部骨折的26%，是老年人群中发病率较高的骨折，约占老年人全身骨折发生率的1/3，女性骨折发生率是男性的2倍。
Reasons that affect the recovery of proximal humerus fractures are ineffective functional exercises due to the pain in shoulder after fracture and adhesive capsulitis caused by dislocations, severe hemorrhages and soft tissue injuries. For most patients with proximal humerus fractures, conservative treatment combined with functional exercises could received satisfactory results. Surgery shall be considered carefully, as it may aggravate shoulder injury and adhesion.
影响肱骨近端骨折疗效的主要原因是骨折后的疼痛使肩关节长期固定而未进行有效的功能锻炼，以及关节脱位及严重骨折的出血和软组织损伤造成肩周粘连。绝大部分骨折经保守治疗配合康复功能锻炼即可获得满意疗效。手术治疗可加重肩关节创伤引起粘连，具有严格适应证。
Surgical neck of humerus locates 2 to 3 cm below the neck and above the insertion of pectoralis major, a transition area from cancellous bone to bone mineral density and a weak link of anatomy with thin supraspinatus muscle. This fracture may happen to anyone, especially the elderly, contributing 11% of shoulder fractures（Figure4-1-11）.
Figure4-1-11 Fracture of surgical neck of humerus
图4-1-11 肱骨外科颈骨折示意图
肱骨外科颈位于解剖颈下2～3 cm，胸大肌止点以上，此处由骨松质向骨密质过渡且稍细，是解剖上的薄弱环节，骨折较为常见，占肩部骨折的11%，各种年龄均可发生，老年人较多（图4-1-11）。
It often caused by indirect violence. For example, one hand or an elbow lands on the ground when falling down.Violence acts on the shaft of humerus, leading to a frature.
骨折多为间接暴力所致，如跌倒时手或肘部着地，暴力沿肱骨干向上传导冲击引起骨折。
Fracture of surgical neck of humerus could be classified into following types according to its displacement:
临床根据移位情况分为：
Non-displaced fractures: the results of both direct violence or indirect violence.
（1）无移位骨折：直接暴力击打引起裂痕骨折或间接传导暴力引起的垂直嵌插骨折。
Abducted fractures: The upper arm is in abducted position when falling down. Therefore, the distal fractured end is abducted while the proximal fractured end is adducted, forming angular displacement inwards.
（2）外展型骨折：跌倒时上肢外展位，骨折远端外展近端相应内收，骨折端向内向前成角移位。
Adducted fractures: The upper arm is in adducted position when falling down. Therefore, the distal fractured end is adducted while the proximal fractured end is abducted, forming angular displacement outwards.
（3）内收型骨折：跌倒时上肢内收，骨折远端内收，近端相应外展，骨折端向外成角移位。
Generalized swelling and tenderness could be presented in the shoulder after an injury,contributing limited movements in each direction to each extent with bone fremitus. Different types of fractures could be identified by X-ray results（Figure4-1-12）.
伤后肩关节有广泛肿胀压痛，肩关节各方向均有不同程度活动受限，常可触及骨摩擦感。X线片可明确及鉴别不同类型骨折（图4-1-12）。
Figure4-1-12 X-rays of fracture of surgical neck of humerus
图4-1-12 肱骨外科颈骨折X线片
With higher healing rate of fractures of surgical neck of humerus, satisfactory results could be received in most cases by bone-setting manipulation with external fixation and functional exercise.Surgery is recommended to patients with comminuted fractured which is not suitable for bone-setting manipulation, intolerable for conservatire treatment and higher requirements for its appearance.
肱骨外科颈骨折不愈合率较低，绝大部分骨折可通过手法复位外固定配合早期功能锻炼获得满意疗效。手术适用于粉碎性骨折手法复位很难成功、无法耐受保守治疗、对肩关节外形功能要求较高的患者。
Bone-setting manipulation
1．整复方法
The patient sits with shoulder abducted 30°, extorted 45°and elbow flexed about 90°. One assistant uses triangular bandage to stretch up throng armpit and the practitioner uses one hand to fix the middle and distal part of upper arm to correct the overlapping and deformity by against resistance.Then the practitioner pushes the fractured end with the other hand according to the displacement while remaining the resistance（Figure4-1-13）.
患者坐立位，患肩关节外展30°、外旋45°，肘关节屈曲90°左右。助手用三角巾绕过患肢腋窝向上牵引，术者一手固定患肢上臂中下段与助手对抗牵引，纠正重叠及旋转畸形。在维持牵引下，术者另一手置于骨折端根据骨折移位情况做推挤手法（图4-1-13）。
Figure4-1-13 Bone-setting of fractures of surgical neck of left humerus
图4-1-13 左肱骨外科颈骨折手法复位示意图
Abducted fractures: The practitioner pushes patient’s distal end of fracture inwards with one thumb while pushes the proximal end outwards with the rest fingers, using the other hand to remain stretching and adducting the injured side gradually. In this way, angular deformity shall be corrected when presenting bone fremitus and resistance between the fractured ends. And alignment shall be checked by pushing a little bit and putting the fractured ends together more closely.
（1）外展型骨折，术者用拇指将患者骨折远端向内推挤，其余四指将骨折近端向外推挤，术者另一手在维持对抗牵引下逐渐内收患肢。如有骨擦感，断端相互抵触，则表示成角畸形矫正，再采用推顶法检查骨折对位情况，同时使骨折端更加紧密对合。
Adducted fractures: The practitioner pushes patient’s proximal end of fracture inwards with one thumb while pushes the distal end outwards with the rest fingers, using the other hand to remain stretching and abducting the injured side gradually. If angular deformity formed excessively, it shall be corrected by lifting the injured arm over the patient’s head.
（2）内收型骨折，术者用拇指将患者骨折近端向内推挤，其余四指将骨折远端向外推挤，术者另一手在维持对抗牵引下逐渐外展患肢，如成角畸形过大，还可继续将患肢上举过头顶以纠正成角。
Fixation
2．固定方法
Shoulder provides the widest range of motion of any part of the body. Effective fixation shall not be achieved by using traditional splint or plaster as it shall lead to the displaced fractured end, malunion or delayed union. Therefore, Guangzhou Orthopaedics Hospital advances the traditional model in all-in-one splint for external fixation（Figure4-1-14）.
肩关节是人体活动度最大的关节，传统的夹板或石膏固定难以形成有效的固定，导致骨折端的移位，畸形愈合或延迟愈合。广州市正骨医院在传统夹板固定的基础上进行改良，使用一体式夹板外固定（图4-1-14）。
Non-displaced fractures: Four splints shall be used in upper arm for 3 to 4 weeks.
Requirements: The upper end of the anterior, lateral and posterior splints should be in the same level of shoulder while the lower end in the distal 1/3 of the injured side. And the inside splint should be in the distal 1/3 of the injured side from armpit to upper arm.
（1）无移位骨折：上臂4夹板固定，夹板规格要求是前侧、外侧、后侧夹板上端平肩关节，下端抵上臂中下1/3交界处，内侧夹板自腋下至上臂中下1/3交界处，固定时间3～4周。
Abducted fractures: The upper arm shall be fixed with anterior, lateral and posterior splints（required as above）for 5 to 6 weeks（depend on the result of X-ray）.
（2）外展型骨折：上臂前后外侧3夹板固定，夹板制作要求同上。固定时间5～6周，根据X线片结果适当增减。
Adducted fractures: Four upper arm splints shall be used for patients who with slight adduction and be relevant stable after bone-setting manipulation. In addition, the distal end of the inside splint should be covered by cotton pad like a mushroom and the rest splints are required as above.
Figure4-1-14 Fixation and bandage of fracture of surgical neck of left humerus
图4-1-14 左肱骨外科颈骨折包扎固定示意图
（3）内收型骨折：对于内收不严重、整复后骨折相对稳定的骨折可采用上臂4夹板固定，夹板制作要求内侧夹板远端用棉花包裹，呈蘑菇头样，即成蘑菇头样大头垫夹板，余3夹板制作同上。部分内收严重、不稳定的内收型骨折需加外展架固定，固定时间同上。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
骨折早、中、晚三期辨证用药。
In the early stage, patients are encouraged to make a fist, bending and stretching elbow and wrist and shrugging to contract muscles of the upper arm. Shoulder movements to each directions with various range could be started gradually in 3 to 4 weeks and external fixation could be removed in 6 weeks.
初期先让患者进行握拳，屈伸肘关节、腕关节，收缩上肢肌肉，耸肩等活动，3～4周骨痂生长后练习肩关节各方向活动，活动范围应循序渐进。一般在6周左右即可解除外固定。
For patients with abducted fractures, their shoulders shall be maintained in adducted position and avoid re-displacements by no outreaching and lifting in the early stage of fixation. For patients with adducted fractures, their shoulders shall be maintained in abducted positions and avoid adduction of the injured sides.
外展型骨折应使肩关节保持在内收位，切不可做肩外展抬举动作，尤其在固定早期更应注意这一点，以免骨折再移位。对内收型骨折，在固定早期则应维持在外展位，勿使患肢做内收动作。
An 8-year-old girl fell down with her right shoulder on the ground first by accident when running and came to Guangzhou Orthopaedics Hospital 3 hours after this injury. She complained pain,swelling, malformation and limited movements in the right shoulder. Physical examination presented swelling, pain and deformity in the right shoulder, tenderness in the proximal end of the humerus and compromised function of the shoulder movements. X-ray shows the fracture of the proximal end of the right humerus（Figure4-1-15）, being managed with bone-setting manipulation and fixed the injured side by splints. Reviewed X-ray shows corrected the displacement with good alignment（Figure4-1-16）.External fixation shall be removed in 4 weeks and standard treatment shall be adopted. The fracture healed with normal function in 5-week follow-up（Figure4-1-17）.
患者女，8岁，跑步时不慎跌倒，右肩部着地致伤，引起右肩关节处疼痛、肿胀、畸形及活动受限，伤后3小时来广州市正骨医院就诊，检查发现：右肩关节处肿胀、疼痛、畸形，肱骨近端压痛明显，肩关节活动功能障碍。X线片示：右肱骨近端骨折（图4-1-15）。行手法整复，夹板固定。复查X线片示：右肱骨近端骨折对位对线良好，骨折移位已复位（图4-1-16）。4周后拆除外固定，按骨折复位后常规处理，5周后复查：骨折已经愈合，肩关节活动度已恢复正常（图4-1-17）。
Figure4-1-15 X-ray before bone-setting manipulation: Fracture of theproximal end of the right humerus with displaced distal end inward
图4-1-15 就诊时X线示右肱骨近端骨折，远端向内侧移位
Figure4 1-16 Reviewed X-ray: Corrected displacement with good alignment
图4-1-16 复位后X线片示右肱骨近端骨折对位对线良好
Figure4 1-17 Five weeks after bone-setting manipulation
图4-1-17 右肱骨近端骨折患儿5周功能恢复情况
Most patients with fracture of the proximal end of the right humerus can receive satisfactory results by conservative treatments. However, functional exercises should be carried out as early as possible.For example, in the early stage, patients could shrug, combining with active and passive exercises at the same time in the middle stage and doing wall-climbing in the late stage after the splints being removed.
大部分肱骨近端骨折患者可以通过保守治疗达到满意效果，但功能康复需提早进行。早期功能锻炼是非常有必要的，如主动耸肩；中期主动和被动功能锻炼同时进行；后期拆除夹板后，指导患者主动锻炼，如爬墙等功能锻炼。
Fracture of the greater tuberosity of the humerus contributes 13% to 33% of the fractures of upper part of the humerus, followed by infraglenoid dislocation or fracture of the surgical neck of the humerus.Missed diagnosis can easily take place due to severe symptoms caused by dislocations and fractures.
肱骨大结节骨折占肱骨上端骨折发生率的13%～33%，常继发于肱骨头盂下脱位，或肱骨外科颈骨折。由于脱位和骨折的症状严重，容易忽略对该病的诊断。
Figure4-1-18 Fracture of the greater tuberosity of the humerus
图4-1-18 肱骨大结节骨折示意图
Isolated fracture of the greater tuberosity of the humerus is normally caused by direct violence, for example, one shoulder landed on the ground first when falling down or the upper arm landed on the ground in abducted and extorted position. Besides, sudden strong contractions of supraspinatus muscle, infraspinatus muscle,teres minor and rotator cuff shall lead to avulsion fracture of the greater tuberosity with displaced fractured segments or even shorten above the articular surface of the humerus.Fracture of the greater tuberosity of the humerus combined with anterior dislocated shoulder joint is usually the result of impaction by the greater tuberosity to the anterior and inferior side of the glenoid cavity. While the fracture of the greater tuberosity combined with fracture of the surgical neck of the humerus is usually the result of indirect violence, for example, one hand or elbow landed on the ground first when falling down. The impacting force, along the upper arm or the shoulder, leads to the fracture of the greater tuberosity and the surgical neck of the humerus（Figure4-1-18）. MR could be ordered to exclude the possibility of rotator cuff injury if necessary.
单纯肱骨大结节骨折多为跌倒时肩部外侧着地直接撞击引起骨折，或上肢外展外旋着地，冈上肌、冈下肌、小圆肌及肩袖突然强力收缩牵拉致肱骨大结节撕脱骨折，骨折块常向外上移位，严重者可缩至肱骨头的关节面以上。合并肩关节前脱位的肱骨大结节骨折系肩关节前脱位时，大结节撞击于肩胛盂前下缘所致。合并肱骨外科颈骨折的大结节骨折多为间接暴力引起，如跌倒时手或肘部着地，暴力沿上肢向肩部冲击，可引起肱骨外科颈及大结节骨折（图4-1-18）。必要时做MR检测，排除肩袖损伤。
Patients shall experience localized swelling, tenderness and aggravated pain when moving the upper arm, especially outreaching up to 70°and extorsion. A clear diagnosis could be made by traumatic history, clinical presentations and X-ray results（Figure4-119）.
伤后集中于肱骨大结节处的局部肿胀、压痛，活动上臂疼痛加重，尤以外展外旋疼痛加重明显，上臂外展常不到70°。根据外伤史、临床表现及X线检查即可诊断（图4-1-19）。
For isolated fracture of the greater tuberosity, the preferred treatment are bone-setting manipulation plus external fixation. And satisfactory results could be received with the combination of functional exercises in the early stage.Furthermore, surgery shall be considered if the fractured segments are too big to perform bone-setting manipulation and combined with other fractures or rotator cuff injuries which will affect the joint’s functions significantly.
对单纯肱骨大结节骨折，首选的治疗方法是闭合手法整复加外固定，配合早期功能锻炼，均能达到满意的效果。骨折块较大、手法难以复位、合并其他骨折或肩袖损伤及严重影响关节功能者，可考虑手术治疗。
Figure4-1-19 X-ray of fracture of the greater tuberosity of the right humerus
图4-1-19 右肱骨大结节骨折X线片
Bone-setting manipulation
1．整复方法
Abduction method could be applied to isolated displaced fracture of the greater tuberosity of the humerus. Specifically, the practitioner shall fix the injured side of the patient in abduction with one hand while push and press the fractured segments and supraspinatus muscle with the other thumb. For patients who combined with dislocated shoulders, the fracture shall be healed spontaneously after the bone-setting manipulation for the dislocation.
对于有移位的单纯大结节骨折，可通过外展法复位：术者一手固定患者患肢使其被动外展，术者另一手拇指向内下推挤患者撕脱的骨折块及冈上肌即可复位。合并肩关节脱位者先整复肩关节脱位，脱位整复后，骨折多可自行复位。
Fixation
2．固定方法
One lateral splint shall be used in fixation after bone-setting manipulation and cotton pads shall be placed in the laterosuperior to avoid re-displacement. For some unstable fractures, abduction splint shall be used for 3 to 4 weeks.
复位后使用单外侧夹板固定，可于肱骨大结节外上方加压垫以防止再移位，部分不稳定骨折可配合上肢外展架固定于肩关节外展位3～4周即可。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
按骨科三期辨证施治。
After performing bone-setting manipulation and fixation, patients could bend and stretch elbow and shoulder, beginning rotation and motion in all directions in 2 to 3 weeks.
肱骨大结节骨折整复固定后即可活动腕及手部，练习肘部、肩部的屈伸活动；2～3周后即可逐步练习旋转活动及各方向的单向活动，直至恢复正常。
Isolated fracture of the surgical usually happen to teenagers aged between 7 to 18 years old whose epiphysis have not fused with the humeral shaft yet, a weak link that results to the separation of epiphysis.
单纯解剖颈骨折少见，多见于7～18岁青少年，该年龄段骨骺尚未与肱骨干融合，为力学薄弱点，外伤可引起该处的骨骺分离。
This fracture is often caused by outreaching, anteflexion, extorsion and intorsion of the upper arm when falling down with violence, up along the humerus, acting on the epiphysis plate or the surgical neck.
骨折多因跌倒时，上肢外展及前屈、外旋及内旋，暴力沿肱骨向上传导作用于骺板或肱骨解剖颈所致。
Bone-setting manipulation combined with external fixation could be applied to teenagers. While surgery shall be performed in the early stage for failed bone-setting manipulation or unstable fixation.
对于青少年的肱骨上端骨骺骨折可尝试手法复位外固定，复位失败者或骨折不稳定再移位者建议早期行切开复位内固定。
Bone-setting manipulation: Do the same as the fracture of surgical neck of the humerus.
（1）整复手法：同肱骨外科颈骨折。
Fixation: Four splints combined with abduction splint could be used for patients with unstable proximal humeral epiphyseal separation.
（2）固定方法：由于肱骨上端骨骺分离骨折相对不稳定，常需要上臂4夹板配合外展架固定。
See Appendix: Recommended TCM Prescriptions during Different Stages of Fractures.
骨折三期辨证用药。
In the early stage, patients are encouraged to make a fist, bending and stretching elbow and wrist and shrugging to contract muscles of the upper arm. Shoulder movements shall be started to each direction with varied range gradually in 3 to 4 weeks and external fixation could be removed in about 6 weeks.
初期先让患者进行握拳，屈伸肘关节、腕关节，收缩上肢肌肉，耸肩等活动，3～4周骨痂生长后可拆除外固定架，练习肩关节各方向活动，活动范围应循序渐进。一般在6周左右即可解除夹板。
A 9-year-old boy hurt his right shoulder during exercise and came to Guangzhou Orthopaedics Hospital 2 hours after this injury. He complained pain, swelling, malformation and limited movements in the right shoulder. Physical examination presented swelling, painful and deformity in the right shoulder and compromised function of the shoulder movements（Figure4-1-20）. X-ray shows right proximal humeral epiphyseal separation（Figure4-1-21）, being managed with bone-setting manipulation and fixed by splints. Reviewed X-ray shows corrected displacement with good alignment（Figure4-1-22, Figure4-1-23）. External fixation was removed after 4 weeks and the fracture healed with normal function in 6-week follow-up.
患者男，9岁，于运动时不慎撞击右肩部，引起右肩关节处疼痛、肿胀、畸形及活动受限，伤后两小时来广州市正骨医院就诊，检查发现：右肩关节处肿胀、疼痛、畸形，肩关节活动功能障碍（图4-1-20）。X线片示：右肱骨上端骨骺分离骨折（图4-1-21）。治疗上行手法整复，夹板固定。复查X线片示：右肱骨上端骨骺分离骨折对位对线良好，骨折移位已复位（图4-1-22、图4-1-23）。4周后拆除外固定，按骨折复位后常规处理，一个半月后复查示骨折已经愈合，肩关节活动度已恢复正常。
Figure4-1-20 Appearance after get injured
图4-1-20 患儿就诊时外观
Figure4-1-21 X-ray before bone-settingmanipulation: Proximal humeral epiphysealseparation with outward displaced distal end
图4-1-21 就诊时X线片示右肱骨上端骨骺分离，远端向外侧移位
Figure4-1-22 Corrected displacement withgood alignment
图4-1-22 复位后复查X线片示骨折端对位对线良好
Figure4-1-23 Fixation after bone-settingmanipulation
图4-1-23 复位后维持固定