肩胛骨的临床解剖学研究
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摘要
目的和意义
肩胛骨为一扁宽形不规则骨，呈不规整三角形，分二面三缘，前面微凸，与胸后上壁相适应，不仅有保护胸腔的作用，还有固定上肢的作用。在上臂上举整个过程中，2／3的活动发生在肩关节，1／3的活动发生于肩胛胸壁之间。肩胛胸壁之间虽不具备典型的关节结构的解剖特点，但却提供相当于关节的功能活动。从肩胛骨功能及其肌肉附着分布上看，肩胛骨外缘和肩峰附着的肌肉最多，故骨质最坚强，该两处的骨嵴长而坚硬。对肩胛骨的活动起到最大的支撑作用，肩胛骨的上缘虽骨质薄而短，因有喙突的加强，对肩胛骨有较大的支撑作用。肩胛骨的一般性的解剖学测量已有足够的数据，但是缺乏大样本的密切结合临床的应用解剖学研究。近年来肩胛骨手术年手术量有不断增加的趋势；针对肩胛骨的手术入路也在不断的改进和完善。但是，各种手术入路对肩胛骨及其血供的影响尚缺乏深入研究，缺乏大样本的密切结合临床的应用解剖学研究，不同疾病手术入路的选择主要依据病变的部位和手术者的习惯，缺乏明确的解剖学依据。现在对肩胛骨的研究仅限于外在形态，本文研究了肩胛骨的详细外形、血供特点及肩胛骨血供的起源、行径、分型、管径、分布规律。在临床上，肩胛骨的骨折、肿瘤、发育异常及肩关节脱位等常用手术的方式的治疗，就对肩胛骨的详细外形及血供特点的临床解剖学研究提出了更高的要求，本研究可以有助于我们加深对肩胛骨血供的了解，以便于肩胛骨手术的处理。
方法
1．随机抽取50侧(左28，右22)成人肩胛骨干燥标本，标本完整无缺损，首先观测标本的大体形态特征，然后用千分尺测量其长度和厚度，精确到0.1mm，用角度仪测量其角度，精确到1°。所有标本都是同一个人用同样的游标卡尺测量。
2．选用20具经防腐固定处理的成人尸体标本(男12，女8)，经股动脉灌注红色乳胶，所有标本均无畸形、骨折、感染及肿瘤，亦无肩胛骨手术史。解剖器械1套，游标卡尺(精确度0.02mm)，量角器，直尺等测量工具，解剖暴露肩胛骨的肩胛上动脉、肩胛背动脉和旋肩胛动脉，观察测量了肩胛骨的血供情况及肩胛骨血供的起源、行径、分型、管径、分布规律。用游标卡尺(精确到0.1mm)测量肩胛骨供血血管的外径。
3．选取1具新鲜成人尸体标本，经腹主动脉灌注聚苯乙烯(PS)，在铸型标本上观察肩胛骨的动脉的分支、分布及吻合。
4．回顾分析2003年1月至2007年1月收治的25例经手术治疗的肩胛骨骨折的临床资料，根据Hardegger的分型方法，体部骨折18例，肩胛颈部骨折12例，肩胛盂缘骨折5例，肩胛盂窝骨折3例，肩胛冈骨折9例，肩峰骨折6例，喙突骨折5例，其中混合型骨折18例，伴有合并损伤16例，采用重建钢板及拉力螺钉的方法行骨折内固定。
结果
1．解剖学研究
1．1肩胛骨是块前凹的不规则的三角形骨，后面被肩胛冈分为上下两部分，冈上窝及冈下窝骨质最薄弱，在肩胛冈根部上面，有一个滋养孔，比较恒定，直径大约2mm。肩胛骨大部分被肌肉包绕，其在肩部功能重要，是连接躯干和上肢的重要结构。
1．2肩胛骨的相关重要结构测量值包括：肩胛骨的长度为154.7±10.7mm，肩胛骨内缘中点处的厚度(距内缘0.5cm为3.6±0.7mm，肩胛盂下1cm、2cm、4cm(距外缘0.5cm)的厚度为14.0±2.1mm、9.5±1.9mm、8.8±2.6mm，距肩胛盂0.5cm、1cm、2cm处的肩胛盂颈厚度为23.1±3.4mm、18.1±1.8mm、13.5±1.5mm，肩胛盂的前后径厚度(28.3±2.7)mm，肩胛盂的上下径厚度(39.2±2.4)mm，肩胛冈内侧4cm、8cm的厚度为3.1±3.4mm、34.3±1.7mm，肩峰的厚度(内前1cm)为7.4±1.1mm，肩盂倾角为18.8±2.3°。
1．3肩胛骨的血液供应来源于肩胛上动脉、肩胛背动脉和旋肩胛动脉，彼此互相吻合，其中肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘分别有肩胛上动脉、肩胛背动脉和旋肩胛动脉供血。肩胛骨的血供属于弥散型供血，血供丰富，肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘等每个区域都有一条主要的供血动脉供应，但是动脉之间都有交通。
2．肩胛骨骨折的手术治疗
25例肩胛骨骨折，损伤后7天内手术12例，3周内手术7例，3周以上手术6例。手术显露：①后上入路6例，用于处理肩峰，盂窝上半骨折。②后方入路12例，用于处理体部，肩胛冈，盂窝及肩胛颈骨折。③前方入路5例，用于处理喙突和盂缘前部骨折。④前后联合入路2例。本组肩胛骨体部骨折应用重建钢板固定14例，肩盂骨折可吸收螺钉固定4例，拉力螺钉固定3例；肩胛颈骨折重建钢板固定8例，经肩胛冈拉力螺钉悬吊固定4例；喙突骨折拉力螺钉固定5例；肩峰骨折斜“6”形钢板固定3例，拉力螺钉固定3例；肩胛冈骨折重建钢板固定3例，张力带钢丝固定1例。15例患者获得随访，随访时间10∽25个月，平均16.5个月，根据Rowe的疗效评价标准，优11例，良2例，可1例，差1例，优良率为86.6％。术后并发症主要包括：切口感染1例，肩关节创伤性关节炎2例，肩关节外展受限肌力减弱2例。
结论
1．肩胛骨为一扁宽形不规则骨，呈不规整三角形，分二面三缘，前面微凸，与胸后上壁相适应，不仅有保护胸腔的作用，还有固定上肢的作用。从肩胛骨功能及其肌肉附着分布上看，肩胛骨外缘和肩峰附着的肌肉最多，故骨质最坚强，该两处的骨嵴长而坚硬。对肩胛骨的活动起到最大的支撑作用，肩胛骨的上缘虽骨质薄而短，因有喙突的加强，对肩胛骨有较大的支撑作用。颈部骨折多由肱骨传导来的间接暴力所致，该处骨折多为嵌插性和粉碎性，体部骨折多为直接暴力所致，因肩胛骨前后均有肌肉保护，多无明显骨折移位。当暴力足够大时可致移位。肩胛骨后面被肩胛冈分为两部分，岗上窝和冈下窝骨质最薄，有时呈透明状，骨折时呈粉碎性，此处无法放置固定物。
2．肩胛骨的外缘及肩胛盂处有足够的骨量可以支持内固定物的植入，如螺钉、钢针、钢丝及钢板等，内固定物的应用有助于稳定肩锁关节和盂肱关节脱位。肩胛冈内侧4cm、8cm的厚度为3.1±3.4mm、34.3±1.7mm，肩峰的厚度(内前1cm)为7.4±1.1mm，因此也可以行内固定物的植入，用于治疗肩胛冈及肩峰处的骨折。肩胛骨的的内外侧缘及肩胛冈构成了整个肩胛骨的支撑系统。对肩胛骨颈部骨折，其外缘骨嵴极适用于安置内固定物，且手术显露较内缘容易。尽管颈部骨折有多种内固定物可供选择，除盂窝处小骨折外，用单一螺钉内固定效果不佳，该处骨折位置深，即使骨折也可良好复位，但沿该处致密骨嵴穿针或螺钉不易控制方向，而它处骨质薄弱，螺钉不能有效地使骨折块固定。同时，颈部骨折多系嵌插性和粉碎性骨折，骨折碎片摘除后用单一螺钉固定势必会造成颈部变短，骨折也难以良好对位，故钢板在该处可起到对骨折拉拢或支撑作用。
3．肩盂倾角为13.3°±6.1°，范围是1°～22°，均为后倾，此角度对于肩胛骨颈部骨折内固定物的植入方向有重要的意义。
4．肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘分别有肩胛上动脉、肩胛背动脉和旋肩胛动脉供血。肩胛骨的血供属于弥散型供血，血供丰富，肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘等每个区域都有一条主要的供血动脉供应，但是动脉之间都有交通。
5．肩胛冈、肩胛骨内缘和肩胛骨外缘分别可以做肩胛上动脉、肩胛背动脉和旋肩胛动脉的带血管蒂的骨移植。
6．肩胛骨骨折选择手术治疗可以通过骨折端的解剖复位和坚强内固定，使患者获得肌肉、骨折部位邻近关节早期无痛的功能锻炼，以免非手术治疗长期制动所造成的肩关节永久性的功能障碍。
Objective and Significance
The scapula is a flat width shape irregular bone, assumes triangle, microfront is raised, on the wall adapts after the chest, not only has protects thechestcavity, but also has the fixed upper limb function, In the upper arm process, 2 /3 activity occurs in the shoulder joint, 1/3 activity has between scapula and chestcavity. The scapula and chestcavity although does not have the model joint structure dissection characteristic, but actually provides equal to the joint function activity。Attach in the distribution from the shoulder blade function and its muscle to look, the scapula outflow boundary and the acromion attaching muscle most, therefore ossein strongest, this bones is long and hard。the scapula' s superior view although is thin and are short, but it has coracoid strengthened, has the bigger strut function to scapula。The scapula general anatomy had the enough data, but lacks the big sample the big union clinical application anatomy research。In recent years, the scapula surgery every year had the increaseing the tendency; Enters the road inview of the scapula surgery also in the increaseing improvement the consummation。But, each kind of surgery entered the road the influence which supplied to the scapula and its the blood supply to lack the thorough research, lacked the big sample the close union clinical application anatomy research, the different disease surgery entereing road, the main choice basis pathological change spot and the surgery custom, lacked the explicit anatomy basis。Now it was restricted in the external shape to the scapula research, this article has studied the scapula detailed contour, the blood supply, the act, dividing which supplied for the characteristic and the scapula blood, the caliber, the distributed rule。In clinics, scapula fracture, tumor, growth exceptionallyand shoulder joint, and so on commonly used surgery way treatment, proposed to the scapula detailed contour and the blood for the characteristic clinical anatomy research a higher request, this research may be helpful to deepen the understanding which supplies to the scapula blood, in order to scapula surgery processing。
Materials and Methods
1.50 sides (left 28, right 22) the adult scapula dry specimen, the specimen integrity does not have the damage, first observes the specimen roughly the shape characteristic, then surveys its length and thickness with the micrometer, precisely arrives 0.1mm, surveys its angle with the goniometer, precisely to 1°。All specimens are measured with Similar by the identical person。
2. Selects 20 specimen after the anticorrosion fixed processing adult corpsespecimen (male 12, female 8), after pours into the red emulsion, all specimens not are abnormal, the bone fracture, the infection and the tumor, also scapula surgery history。Dissects the instrument 1 set, vernier caliper (precision 0. 02mm), the angle gauge, measuring tool and so on straight edge, the dissection exposed the suprascapular artery, the scapular dorsal artery and the circumflexa scapular artery, the observation has surveyed the sscapu]a blood' s origin, the act, dividing which supplied for the situation and the scapula blood, the caliber, the distributed rule。Vernier caliper (aspreciselyas 0.1mm) surveys the scapula to donate the blood vessel outer diameter。
3. Selects 1 fresh adult specimen, pours the polystyrene into the abdomen aorta (PS), in casts on the specimen to observe the scapular artery branch, the distribution and tallies。
4. 25 cases of scapular fractures were reviewed from January 2003 to January 2007, According to Hardegger' s classification, 18 fractures of the scapular body , 12 fractures of the scapular neck, 5 fractures of the glenoid rim , 3 fractures of the glenoid fossa, 9 fractures of scapular spine, 6 fractures of the acromion, 5 fractures of the coracoid process, 18 complex fractures of scapular, 16 cases had association injures。All cases were fixed with reconstruction plate and lag screws。
Results
1. Anatomy research
1.1 scapula are in front of the block the concave irregular triangle bone, behind is divided into two parts by the scapula post, in the post the nest and the ossein weakest, above the scapula post root, quite is constant, diameter approximately 2mm。the scapula by muscle encystation, it is important in the shoulder department function, connects the torso and the upper limb' s important structure。
1.2 scapula correlation important structure observed valuesinclude: the scapula length for154.7±10.7mm, in thescapulareason center point place thickness (is apart from reason 0. 5cm) is 3.6±0.7mm, under the scapular glenoid 1cm, 2cm, 4cm (are apart from outflow boundary 0. 5cm) thickness for 14.0±2.1mm, 9.5±1.9mm, 8.8±2.6mm, is apart from scapular glenoid 0.5cm, 1cm, 2cm place scapular glenoid neck thickness for 23.1±3.4mm, 18.1±1.8mm, 13.5±1.5mm, the dimensions of the glenbid fossa is (28.3±2.7) mm, (39.2±2.4) mm, the scapular spine inside4cm, the8cm thickness for3.1±3.4mm, 34.3±1.7mm, acromion' s thickness is 7.4±1. 1mm, The glenoid tilt angle is(18.8±2.3)。
1.3 scapular blood supplies originates from the suprascapular artery, the scapular dorsal artery and the circumflexa scapular artery, each other tallies, the scapularspine, the scapula inflow boundary and the scapula outflow boundary separately has the suprascapular artery, the scapular dorsal artery and the circumflexa scapular artery to supply the blood。The scapular blood belongs to the dissemination to donate blood, the blood supplies richly, between the artery all has the transportation。
2. scapular fractures surgery treatment 25 examples scapular fracture, damages in latter 7day surgery 12, in 3 weeks surgery 7, above 3 weeks surgery 6. The surgery revealed that, (1) the posteriorsuperior approach 6 examples, used to process the acromion, scapular glenoid fracture。(2) the posterior approach 12 examples, uses to process the body department, scapular spine, scapular glenoid fossea, scapular neck fracture。(3) the anterior approach 5 examples, uses to process coracoid and scapular glenoid' s anterior department fracture。(4) the posterior and anterior approach 2 examples。This group of scapular fracture applicationre construction steel plate fixed 14 examples, the scapular containerbone bolt absorbed 4 examples, the pulling force bolt 3 examples; scapular neck bone fracturereconstruction steel plate fixed 8 examples, after scapular spine postpulling force bolt suspension fixed 4 examples; coracoid fracture pulling force bolt 5 examples; The acromion fractureis slanting "6" the shape steel plate fixed 3 examples, the pullingforce bolt 3 examples; scapular post bone fracturereconstruction steel plate fixed 3 examples, steel wire fixed 1 example。15 examples patients obtain a follow-up visit, make a follow-up visit for 10～25 months, the average 16.5months, according to Rowe curative effect evaluation criteria, superior 11 examples, good 2 examples, general 1 example, bad lexample, fine rate is 86.6%. After the surgery, the illnesscomplication mainly includes: The margin infects 1 example, the shoulder joint wound arthritis 2 examples, the shoulder joint limited and the myo- strength weakened 2 examples。
Conclusion
1. The scapula is a flatwidth shape irregular bone, assumes triangle, microfront is raised, on the wall adapts after the chest, not only has protects the chestcavity, but also has the fixed upper limb function。In the upper arm process, 2/3 activity occurs in the shoulder joint, 1/3 activity has between scapula and chestcavity。The scapula and chestcavity although does not have the model joint structure dissection characteristic, but actually provides equal to the joint function activity。Attach in the distribution from the shoulder blade function and its muscle to look, the scapula outflow boundary and the acromion attaching muscle most, therefore ossein strongest, this bones is long and hard。the scapula' s superior view although is thin and are short, but it has coracoid strengthened, has the bigger strut function to scapula
2. scapular outflow boundaries and the scapular glenoid have the enough bone quantity to be allowed to support fixture implanting, like the bolt, the steel needle, the steel wire and the steel plate, and so on, in the fixture application is belpfulto the stable shoulder。scapular spine inside 4cm, the 8cm thickness is 3.1±3.4mm, 34.3±1.7mm, acromion thickness is 7. 4±1.1mm, therefore this also may use the line fixture implanting, used to treat acromion and the scapular spine' s fracture, scapular inside and outside and the scapular spine constituted the entire shoulder blade strut system. To the scapular fracture, its outflow boundary bone extremely is suitable in the placement the fixture, also the surgery revealed in the reason is easier. Although the pate bone fracture has the many kinds of in fixtures to be possible to supply the choice, besides the container nest small bone fracture, the fixed effect is not good with the sole bolt in, this place bone fracture position, even if the bone fracture also may good reposition, but threads a needle or the bolt along the this place compact bone is noteasy to control the direction, but it locates the ossein weakly, the bolt cannot effectively cause the bone fracture block to be fixed。At the same time, the pate bone fracture many will be inlays inserts the natural and the smashing bone fracture, after the bone fracturefragment excises with is unitary inevitably will be able to create the pate to shorten, bone fracture also with difficulty to position, therefore the steel plate might play in this place or the strut role to the bone fracture。
3. The glenoid tilt angle is 13.3°～6.1°, the scope is 1°～22°, this angle of the fixture implants the direction regarding the scapular fracture have the vital significance。
4. 3 scapular blood supplies originates from the suprascapular artery, the scapular dorsal artery and the circumflexa scapular arteryo The scapula belongs to the dissemination to donate blood, the blood supplies richly, in the scapular post and its the scapular post in the nest, the scapular spine and scapular outflow boundary and so on each region has mainly the artery supply, all of the artery has transportation。
5. the scapular spine and the scapular outflow boundary and the scapular outflow boundary may make the scapula transplant with artery。
6. The scapula fracture choice surgery treats and strong fixition, causes the patient to obtain the muscle, the bone fracture spot neighbor joint early time non-pain function exercise, in order to avoid the nonsurgery treats the shoulder joint permanentfunction barrier whichapplies the brake to create for a long time。
肩胛骨为一扁宽形不规则骨，呈不规整三角形，分二面三缘，前面微凸，与胸后上壁相适应，不仅有保护胸腔的作用，还有固定上肢的作用。在上臂上举整个过程中，2／3的活动发生在肩关节，1／3的活动发生于肩胛胸壁之间。肩胛胸壁之间虽不具备典型的关节结构的解剖特点，但却提供相当于关节的功能活动。从肩胛骨功能及其肌肉附着分布上看，肩胛骨外缘和肩峰附着的肌肉最多，故骨质最坚强，该两处的骨嵴长而坚硬。对肩胛骨的活动起到最大的支撑作用，肩胛骨的上缘虽骨质薄而短，因有喙突的加强，对肩胛骨有较大的支撑作用。肩胛骨的一般性的解剖学测量已有足够的数据，但是缺乏大样本的密切结合临床的应用解剖学研究。近年来肩胛骨手术年手术量有不断增加的趋势；针对肩胛骨的手术入路也在不断的改进和完善。但是，各种手术入路对肩胛骨及其血供的影响尚缺乏深入研究，缺乏大样本的密切结合临床的应用解剖学研究，不同疾病手术入路的选择主要依据病变的部位和手术者的习惯，缺乏明确的解剖学依据。现在对肩胛骨的研究仅限于外在形态，本文研究了肩胛骨的详细外形、血供特点及肩胛骨血供的起源、行径、分型、管径、分布规律。在临床上，肩胛骨的骨折、肿瘤、发育异常及肩关节脱位等常用手术的方式的治疗，就对肩胛骨的详细外形及血供特点的临床解剖学研究提出了更高的要求，本研究可以有助于我们加深对肩胛骨血供的了解，以便于肩胛骨手术的处理。
方法
1．随机抽取50侧(左28，右22)成人肩胛骨干燥标本，标本完整无缺损，首先观测标本的大体形态特征，然后用千分尺测量其长度和厚度，精确到0.1mm，用角度仪测量其角度，精确到1°。所有标本都是同一个人用同样的游标卡尺测量。
2．选用20具经防腐固定处理的成人尸体标本(男12，女8)，经股动脉灌注红色乳胶，所有标本均无畸形、骨折、感染及肿瘤，亦无肩胛骨手术史。解剖器械1套，游标卡尺(精确度0.02mm)，量角器，直尺等测量工具，解剖暴露肩胛骨的肩胛上动脉、肩胛背动脉和旋肩胛动脉，观察测量了肩胛骨的血供情况及肩胛骨血供的起源、行径、分型、管径、分布规律。用游标卡尺(精确到0.1mm)测量肩胛骨供血血管的外径。
3．选取1具新鲜成人尸体标本，经腹主动脉灌注聚苯乙烯(PS)，在铸型标本上观察肩胛骨的动脉的分支、分布及吻合。
4．回顾分析2003年1月至2007年1月收治的25例经手术治疗的肩胛骨骨折的临床资料，根据Hardegger的分型方法，体部骨折18例，肩胛颈部骨折12例，肩胛盂缘骨折5例，肩胛盂窝骨折3例，肩胛冈骨折9例，肩峰骨折6例，喙突骨折5例，其中混合型骨折18例，伴有合并损伤16例，采用重建钢板及拉力螺钉的方法行骨折内固定。
结果
1．解剖学研究
1．1肩胛骨是块前凹的不规则的三角形骨，后面被肩胛冈分为上下两部分，冈上窝及冈下窝骨质最薄弱，在肩胛冈根部上面，有一个滋养孔，比较恒定，直径大约2mm。肩胛骨大部分被肌肉包绕，其在肩部功能重要，是连接躯干和上肢的重要结构。
1．2肩胛骨的相关重要结构测量值包括：肩胛骨的长度为154.7±10.7mm，肩胛骨内缘中点处的厚度(距内缘0.5cm为3.6±0.7mm，肩胛盂下1cm、2cm、4cm(距外缘0.5cm)的厚度为14.0±2.1mm、9.5±1.9mm、8.8±2.6mm，距肩胛盂0.5cm、1cm、2cm处的肩胛盂颈厚度为23.1±3.4mm、18.1±1.8mm、13.5±1.5mm，肩胛盂的前后径厚度(28.3±2.7)mm，肩胛盂的上下径厚度(39.2±2.4)mm，肩胛冈内侧4cm、8cm的厚度为3.1±3.4mm、34.3±1.7mm，肩峰的厚度(内前1cm)为7.4±1.1mm，肩盂倾角为18.8±2.3°。
1．3肩胛骨的血液供应来源于肩胛上动脉、肩胛背动脉和旋肩胛动脉，彼此互相吻合，其中肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘分别有肩胛上动脉、肩胛背动脉和旋肩胛动脉供血。肩胛骨的血供属于弥散型供血，血供丰富，肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘等每个区域都有一条主要的供血动脉供应，但是动脉之间都有交通。
2．肩胛骨骨折的手术治疗
25例肩胛骨骨折，损伤后7天内手术12例，3周内手术7例，3周以上手术6例。手术显露：①后上入路6例，用于处理肩峰，盂窝上半骨折。②后方入路12例，用于处理体部，肩胛冈，盂窝及肩胛颈骨折。③前方入路5例，用于处理喙突和盂缘前部骨折。④前后联合入路2例。本组肩胛骨体部骨折应用重建钢板固定14例，肩盂骨折可吸收螺钉固定4例，拉力螺钉固定3例；肩胛颈骨折重建钢板固定8例，经肩胛冈拉力螺钉悬吊固定4例；喙突骨折拉力螺钉固定5例；肩峰骨折斜“6”形钢板固定3例，拉力螺钉固定3例；肩胛冈骨折重建钢板固定3例，张力带钢丝固定1例。15例患者获得随访，随访时间10∽25个月，平均16.5个月，根据Rowe的疗效评价标准，优11例，良2例，可1例，差1例，优良率为86.6％。术后并发症主要包括：切口感染1例，肩关节创伤性关节炎2例，肩关节外展受限肌力减弱2例。
结论
1．肩胛骨为一扁宽形不规则骨，呈不规整三角形，分二面三缘，前面微凸，与胸后上壁相适应，不仅有保护胸腔的作用，还有固定上肢的作用。从肩胛骨功能及其肌肉附着分布上看，肩胛骨外缘和肩峰附着的肌肉最多，故骨质最坚强，该两处的骨嵴长而坚硬。对肩胛骨的活动起到最大的支撑作用，肩胛骨的上缘虽骨质薄而短，因有喙突的加强，对肩胛骨有较大的支撑作用。颈部骨折多由肱骨传导来的间接暴力所致，该处骨折多为嵌插性和粉碎性，体部骨折多为直接暴力所致，因肩胛骨前后均有肌肉保护，多无明显骨折移位。当暴力足够大时可致移位。肩胛骨后面被肩胛冈分为两部分，岗上窝和冈下窝骨质最薄，有时呈透明状，骨折时呈粉碎性，此处无法放置固定物。
2．肩胛骨的外缘及肩胛盂处有足够的骨量可以支持内固定物的植入，如螺钉、钢针、钢丝及钢板等，内固定物的应用有助于稳定肩锁关节和盂肱关节脱位。肩胛冈内侧4cm、8cm的厚度为3.1±3.4mm、34.3±1.7mm，肩峰的厚度(内前1cm)为7.4±1.1mm，因此也可以行内固定物的植入，用于治疗肩胛冈及肩峰处的骨折。肩胛骨的的内外侧缘及肩胛冈构成了整个肩胛骨的支撑系统。对肩胛骨颈部骨折，其外缘骨嵴极适用于安置内固定物，且手术显露较内缘容易。尽管颈部骨折有多种内固定物可供选择，除盂窝处小骨折外，用单一螺钉内固定效果不佳，该处骨折位置深，即使骨折也可良好复位，但沿该处致密骨嵴穿针或螺钉不易控制方向，而它处骨质薄弱，螺钉不能有效地使骨折块固定。同时，颈部骨折多系嵌插性和粉碎性骨折，骨折碎片摘除后用单一螺钉固定势必会造成颈部变短，骨折也难以良好对位，故钢板在该处可起到对骨折拉拢或支撑作用。
3．肩盂倾角为13.3°±6.1°，范围是1°～22°，均为后倾，此角度对于肩胛骨颈部骨折内固定物的植入方向有重要的意义。
4．肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘分别有肩胛上动脉、肩胛背动脉和旋肩胛动脉供血。肩胛骨的血供属于弥散型供血，血供丰富，肩胛冈及其肩胛冈上窝、肩胛骨内缘和肩胛骨外缘等每个区域都有一条主要的供血动脉供应，但是动脉之间都有交通。
5．肩胛冈、肩胛骨内缘和肩胛骨外缘分别可以做肩胛上动脉、肩胛背动脉和旋肩胛动脉的带血管蒂的骨移植。
6．肩胛骨骨折选择手术治疗可以通过骨折端的解剖复位和坚强内固定，使患者获得肌肉、骨折部位邻近关节早期无痛的功能锻炼，以免非手术治疗长期制动所造成的肩关节永久性的功能障碍。
Objective and Significance
The scapula is a flat width shape irregular bone, assumes triangle, microfront is raised, on the wall adapts after the chest, not only has protects thechestcavity, but also has the fixed upper limb function, In the upper arm process, 2 /3 activity occurs in the shoulder joint, 1/3 activity has between scapula and chestcavity. The scapula and chestcavity although does not have the model joint structure dissection characteristic, but actually provides equal to the joint function activity。Attach in the distribution from the shoulder blade function and its muscle to look, the scapula outflow boundary and the acromion attaching muscle most, therefore ossein strongest, this bones is long and hard。the scapula' s superior view although is thin and are short, but it has coracoid strengthened, has the bigger strut function to scapula。The scapula general anatomy had the enough data, but lacks the big sample the big union clinical application anatomy research。In recent years, the scapula surgery every year had the increaseing the tendency; Enters the road inview of the scapula surgery also in the increaseing improvement the consummation。But, each kind of surgery entered the road the influence which supplied to the scapula and its the blood supply to lack the thorough research, lacked the big sample the close union clinical application anatomy research, the different disease surgery entereing road, the main choice basis pathological change spot and the surgery custom, lacked the explicit anatomy basis。Now it was restricted in the external shape to the scapula research, this article has studied the scapula detailed contour, the blood supply, the act, dividing which supplied for the characteristic and the scapula blood, the caliber, the distributed rule。In clinics, scapula fracture, tumor, growth exceptionallyand shoulder joint, and so on commonly used surgery way treatment, proposed to the scapula detailed contour and the blood for the characteristic clinical anatomy research a higher request, this research may be helpful to deepen the understanding which supplies to the scapula blood, in order to scapula surgery processing。
Materials and Methods
1.50 sides (left 28, right 22) the adult scapula dry specimen, the specimen integrity does not have the damage, first observes the specimen roughly the shape characteristic, then surveys its length and thickness with the micrometer, precisely arrives 0.1mm, surveys its angle with the goniometer, precisely to 1°。All specimens are measured with Similar by the identical person。
2. Selects 20 specimen after the anticorrosion fixed processing adult corpsespecimen (male 12, female 8), after pours into the red emulsion, all specimens not are abnormal, the bone fracture, the infection and the tumor, also scapula surgery history。Dissects the instrument 1 set, vernier caliper (precision 0. 02mm), the angle gauge, measuring tool and so on straight edge, the dissection exposed the suprascapular artery, the scapular dorsal artery and the circumflexa scapular artery, the observation has surveyed the sscapu]a blood' s origin, the act, dividing which supplied for the situation and the scapula blood, the caliber, the distributed rule。Vernier caliper (aspreciselyas 0.1mm) surveys the scapula to donate the blood vessel outer diameter。
3. Selects 1 fresh adult specimen, pours the polystyrene into the abdomen aorta (PS), in casts on the specimen to observe the scapular artery branch, the distribution and tallies。
4. 25 cases of scapular fractures were reviewed from January 2003 to January 2007, According to Hardegger' s classification, 18 fractures of the scapular body , 12 fractures of the scapular neck, 5 fractures of the glenoid rim , 3 fractures of the glenoid fossa, 9 fractures of scapular spine, 6 fractures of the acromion, 5 fractures of the coracoid process, 18 complex fractures of scapular, 16 cases had association injures。All cases were fixed with reconstruction plate and lag screws。
Results
1. Anatomy research
1.1 scapula are in front of the block the concave irregular triangle bone, behind is divided into two parts by the scapula post, in the post the nest and the ossein weakest, above the scapula post root, quite is constant, diameter approximately 2mm。the scapula by muscle encystation, it is important in the shoulder department function, connects the torso and the upper limb' s important structure。
1.2 scapula correlation important structure observed valuesinclude: the scapula length for154.7±10.7mm, in thescapulareason center point place thickness (is apart from reason 0. 5cm) is 3.6±0.7mm, under the scapular glenoid 1cm, 2cm, 4cm (are apart from outflow boundary 0. 5cm) thickness for 14.0±2.1mm, 9.5±1.9mm, 8.8±2.6mm, is apart from scapular glenoid 0.5cm, 1cm, 2cm place scapular glenoid neck thickness for 23.1±3.4mm, 18.1±1.8mm, 13.5±1.5mm, the dimensions of the glenbid fossa is (28.3±2.7) mm, (39.2±2.4) mm, the scapular spine inside4cm, the8cm thickness for3.1±3.4mm, 34.3±1.7mm, acromion' s thickness is 7.4±1. 1mm, The glenoid tilt angle is(18.8±2.3)。
1.3 scapular blood supplies originates from the suprascapular artery, the scapular dorsal artery and the circumflexa scapular artery, each other tallies, the scapularspine, the scapula inflow boundary and the scapula outflow boundary separately has the suprascapular artery, the scapular dorsal artery and the circumflexa scapular artery to supply the blood。The scapular blood belongs to the dissemination to donate blood, the blood supplies richly, between the artery all has the transportation。
2. scapular fractures surgery treatment 25 examples scapular fracture, damages in latter 7day surgery 12, in 3 weeks surgery 7, above 3 weeks surgery 6. The surgery revealed that, (1) the posteriorsuperior approach 6 examples, used to process the acromion, scapular glenoid fracture。(2) the posterior approach 12 examples, uses to process the body department, scapular spine, scapular glenoid fossea, scapular neck fracture。(3) the anterior approach 5 examples, uses to process coracoid and scapular glenoid' s anterior department fracture。(4) the posterior and anterior approach 2 examples。This group of scapular fracture applicationre construction steel plate fixed 14 examples, the scapular containerbone bolt absorbed 4 examples, the pulling force bolt 3 examples; scapular neck bone fracturereconstruction steel plate fixed 8 examples, after scapular spine postpulling force bolt suspension fixed 4 examples; coracoid fracture pulling force bolt 5 examples; The acromion fractureis slanting "6" the shape steel plate fixed 3 examples, the pullingforce bolt 3 examples; scapular post bone fracturereconstruction steel plate fixed 3 examples, steel wire fixed 1 example。15 examples patients obtain a follow-up visit, make a follow-up visit for 10～25 months, the average 16.5months, according to Rowe curative effect evaluation criteria, superior 11 examples, good 2 examples, general 1 example, bad lexample, fine rate is 86.6%. After the surgery, the illnesscomplication mainly includes: The margin infects 1 example, the shoulder joint wound arthritis 2 examples, the shoulder joint limited and the myo- strength weakened 2 examples。
Conclusion
1. The scapula is a flatwidth shape irregular bone, assumes triangle, microfront is raised, on the wall adapts after the chest, not only has protects the chestcavity, but also has the fixed upper limb function。In the upper arm process, 2/3 activity occurs in the shoulder joint, 1/3 activity has between scapula and chestcavity。The scapula and chestcavity although does not have the model joint structure dissection characteristic, but actually provides equal to the joint function activity。Attach in the distribution from the shoulder blade function and its muscle to look, the scapula outflow boundary and the acromion attaching muscle most, therefore ossein strongest, this bones is long and hard。the scapula' s superior view although is thin and are short, but it has coracoid strengthened, has the bigger strut function to scapula
2. scapular outflow boundaries and the scapular glenoid have the enough bone quantity to be allowed to support fixture implanting, like the bolt, the steel needle, the steel wire and the steel plate, and so on, in the fixture application is belpfulto the stable shoulder。scapular spine inside 4cm, the 8cm thickness is 3.1±3.4mm, 34.3±1.7mm, acromion thickness is 7. 4±1.1mm, therefore this also may use the line fixture implanting, used to treat acromion and the scapular spine' s fracture, scapular inside and outside and the scapular spine constituted the entire shoulder blade strut system. To the scapular fracture, its outflow boundary bone extremely is suitable in the placement the fixture, also the surgery revealed in the reason is easier. Although the pate bone fracture has the many kinds of in fixtures to be possible to supply the choice, besides the container nest small bone fracture, the fixed effect is not good with the sole bolt in, this place bone fracture position, even if the bone fracture also may good reposition, but threads a needle or the bolt along the this place compact bone is noteasy to control the direction, but it locates the ossein weakly, the bolt cannot effectively cause the bone fracture block to be fixed。At the same time, the pate bone fracture many will be inlays inserts the natural and the smashing bone fracture, after the bone fracturefragment excises with is unitary inevitably will be able to create the pate to shorten, bone fracture also with difficulty to position, therefore the steel plate might play in this place or the strut role to the bone fracture。
3. The glenoid tilt angle is 13.3°～6.1°, the scope is 1°～22°, this angle of the fixture implants the direction regarding the scapular fracture have the vital significance。
4. 3 scapular blood supplies originates from the suprascapular artery, the scapular dorsal artery and the circumflexa scapular arteryo The scapula belongs to the dissemination to donate blood, the blood supplies richly, in the scapular post and its the scapular post in the nest, the scapular spine and scapular outflow boundary and so on each region has mainly the artery supply, all of the artery has transportation。
5. the scapular spine and the scapular outflow boundary and the scapular outflow boundary may make the scapula transplant with artery。
6. The scapula fracture choice surgery treats and strong fixition, causes the patient to obtain the muscle, the bone fracture spot neighbor joint early time non-pain function exercise, in order to avoid the nonsurgery treats the shoulder joint permanentfunction barrier whichapplies the brake to create for a long time。
引文
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14. Kreel L: Pseudotumour of the scapula. Postgrad Med J 65:94 - 95, 1989. 29.Momose T, Nakatuchi Y, Saitoh S: Total scapulectomy for metastatic pheochomocytoma of the scapula. Arch Orthop Trauma Surg 107:381 -384,1988.
30. Nercessian O, Denton JR: Cartilaginous exostosisarising from the ventral surface of the scapula. ClinOrthop 236:145-147, 1988.
31. Rubenstein DJ, Harkavy L, Glantz L: Periostealchondroma of the scapula. Skeletal Radiol 18:47-49,1989.
1. Hardegger Fh, simpsonLA, Weber BG. The operative treatment of scapular fracture bone .J bone Surg BR 1984, 66:725-731.
2. Nordqvis, petersson, fracture of the body, neck orspine of the scapular a long-term follow-up study clinorthop 1992, 283:139-144.
3. Ideberg R, Grevsten S, Larsson A, et al. Epidemiology of scapular fractures. Incidence and classification of 338 fractures [J]. A cta O rthopScand, 1995, 66: 3952397.
4. Hardegger FH, Simpson L EX A, Weber BG. The operative treatment of scapular fracture [J]. J Bone Joint Surg (Br), 1984, 66: 7252731.
5. Brian F, Kavanagh, John K, et al. Open reduction and internal fixation of displaced intraarticular fractures of the glenod fossa [J]. J Bone Joint Surg (Am), 1993, 75: 4792484.
6．王兆杰，安荣泽，薛黔，等．肩胛盂骨折后方手术入路的解剖及临床应用[J]．中国矫形外科杂志，2001，8：6562658．
7. Norris TR, Green A. Proximal humerus fractures and gleno2humeral dislocations. In: Browner BD, Jupiter JB, Levine AM, et al eds. Skeletal Trauma. 2 ed. Philadelphia : WB Saunders, 1998.
8. McAdams TR, Blevins FT, Martin TP, et al. The role of plainfilms and computed tomography in the evaluation of scapular neckfractures. J Orthop Trauma, 2002, 16: 7211.
9. Miler ME, Ada JR. injurie to shouder girdle. WB saunders Harcourt publisher simited 1998.1657-1670.
10. Cole PA. Scapula fractures. Orthop Clin North Am , 2002 , 33 :12 18.
11. Miller MR , Ada JR. Injuries to the shoulder girdle. In : Browner BD , J upiter JB , Levine AM , et al (eds) . Skeletal Trauma , ed 2. Philadelphia : WB Saunders , 1998.
12. Goss TP. Glenoid Fractures : Open reduction internal fixation. InWiss DA , ed. Master Techniques in Orthopaedic Surgery : Frac2tures. Philadelphia : Lippincott2Raven , 1998.
13.van Noort A , te Slaa RL , Marti RK, et al. The floating shoulder . A multicentre study. J Bone Joint Surg Br , 2001 , 83 :7952 798.
1. Hardegger Fh, simpsonLA, Weber BG. The operative treatment of scapular fracture bone. J bone Surg BR 1984, 66:725-731.
2. Nordqvis, petersson, fracture of the body, neck orspine of the scapular a long-term follow-up study clinorthop 1992, 283:139-144.
3. Cole PA. Scapula fractures. Orthop Clin North Am, 2002, 33:12 18.
4. Miller MR, Ada JR. Injuries to the shoulder girdle. In: Browner BD, J upiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 2. Philadelphia : WB Saunders, 1998.
5. Brian F, Kavanagh, John K, et al. Open reduction and internal fixation of displaced intraarticular fractures of the glenod fossa [J]. J Bone Joint Surg (Am), 1993, 75: 4792484.
6．王兆杰，安荣泽，薛黔，等．肩胛盂骨折后方手术入路的解剖及临床应用[J]．中国矫形外科杂志，2001，8：6562658．
7. Scavenius M, Sloth C. Fractures of the scapu]a. Acta OrthopBelg, 1996, 62:1292132.
8. Ideberg R , GrevstenS , Larsson S. Epidemiology of scapularfractures : Incidence and classification of 338 fractures. Acta Orthop Scand , 1995 , 66 :3952397.
9.Miler ME, Ada JR. injurie to shouder girdle. WB saunders Harcourt publisher simited 1998.1657-1670.
10. Mayo KA , Benirschke SK, Mast JW. Displaced fractures of theglenoid fossa : Results of open reduction and internal fixation. Clin Orthop , 1998 , (347) :1222130.
11.Norris TR , Green A. Proximal humerus fractures and gleno2humeral dislocations. In : Browner BD , J upiter JB , Levine AM , et al eds. Skeletal Trauma. 2 ed. Philadelphia : WB Saunders , 1998.
12. McAdams TR , Blevins FT , Martin TP , et al. The role of plainfilms and computedtomography in the evaluation of scapular neckfractures. J Orthop Trauma , 2002 , 16 : 7211.
13. Goss TP. Glenoid Fractures : Open reduction internal fixation. InWiss DA , ed. Master Techniques in Orthopaedic Surgery : Frac2tures. Philadelphia : Lippincott2Raven , 1998.
14. van Noort A , te Slaa RL , Marti RK, et al. The floating shoulder . A multicentre study. J Bone Joint Surg Br , 2001 , 83 :7952 798.
15. Ramos L , Mencia R , Alonso A , et al. Conservative treatment ofipsilateral fractures of the scapula and clavicle. J Trauma , 1997 , 42 :2392242.
16. Egol KA , Connor PM , Karunakar MA , et al. The floating shoulder : Clinical and functional results. J Bone Joint Surg Am , 2001 , 832A :118821194.
17. Ramsey ML , SilverbergD , Lannotti JP , et al. Ipsilateral glenoid neck and clavicle fracture : a clinical investigation. Read at the an2nual Meeting of the American Academy of Orthopaedic Surgeons , 1999 , 428.
18. Reudi T , Chapman MW. Fractures of the scapula and clavicle. In : Chapman MW , ed. Operative Orthopaedics. Philadelphia :JB Lippincott , 1998 , 1972202.
19. Goss TP. The scapula : coracoid , acromial and avulsion fractures. Am J Orthop , 1996 , 25 :1062115.
20. Ogawa K, Naniwa T. Fractures of the acromion and the lateralscapular spine. J Shoulder Elbow Surg , 1997 , 6 :5442548.
21. Ogawa K, Yoshida A. Fracture of the superior border of the scapula. Int Orthop , 1997 , 21 : 3712373.
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16. Nercessian 0, Denton JR: Cartilaginous exostosisarising from the ventral surface of the scapula. ClinOrthop 236:145-147, 1988.
17. Rubenstein DJ, Harkavy L, Glantz L: Periostealchondroma of the scapula. Skeletal Radiol 18:47-49, 1989.
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28. Kreel L: Pseudotumour of the scapula. Postgrad Med J 65:94 - 95, 1989.
14. Kreel L: Pseudotumour of the scapula. Postgrad Med J 65:94 - 95, 1989. 29.Momose T, Nakatuchi Y, Saitoh S: Total scapulectomy for metastatic pheochomocytoma of the scapula. Arch Orthop Trauma Surg 107:381 -384,1988.
30. Nercessian O, Denton JR: Cartilaginous exostosisarising from the ventral surface of the scapula. ClinOrthop 236:145-147, 1988.
31. Rubenstein DJ, Harkavy L, Glantz L: Periostealchondroma of the scapula. Skeletal Radiol 18:47-49,1989.
1. Hardegger Fh, simpsonLA, Weber BG. The operative treatment of scapular fracture bone .J bone Surg BR 1984, 66:725-731.
2. Nordqvis, petersson, fracture of the body, neck orspine of the scapular a long-term follow-up study clinorthop 1992, 283:139-144.
3. Ideberg R, Grevsten S, Larsson A, et al. Epidemiology of scapular fractures. Incidence and classification of 338 fractures [J]. A cta O rthopScand, 1995, 66: 3952397.
4. Hardegger FH, Simpson L EX A, Weber BG. The operative treatment of scapular fracture [J]. J Bone Joint Surg (Br), 1984, 66: 7252731.
5. Brian F, Kavanagh, John K, et al. Open reduction and internal fixation of displaced intraarticular fractures of the glenod fossa [J]. J Bone Joint Surg (Am), 1993, 75: 4792484.
6．王兆杰，安荣泽，薛黔，等．肩胛盂骨折后方手术入路的解剖及临床应用[J]．中国矫形外科杂志，2001，8：6562658．
7. Norris TR, Green A. Proximal humerus fractures and gleno2humeral dislocations. In: Browner BD, Jupiter JB, Levine AM, et al eds. Skeletal Trauma. 2 ed. Philadelphia : WB Saunders, 1998.
8. McAdams TR, Blevins FT, Martin TP, et al. The role of plainfilms and computed tomography in the evaluation of scapular neckfractures. J Orthop Trauma, 2002, 16: 7211.
9. Miler ME, Ada JR. injurie to shouder girdle. WB saunders Harcourt publisher simited 1998.1657-1670.
10. Cole PA. Scapula fractures. Orthop Clin North Am , 2002 , 33 :12 18.
11. Miller MR , Ada JR. Injuries to the shoulder girdle. In : Browner BD , J upiter JB , Levine AM , et al (eds) . Skeletal Trauma , ed 2. Philadelphia : WB Saunders , 1998.
12. Goss TP. Glenoid Fractures : Open reduction internal fixation. InWiss DA , ed. Master Techniques in Orthopaedic Surgery : Frac2tures. Philadelphia : Lippincott2Raven , 1998.
13.van Noort A , te Slaa RL , Marti RK, et al. The floating shoulder . A multicentre study. J Bone Joint Surg Br , 2001 , 83 :7952 798.
1. Hardegger Fh, simpsonLA, Weber BG. The operative treatment of scapular fracture bone. J bone Surg BR 1984, 66:725-731.
2. Nordqvis, petersson, fracture of the body, neck orspine of the scapular a long-term follow-up study clinorthop 1992, 283:139-144.
3. Cole PA. Scapula fractures. Orthop Clin North Am, 2002, 33:12 18.
4. Miller MR, Ada JR. Injuries to the shoulder girdle. In: Browner BD, J upiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 2. Philadelphia : WB Saunders, 1998.
5. Brian F, Kavanagh, John K, et al. Open reduction and internal fixation of displaced intraarticular fractures of the glenod fossa [J]. J Bone Joint Surg (Am), 1993, 75: 4792484.
6．王兆杰，安荣泽，薛黔，等．肩胛盂骨折后方手术入路的解剖及临床应用[J]．中国矫形外科杂志，2001，8：6562658．
7. Scavenius M, Sloth C. Fractures of the scapu]a. Acta OrthopBelg, 1996, 62:1292132.
8. Ideberg R , GrevstenS , Larsson S. Epidemiology of scapularfractures : Incidence and classification of 338 fractures. Acta Orthop Scand , 1995 , 66 :3952397.
9.Miler ME, Ada JR. injurie to shouder girdle. WB saunders Harcourt publisher simited 1998.1657-1670.
10. Mayo KA , Benirschke SK, Mast JW. Displaced fractures of theglenoid fossa : Results of open reduction and internal fixation. Clin Orthop , 1998 , (347) :1222130.
11.Norris TR , Green A. Proximal humerus fractures and gleno2humeral dislocations. In : Browner BD , J upiter JB , Levine AM , et al eds. Skeletal Trauma. 2 ed. Philadelphia : WB Saunders , 1998.
12. McAdams TR , Blevins FT , Martin TP , et al. The role of plainfilms and computedtomography in the evaluation of scapular neckfractures. J Orthop Trauma , 2002 , 16 : 7211.
13. Goss TP. Glenoid Fractures : Open reduction internal fixation. InWiss DA , ed. Master Techniques in Orthopaedic Surgery : Frac2tures. Philadelphia : Lippincott2Raven , 1998.
14. van Noort A , te Slaa RL , Marti RK, et al. The floating shoulder . A multicentre study. J Bone Joint Surg Br , 2001 , 83 :7952 798.
15. Ramos L , Mencia R , Alonso A , et al. Conservative treatment ofipsilateral fractures of the scapula and clavicle. J Trauma , 1997 , 42 :2392242.
16. Egol KA , Connor PM , Karunakar MA , et al. The floating shoulder : Clinical and functional results. J Bone Joint Surg Am , 2001 , 832A :118821194.
17. Ramsey ML , SilverbergD , Lannotti JP , et al. Ipsilateral glenoid neck and clavicle fracture : a clinical investigation. Read at the an2nual Meeting of the American Academy of Orthopaedic Surgeons , 1999 , 428.
18. Reudi T , Chapman MW. Fractures of the scapula and clavicle. In : Chapman MW , ed. Operative Orthopaedics. Philadelphia :JB Lippincott , 1998 , 1972202.
19. Goss TP. The scapula : coracoid , acromial and avulsion fractures. Am J Orthop , 1996 , 25 :1062115.
20. Ogawa K, Naniwa T. Fractures of the acromion and the lateralscapular spine. J Shoulder Elbow Surg , 1997 , 6 :5442548.
21. Ogawa K, Yoshida A. Fracture of the superior border of the scapula. Int Orthop , 1997 , 21 : 3712373.