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肩锁关节损伤(肩关节分离)

A shoulder separation from a fall on the point of the shoulder — grading, the bump that may remain, and when surgery is needed.

肩锁关节脱位示意图,外侧锁骨向上移位。
肩锁关节损伤(肩关节分离):锁骨远端向上翘起,远离肩胛骨。 Root4(one) / Wikimedia Commons, CC BY 2.5

本页面由机器翻译,尚未经临床医生审核。英文版本为权威版本。

您的感受

这种损伤几乎总是由直接跌倒在肩峰处引起的:从自行车上摔下、运动中的擒抱或剧烈身体接触,或者简单地绊倒在坚硬表面上。起初,肩部顶端就会感到疼痛,随后的一两天内,在锁骨与肩部相接的尖端处,常常会出现一个压痛的肿块或台阶感。

该区域在触摸和抬臂时都会感到疼痛,而将手臂横过身体或举过头顶时可能会特别不适。如果按压肿块,会感觉有弹性,就像向下按压锁骨末端时感觉它弹回一样,有点像钢琴键。许多人会本能地用手托住手臂,因为让手臂自然下垂会牵拉到疼痛的关节。这就是人们所说的“肩关节分离”,它与肩关节脱位不同,后者是指肩关节的球部从关节窝中脱出。

实际发生了什么

在肩部的最顶端,有一个小关节,是锁骨(clavicle)的外端与肩胛骨上一个称为肩峰(acromion)的骨性突起相连接的地方。这就是肩锁关节(AC joint)。该关节由韧带维持稳定,包括关节周围的韧带,以及位置稍低的一组强韧韧带(喙锁韧带,或称CC韧带),它们像缆绳一样将锁骨向下锚定。

当肩部尖端着地摔倒时,肩胛骨会向下移动,而锁骨保持原位,从而导致这些韧带拉伤或撕裂。如果仅有关节自身的韧带拉伤,锁骨大致保持在原位。如果更坚固的缆绳状韧带也发生撕裂,锁骨将不再被向下固定,而是向上移位,从而形成可见的隆起和台阶感。

外科医生根据损伤程度对这些损伤进行分级,使用一种称为Rockwood分级,I至VI级的分级系统。I级和II级为拉伤,移位很少或没有移位;III级介于两者之间,有明显的隆起,但肩部功能仍相对正常;IV至VI级为高损伤等级,锁骨严重脱位。值得注意的是,这与退化的、关节炎性的肩锁关节(多年磨损所致)以及锁骨骨折(两者我们分别单独介绍)是不同的问题。

我们如何处理该问题

在我们的诊所,Kieran Hirpara 医生通过全面评估和影像学检查首先确认诊断,以处理此类损伤。

好消息是,大多数肩锁关节损伤无需手术。

低级别损伤(I 级、II 级及大多数 III 级)的治疗较为简单。 佩戴吊带以提供舒适感数周,可减轻关节的牵拉, 并让炎症消退。一旦早期疼痛缓解,物理治疗 将恢复活动度,并重建肩胛骨和肩部周围的肌肉。患者通常能恢复良好,甚至完全的功能,并重返工作和运动。唯一诚实的保留意见是外观方面:即使所有组织愈合后,肩部顶部的凸起往往也会永久存在。它看起来与另一侧不同,但通常不会阻碍肩部的功能。

手术仅保留给需要手术治疗的损伤。 这意味着 高级别损伤(IV 级、V 级和 VI 级),即锁骨严重移位的情况,以及尽管经过适当康复但仍持续疼痛、无力或不稳定的较小比例的低级别损伤,特别是在从事重体力劳动或过头作业的人群,或严重运动员中。手术通过重建撕裂的韧带,将锁骨拉回其正确位置,并在愈合期间将其固定。我们将在“肩锁关节稳定术”部分单独讨论该手术。

预期情况

对于绝大多数低等级损伤患者而言,预后令人安心。剧烈疼痛会在数周内消退,并通过物理治疗,肩部力量和活动范围稳步恢复。大多数人能够恢复正常活动和体育运动,并接受骨性突起可能是损伤的永久性标志这一事实,尽管它不会限制肩部的功能。即使是某些起初看起来较为严重的III级损伤,在不进行手术的情况下也能获得良好的恢复。

恢复时间较长的是高等级损伤,以及那些始终无法稳定的低等级损伤。此时的问题是重建手术是否能为您提供一个更稳定、更强壮、疼痛更少的肩部,以应对您对其提出的要求,而答案在很大程度上取决于您的工作、运动类型以及肩部在最初几周内的表现。有充分证据表明,这一决定最好在从容不迫的情况下做出,在承诺进行手术之前给予肩部一个公平的观察期,同时也不让明显不稳定、高等级的损伤无限期拖延。

何时就医

  • 肩部尖端着地摔倒后肩部疼痛,顶部出现压痛性肿块或台阶感,建议进行评估,以判断损伤程度并排除锁骨骨折。
  • 明显突出的肿块,且手臂有下垂感:这提示较高级别的损伤,需要专业评估。
  • 使用吊带和物理治疗数周后,疼痛或无力症状仍未缓解,尤其是从事重体力劳动、高举过头的工作或运动时。
  • 肿块上方皮肤紧绷、该处皮肤颜色改变,或感觉骨骼强烈顶压皮肤:应尽早就诊。

深入探讨

Advanced reading: the deeper science (optional)

本节内容超出了您做出自身治疗决策所需的深度。由于存在一个处于所有相关决策核心的矛盾,肩锁关节损伤值得额外阅读:手术能可靠地纠正X线片上显示的情况,但无法可靠地改变肩关节最终的功能表现。

手术矫正的是影像表现,而非临床结局

高位分离在影像上看起来令人担忧,锁骨明显高于肩胛骨,直觉上认为复位复位必然更好。汇总954例急性高位脱位患者,手术组与非手术组在功能结局评分方面无临床差异。差异体现在两个方向:非手术组更快恢复工作,但接受较差的 cosmetic 结果;而手术组获得了更好的影像学复位效果 [1]。

聚焦于 Rockwood III 型——这一分级中争议确实存在的级别——一项针对397例患者的 2025 年综述发现,患者报告结局或客观功能方面无显著差异,手术改善了关节复位,但增加了手术并发症的风险 [2]。一项针对646例肩关节的早期综述从不同角度得出了相同结论:后期关节炎或持续性疼痛方面无显著差异,手术组14%的复发率 [3]。

三个独立的证据体系,一个结论。畸形是真实的,若不手术则永久存在,且矫正它并不能可测量地改变肩关节的功能。

因此,决策的核心在于骨性突起,而非功能

这种视角的转换正是该证据的实际价值所在。如果问题是“手术能否让我的肩部功能更好”,诚实的回答是:目前尚未证明其能实现这一点。如果问题是“手术能否消除我锁骨上的台阶感”,答案通常是肯定的,而且对于某些人、某些职业和某些运动而言,仅凭这一点就足以构成手术的理由。

这是一个合理的手术指征。它只是与大多数人认为他们被提供的那个理由有所不同。

尚无技术胜出,且有一项技术可测量地更差

一旦决定进行手术,对固定结构的选型备受关注,但各方案间的差异却很小。在 939 例患者中,手术治疗后的主观结局在所有方式之间均具有可比性,但钩板与克氏针固定的并发症发生率最高,改良 Weaver-Dunn 术式的非计划再手术率最高 [4]。在 399 例患者中比较当今最常用的两种技术,缝线纽扣在功能评分和疼痛方面优于钩板,且手术时间、并发症或复位丢失方面无显著差异 [5]。

重建研究也指向相同的方向。在 4,473 例患者中,生物性和合成性重建的功能评分优于内固定 [6];在 1,020 例患者中,解剖学重建表现最佳,且关节镜入路优于开放入路 [7]。

其模式是:现代解剖学重建技术聚集在一起,而较旧的刚性植入物则落后。在现代组内,差异小到足以使术者熟悉程度成为选择技术的合理依据。

五分之一患者关节内存在其他病变

这一发现值得知晓,因为它在驱动诊断的影像片上不可见。 汇总860例经手术治疗的急性肩锁关节脱位患者,约五分之一伴有需要进一步干预的关节内病变,最常见的是盂唇或肩袖病变,因此作者主张即使重建手术本身采用开放方式进行,也应进行关节镜下关节探查 [8]。

这也为少数令人沮丧的病例提供了解释:在技术上成功重建后肩部仍持续疼痛的患者,可能从一开始就存在第二处损伤。

参考文献

[1] Chang N, Furey A, Kurdin A. 急性高级别肩锁关节脱位的切开复位内固定与非手术治疗:系统评价与荟萃分析. J Orthop Trauma. 2018;32(1):1-9. https://doi.org/10.1097/BOT.0000000000001004

[2] Bianco Prevot L, Accetta R, Fozzato S, Moroder P, Basile G. 手术与保守治疗:急性Rockwood III型肩锁关节脱位的最佳治疗方案. EFORT Open Rev. 2025;10(3):141-50. https://doi.org/10.1530/EOR-2024-0077

[3] Longo UG, Ciuffreda M, Rizzello G, Mannering N, Maffulli N, Denaro V. III型肩锁关节脱位的手术与保守治疗:系统评价. Br Med Bull. 2017;122(1):31-49. https://doi.org/10.1093/bmb/ldx003

[4] Moatshe G, Kruckeberg BM, Chahla J, Godin JA, Cinque ME, Provencher MT, et al. 肩锁关节及喙锁韧带重建治疗肩锁关节不稳:临床及影像学结局的系统评价. Arthroscopy. 2018;34(6):1979-95. https://doi.org/10.1016/j.arthro.2018.01.016

[5] Wang C, Meng J, Zhang Y, Shi M. 缝线锚钉与钩钢板治疗急性不稳定型肩锁关节脱位:荟萃分析. Am J Sports Med. 2019;48(4):1023-30. https://doi.org/10.1177/0363546519858745

[6] Saccomanno MF, Sircana G, Cardona V, Vismara V, Scaini A, Salvi AG, et al. 在治疗急性肩锁关节脱位中,生物性及合成韧带重建的功能评分优于内固定术. Knee Surg Sports Traumatol Arthrosc. 2020;29(7):2175-93. https://doi.org/10.1007/s00167-020-06217-9

[7] Sircana G, Saccomanno MF, Mocini F, Campana V, Messinese P, Monteleone A, et al. 肩锁关节解剖重建在治疗慢性不稳中可提供最佳功能结局. Knee Surg Sports Traumatol Arthrosc. 2020;29(7):2237-48. https://doi.org/10.1007/s00167-020-06059-5

[8] Ruiz Ibán MA, Moreno Romero MS, Diaz Heredia J, Ruiz Díaz R, Muriel A, López-Alcalde J. 急性肩锁关节损伤后关节内合并损伤的发生率为20%。系统评价与荟萃分析. Knee Surg Sports Traumatol Arthrosc. 2020;29(7):2024-38. https://doi.org/10.1007/s00167-020-05917-6


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a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.


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