锁骨骨折患者并发症的原因分析与对策

Analyses and countermeasures of complications in patients with clavicle fractures

目的探讨锁骨骨折患者并发症的原因及相应对策。方法选自1999年1月至2016年9月北京大学人民医院创伤骨科收治的锁骨骨折患者465例,对所有病例进行检索,并收集并发症患者的相关病历资料,分析其发生原因并据此采取相应对策。结果本组共有17例患者出现并发症,占全部锁骨骨折住院患者总数的3.87%;住院时间为3~36d,平均(12.35±10.39)d。所有患者初次致伤后按照Craig分型分类,其中Ⅰ型骨折13例、Ⅱ型骨折3例,Ⅲ型骨折1例。本组患者并发症出现时间大多在20d至1年内,仅有1例医源性骨折患者发生于术后26年。5例患者有内科合并症,其中超过3项术后合并症的患者有3例。9例患者出现骨折不愈合,其中包括4例钢板断裂、2例内固定松动和3例出现骨折不愈合;3例患者出现内固定取出后原位置再骨折;2例出现伤口愈合不良;1例出现内固定外露;1例患者内固定术后同侧锁骨因外伤出现新发骨折。再次手术的16例患者中,有7例患者行自体髂骨植骨术。除外1例保守治疗导致锁骨严重畸形愈合患者因手术禁忌而继续采取保守治疗措施,其他16例患者均再次行手术治疗并痊愈出院。结论本组锁骨骨折病例的并发症多与内固定手术有关,针对已发生并发症的锁骨骨折患者应制定个性化的治疗方案,但大多需通过再次手术实现;严密的术前评估与手术计划,规范的术中操作以及合理的功能锻炼是预防并发症发生的主要措施。

Background Clavicle fracture is one of the most common fractures,and its incidence rate weights about 2.6%-4.0% of total body fractures.The traditional view believes that most of the clavicle fractures can be managed well via conservative treatment.However,a Meta-analysis by Zlowodzki et al.showed that the incidence of nonunion for clavicle fractures with non-surgical treatment was approximately 5.9%.Most of the patients with clavicle fractures of significant shift （shift or shortening of more than 2 cm） and comminuted bone fractures （multiple fractures with more than 3 fragments） are currently recommend with surgery to lower the incidence of complications,but there are still some risks.Ricci et al.reported that the reoperation of mid-shaft clavicle fractures with previous open reduction and internal fixation was caused by nonunion,deep infection and malunion,the complications that had an incidence rate much lower than that of the complications caused by conservative treatments.Nowadays,there is still a lack of clinical guidelines for the standardized treatment of clavicle fractures.In this study,we conducted a retrospective analysis on 17 cases of clavicle fractures with postsurgical complications to summarize causes of complications and to take relevant measures.Methods （1）General data.From January 1999 to September 2016,17 out of 465 cases of treated clavicle fractures were found with complications.A retrospective study was conducted based on indicators including gender,age,affected side,causes of injury,occurring time of complications and related retreating measures,major combined diseases,therapeutic measures,duration of hospitalization and discharge conditions.17 patients （9 males and 8 females） were included in the group of this study,and the average age was （43.53±13.01） years （20-69 years）.10 cases had the left side affected,and 7 cases had the right side affected.Trauma was the cause of primary cause for all patients,including fall injury （13 cases）,injury by traffic accidents （2 cases） and iatrogenic clavicle fractures （2 cases）.16 patients received the surgical treatment,and 1 patient was treated conservatively due to surgical contraindications.In addition,11 cases occurred in daily activities without any obvious trauma cause;1 case occurred with repeated fall injury;1 case occurred during overloading of the affected limb;2 cases had poor wound healing due to suspected infection;1 case had exposure of internal fixator because of the long-term friction between internal fixator and subcutaneous tissue/skin.（2）16 cases received further surgical treatments.The therapeutic measures included： 3 cases of removal of internal fixator and reopening for reduction of internal fixation with autologous bone graft;4 cases of removal of internal fixator and reopening for reduction of internal fixation without bone graft;4 cases of opening for reduction of internal fixation with iliac crest bone graft;1 case of skin and soft tissue debridement after removal of internal fixator;1 case of internal fixator removal;1 case of skin and soft tissue debridement.Another patient did not receive the surgical treatment due to contraindications.（3）Postoperative management.The affected shoulder of all patients was immobilized with forearm sling postoperatively for 2 weeks.The active and passive movements of shoulder were gradually restored 2 weeks after the operation,and the pragmatic functional training was allowed 6 to 8 weeks later.One patient with conservative treatment had clavicle malunion.Thus,the active and passive activities of affected shoulder were no longer limited.The only request was to avoid weight-bearing of the affected upper limb.（4）Statistical analysis.All data were collected using Microsoft Excel 2016,and the software SPSS 20.0 was used for data analysis and process.The measurement data were expressed as mean±standard deviation.Results The 17 patients in this study accounted for 3.66% of the total patients with clavicle fractures,and the length of stay ranged from 3 to 36 days.According to Craig classification： 13 cases were type Ⅰ fractures;3 cases were type Ⅱ fractures;1 case was type Ⅲ fractures.Most of the complications occurred 20 days to 1 year after the surgery,and only 1 case of iatrogenic fractures occurred 26 years postoperatively.5 cases had medical complications,including 3 cases with more than 3 complications.9 cases had fracture nonunion,including 4 cases （No.1,3,6 and 14） of plate fractures,2 cases （No.5 and 10） of internal fixator loosening and 3 cases （No.2,7 and 8） of simple fracture nonunion;3 cases （NO.13,16 and 17） had clavicle fractures at the original position after plate removal;2 cases （No.12 and 15） had poor wound healing;1 case （No.11） had exposure of internal fixator;1 cases （NO.19） had fresh clavicle fractures due to trauma of the operated side;another one （No.4） with conservative treatments had fracture malunion due to surgical contraindication.Out of the 16 patients who underwent reoperation,7 patients were performed with autologous iliac bone grafting.Conclusions The causes of complications of clavicular fractures varies,which usually relate to impropriate selection of internal fixators or intraoperative operation.Therefore,proper type and length of internal fixators should be chosen according to the fracture classification.Also,excessive remodeling of plates should be avoided as well.Blood supply of the fracture ends should be protected,and strict aseptic operative regulations should be followed during the surgery.The affected shoulder should be protected for immobilization,and functional rehabilitations should be guided scientifically after operation.With these beneficial measures,the postoperative complication rate can be lowered.