弹性带锁髓内钉固定治疗锁骨中段骨折

Elastic locking intramedullary nail fixation for the treatment of mid-clavicle fracture

目的探讨弹性带锁髓内钉(elastic locking intramedullary nail,ELIN)治疗锁骨中段骨折的疗效。方法回顾性分析2014年1月至2020年12月应用ELIN治疗并获得随访的61例锁骨中段骨折患者资料。其中38例来自南开大学附属第四中心医院,23例来自呼伦贝尔市第二人民医院,男36例、女25例;年龄19~85岁,平均54.5岁;均为单侧,左侧39例、右侧22例;Robinson分型:2A2型20例,2B1型29例,2B2型12例。术前均无神经、血管损伤。术后评价切口长度、手术时间、失血量、骨折复位情况、骨折愈合时间、内固定取出时间、肩关节Constant-Murley评分、上肢功能障碍(disabilities of the arm,shoulder,and hand,DASH)评分及相关并发症。结果61例患者随访时间13~51周,平均21.8周。其中闭合复位穿钉34例;微创切开27例,切口长度(2.04±1.08)cm。闭合复位手术时间(20.32±7.11)min,微创切开手术时间(20.30±5.37)min;闭合复位术中失血量(6.47±2.31)ml,微创切开术中失血量(27.41±11.55)ml。术前患侧与健侧相比锁骨长度短缩7.74%±3.51%,术后锁骨长度短缩0.71%±1.00%,术前、术后锁骨短缩长度比较差异有统计学意义(t=3.84,P<0.001)。骨折愈合时间(10.48±2.39)周;取出ELIN时间为术后(13.39±2.69)周。末次随访时Constant-Murley评分(98.87±1.74)分;DASH评分0~10分,平均1.13分。术后18例发生皮肤刺激,其中13例于术后3~6周钉尾端形成压疮,采用换药、保持清洁治疗;4例钉尾端刺激皮肤形成滑囊炎,取出内固定后消失;1例ELIN尖端从锁骨近侧穿透前侧骨皮质,刺激皮肤,术后4周X线片示骨痂连续,局部无压痛,达到临床愈合标准,取钉后症状缓解。61例患者无一例发生神经和血管损伤、断钉、延迟愈合、感染、锁骨下区麻木或不适感,所有患者均对局部皮肤外观满意或基本满意。结论ELIN治疗锁骨中段骨折,具有手术操作简便、微创、抗锁骨短缩、骨折愈合快、术后皮肤美观等优点,是治疗锁骨中段骨折的有效手术方式。

Objective To investigate the efficacy of elastic locking intramedullary nail(ELIN)in the treatment of mid clavicle fractures.Methods From January 2014 to December 2020,the data of 61 patients with mid-clavicle fracture treated with ELIN were retrospectively analyzed.Among them,38 patients were from the Fourth Central Hospital Affiliated to Nankai University and 23 were from the Second People's Hospital of Hulunbuir City.There were 36 males and 25 females,aged from 19 to 85 years(average,54.5 years),39 cases on the left side and 22 cases on the right side.According to Robinson's classification,there were 20 cases of type 2A2,29 cases of type 2B1 and 12 cases of type 2B2.There was no nerve or vascular injury before operation.The postoperative evaluation measures included incision length,operation time,blood loss,fracture reduction,fracture healing time,ELIN removal time,shoulder Constant-Murley score,disabilities of the arm,shoulder,and hand(DASH)score,and related complications.Results All patients were followed up for 13-51 weeks(average,21.8 weeks).There were 34 cases of closed reduction and 27 cases of mini-open reduction,and the length of incision was 2.04±1.08 cm.The closed reduction operation time was 20.32±7.11 min,and the mini-open reduction operation time was 20.30±5.37 min.The intraoperative blood loss was 6.47±2.31 ml in the closed reduction group and 27.41±11.55 ml in the mini-open reduction group.Compared with the healthy side,the clavicle length of the affected side was shortened by 7.74%±3.51%of pre-operation and 0.71%±1.00%of post-operation,there was statistically significant difference in the length of clavicle shortening of pre-and post-operation(t=3.84,P<0.001).The fracture healing time was 10.48±2.39 weeks.The removal time of ELIN was 13.39±2.69 weeks.At the last follow-up,the Constant-Murley score of shoulder joint was 98.87±1.74.The average of DASH score was 1.13(range,0-10).There were 18 cases of skin irritation after operation,of which 13 cases formed pressure sores at the tail end 3-6 weeks after the operation,and were treated with dressing change and keeping clean;4 cases of skin irritation at the tail end formed bursitis,which disappeared after removal of the internal fixation.In 1 case,the tip of ELIN penetrated the anterior cortex from the proximal clavicle and stimulated the skin.Radiograms showed continuous callus at 4 weeks after operation,and there was no local tenderness on the physical examination,which reached the clinical healing standard,and the symptoms were relieved after the nail was removed.No serious complications such as neural and vascular injury,nail breaking,delayed healing,infection,numbness or discomfort in the subclavian area occurred in all cases,and all patients were satisfied or basically satisfied with the aesthetic of the skin appearance.Conclusion Minimally invasive and microstress shielding fixation of mid-clavicle fracture with ELIN have the advantages of simple operation,minimally invasive,beautiful appearance,anti-short-shrinkage and rapid fracture healing etc.It is an effective surgical method for the treatment of mid-clavicle fractures.