锁骨外侧端骨折公济分型的建立及其治疗策略

Gongji classification and treatment strategies for lateral clavicle fractures

目的建立不稳定型锁骨外侧端骨折的新分型以指导临床治疗,并评价其临床应用效果。方法收集2016年1月至2020年12月收治的67例锁骨外侧端骨折患者的病历资料。上海市第一人民医院提供37例,男22,女15例;平均年龄为49.1岁(范围22~78岁)。天津市天津医院上肢二病区提供30例,男20例,女10例,平均年龄为47.6岁(范围19~76岁)。通过肩关节Zanca位X线片及CT测量喙锁间隙和锁骨下表面骨折块至锁骨远端的距离来判断韧带损伤情况。以肩关节Zanca位X线片及锁骨下表面CT三维重建像测量为基础,根据骨折与喙锁韧带止点关系、喙锁韧带损伤、肩锁关节是否受累及骨折稳定性等要素建立锁骨外侧端骨折公济分型,对稳定型骨折推荐采用保守治疗,不稳定型骨折推荐采用手术治疗。3名经验丰富的骨科医生和3名放射科医生独立观察67例锁骨远端骨折患者的影像学资料,根据新建立的公济分型确定骨折类型,间隔4周后随机进行再次分型;最后随机选取15例资料由2名经简单培训的低年资骨科医生进行分型(内部验证);计算组内相关系数(intra-class correlation efficient,ICC)进行一致性检验。结果锁骨外侧端骨折公济分型共5型,1型:孤立的锥状结节撕脱性骨折,骨折线位于喙突内侧;2型:完整累及斜方韧带和锥状韧带锁骨止点,骨折线延伸至锁骨中段,肩锁关节完整;3型:锁骨下表面骨折块分别累及斜方韧带和锥状韧带锁骨止点;4型:锥状韧带断裂,斜方韧带锁骨止点撕脱性骨折;5型:锥状韧带完整,斜方韧带锁骨止点撕脱性骨折。67例中例1型18例,2型4例,3型8例,4型32例,5型5例。公济分型的观察者内及观察者间的一致性均良好(骨科医生ICC为0.782,放射科医生ICC为0.750;骨科医生与放射科医生第1次ICC为0.764,第2次ICC为0.778;内部检验ICC为0.793)。1型和2型骨折行锁骨外侧端解剖钢板固定联合喙突锚钉固定,3型和4型骨折行锁骨钩钢板联合喙突锚钉固定,5型骨折行保守治疗。末次随访时所有患者均无明显的肩关节不稳和疼痛,未出现内固定失败和固定物断裂。结论建立的公济分型在观察者内及观察者间具有中等可靠性,锁骨远端骨折公济分型对锁骨远端骨折稳定性的判断及治疗选择更具指导意义。

Objective To establish a new classification of lateral clavicle fractures and to evaluate its clinical value.Methods The data of 67 patients with lateral clavicle fractures admitted from January 2016 to December 2020 were included.Thirty-seven cases were from Shanghai First People's Hospital,including 22 males and 15 females,with an average age of 49.1 years(22-78 years).Thirty cases were from the Second Upper Limb Ward of Tianjin Hospital of Tianjin,including 20 males and 10 females,with an average age of 47.6 years(19-76 years).The ligament injury was determined by measuring the coracoclavicular space on Zanca view X-ray and the distance between the fracture fragment on the inferior surface of the 3D-CT and the distal end of the clavicle.All patients were classified according to the new classification(based on the measurement on Zanca view X-ray and 3D-CT reconstruction,the relationship between the fracture and the coracoclavicular ligament footprint,coracoclavicular ligament injury,the injury of the acromioclavicular joint and the stability of the fracture),conservative treatment is preferable for stable fractures,and surgical treatment for unstable fractures.Three experienced orthopaedic surgeons and three radiologists independently observed the imaging data of 67 patients with distal clavicle fractures,determined the fracture type according to the new classification,and randomly reclassified after 4 weeks interval.Finally,15 cases were randomly selected for internal control(2 junior orthopedic physicians),and the ICC value was used to assess the reliability.Results The lateral clavicle fractures were divided into 5 types according to the Gongji classification.Type 1:isolated conical tubercle avulsion fracture,and the fracture line is located medial to the coracoid process;Type 2:complete involvement of the trapezoid&conical ligament at the clavicle insertion,and the fracture line extends to the middle of the clavicle,mean while the acromioclavicular joint is intact;Type 3:fracture fragments on the inferior surface involving the trapezoidal/conical ligament,respectively;Type 4:rupture of the conical ligament,and avulsion fracture of the trapezoid ligament;Type 5:conical ligament intact,and avulsion fracture of clavicle insertion of the trapezoid ligament.There were 18 cases of type 1,4 cases of type 2,8 cases of type 3,32 cases of type 4,and 5 cases of type 5.The inter-observer and intra-observer agreement of all included cases was good(inter-group:first ICC=0.764,second ICC=0.778;intra-group:shoulder specialist ICC=0.782,radiologist ICC=0.750,internal control ICC=0.793).Types 1 and 2 fractures were fixed with anatomical plate and coracoid anchor.Type 3 and 4 fractures were fixed with clavicle hook plate and coracoid anchor.And type 5 underwent conservative treatment.At the last follow-up,all patients had no obvious shoulder joint instability and pain,and no internal fixation failure or fixation breakage was found.Conclusion The Gongji classification has moderate reliability between observers and intra-observers,and the Gongji distal clavicle fracture classification has a good significance for evaluating the stability of the fracture and guiding the selection of the treatment.