低切迹解剖锁定钢板治疗成人锁骨中段骨折的临床疗效

Analysis on the clinical curative effects of low-profile locking anatomic plate therapy on the middle clavicular fracture of adult

目的探讨低切迹解剖锁定钢板治疗成人锁骨中段骨折的临床疗效。方法上海市浦东医院骨科于2012年1月至2013年12月采用低切迹解剖锁定钢板治疗38例成人锁骨中段骨折,其中36例获得完整随访资料,男性20例,女性16例;年龄18~60岁,平均38.0岁。结果 36例患者术后获12~16个月随访,平均14.5个月,手术时间35~65min,平均45min,术中出血量25~55ml,平均35ml。所有患者切口均一期愈合,未出现伤口感染、血管神经损伤及内固定松动或断裂,5例患者出现钢板顶住皮肤引起的不适(占13.9%)。患者对治疗结果的满意度:完全满意33例,部分满意2例,不满意1例,满意率高达91.7%。末次随访时肩关节Constant评分平均92分(80~94.5分),其中优14例,良1例;DASH评分平均5.5分(1.5~10.0分)。结论低切迹解剖锁定钢板治疗明显移位的锁骨中段骨折不仅可以达到良好复位,稳定内固定,而且降低了与内固定相关并发症的发生,是锁骨中段骨折手术治疗的新选择。

Background Middle clavicular fracture is a clinically common fracture,and there are still disputes over its operation indications.According to literature reports over recent years,in comparison with conservative treatment, operative treatment on middle clavicular fracture with obvious fracture displacement has lower complications (including symptomatic malunion and bone ununion),faster functional rehabilitation and functional result.However,there are some disputes over the selection of internal fixators during operation.In particular,since the patients have higher requirments for appearance and functions,the occurrence rate of internal fixator relevant complications has been gradually rising.However,theoretically,the clinical curative effects of low-profile locking anatomic plate can avoid the traditional clavicular plate related complications to certain extent.During the period from January 2012 to December 12,our department adopted ow-profile locking anatomic plate in the treatment of 38 adult cases of middle clavicular fracture,obtained integral follow-up data of 36 cases and achieved good curative effects.The specific conditions are hereby reported as follows. Method I.General materials:This groups includes totaled 36 cases (20 male cases and 1 6 female cases);they are aged 18-60,with an average age of 38.0 years.Injury causes:traffic injury 9 cases, motorcycle falling injury 8 cases,bicycle falling injury 8 cases,exercise falling injury 6 cases and other injury 5 cases.Classification by the standard established by US Orthopaedic Trauma Association (OTA):8 cases of A type,4 cases of B type and 1 6 cases of C type;All the patients received open reduction and internal fixation with low-profile locking anatomic plate in a week after injury.Case inclusion criteria:(1)Middle clavicular fracture with obvious displacement,with shortening >2 cm;has obvious angulation deformity and risk of piercing skin.Case exclusion criteria:(1)Displacement of less than 2 cm;(2)Without risk of piercing skin;(3)Complicated with fractured on other sites;(4)Clavicular pathologic fracture.II.Operative method:Under general anesthesia or brachial plexus combined cervical plexus nerve block anaesthesia,allow the patient to lie on beach chair position;with the fracture end as the center,make incision in length of 10-12 cm at the anterior-superior clavicular, cut open skin and subcutaneous tissues layer by layer, pay attention to the protection of supraclavicular nerve branches,expose the fracture end,remove the aemorrhage at fracture end,strip partial periosteum,and use tongs to respectively clamp the clavicular diaphysis on both sides for fracture reduction.For Type A fracture,try for anatomical reduction.If the fracture presents spiral or long oblique,after reduction use Kirschner wires for temporary fixation and place low-profile locking anatomic plate on the anterior superior clavicular for fixation.For type B fracture,also try for anatomical reduction,adopt lag screws to perform reduction and fixation of butterfly bone blocks with diaphysis on other side,turn it into type A fracture,then place low-profile locking anatomic plate at anterior superior clavicular for fixation.For type C fracture,not try for anatomical reduction,and key measure is to correct shortening and rotation displacement;bigger bone blocks can be fixed by means of lag screws.The bone blocks which cannot be fixed through lag screws can be tied and fixed through absorbable wires.During the operation,pay attention to protecting the blood supply for bone blocks, and adopt at least 3 screws at each end of plate for 6-layer cortex fixation.III. Postoperative treatment:Upon completion of operation,use a piece of triangle bandage to suspend and brake affected shoulder for 4-6 weeks,encourage the patient to perform active functional exercise of elbow joint and perform pendulum exercise of shoulder joint;3 weeks later,start passive functional exercise of shoulder joint,and gradually perform active functional exercise of shoulder joint and enhance strength training.IV.Evaluation criteria for curative effects:(1)Operation time and intraoperatve blood loss;(2)Patient satisfaction to treatment;(3 )Occurrence of complications,including wound infection, vascular nerve injury and internal fixator related complications (internal fixation fracture and skin irritation by internal fixation);(4 )Shoulder joint function Constant scoring as well as scoring of disabilities of the arm,shoulder and hand,DASH.Results 36 cases received postoperative follow-up for 12-1 6 months (14.5 months on average),and 2 cases lost follow-up.The operation time is 35-65 min,with average time being 45 min;the intraoperatve blood loss is 25-55 ml,with average value of 35 ml.All the incisions are healed at phase I,without occurrence of wound infection and vascular nerve injury,without internal fixation loosening or fracture;5 cases have discomfort caused by plate pressing aginst skin (accounting for 13.9%),in which 3 cases are caused by proximal end of plate not fitting with clavicular,and 2 cases are caused by distal end of plate not fitting with clavicular.The degree of satisfaction of the patients to treatment:33 cases are completely satisfied with the therapy result,2 cases are partially satisfied and 1 case is not satisfied,with satisfaction rate as high as 91.7%.The reason for partial satisfactory is that the scar is relatively obvious and may affect esthetic appearance;the cause for dissatisfaction is that the steel plate presses aginst skin,thus causing discomfort and affecting daily life.In final follow-up,Constant score of shoulder joint is 92 points on average(80-94.5 points),including 14 cases with excellent score and 1 case with good score;DASH score is 5.5 points on average (1.5-10.0 points).Conclusion Low-profile locking anatomic plate therapy of middle clavicular fracture with obvious displacement can not only achieve good fracture reduction and stable internal fixation,but also reduce the occurrence of internal fixation related complications.Therefore it is a new option for operative treatment of middle clavicular fracture.