专题文献--锁骨骨折治疗进展
这个帖子发布于 15 年零 17 天前，其中的信息可能已发生改变或有所发展。
希望文献翻译里能多些常见病的治疗新进展,或总结,让我们对它们更深层的认识和记忆
毕竟园子里面基层医院还是比较多的,而对于推广治疗理念也应当由此开始,并纠正一些
常规治疗中的错误.让规范化更规范化.望各位版主考虑,谢谢!选了这么一篇翻后上传,第一次也不知能否规范.
Acute Midshaft Clavicular Fracture
Dr. Jeray is Program Director,
Orthopaedic Surgery Education,
Greenville Hospital System, Greenville,
SC.
Neither Dr. Jeray nor the department
with which he is affiliated has received
anything of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. Jeray, Greenville
Hospital System, University Medical
Center, Orthopaedic Surgery Education,
701 Grove Road, 2nd Floor ERC
Support Tower, Greenville, SC 29605.
J Am Acad Orthop Surg 2007;15:239-
248
Copyright 2007 by the American
Academy of Orthopaedic Surgeons
Abstract: Clavicular fractures represent 2.6% to 5% of all fractures, and middle third
fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; thenonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons preposesurgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.
摘要：锁骨骨折占全身所有骨折的2.6%-5%，而中1/3骨折占所有锁骨骨折的69%-82%。锁骨中外1/3是最细的部分也是唯一没有附着的肌肉和韧带保护。这种解剖特征使其易于骨折，尤其是当摔倒后肩部着地产生一个对锁骨的轴向暴力时。对于无移位或轻度移位的锁骨中段骨折应首选悬带带或“8”字绷带治疗，其不愈合率也非常低。然而当为完全移位或粉碎性的锁骨中段骨折，并且患者为老年人或女性，不愈合，外观缺陷和较差的临床疗效的风险将显著增高。因此，一些学者建议使用钢板螺钉或髓内糸统治疗复杂的的锁骨中段骨折。为了给临床治疗决断提供基础，更进一步的随机前瞻性试验有必要进行的。
The clavicle is one of the most commonly fractured bones; cla-vicular fractures represent 2.6% to 5% of all fractures.1,2 The incidence of clavicular fracture in adults is es-timated to be 71 in 100,000 for men and 30 in 100,000 for women, with the incidence of midshaft fractures decreasing with increasing age. Mid-shaft fractures account for 69% to 82% of all clavicular fractures.1-5 Midshaft fractures are more common in children and young adults. The in-cidence of high-energy clavicular fractures with comminution, dis-placement, and shortening appears to be increasing.2
Traditionally, fractures of the clavicle have been treated with closed reduction. More than 200 methods have been described for closed reduction, yet a classic text-book recognizes that “reduction ispractically impossible to maintain, and a certain amount ofdeformity is to be expected, generally compatible with satisfactory return of function in the shoulder.”6 The same text¬book states that even completely displaced fractures “generally do well with non-operative manage¬ment....”6
However, most previous studies describing the results of clavicular fracture have used surgeon-based or radiographic outcome measures that equate union with success. Very few studies on clavicular fracture have been published using patient-based outcomes such as the Medical Out-comes Study 36-Item Short Form (QualityMetric, Lincoln, RI) or the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH; In-stitute for Work and Health, Toron¬ta, Canada, and the American Academy of Orthopaedic Surgeons [AAOS]). Recent studies have indi-cated that outcomes are not always excellent, particularly in high-energy fractures.7-11 These studies raise the question whether acute m idshaft clavicular fractures should be internally fixed.
锁骨骨折是最普通的一种骨折，约占全身骨折的2。6%—5%。[1，2]锁骨骨折在成人的发生率，在男性大约十万分之七十一，女性约为十万分之三十，并且随着年龄的增大而增加。锁骨中段骨折占所有锁骨骨折的69%-82%。[1-5]锁骨中段骨折不论在儿童和青年人都是很常见的。而粉碎性的，移位的，短缩的高能理锁骨骨折发生率也正在增长。[2]
传统上锁骨骨折都是使用闭合复位进行治疗。这种方法文献中提到将近二百多种。而一本经典的书上也说，复位实际上是不可能维持的，一定数目伴有肩关节功能恢复尚可满意的的畸形存在是可是料想得到的。同是这本书还说既便是完全移位的锁骨骨折通过保守治疗通常也能收到良好疗效。[6]
然而大多数早期的报道评定锁骨骨折的疗效时，把医生主观经验或者影像学的结论等同于成功的愈合。很少有文献是以病人角度来客观评定临床疗效的。近来的研究发现保守治疗效果并没有总是很好的，特别在高能量的锁骨骨折上。[7-11]这些研究提出一个问题：急性锁骨中段骨折是否应当手术？
Anatomy and Function
The clavicle is the first bone to ossify in the fifth week of fetal life, and it is the only long bone to ossify by in-tram embranous ossification. Initial growth up to age 5 years arises from the ossification center in the central portion ofthe clavicle, with contin¬ued growth occurring at the epiphy¬seal plates at the medial and lateral ends of the bone. The medial growth plate, typically the only plate seen ra¬diographically, accounts for up to 80% of longitudinal growth. The me¬dial growth plate is the last physis to close, generally at age 22 to 25 years. The clavicle is subcutaneous, with
only the supraclavicular nerves cross¬ing the bone. However, several fascial layers and muscles attach to the bone itself and help to create the predict¬able deformity seen with fractures. The proximal fragment is pulled su¬periorly and posteriorly by the ster¬nocleidomastoid muscle. The distal segment sags forward and rotates in¬feriorly because ofthe weight of the upper extremity and, to a lesser ex¬tent, the pull of the pectoralis mus¬cle on the humerus.
The clavicle is a strut that con-nects the upper extremity to the trunk and is the only link to the ax-ial skeleton. It also provides protec-tion for the adjacent axillary and subclavicular neurovascular struc-tures and the apex of the lungs. Lat-erally, the clavicle is secured by the acrom ioclavicular (AC) and coraco-clavicular ligaments where it articu-lates with the acromion. Medially, the clavicle articulates with the ster-num and is strongly secured to the first rib by the intra-articular ster-noclavicular (SC) joint cartilage, the oblique fibers of the costoclavicular ligaments, and the subclavius mus-cle. The clavicle is S-shaped and double-curved, concave ventrally on its lateral half and convex ventrally on its medial half. The cross-sectional geometry changes from flat laterally to tubular centrally to trian¬gular medially (Figure 1).
The shape of the clavicle and the ligamentous and muscle attach¬ments play a role in fracture pat¬terns. The junction of the outer and middle thirds is the thinnest part of the bone and is the only area not pro¬tected by or reinforced with muscle and ligamentous attachments, there¬by rendering it prone to fracture, par¬ticularly with axial loading.12 This helps to explain why the middle third is the most common site of fracture, occurring at the junction where the bone geometry changes from flat to tubular.
The motion of the clavicle is ulti-mately linked to the surrounding motion ofthe scapula because ofthe anatomic attachment to the scapula through the AC joint and to the ster-num through the SC joint. Motion of the clavicle occurs with elevation and abduction ofthe arm. Duringel-evation, with respect to the SC joint, the clavicle undergoes elevation of 11° to 15°, retraction of 15° to 29°, and posterior long-axis rotation of 15° to 31°, with the magnitude and planes varying among subjects.13 Other studies suggest that rotation may be as much as 50° and elevation as high as 30°.14 More importantly, clavicle rotation is relatively small until humeral elevation exceeds 90°; thus, early rehabilitation that avoids over-the-shoulder activity will sig-nificantly limit rotational forces at the site ofa clavicular fracture.15
1.锁骨的解剖及功能
锁骨是在胚胎第五周时第一根开始骨化的骨骼，同是也是最初唯一通过骨膜内骨化进行成骨的长骨。从出生到5岁是从锁骨中部的骨化中心开始生长，接着便通过干骺端的骨骺来继续生长，它内外侧端各有一继发骨骺。锁骨的中央生长板是唯一能在X线上能显影的生长板，它的生长力占锁骨长度的80%左右。这个中央生长板闭合最晚，一般都要在22-25岁时才闭合。锁骨就位于皮下，却只有锁骨上神经跨过该骨。因此，当骨折时，一些韧带和肌肉的附着使这种可预知的畸形很容易就显现出来。骨折近端由于胸锁乳突肌的牵拉而向上向后。骨折远端则由于胸肌的牵拉和上肢的重量使得其向前凹陷向下旋转。
锁骨桥架于上肢带与躯干之间，也是上肢带与中枢骨唯一相连的骨性结构。它为邻近的腋窝，锁骨下神经血管以及肺的上叶提供了保护。外侧，锁骨由肩锁韧带和与肩峰相连的喙锁韧带固定。锁骨近端同胸骨相关节，并且通过关节软骨，斜形纤维的肋锁韧带以及连于第一肋骨的锁骨下肌牢固稳定。锁骨形似“S”，有双向弧形，前凸后凹。它的纵轴几何形状从外侧的扁平渐变成中段圆柱形，向近端延伸为三棱形。
锁骨的形状以及韧带和肌肉的附着影响着骨折发生的类型。外中1/3交接处是骨骼的最薄弱部分，也是唯一没有肌肉和韧带保护的区域，因此很容易骨折，特别当受轴向暴力时。[12]这也解释了为什么中1/3是骨折最常见部位，为什么骨折常发生在从扁平转向管型部位。
由于锁骨通过胸锁关节与胸骨相连，通过肩锁关节与肩胛骨相连，因此锁骨的运动始终与肩胛骨的运动相关联。而只有当肩关节上举与外展时锁骨的运动才进行。由于同胸锁关节的相连，在上举时，锁骨需要提升11°到15°，内收15°到29°，围绕后方长轴旋转15°到31°，过程中长度和平面都发生变化。[13]其它研究认为[14]锁骨旋转最多只能到50°，上升只能到30°。更重要的是如果肱骨上升不超过90°，锁骨旋转是很小的。因此早期康复时避免进行过肩活动将明显减少锁骨骨折断端之间产生旋转应力。[15]
Mechanism of InjuryMidshaft clavicular fractures have traditionally been thought to occur from a fall on an outstretched hand. However, a biomechanical analysis of the forces demonstrated
that a direct injury from the shoul¬der (rather than the hand) that pro¬duces a force equal to the body weight would exceed the critical buckling load and result in a mid-shaft clavicular fracture.16 Several studies have demonstrated that a di¬rect fall or blow onto the point of the shoulder accounts for 85% to 94% of the injuries.2,3,5,16,17 When the forces are transmitted through the arm, as with a fall on an outstretched hand, the forces are not directly delivered to the clavicle; thus, they are unlike¬ly to produce a midshaft fracture. This mechanism accounts for 2% to 5% of all midshaft fractures. A direct blow to the clavicle, such as from a hockey stick or a seat belt shoulder-strap injury, also may produce a frac¬ture and accounts for 10% to 13% of midshaft fractures in most stud¬ies.16 Although rare, direct force on the top ofthe shoulder may drive the midshaft clavicle against the first rib, resulting in a fracture.
2.损伤机制
锁骨中段骨折传统被认为是由于伸展位摔倒引起的。然而一项对这种暴力的生物力学分析表明，[16]一个来自肩部的超过急性压曲的相当于身体重量的直接暴力，真正引起锁骨中段的骨折。还有几项研究[2,3,5,16,17]也显示由于跌倒或打击对肩部的直接暴力占损伤的85%-94%。而由于伸展位摔倒引起的暴力传导到肩部是不会直接传至锁骨的，它也不太可能引起锁骨中段骨折。大量的研究表明[16]，这种机制造成的骨折在所有锁骨中段骨折中只占2%-5%。而象来自棍棒或安全带的肩带伤产生的对锁骨的直接暴力占10%-13%。直接来自肩关节上方的直接暴力虽然很罕见，但它能让锁骨中段相第一肋骨相顶触撞击结果造成骨折。
Classification
Clavicular fractures have been classified by Allm an18 into three ana¬tomic regions, with the middle third being group I. The classification sys¬tem of the Orthopaedic Trauma As¬sociation separates diaphyseal cla¬vicular fractures into three types: 06-A (simple), 06-B (wedge) and 06-C (complex).19 Each type is further bro¬ken down into three groups.
The system developed by Robin-son3 divides midshaft clavicular frac¬tures into type 2A (cortical align¬ment fracture) and type 2B(displaced fracture). In an effort to provide di¬rection for treatment and prognosis, Robinson further divides these into subgroup types 2A1 (nondisplaced), 2A2 (angulated), 2B1 (simple or wedge comminuted), and 2B2 (isolat¬ed or comminuted segmental) (Fig¬ure 2). Robinson’s classification sys¬tem has demonstrated satisfactory levels of interobserver and intraob¬server reliability and reproducibility. However, additional studies are needed to determine whether thisclassification system will reliably predict treatment and functional outcomes.
3.分类
锁骨骨折Allman分型[18]分为三型。中1/3属I型。AO分类系统将锁骨干骨折分为3类：06-A（简单骨折）,06-B（楔型骨折）,06-C（复杂型骨折）[19]。每一类型进一步分为三个亚型。
这种分类系统被Robinson发展[3]，锁骨中段骨折分进为2A型(皮质仍残留骨接触的骨折)和2B(无骨接触的移位骨折)。为了尽力为治疗和诊断提供指导，Robinson进一步分出亚型：2A1(无移位的骨折)，2A2(成角的骨折)；2B1 (单纯或楔形粉碎性骨折)和2B2 (孤立的或粉碎性节段性骨折)。2个亚型的Robinson的分类系统显示了其具有良好可信度和可重复性。然而,另外的研究需要确定这种分型系统是否能可靠地预测治疗和临床效果。
Clinical Evaluation
Often with clavicular fracture, a bruise or abrasion is seen, either over the point ofthe shoulder (indicating a direct blow) or over the midline (suggesting a seat belt shoulder-strap injury). The shoulder has a droop, the scapula appears slightly internal¬ly rotated, and the shoulder appears shortened relative to the opposite side. This characteristic deformity is produced by the pull ofmuscles at¬tached to the clavicle. Immediate swelling may obscure the deformity of the bone, which will be seen on radiographs if the fracture is dis¬placed. Palpation over the area will reveal tenderness, and gentle manip¬ulation may produce crepitus and
motion at the fracture site. A non-displaced or minimally displaced fracture may be suspected when pain and/or skin changes are present over the clavicle.
Because middle third fractures frequently occur with high-energy trauma, a complete examination should be performed to avoid miss-ing associated injuries. Skeletal inju¬ries include fracture-dislocations of the SC and AC joints or, in younger patients, physeal injuries. Chest wall trauma may result in high rib frac¬tures, scapular neck and body frac¬tures, and a pneumothorax or he¬mothorax. Although acute brachial plexus injury is rare, the ulnar nerve is at highest risk because of its loca¬tion adjacent to the middle third of the clavicle. When a nerve injury is identified, a thorough vascular ex¬amination and evaluation of the scapulothoracic articulation should
Figure 3
Standard radiographic anteroposterior view (A) and 45° cephalic tilt view (B). Both are necessary to determine the extent of fracture displacement.
be undertaken to avoid missing an associated injury. Penetrating trau¬ma is typically the cause of vascular injury. However, vascular injury can occur from blunt trauma, resulting in spasm or thrombosis of the sub-clavian vessels.
4．临床诊断
锁骨骨折常常伴有瘀伤或擦伤，查体可以在肩部的外侧(预示为直接暴力)或在锁骨中线上(预示这可能是安全带引起的肩带损伤)发现。伤肩有下垂症象，肩胛骨会出现轻微的向内旋转,并且肩关节与健侧相比要短缩。这个特征性的畸形是由于附着锁骨肌肉的牵拉而引起的。急性的肿胀可能掩盖在X片上可以看到的移位骨折。触诊骨折段会出现明显的疼痛，轻柔的触诊可触及骨擦音和骨折断段的移动。当锁骨上方出现疼痛并/或有皮肤损伤时，应当怀疑可能存在无移位或轻微的骨折。.
因为中1/3骨折通常是由于高能量创伤引起，所以应当进行一个全面的检查以免遗漏复合伤。年轻的骨折干骺端损伤的患者常会伴有肩锁和胸锁关节骨折脱位。 胸壁损伤可能导致高位肋骨骨折、肩胛骨颈和体部骨折,甚至伴有气血胸出现。尽管急性的臂丛损伤很少见，但尺神经因为它的位置靠近中1/3锁骨，其损伤的风险最高。当神经损伤确诊，应当进行一个全面的血管检查和肩胸关节检查以免漏诊其它相关损伤。血管损伤通常由穿透伤引起。然而钝挫伤也能引起血管损伤，可引起锁骨下血管血栓形成或血管痉挛。
为了判定骨折的类型和移位程度，应当拍摄二个投照位的X片，一个标准的前后位和45度头倾位。肩带骨和肺上部区域应仔细检查，以避免漏诊骨折引起的轻度气胸。阅读X片时应当判定该骨折的类型，是否为粉碎性，有无移位，是短缩骨折还是分离骨折。
拍摄几张X片有助于医生对治疗的选择。无骨接触的移位尤其是伴有横型骨折碎片的骨折，已被认为是遗留长期后遗症的一项很大风险因素[7]。另外的放射学参数——断端移位>1.5cm骨折将增加疼痛，活动障碍，骨折不愈合发生的风险。在任何放射学上显示中，移位可以包括短缩移位，分离移位，骨折远端单独向前或向后移位。[20-22]第二片子在第一张基础上倾斜了45度将更清楚地显示移位。移位通常在单独的一张片子是无法判定的。
Radiographic Evaluation
To determine the fracture pattern and displacement, radiographs in two projections are necessary. A standard anteroposterior view should be accompanied by a 45° cephalic tilt view (Figure 3). The shoulder girdle and upper lung fields should be carefully assessed to avoid missing associated fractures or a subtle pneu¬mothorax. The radiographic evalua¬tion should assess the fracture pat¬tern, presence of comminution, displacement, and shortening or dis¬traction of the fracture.
Several radiographic findings can help guide the surgeon’s choice oftreatment. Displacement without bony contact, especially with a transversely displaced fragment, is a risk factor strongly predictive of long-term sequelae.7 Additional ra-diographic parameters predictive of increased risk for pain, limitation of motion, or nonunion include an overall displacement of the fracture ends >1.5 cm. This displacement in-cludes shortening, distraction, or separation of the ends in the anteri¬or or posterior direction in any radio¬graphic view.20-22 A second view, at least 45° off plane from the first, helps to further delineate the dis¬placement. Often, the displacement is difficult to assess on a single radio¬graph. For example, as seen in Figure 3, both views reveal distraction at the fracture site ofat least 1.5 cm.
为了判定骨折的类型和移位程度，应当拍摄二个投照位的X片，一个标准的前后位和45度头倾位。肩带骨和肺上部区域应仔细检查，以避免漏诊骨折引起的轻度气胸。阅读X片时应当判定该骨折的类型，是否为粉碎性，有无移位，是短缩骨折还是分离骨折。
拍摄几张X片有助于医生对治疗的选择。无骨接触的移位尤其是伴有横型骨折碎片的骨折，已被认为是遗留长期后遗症的一项很大风险因素[7]。另外的放射学参数——断端移位>1.5cm骨折将增加疼痛，活动障碍，骨折不愈合发生的风险。在任何放射学上显示中，移位可以包括短缩移位，分离移位，骨折远端单独向前或向后移位。[20-22]第二片子在第一张基础上倾斜了45度将更清楚地显示移位。移位通常在单独的一张片子是无法判定的。
Management
Indications
The primary goal in treatment is to restore shoulder function to thepreinjury level. By allowing the clav¬icle to heal with minimal deformity, loss ofmotion and pain can be min¬imized. Indications for nonsurgical treatment include a nondisplaced or minimally displaced midshaft clav¬icular fracture. Indications for surgi¬cal treatment include open fractures and fractures associated with skin compromise or with neurologic or vascular injury.
Relative surgical indications in-clude certain multiple-system trau¬m atized patients, a floating shoulder, and a painful malunion or nonunion. More recently, relative indications for surgical treatment have been ex-panded to include high-energy closed fractures with >15 to 20 mm of shortening, fractures with complete displacement, and fractures with comminution.23-26 Although these re-cently adopted indications have re-ceived attention in the current liter-ature, articles dating as far back as the 1960s have described similar sur¬gical indications—including Neer’s
article,17 which is often cited as sup-port for nonsurgical management. Randomized controlled trials, one of which has recently been complet-ed,11 and another that is currently under way, are necessary to deter-mine whether these relative indica-tions should be considered routine and, if so, in which patients with which fracture types.
Nonsurgical Treatment
Historically, nonsurgical treat¬ment has been the mainstay for clavicular fractures. It has varied from plaster shoulder spica casts to benign neglect. Most commonly, a sling or figure-of-8 brace is applied in the acute setting. With either de¬vice, immobilization is typically for
2 to 6 weeks, based on the patient’s level of comfort. Often, mild dis-comfort can linger in adults for
3 months. Return to athletics or heavy labor is permitted 4 to 6 weeks after clinical and radiograph¬ic union has occurred. Light work with restricted overhead activity can begin once the patient’s comfort allows, usually in 2 to 4 weeks after fracture healing.
In a prospective, randomized study,27 26% ofpatients treated with a figure-of-8 bandage were dissatis-fied compared with 7% of those treated with a sling. The patients treated with a sling reported less dis¬comfort. There was no difference in overall healing and alignment of the fractures, indicating that a figure¬of-8 bandage does little to obtain or maintain reduction.
Surgical Techniques
Plates
Open reduction and internal fixa-tion using plates and screws can be done with the patient in either the supine or the beach-chair position, with the head and neck tilted away from the surgical site. A bump is placed behind the scapula to aid in the reduction. The arm is prepped in the field to allow for traction and manipulation to assist in the reduc-tion. Traditionally, a skin incision is made over the clavicle following Langer’s lines, as the skin permits. A newly described alternative is to in-cise the inferior skin after pulling it over the fracture site.28 As the skin is released, it will fall 1 to 2 cm below the clavicle and prevent the wound from being in contact with the plate on the clavicle. The aim is to im¬prove cosmesis and prevent wound complications. The dissection is taken down to bone with care to identify the cutaneous supraclavic-ular nerves. When necessary, they can be sacrificed. It is important to inform the patient before surgery of the possibility of a patch of numb-ness in the skin inferior to the clav-icle.
Minimizing subperiosteal strip¬ping with gentle handling ofthe skin and soft tissue helps avoid complica¬tions. The plate usually is placed on the tension side ofthe bone—for the clavicle, the anterosuperior position (Figure 4). Biomechanically, this position provides the best stabili-ty.29 However, clinically successful treatment with anteroinferior place-ment also has been described.30 Theanteroinferior position, although less favorable biom ech anically,29 al¬lows for drilling in a direction away from the subclavian vessels and lung. It also keeps the plate from be¬ing placed under the incision. This position theoretically is less likely to cause irritation, thereby decreasing the need for plate removal. However, the anteroinferior position demands additional soft-tissue stripping and a more difficult contouring of the plate compared with the anterosupe-rior position.
Ideally, a 3.5-mm dynamic com-pression plate or plate of similar strength should be used, with at least six cortices on each side. Semi-tubular plates are not as rigid and should not be used.24,31 Reconstruc¬tion plates are more easily contoured and have been used with success; however, they account for several failures to obtain union and would not be the author’s first choice.24,31 Precontoured plates of suitable thickness offer the advantage of ease ofplacement without manipulation of the plate. Locked plates are not necessary for the acute plating of nonosteoporotic clavicular fractures;
there is no significant advantage over conventional plating, and the cost is higher.
Once plating is completed, the fascia is repaired over the plate, if possible, and the skin incision is closed. Suture closure is preferable to staples. With a sufficiently stable construct, unrestricted shoulder mo-tion is allowed, with the exception of overhead lifting for 6 weeks. Of-ten, the pain relief associated with stabilizing the fracture is dramatic, and efforts to limit the patient’s ac¬tivity may be needed. Pain relief is cited as one ofthe potential benefits of surgical intervention.
Intramedullary Fixation
An alternative to plating is in-tramedullary (IM) fixation. Many variations of IM implants have been described over the past 40 years, in-cluding Hagie pins, modified Hagie pins, Knowles pins, Herbert screws, Steinmann pins, elastic nails, can-cellous screws, and Kirschner wires.32-36 Modifications in the tech-nique have led to a resurgence of in-terest in IM fixation of these frac-tures. The potential benefits of IMfixation compared with plate fixa-tion include less soft-tissue stripping at the fracture site, better cosmesis with a smaller skin incision, easier hardware removal, and less weak¬ness of the bone after hardware re¬moval. Biomechanically, however, the ability to resist torsional forces with IM fixation is much less than that with a plate. Migration of the pins also has been a major concern. Newer designs, which include lock¬ing nuts on the lateral end of the IM devices, prevent medial pin migra¬tion. Newer techniques that avoid penetration of the medial fragment cortex also prevent medial migration of the devices.34
Patient positioning is similar to that for plate fixation. A small inci-sion is made over the fracture site, exposing the fracture ends. The me-dial segment is prepared by drilling into the medullary canal, but the an-terior medial cortex is not violated. The distal segment is drilled retro-grade through the canal, exiting the posterior lateral cortex. The pin is inserted retrograde through the ca¬nal and exits through the posterolat¬eral hole and out the skin. Next, thefracture is reduced, and the pin is ad-vanced antegrade across the fracture into the medullary canal of the me-dial segment. The Rockwood Clavi-cle Pin (DePuy Orthopaedics, War-saw, IN) has two nuts that go over the threaded end of the inserted pin posterolaterally. Once the pin is across the fracture, the first nut is in¬serted posterolaterally, compressing the fracture, followed by the second nut, which is cold-welded to the first. Figure 5 shows the Rockwood Clavicle Pin in place. Some ofthe IM techniques vary slightly depending on the device, and not all ofthe tech-niques allow for fracture compres-sion.
Patients are allowed to begin shoulder motion immediately post-operatively. When rotational stabil-ity is a concern, forward elevation should be restricted to 90° and ab¬duction to 90° for the first 4 weeks. The Rockwood pin should be re¬moved at 8 to 14 weeks. In some sit¬uations, this can be done under local anesthesia in the office; however, most Rockwood pins need to be re-moved in the operating room. Some ofthe other IM devices, such as Her-bert screws, do not need to be re-moved.
As with plating, a major benefit is early return to activities. Several studies have reported athletes’ re-turning to their sport activities by 2 to 3 weeks.35,37
5．治法
5.1 治疗指征
治疗的目的是恢复肩关节的功能到受伤前水平。治疗应当让最低限度地减少畸形、活动能力的丧失以及疼痛。非手术治疗的适应症包括无移位或有轻微移位的锁骨骨折。手术适应症包括开放性骨折和伴有皮肤缺损或血管神经损伤的骨折。
相对的手术适应症包括复合伤患者，漂浮肩和伴有疼痛的骨折畸形愈合和延迟愈合。最近报道的另外相对手术适应症：高能量的伴有1.5cm-2.0cm短缩的闭合性骨折，完全移位的骨折和粉碎性的骨折。[23-26]这些最近采用的手术适应症已经被象1960年就曾描述过的——包括常常被用来支持非手术治疗的neer的文章——类似适应症的文献注意。随机对照试验一项已经完成，[11]和另一项目前正在进行中。它对于决定这些相对的适应症是否应当考虑进去是相当必要的。如果考虑进去，那么是具有那种类型骨折的那种病人？
5.2 非手术治疗
历史上，非手术治疗曾被作锁骨骨折主要的治法。从肩人字形圆柱型石膏到现在的锁骨带，在急诊室，最常用的悬吊带或“8”字绷带。基于患者的耐受水平，通常使用二者中的一种制动2-6周。如果只有轻度的不适，在成人最多可延续3个月。而要进行运动和重体力劳力则需在临床愈合和放射学上的愈合出现4-6周以后才能进行。不过头的轻体力劳动一旦患者可耐受，通常在骨折愈合后2-4周后进行。
在一项前瞩性的随机试验中[27]，使用八字绷带治疗的患者有26%感到不适，而使用悬吊带治疗中有7%，悬吊带治疗不适率更少。而在治愈情况与复位情况上两者没有差异，这也说明了八字绷带对复位和维持复位作用甚微。
5.3 手术治疗
5.3.1 钢板内固定治疗
使用钢板或螺钉来进行切开复位内固定术，患者头颈只需偏离患侧，仰卧位或沙滩椅位都可进行。手术前在肩胛骨后垫上沙袋将有助于复位。而在肩部应当准备足够空间以利于复位时的牵引和手术操作。传统上，手术切口通常位于锁骨上沿langer’s线。现在有一种新方法可供选择，[28]作切口时将锁骨下皮肤推至锁骨上，当松开皮肤时，它将下降1-2cm位于锁骨下方，这样可以防止切口直接同锁骨下钢板接触。此切口的目的可以提高美观也避免切口并发症的发生。作此切口时应当小心辩认锁骨上皮神经。如果有必要，也可以将其切断，但在手术前应当靠知患者术后可能造成锁骨下部分皮肤的麻木。
最少地剥离骨膜同时对皮肤软组织进行轻柔操作将有助于避免并发症的发生。钢板通常放在骨骼的张力侧，即锁骨则在前上方。从生物力学上讲放置于此位置能提供最好的稳定性。[29]然而，临床上将钢板放置于前下方成功治疗锁骨也有相应的报道。[30]前下方这个位置尽管生物力学方面优势相对减少，[29]但它可以在进行钻孔时远离锁骨下血管和肺。这种方法也使钢板在切口下方远离切口。这个位置从理论上讲也可能引起更少的刺激从而也减少了拆除钢板的必要。但是前下方需要更多的剥离软组织，同前上方相比钢板塑形也更困难。而最近有学者研究锁骨[31]解剖后对锁骨骨折采用三维固定，即在锁骨远端将钢板固定在锁骨上方，在锁骨近中端将钢板固定在锁骨前方，使其与骨面紧密贴附。其方法在治疗粉碎性骨折上已取得良好疗法。
理想上，锁骨中段骨折应使用3.5mm 动力加压钢板或相似强度的钢板，然后骨折两端分别至少穿透六层皮质骨进行固定。1/2管形强度不够而不被推荐使用。[24，32]重建钢板因其更易塑形已被成功使用，但它对骨折愈合方面有影响，所以不应作为术者首选[24，32]。适合厚度的解剖钢板具有不需对钢板进行塑形就能与骨骼贴敷的优点。锁定钢板对于急性无骨质疏松的骨折是没有必要使用的，它与常用钢板相比没有明显优点，价格却更昂贵。
一旦固定完成，应当缝合钢板上筋膜，同时只要有可能就应当尽量闭合切口。用缝线闭合切口比U型钉要更适合。固定如果达到有效稳定，除过头上举运动应限制6周外，肩关节活动可以适当进行。通常骨折固定后疼痛即可得到明显减轻，所以应当尽量限制患者的活动。减轻疼痛也是外科手术潜在的益处之一。
5.3.2 髓内固定
髓内固定（IM）是另一种可选择的固定方式。在过去40年里，许多各式的髓内内植物曾被运用，例如Hagie 针、 改良Hagie 针、Knowles 针、Herbert 钉、Steinmann 针、 弹性髓内钉、 松质螺钉、 和克氏针。[33-37] 由于技术改进，人们对这些髓内固定的兴趣重新召起。与钢板内固定与相比，IM具有以下潜在优势：对软组织剥离较少、切口更小相对较美观、拆除内固定更方便以及内固定拆除后骨骼质相对更好。然而，在生物力学上，髓内固定的抗旋能力要比钢板差。针的滑移也是主要担心的问题。现在可防止针滑移的尾端带锁钉的髓内固定已被设计出。这种新技术能避免穿透中段皮质也就能阻止其从中段滑移。[35]
手术时，患者的体位同钢板内固定时相似。在锁骨上方骨折处作一小切口暴露骨的断端。近端用钻头先行扩髓，但不穿透皮质。远侧端逆行扩髓并从后外侧穿出皮质。然后髓内针逆行从后外侧骨洞穿出露于皮肤外。接着复位骨折，再将髓内针顺行打入穿过骨折断端进入骨折近端。Rockwood 锁骨钉（DEPUY公司生产）有两个螺母，它们都能顺着针后方的螺纹进入。当髓内针穿过骨折后，第一个螺母旋入加压骨折端，紧接着旋入第二颗螺母锁定第一颗。有些IM技术在器械上改动较少，所以不是所有的技术都可以对骨折断端进行加压。
当髓内固定完成后，一个主要的优点就是可以早期进行活动。几项研究报道运动员术后2-3周即可返回进行运动训炼。[36，38]
Complications
Complications can occur from non-surgical treatment as well as surgical treatment. Both can produce a cos-metic deformity (Figure 6). Both can result in malunion, nonunion, pain, local tenderness or irritation, and limitation of motion. Other rare complications following surgical or nonsurgical treatment are residual nerve paresthesia; subclavian ves¬sel compression, thrombosis, and pseudoaneurysm; thoracic outlet syndrome; and brachial plexus neu-ropathy.
Figure 6
A, Healed clavicular fracture managed nonsurgically. The bump, shortened shoulder width, and subtle droop are evident.
B, A healed clavicular fracture treated with plate and screws, showing prominence of the anterior-superior–positioned plate.
Some complications are unique to surgical intervention, such as in-fection and hardware problems. In-fection rates vary from 0% to 18%, with the lower rates reported in the more recent studies.24,31,37,38 Painful, irritating hardware requiring plate or pin removal is reported to be as high as 50% to 100%.24,39 Following plate removal, the risk for refracture rang¬es from 0% to 8%.24,31 Adhesive cap-sulitis of the shoulder has been re-ported with surgical treatment in 0% to 7% of cases.24,28
IM devices are associated with unique complications, including mi-gration ofthe pin and hardware irri-tation, resulting in local skin break-down that often requires antibiotics and, ultimately, hardware rem ov-al.39 Figure 7 illustrates skin break-down from an IM pin. Although most ofthese complications are rare, a second surgery for plate or pin re¬moval is sufficiently frequent to be considered when reviewing treat¬ment choices.
6．并发症
非手术治疗可以引发并发症，手术治疗同样会引起。二者都可造成外观上的缺陷，
同时也能引起以下并发症：骨折畸形愈合，不愈合、疼痛、局部的触痛或排异反应以及活动障碍。手术治疗其它的并发症较少，但非手术治疗还可能会遗留神经上的感觉异常、锁骨下血管压迫、血栓、假性动脉瘤、胸廓出口综合症以及臂从神经病变等。
然而一些并发症也是外科手术特有的，例如：感染和内植物问题。手术治疗感染率在0%-18%内变化，最近许多研究报道的感染率有所降低。[24，32，38，39]另有文献报道由于疼痛，钢板的排异而要求拆除钢板或髓内钉的高达50%-100%。[24，40]钢板拆除后再骨折率有将近0%-8%。而有报道[24，28]表明术后肩关节粘连的病例达0%-7%。
IM内固定糸统特有的并发症包括针的滑移和内植物的排异反应，而这种排异反应将造成局部皮肤的破溃常需要抗生素来治疗，最终只能提早拆除内植物。尽管这些并发症很少，回头来看做治疗选择时，再次手术移出钢板或髓内钉应当充分考虑进去。
Results
Whether treated nonsurgically or surgically, most clavicular fractures heal without incident when length and alignment are maintained. Ac-ceptable cosmetic and functional re-sults should be expected. Satisfacto-ry results occur less consistently when the fracture fails to heal or heals with a significant deformity.
Nonunion
Most cases ofnonunion are symp-tomatic, presenting with pain, loss of function, neurologic changes, and/or unsightly clavicular deform i-ty. Although clavicular nonunion has not been clearly defined in the literature, most authors concur that nonunion is present when healing has not occurred by 16 weeks.
Traditional thinking is that cla-vicular fractures treated nonsurgical¬ly almost always heal and that surgi¬cal treatment increases the risk of nonunion. Rowe4 reported a non-union rate of 3.7% in patients who underwent surgery compared with 0.8% in those treated without sur¬gery. Neer17 reported nonunion rates of 0.1% with nonsurgical treatment and 4.6% with surgical treatment. Neer17 suggested that the most im¬portant causal factor for nonunion of a midshaft clavicular fracture is im¬proper open surgery. This may be true to some extent; aggressive soft-tissue stripping, inability to reduce the fracture, and inadequate internal fixation all can lead to poor results.
Several recent studies have re¬ported high union rates with surgical intervention using a variety of inter-nal fixation devices, including plat-ing and IM pin or rod fixation.39,40 In addition, there is evidence that the nonunion rate after nonsurgical treat¬ment may be higher than previously reported, particularly in certain frac¬ture types and in certain patients. In their review of 581 nonsurgically treated fractures, Robinson et al20 re¬ported an overall nonunion rate of
Figure 7
Healed clavicular fracture treated with intramedullary pinning. A, Note incision size and location over fracture and posterolateral prominence. B, Early breakdown of the skin resulting from a prominent pin at the posterolateral insertion site.
4.5% for diaphyseal fractures. Strat-ification of Robinson’s data revealed that women with displaced diaphy¬seal fractures had a nonunion rate ranging from 19% to 33%. When comminution was combined with displacement, the nonunion rate in women increased to a range of 33% to 47%.41 In addition to fracture frag¬ment displacement, female sex, and comminution, other risk factors identified with nonunion include ad-vancing age, lack of cortical apposi-tion, severity of the initial trauma, the extent of fracture fragment dis-placement,25 and, arguably, soft-tissue interposition.42 Early m obiliza¬tion has not been associated with the development of a nonunion, whether treated surgically or non surgically.
A recently published systematic review ofthe literature on nonunion after treatment ofmidshaft clavicu¬lar fractures revealed a 5.9% non¬union rate in nonsurgically managed fractures.8 In the completely dis-placed fractures, the rate increased to 15.1%. In surgically treated displaced fractures, plating of 460 fractures re¬sulted in a nonunion rate of 2.2%, and IM fixation of 152 fractures re-sulted in a nonunion rate of 2.0%.8 These data should be interpreted with caution, however, because mostwere from evidence-based level III, IV, and V studies (ie, observational, retrospective, case series, and expert opinion studies) rather than from level Iand II studies (ie, randomized, prospective studies).
Surgical treatment of nonunion has a high success rate. Techniques include plate fixation with bone graft, IM pin fixation with bone graft, and external fixation. Union rates with each method have been reported to be >92% and as high as 100%.42-45 Plate fixation has the largest support in the literature and is currently the most predictable and recommended treatment for symptomatic nonunion. Other methods may be successful in the hands of an experienced surgeon.
M a lu n ion
Most nonsurgically treated cla-vicular fractures heal with some de-formity. The literature does not clearly define when a deformity is considered to be a malunion; howev-er, the evidence strongly suggests that some clavicular deformities re-sult in unsatisfactory outcomes. The deformity is a three-dimensional problem; the most consistent char-acteristic is shortening with inferior displacement of the medial frag¬ment. Symptomatic patients help define the malunion. Symptoms in¬clude weakness and pain in the in¬volved shoulder, loss of shoulder motion, loss of endurance, neurolog¬ic symptoms consistent with thorac¬ic outlet syndrome and brachial plexus impingement, and cosmetic deformity.46
In 1986, Eskola et al21 noted in 89 patients that shortening >12mm was associated with increased pain. Wick et al22 concluded in a retrospec¬tive study that shortening of2 cm in midshaft clavicular fractures was as¬sociated with an increased risk of pain, limitation of motion, or non¬union. McKee et al9 assessed func¬tional outcome following displaced clavicular fractures and noted signif¬icantly inferior scores for both the upper extremity–specific (DASH) outcome scores (P = 0.02) and the Constant scores (P = 0.01) compared with the general population. They concluded that fractures with >2 cm ofshortening tended to be associated with decreased abduction strength and greater patient dissatisfaction. Hill et al25 reported on completely displaced middle third clavicular fractures and concluded that final shortening ≥2 cm was associated with an unsatisfactory result but not
with nonunion. After closed treat-ment, 31% ofpatients were dissatis-fied with the final result, 54% were unhappy with the appearance, and 15% of fractures failed to unite. Us-ingthe same subjective patient ques-tionnaire as that used by Hill et al,25 Lazarides and Zafiropoulos10 re-ported that final clavicular shorten-ing>18 mm in males and >14mm in females was associated with unsatis-factory results and with increased patient symptoms.
Ledger et al47 showed the effect of clavicular shortening >15 mm on biomechanical parameters of the shoulder. They found a significant increase in upward angulation (mean, 10.7°; P < 0.005) of the SC joint on the injured side compared with the uninjured side. The muscle torque ofthe injured arm was signif-icantly weaker than that ofthe unin-jured arm in extension (P <0.05), ad-duction (P < 0.05), and internal rotation (P < 0.05).47
These studies indicate that al-though clavicular deformities are complex and hard to assess, shorten-ingof1.5 to 2cm, which results in an increased incidence ofclinical symp-toms, is one parameter that can be measured. Further investigation is needed to clearly define the patients as well as the fracture deformity that is likely to be symptomatic with a clavicular malunion. In this way, acute surgical treatment could be of-fered to the patients who are most likely to benefit. In addition, compar¬ative trials are necessary to establish that patients with clavicular frac¬tures that predictably result in defor¬mity have better outcomes when treated surgically rather than nonsur¬gically. Several randomized trials cur¬rently are under way, and one has been completed, assessing the surgi¬cal versus nonsurgical management of acute displaced midshaft clavicu¬lar fractures. The Canadian Ortho¬paedic Trauma Society has shown in a multicenter randomized trial of 132 patients that for displaced fractures of the clavicular shaft, surgical fixa-tion with a plate and screws resulted in an improved functional outcome and a lower rate of malunion and nonunion compared with nonsurgi¬cal treatment at 1 year.11
Treatment of a malunion consists of surgical correction to restore length, angular deformity, and rota-tion of the clavicle. Treatment may or may not involve an intercalary bone graft. Often, after removing the callus of the malunion, it is possible to identify the proximal and distal fragments in order to anatomically reconstruct the clavicle.46,48 The ben¬efit of this technique is that there is no donor-site morbidity for a bone graft. When difficulty in determining the length of the malunited clavicle is anticipated, a preoperative radio-graphic image of both clavicles is helpful. Both IM devices and plates have been used successfully to treat
m alunions.46,48-50 Treatment ofsymp¬tomatic malunions has resulted in improvement of the function of the upper extremity, decreased pain, and increased patient satisfaction.46,50
7．讨论
是非手术治疗还是手术治疗？大多数锁骨骨折没有对位对线维持时也能愈合。外观上的接受程度和功能恢恢复情况应当考虑到。但当骨折不愈合或畸形愈合，那么满意的疗效是很少能持续的。
7.1 骨折不愈合
大多数不愈合是有症状的，如出现疼痛、功能的丧失，神经学上的改变，并/或存在难看的锁骨畸形愈合。尽管锁骨骨折不愈合在文献中没有清楚定义，但大多数学者一致认为16周后骨折未出现愈合则为骨折不愈合。
传统思想认为非手术治疗锁骨骨折通常可以愈合，手术治疗反而增加了不愈合的风险。Rowe[4]研究报道手术治疗的不愈合率为3.7%而非手术治疗为0.8%。NEER[17]报道的非手术治疗的不愈合率为0.1%，手术治疗为4.6%。NEER[17]认为锁骨中段骨折不愈合最重要的发生因素是不恰当的开放手术治疗。这可能由于以下原因造成：对软组织过分的剥离，不能复位骨折，选用不恰当的内植物，所有这些都能导致较差的临床疗效。几项研究报道[40，41]使用各式内植物包括钢板，髓内钉或外固定器进行手术治疗均取得较高的愈合率。另外，有证据认为非手术治疗的不愈合率可能比早期报道的要高，尤其是在某此特殊骨折类型和特殊的患者中。Robinson等[42]回顾了581例非手术治疗的病例，锁骨干骨折不愈合率总体为4.5%。而在Robinson分层数据中表明移位锁骨干骨折的女性患者不愈合率为19%-33%。而当为粉碎性时，不愈合率增加到33%-47%。除了骨折断端移位、女性和粉碎性，其它因素如年龄增长，皮质无对合，损伤的严重程度，骨折的移位程度[25]，和可以确认的骨折断端软组织嵌入[43]都可影响骨折的不愈合率。不论是手术治疗还是非手术治疗，早期的功能锻炼是与不愈合的增加没有关联的。
最近一篇关于锁骨中段骨折不愈合的糸统性回顾文献表明，[8]非手术治疗骨不愈合率为5.9%。而完全移位的骨折概率增加到15.1%。在手术治疗的移位骨折中，钢板治疗460例骨折不愈合率为2.2%，IM治疗的152例骨折则为2.0%。[8]然而，这些数据应当谨慎读解，因为这些大部分来自于III、IV、V型研究设计而不是来自I、II型。
手术治疗骨折不愈合有很高的治愈率。方法包括植骨钢板内固定，植骨髓内钉内固定和外固定器。每种方法的愈合率都大于92%，甚至达到100%。[43-46]在文献中，钢板内固定是最受推崇，也是当前对有症状的骨不愈合最具疗效和最受推荐的治法。其它方法在具有经验的术者操作下也是可以获得成功的。
7.2 畸形愈合
大多数非手术治疗锁骨骨折伴有一些畸形。文献中没有定义当畸形到那种度时将考虑为骨折畸形愈合。然而，一些锁骨的畸形引发不良临床疗效是不容置疑的。这种畸形是一个三维的问题：最多见的特征就是骨折短缩并伴有近端向下方移位。有症状的患者有助于诊断畸形愈合。这些症状包括：肩关节的无力和疼痛，肩关节活动范围的丢失，耐受力的下降，因存在胸廓出口综合征和侵及臂丛引起持续的神经学症状以及外观上畸形。[47]
Eskola等[21]在1986年在89例患者中就注意到伴有>12mm短缩的患者与疼痛增加有关。Wick等在一项回顾性研究中发现[22]锁骨中段短缩2cm的骨折同疼痛，活动受限或者骨不愈合并发症的发生有关。McKee等[9]对移位的锁骨骨折愈合后的功能使用DASH和Constant评分进行分析，两者评分都比正常人明显降低。（P=0.02，P=0.01）他们也得出结论骨折短缩>2cm同患肩外展力量减少和许多患者的不适相关。Hill等认为[25]完全移位但最后短缩≥2cm并未骨折不愈合的锁骨中1/3的骨折与不满意的临床疗效是存在关联的。而保守治疗后，31%的患者对最后的结果不满意，54%的患者对外观不满意，还有15%的骨折无法愈合。Lazarides and Zafiropoulos使用同Hill等同样的客观问卷调查发现，[10]骨折愈合后男性短缩>18mm，女性>14mm的患者临床结果不满意，同时患者症状也有所增加。
Ledger等[48]认为当锁骨短缩>15mm对肩关节的生物力学参数有影响。他们发现与健侧相比较患侧胸锁关节存在明显向上成角（平均10.7度，P<0.005）。而患肩的外展，内收以及内旋的肌力明显比健侧减弱。
这些研究表明了锁骨畸形是复杂的，也是难于评定的，但短缩1.5-2cm可引发临床症状发生率的增加是一种可测的参数。更进一步研究应当清楚地评定锁骨骨折畸形愈合，畸形程度怎样可引发临床症状发生。这样看来，进行急诊手术治疗是最能给患者益处的。另外，我们也有必要建立对照研究以说明进行手术治疗对可能出现畸形愈合的患者比非手术治疗能获得更好的临床疗效。一项关于手术治疗与非手术治疗急性锁骨中段移位骨折对比研究已完成。加拿大骨创伤中心在经过一项关于132例锁骨中段移位骨折患者的多中心随机试验发现，[11]随访一年使用钢板螺钉手术治疗的患者与非手术治疗相比，功能疗效有提高而畸形愈合率和不愈合率明显降低。
手术治疗骨折畸形愈合可以恢复其长度、矫正其畸形成角以及锁骨的旋转。这种治疗可能需要或不需要作骨移植。我们手术时常规都去除畸形愈合处的骨痂，这样可以辨清骨折两端也有助于锁骨的解剖重建。[47，49]术前拍摄双侧锁骨的X片对术中出现无法确定愈合不良的锁骨实际长度很有帮助。在治疗有症状的锁骨畸形愈合方面，IM内固定和钢板内固定都成功地提高上肢功能，减轻了疼痛也提高了患者的满意度。[47，51]
毕竟园子里面基层医院还是比较多的,而对于推广治疗理念也应当由此开始,并纠正一些
常规治疗中的错误.让规范化更规范化.望各位版主考虑,谢谢!选了这么一篇翻后上传,第一次也不知能否规范.
Acute Midshaft Clavicular Fracture
Dr. Jeray is Program Director,
Orthopaedic Surgery Education,
Greenville Hospital System, Greenville,
SC.
Neither Dr. Jeray nor the department
with which he is affiliated has received
anything of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. Jeray, Greenville
Hospital System, University Medical
Center, Orthopaedic Surgery Education,
701 Grove Road, 2nd Floor ERC
Support Tower, Greenville, SC 29605.
J Am Acad Orthop Surg 2007;15:239-
248
Copyright 2007 by the American
Academy of Orthopaedic Surgeons
Abstract: Clavicular fractures represent 2.6% to 5% of all fractures, and middle third
fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; thenonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons preposesurgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.
摘要：锁骨骨折占全身所有骨折的2.6%-5%，而中1/3骨折占所有锁骨骨折的69%-82%。锁骨中外1/3是最细的部分也是唯一没有附着的肌肉和韧带保护。这种解剖特征使其易于骨折，尤其是当摔倒后肩部着地产生一个对锁骨的轴向暴力时。对于无移位或轻度移位的锁骨中段骨折应首选悬带带或“8”字绷带治疗，其不愈合率也非常低。然而当为完全移位或粉碎性的锁骨中段骨折，并且患者为老年人或女性，不愈合，外观缺陷和较差的临床疗效的风险将显著增高。因此，一些学者建议使用钢板螺钉或髓内糸统治疗复杂的的锁骨中段骨折。为了给临床治疗决断提供基础，更进一步的随机前瞻性试验有必要进行的。
The clavicle is one of the most commonly fractured bones; cla-vicular fractures represent 2.6% to 5% of all fractures.1,2 The incidence of clavicular fracture in adults is es-timated to be 71 in 100,000 for men and 30 in 100,000 for women, with the incidence of midshaft fractures decreasing with increasing age. Mid-shaft fractures account for 69% to 82% of all clavicular fractures.1-5 Midshaft fractures are more common in children and young adults. The in-cidence of high-energy clavicular fractures with comminution, dis-placement, and shortening appears to be increasing.2
Traditionally, fractures of the clavicle have been treated with closed reduction. More than 200 methods have been described for closed reduction, yet a classic text-book recognizes that “reduction ispractically impossible to maintain, and a certain amount ofdeformity is to be expected, generally compatible with satisfactory return of function in the shoulder.”6 The same text¬book states that even completely displaced fractures “generally do well with non-operative manage¬ment....”6
However, most previous studies describing the results of clavicular fracture have used surgeon-based or radiographic outcome measures that equate union with success. Very few studies on clavicular fracture have been published using patient-based outcomes such as the Medical Out-comes Study 36-Item Short Form (QualityMetric, Lincoln, RI) or the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH; In-stitute for Work and Health, Toron¬ta, Canada, and the American Academy of Orthopaedic Surgeons [AAOS]). Recent studies have indi-cated that outcomes are not always excellent, particularly in high-energy fractures.7-11 These studies raise the question whether acute m idshaft clavicular fractures should be internally fixed.
锁骨骨折是最普通的一种骨折，约占全身骨折的2。6%—5%。[1，2]锁骨骨折在成人的发生率，在男性大约十万分之七十一，女性约为十万分之三十，并且随着年龄的增大而增加。锁骨中段骨折占所有锁骨骨折的69%-82%。[1-5]锁骨中段骨折不论在儿童和青年人都是很常见的。而粉碎性的，移位的，短缩的高能理锁骨骨折发生率也正在增长。[2]
传统上锁骨骨折都是使用闭合复位进行治疗。这种方法文献中提到将近二百多种。而一本经典的书上也说，复位实际上是不可能维持的，一定数目伴有肩关节功能恢复尚可满意的的畸形存在是可是料想得到的。同是这本书还说既便是完全移位的锁骨骨折通过保守治疗通常也能收到良好疗效。[6]
然而大多数早期的报道评定锁骨骨折的疗效时，把医生主观经验或者影像学的结论等同于成功的愈合。很少有文献是以病人角度来客观评定临床疗效的。近来的研究发现保守治疗效果并没有总是很好的，特别在高能量的锁骨骨折上。[7-11]这些研究提出一个问题：急性锁骨中段骨折是否应当手术？
Anatomy and Function
The clavicle is the first bone to ossify in the fifth week of fetal life, and it is the only long bone to ossify by in-tram embranous ossification. Initial growth up to age 5 years arises from the ossification center in the central portion ofthe clavicle, with contin¬ued growth occurring at the epiphy¬seal plates at the medial and lateral ends of the bone. The medial growth plate, typically the only plate seen ra¬diographically, accounts for up to 80% of longitudinal growth. The me¬dial growth plate is the last physis to close, generally at age 22 to 25 years. The clavicle is subcutaneous, with
only the supraclavicular nerves cross¬ing the bone. However, several fascial layers and muscles attach to the bone itself and help to create the predict¬able deformity seen with fractures. The proximal fragment is pulled su¬periorly and posteriorly by the ster¬nocleidomastoid muscle. The distal segment sags forward and rotates in¬feriorly because ofthe weight of the upper extremity and, to a lesser ex¬tent, the pull of the pectoralis mus¬cle on the humerus.
The clavicle is a strut that con-nects the upper extremity to the trunk and is the only link to the ax-ial skeleton. It also provides protec-tion for the adjacent axillary and subclavicular neurovascular struc-tures and the apex of the lungs. Lat-erally, the clavicle is secured by the acrom ioclavicular (AC) and coraco-clavicular ligaments where it articu-lates with the acromion. Medially, the clavicle articulates with the ster-num and is strongly secured to the first rib by the intra-articular ster-noclavicular (SC) joint cartilage, the oblique fibers of the costoclavicular ligaments, and the subclavius mus-cle. The clavicle is S-shaped and double-curved, concave ventrally on its lateral half and convex ventrally on its medial half. The cross-sectional geometry changes from flat laterally to tubular centrally to trian¬gular medially (Figure 1).
The shape of the clavicle and the ligamentous and muscle attach¬ments play a role in fracture pat¬terns. The junction of the outer and middle thirds is the thinnest part of the bone and is the only area not pro¬tected by or reinforced with muscle and ligamentous attachments, there¬by rendering it prone to fracture, par¬ticularly with axial loading.12 This helps to explain why the middle third is the most common site of fracture, occurring at the junction where the bone geometry changes from flat to tubular.
The motion of the clavicle is ulti-mately linked to the surrounding motion ofthe scapula because ofthe anatomic attachment to the scapula through the AC joint and to the ster-num through the SC joint. Motion of the clavicle occurs with elevation and abduction ofthe arm. Duringel-evation, with respect to the SC joint, the clavicle undergoes elevation of 11° to 15°, retraction of 15° to 29°, and posterior long-axis rotation of 15° to 31°, with the magnitude and planes varying among subjects.13 Other studies suggest that rotation may be as much as 50° and elevation as high as 30°.14 More importantly, clavicle rotation is relatively small until humeral elevation exceeds 90°; thus, early rehabilitation that avoids over-the-shoulder activity will sig-nificantly limit rotational forces at the site ofa clavicular fracture.15
1.锁骨的解剖及功能
锁骨是在胚胎第五周时第一根开始骨化的骨骼，同是也是最初唯一通过骨膜内骨化进行成骨的长骨。从出生到5岁是从锁骨中部的骨化中心开始生长，接着便通过干骺端的骨骺来继续生长，它内外侧端各有一继发骨骺。锁骨的中央生长板是唯一能在X线上能显影的生长板，它的生长力占锁骨长度的80%左右。这个中央生长板闭合最晚，一般都要在22-25岁时才闭合。锁骨就位于皮下，却只有锁骨上神经跨过该骨。因此，当骨折时，一些韧带和肌肉的附着使这种可预知的畸形很容易就显现出来。骨折近端由于胸锁乳突肌的牵拉而向上向后。骨折远端则由于胸肌的牵拉和上肢的重量使得其向前凹陷向下旋转。
锁骨桥架于上肢带与躯干之间，也是上肢带与中枢骨唯一相连的骨性结构。它为邻近的腋窝，锁骨下神经血管以及肺的上叶提供了保护。外侧，锁骨由肩锁韧带和与肩峰相连的喙锁韧带固定。锁骨近端同胸骨相关节，并且通过关节软骨，斜形纤维的肋锁韧带以及连于第一肋骨的锁骨下肌牢固稳定。锁骨形似“S”，有双向弧形，前凸后凹。它的纵轴几何形状从外侧的扁平渐变成中段圆柱形，向近端延伸为三棱形。
锁骨的形状以及韧带和肌肉的附着影响着骨折发生的类型。外中1/3交接处是骨骼的最薄弱部分，也是唯一没有肌肉和韧带保护的区域，因此很容易骨折，特别当受轴向暴力时。[12]这也解释了为什么中1/3是骨折最常见部位，为什么骨折常发生在从扁平转向管型部位。
由于锁骨通过胸锁关节与胸骨相连，通过肩锁关节与肩胛骨相连，因此锁骨的运动始终与肩胛骨的运动相关联。而只有当肩关节上举与外展时锁骨的运动才进行。由于同胸锁关节的相连，在上举时，锁骨需要提升11°到15°，内收15°到29°，围绕后方长轴旋转15°到31°，过程中长度和平面都发生变化。[13]其它研究认为[14]锁骨旋转最多只能到50°，上升只能到30°。更重要的是如果肱骨上升不超过90°，锁骨旋转是很小的。因此早期康复时避免进行过肩活动将明显减少锁骨骨折断端之间产生旋转应力。[15]
Mechanism of InjuryMidshaft clavicular fractures have traditionally been thought to occur from a fall on an outstretched hand. However, a biomechanical analysis of the forces demonstrated
that a direct injury from the shoul¬der (rather than the hand) that pro¬duces a force equal to the body weight would exceed the critical buckling load and result in a mid-shaft clavicular fracture.16 Several studies have demonstrated that a di¬rect fall or blow onto the point of the shoulder accounts for 85% to 94% of the injuries.2,3,5,16,17 When the forces are transmitted through the arm, as with a fall on an outstretched hand, the forces are not directly delivered to the clavicle; thus, they are unlike¬ly to produce a midshaft fracture. This mechanism accounts for 2% to 5% of all midshaft fractures. A direct blow to the clavicle, such as from a hockey stick or a seat belt shoulder-strap injury, also may produce a frac¬ture and accounts for 10% to 13% of midshaft fractures in most stud¬ies.16 Although rare, direct force on the top ofthe shoulder may drive the midshaft clavicle against the first rib, resulting in a fracture.
2.损伤机制
锁骨中段骨折传统被认为是由于伸展位摔倒引起的。然而一项对这种暴力的生物力学分析表明，[16]一个来自肩部的超过急性压曲的相当于身体重量的直接暴力，真正引起锁骨中段的骨折。还有几项研究[2,3,5,16,17]也显示由于跌倒或打击对肩部的直接暴力占损伤的85%-94%。而由于伸展位摔倒引起的暴力传导到肩部是不会直接传至锁骨的，它也不太可能引起锁骨中段骨折。大量的研究表明[16]，这种机制造成的骨折在所有锁骨中段骨折中只占2%-5%。而象来自棍棒或安全带的肩带伤产生的对锁骨的直接暴力占10%-13%。直接来自肩关节上方的直接暴力虽然很罕见，但它能让锁骨中段相第一肋骨相顶触撞击结果造成骨折。
Classification
Clavicular fractures have been classified by Allm an18 into three ana¬tomic regions, with the middle third being group I. The classification sys¬tem of the Orthopaedic Trauma As¬sociation separates diaphyseal cla¬vicular fractures into three types: 06-A (simple), 06-B (wedge) and 06-C (complex).19 Each type is further bro¬ken down into three groups.
The system developed by Robin-son3 divides midshaft clavicular frac¬tures into type 2A (cortical align¬ment fracture) and type 2B(displaced fracture). In an effort to provide di¬rection for treatment and prognosis, Robinson further divides these into subgroup types 2A1 (nondisplaced), 2A2 (angulated), 2B1 (simple or wedge comminuted), and 2B2 (isolat¬ed or comminuted segmental) (Fig¬ure 2). Robinson’s classification sys¬tem has demonstrated satisfactory levels of interobserver and intraob¬server reliability and reproducibility. However, additional studies are needed to determine whether thisclassification system will reliably predict treatment and functional outcomes.
3.分类
锁骨骨折Allman分型[18]分为三型。中1/3属I型。AO分类系统将锁骨干骨折分为3类：06-A（简单骨折）,06-B（楔型骨折）,06-C（复杂型骨折）[19]。每一类型进一步分为三个亚型。
这种分类系统被Robinson发展[3]，锁骨中段骨折分进为2A型(皮质仍残留骨接触的骨折)和2B(无骨接触的移位骨折)。为了尽力为治疗和诊断提供指导，Robinson进一步分出亚型：2A1(无移位的骨折)，2A2(成角的骨折)；2B1 (单纯或楔形粉碎性骨折)和2B2 (孤立的或粉碎性节段性骨折)。2个亚型的Robinson的分类系统显示了其具有良好可信度和可重复性。然而,另外的研究需要确定这种分型系统是否能可靠地预测治疗和临床效果。
Clinical Evaluation
Often with clavicular fracture, a bruise or abrasion is seen, either over the point ofthe shoulder (indicating a direct blow) or over the midline (suggesting a seat belt shoulder-strap injury). The shoulder has a droop, the scapula appears slightly internal¬ly rotated, and the shoulder appears shortened relative to the opposite side. This characteristic deformity is produced by the pull ofmuscles at¬tached to the clavicle. Immediate swelling may obscure the deformity of the bone, which will be seen on radiographs if the fracture is dis¬placed. Palpation over the area will reveal tenderness, and gentle manip¬ulation may produce crepitus and
motion at the fracture site. A non-displaced or minimally displaced fracture may be suspected when pain and/or skin changes are present over the clavicle.
Because middle third fractures frequently occur with high-energy trauma, a complete examination should be performed to avoid miss-ing associated injuries. Skeletal inju¬ries include fracture-dislocations of the SC and AC joints or, in younger patients, physeal injuries. Chest wall trauma may result in high rib frac¬tures, scapular neck and body frac¬tures, and a pneumothorax or he¬mothorax. Although acute brachial plexus injury is rare, the ulnar nerve is at highest risk because of its loca¬tion adjacent to the middle third of the clavicle. When a nerve injury is identified, a thorough vascular ex¬amination and evaluation of the scapulothoracic articulation should
Figure 3
Standard radiographic anteroposterior view (A) and 45° cephalic tilt view (B). Both are necessary to determine the extent of fracture displacement.
be undertaken to avoid missing an associated injury. Penetrating trau¬ma is typically the cause of vascular injury. However, vascular injury can occur from blunt trauma, resulting in spasm or thrombosis of the sub-clavian vessels.
4．临床诊断
锁骨骨折常常伴有瘀伤或擦伤，查体可以在肩部的外侧(预示为直接暴力)或在锁骨中线上(预示这可能是安全带引起的肩带损伤)发现。伤肩有下垂症象，肩胛骨会出现轻微的向内旋转,并且肩关节与健侧相比要短缩。这个特征性的畸形是由于附着锁骨肌肉的牵拉而引起的。急性的肿胀可能掩盖在X片上可以看到的移位骨折。触诊骨折段会出现明显的疼痛，轻柔的触诊可触及骨擦音和骨折断段的移动。当锁骨上方出现疼痛并/或有皮肤损伤时，应当怀疑可能存在无移位或轻微的骨折。.
因为中1/3骨折通常是由于高能量创伤引起，所以应当进行一个全面的检查以免遗漏复合伤。年轻的骨折干骺端损伤的患者常会伴有肩锁和胸锁关节骨折脱位。 胸壁损伤可能导致高位肋骨骨折、肩胛骨颈和体部骨折,甚至伴有气血胸出现。尽管急性的臂丛损伤很少见，但尺神经因为它的位置靠近中1/3锁骨，其损伤的风险最高。当神经损伤确诊，应当进行一个全面的血管检查和肩胸关节检查以免漏诊其它相关损伤。血管损伤通常由穿透伤引起。然而钝挫伤也能引起血管损伤，可引起锁骨下血管血栓形成或血管痉挛。
为了判定骨折的类型和移位程度，应当拍摄二个投照位的X片，一个标准的前后位和45度头倾位。肩带骨和肺上部区域应仔细检查，以避免漏诊骨折引起的轻度气胸。阅读X片时应当判定该骨折的类型，是否为粉碎性，有无移位，是短缩骨折还是分离骨折。
拍摄几张X片有助于医生对治疗的选择。无骨接触的移位尤其是伴有横型骨折碎片的骨折，已被认为是遗留长期后遗症的一项很大风险因素[7]。另外的放射学参数——断端移位>1.5cm骨折将增加疼痛，活动障碍，骨折不愈合发生的风险。在任何放射学上显示中，移位可以包括短缩移位，分离移位，骨折远端单独向前或向后移位。[20-22]第二片子在第一张基础上倾斜了45度将更清楚地显示移位。移位通常在单独的一张片子是无法判定的。
Radiographic Evaluation
To determine the fracture pattern and displacement, radiographs in two projections are necessary. A standard anteroposterior view should be accompanied by a 45° cephalic tilt view (Figure 3). The shoulder girdle and upper lung fields should be carefully assessed to avoid missing associated fractures or a subtle pneu¬mothorax. The radiographic evalua¬tion should assess the fracture pat¬tern, presence of comminution, displacement, and shortening or dis¬traction of the fracture.
Several radiographic findings can help guide the surgeon’s choice oftreatment. Displacement without bony contact, especially with a transversely displaced fragment, is a risk factor strongly predictive of long-term sequelae.7 Additional ra-diographic parameters predictive of increased risk for pain, limitation of motion, or nonunion include an overall displacement of the fracture ends >1.5 cm. This displacement in-cludes shortening, distraction, or separation of the ends in the anteri¬or or posterior direction in any radio¬graphic view.20-22 A second view, at least 45° off plane from the first, helps to further delineate the dis¬placement. Often, the displacement is difficult to assess on a single radio¬graph. For example, as seen in Figure 3, both views reveal distraction at the fracture site ofat least 1.5 cm.
为了判定骨折的类型和移位程度，应当拍摄二个投照位的X片，一个标准的前后位和45度头倾位。肩带骨和肺上部区域应仔细检查，以避免漏诊骨折引起的轻度气胸。阅读X片时应当判定该骨折的类型，是否为粉碎性，有无移位，是短缩骨折还是分离骨折。
拍摄几张X片有助于医生对治疗的选择。无骨接触的移位尤其是伴有横型骨折碎片的骨折，已被认为是遗留长期后遗症的一项很大风险因素[7]。另外的放射学参数——断端移位>1.5cm骨折将增加疼痛，活动障碍，骨折不愈合发生的风险。在任何放射学上显示中，移位可以包括短缩移位，分离移位，骨折远端单独向前或向后移位。[20-22]第二片子在第一张基础上倾斜了45度将更清楚地显示移位。移位通常在单独的一张片子是无法判定的。
Management
Indications
The primary goal in treatment is to restore shoulder function to thepreinjury level. By allowing the clav¬icle to heal with minimal deformity, loss ofmotion and pain can be min¬imized. Indications for nonsurgical treatment include a nondisplaced or minimally displaced midshaft clav¬icular fracture. Indications for surgi¬cal treatment include open fractures and fractures associated with skin compromise or with neurologic or vascular injury.
Relative surgical indications in-clude certain multiple-system trau¬m atized patients, a floating shoulder, and a painful malunion or nonunion. More recently, relative indications for surgical treatment have been ex-panded to include high-energy closed fractures with >15 to 20 mm of shortening, fractures with complete displacement, and fractures with comminution.23-26 Although these re-cently adopted indications have re-ceived attention in the current liter-ature, articles dating as far back as the 1960s have described similar sur¬gical indications—including Neer’s
article,17 which is often cited as sup-port for nonsurgical management. Randomized controlled trials, one of which has recently been complet-ed,11 and another that is currently under way, are necessary to deter-mine whether these relative indica-tions should be considered routine and, if so, in which patients with which fracture types.
Nonsurgical Treatment
Historically, nonsurgical treat¬ment has been the mainstay for clavicular fractures. It has varied from plaster shoulder spica casts to benign neglect. Most commonly, a sling or figure-of-8 brace is applied in the acute setting. With either de¬vice, immobilization is typically for
2 to 6 weeks, based on the patient’s level of comfort. Often, mild dis-comfort can linger in adults for
3 months. Return to athletics or heavy labor is permitted 4 to 6 weeks after clinical and radiograph¬ic union has occurred. Light work with restricted overhead activity can begin once the patient’s comfort allows, usually in 2 to 4 weeks after fracture healing.
In a prospective, randomized study,27 26% ofpatients treated with a figure-of-8 bandage were dissatis-fied compared with 7% of those treated with a sling. The patients treated with a sling reported less dis¬comfort. There was no difference in overall healing and alignment of the fractures, indicating that a figure¬of-8 bandage does little to obtain or maintain reduction.
Surgical Techniques
Plates
Open reduction and internal fixa-tion using plates and screws can be done with the patient in either the supine or the beach-chair position, with the head and neck tilted away from the surgical site. A bump is placed behind the scapula to aid in the reduction. The arm is prepped in the field to allow for traction and manipulation to assist in the reduc-tion. Traditionally, a skin incision is made over the clavicle following Langer’s lines, as the skin permits. A newly described alternative is to in-cise the inferior skin after pulling it over the fracture site.28 As the skin is released, it will fall 1 to 2 cm below the clavicle and prevent the wound from being in contact with the plate on the clavicle. The aim is to im¬prove cosmesis and prevent wound complications. The dissection is taken down to bone with care to identify the cutaneous supraclavic-ular nerves. When necessary, they can be sacrificed. It is important to inform the patient before surgery of the possibility of a patch of numb-ness in the skin inferior to the clav-icle.
Minimizing subperiosteal strip¬ping with gentle handling ofthe skin and soft tissue helps avoid complica¬tions. The plate usually is placed on the tension side ofthe bone—for the clavicle, the anterosuperior position (Figure 4). Biomechanically, this position provides the best stabili-ty.29 However, clinically successful treatment with anteroinferior place-ment also has been described.30 Theanteroinferior position, although less favorable biom ech anically,29 al¬lows for drilling in a direction away from the subclavian vessels and lung. It also keeps the plate from be¬ing placed under the incision. This position theoretically is less likely to cause irritation, thereby decreasing the need for plate removal. However, the anteroinferior position demands additional soft-tissue stripping and a more difficult contouring of the plate compared with the anterosupe-rior position.
Ideally, a 3.5-mm dynamic com-pression plate or plate of similar strength should be used, with at least six cortices on each side. Semi-tubular plates are not as rigid and should not be used.24,31 Reconstruc¬tion plates are more easily contoured and have been used with success; however, they account for several failures to obtain union and would not be the author’s first choice.24,31 Precontoured plates of suitable thickness offer the advantage of ease ofplacement without manipulation of the plate. Locked plates are not necessary for the acute plating of nonosteoporotic clavicular fractures;
there is no significant advantage over conventional plating, and the cost is higher.
Once plating is completed, the fascia is repaired over the plate, if possible, and the skin incision is closed. Suture closure is preferable to staples. With a sufficiently stable construct, unrestricted shoulder mo-tion is allowed, with the exception of overhead lifting for 6 weeks. Of-ten, the pain relief associated with stabilizing the fracture is dramatic, and efforts to limit the patient’s ac¬tivity may be needed. Pain relief is cited as one ofthe potential benefits of surgical intervention.
Intramedullary Fixation
An alternative to plating is in-tramedullary (IM) fixation. Many variations of IM implants have been described over the past 40 years, in-cluding Hagie pins, modified Hagie pins, Knowles pins, Herbert screws, Steinmann pins, elastic nails, can-cellous screws, and Kirschner wires.32-36 Modifications in the tech-nique have led to a resurgence of in-terest in IM fixation of these frac-tures. The potential benefits of IMfixation compared with plate fixa-tion include less soft-tissue stripping at the fracture site, better cosmesis with a smaller skin incision, easier hardware removal, and less weak¬ness of the bone after hardware re¬moval. Biomechanically, however, the ability to resist torsional forces with IM fixation is much less than that with a plate. Migration of the pins also has been a major concern. Newer designs, which include lock¬ing nuts on the lateral end of the IM devices, prevent medial pin migra¬tion. Newer techniques that avoid penetration of the medial fragment cortex also prevent medial migration of the devices.34
Patient positioning is similar to that for plate fixation. A small inci-sion is made over the fracture site, exposing the fracture ends. The me-dial segment is prepared by drilling into the medullary canal, but the an-terior medial cortex is not violated. The distal segment is drilled retro-grade through the canal, exiting the posterior lateral cortex. The pin is inserted retrograde through the ca¬nal and exits through the posterolat¬eral hole and out the skin. Next, thefracture is reduced, and the pin is ad-vanced antegrade across the fracture into the medullary canal of the me-dial segment. The Rockwood Clavi-cle Pin (DePuy Orthopaedics, War-saw, IN) has two nuts that go over the threaded end of the inserted pin posterolaterally. Once the pin is across the fracture, the first nut is in¬serted posterolaterally, compressing the fracture, followed by the second nut, which is cold-welded to the first. Figure 5 shows the Rockwood Clavicle Pin in place. Some ofthe IM techniques vary slightly depending on the device, and not all ofthe tech-niques allow for fracture compres-sion.
Patients are allowed to begin shoulder motion immediately post-operatively. When rotational stabil-ity is a concern, forward elevation should be restricted to 90° and ab¬duction to 90° for the first 4 weeks. The Rockwood pin should be re¬moved at 8 to 14 weeks. In some sit¬uations, this can be done under local anesthesia in the office; however, most Rockwood pins need to be re-moved in the operating room. Some ofthe other IM devices, such as Her-bert screws, do not need to be re-moved.
As with plating, a major benefit is early return to activities. Several studies have reported athletes’ re-turning to their sport activities by 2 to 3 weeks.35,37
5．治法
5.1 治疗指征
治疗的目的是恢复肩关节的功能到受伤前水平。治疗应当让最低限度地减少畸形、活动能力的丧失以及疼痛。非手术治疗的适应症包括无移位或有轻微移位的锁骨骨折。手术适应症包括开放性骨折和伴有皮肤缺损或血管神经损伤的骨折。
相对的手术适应症包括复合伤患者，漂浮肩和伴有疼痛的骨折畸形愈合和延迟愈合。最近报道的另外相对手术适应症：高能量的伴有1.5cm-2.0cm短缩的闭合性骨折，完全移位的骨折和粉碎性的骨折。[23-26]这些最近采用的手术适应症已经被象1960年就曾描述过的——包括常常被用来支持非手术治疗的neer的文章——类似适应症的文献注意。随机对照试验一项已经完成，[11]和另一项目前正在进行中。它对于决定这些相对的适应症是否应当考虑进去是相当必要的。如果考虑进去，那么是具有那种类型骨折的那种病人？
5.2 非手术治疗
历史上，非手术治疗曾被作锁骨骨折主要的治法。从肩人字形圆柱型石膏到现在的锁骨带，在急诊室，最常用的悬吊带或“8”字绷带。基于患者的耐受水平，通常使用二者中的一种制动2-6周。如果只有轻度的不适，在成人最多可延续3个月。而要进行运动和重体力劳力则需在临床愈合和放射学上的愈合出现4-6周以后才能进行。不过头的轻体力劳动一旦患者可耐受，通常在骨折愈合后2-4周后进行。
在一项前瞩性的随机试验中[27]，使用八字绷带治疗的患者有26%感到不适，而使用悬吊带治疗中有7%，悬吊带治疗不适率更少。而在治愈情况与复位情况上两者没有差异，这也说明了八字绷带对复位和维持复位作用甚微。
5.3 手术治疗
5.3.1 钢板内固定治疗
使用钢板或螺钉来进行切开复位内固定术，患者头颈只需偏离患侧，仰卧位或沙滩椅位都可进行。手术前在肩胛骨后垫上沙袋将有助于复位。而在肩部应当准备足够空间以利于复位时的牵引和手术操作。传统上，手术切口通常位于锁骨上沿langer’s线。现在有一种新方法可供选择，[28]作切口时将锁骨下皮肤推至锁骨上，当松开皮肤时，它将下降1-2cm位于锁骨下方，这样可以防止切口直接同锁骨下钢板接触。此切口的目的可以提高美观也避免切口并发症的发生。作此切口时应当小心辩认锁骨上皮神经。如果有必要，也可以将其切断，但在手术前应当靠知患者术后可能造成锁骨下部分皮肤的麻木。
最少地剥离骨膜同时对皮肤软组织进行轻柔操作将有助于避免并发症的发生。钢板通常放在骨骼的张力侧，即锁骨则在前上方。从生物力学上讲放置于此位置能提供最好的稳定性。[29]然而，临床上将钢板放置于前下方成功治疗锁骨也有相应的报道。[30]前下方这个位置尽管生物力学方面优势相对减少，[29]但它可以在进行钻孔时远离锁骨下血管和肺。这种方法也使钢板在切口下方远离切口。这个位置从理论上讲也可能引起更少的刺激从而也减少了拆除钢板的必要。但是前下方需要更多的剥离软组织，同前上方相比钢板塑形也更困难。而最近有学者研究锁骨[31]解剖后对锁骨骨折采用三维固定，即在锁骨远端将钢板固定在锁骨上方，在锁骨近中端将钢板固定在锁骨前方，使其与骨面紧密贴附。其方法在治疗粉碎性骨折上已取得良好疗法。
理想上，锁骨中段骨折应使用3.5mm 动力加压钢板或相似强度的钢板，然后骨折两端分别至少穿透六层皮质骨进行固定。1/2管形强度不够而不被推荐使用。[24，32]重建钢板因其更易塑形已被成功使用，但它对骨折愈合方面有影响，所以不应作为术者首选[24，32]。适合厚度的解剖钢板具有不需对钢板进行塑形就能与骨骼贴敷的优点。锁定钢板对于急性无骨质疏松的骨折是没有必要使用的，它与常用钢板相比没有明显优点，价格却更昂贵。
一旦固定完成，应当缝合钢板上筋膜，同时只要有可能就应当尽量闭合切口。用缝线闭合切口比U型钉要更适合。固定如果达到有效稳定，除过头上举运动应限制6周外，肩关节活动可以适当进行。通常骨折固定后疼痛即可得到明显减轻，所以应当尽量限制患者的活动。减轻疼痛也是外科手术潜在的益处之一。
5.3.2 髓内固定
髓内固定（IM）是另一种可选择的固定方式。在过去40年里，许多各式的髓内内植物曾被运用，例如Hagie 针、 改良Hagie 针、Knowles 针、Herbert 钉、Steinmann 针、 弹性髓内钉、 松质螺钉、 和克氏针。[33-37] 由于技术改进，人们对这些髓内固定的兴趣重新召起。与钢板内固定与相比，IM具有以下潜在优势：对软组织剥离较少、切口更小相对较美观、拆除内固定更方便以及内固定拆除后骨骼质相对更好。然而，在生物力学上，髓内固定的抗旋能力要比钢板差。针的滑移也是主要担心的问题。现在可防止针滑移的尾端带锁钉的髓内固定已被设计出。这种新技术能避免穿透中段皮质也就能阻止其从中段滑移。[35]
手术时，患者的体位同钢板内固定时相似。在锁骨上方骨折处作一小切口暴露骨的断端。近端用钻头先行扩髓，但不穿透皮质。远侧端逆行扩髓并从后外侧穿出皮质。然后髓内针逆行从后外侧骨洞穿出露于皮肤外。接着复位骨折，再将髓内针顺行打入穿过骨折断端进入骨折近端。Rockwood 锁骨钉（DEPUY公司生产）有两个螺母，它们都能顺着针后方的螺纹进入。当髓内针穿过骨折后，第一个螺母旋入加压骨折端，紧接着旋入第二颗螺母锁定第一颗。有些IM技术在器械上改动较少，所以不是所有的技术都可以对骨折断端进行加压。
当髓内固定完成后，一个主要的优点就是可以早期进行活动。几项研究报道运动员术后2-3周即可返回进行运动训炼。[36，38]
Complications
Complications can occur from non-surgical treatment as well as surgical treatment. Both can produce a cos-metic deformity (Figure 6). Both can result in malunion, nonunion, pain, local tenderness or irritation, and limitation of motion. Other rare complications following surgical or nonsurgical treatment are residual nerve paresthesia; subclavian ves¬sel compression, thrombosis, and pseudoaneurysm; thoracic outlet syndrome; and brachial plexus neu-ropathy.
Figure 6
A, Healed clavicular fracture managed nonsurgically. The bump, shortened shoulder width, and subtle droop are evident.
B, A healed clavicular fracture treated with plate and screws, showing prominence of the anterior-superior–positioned plate.
Some complications are unique to surgical intervention, such as in-fection and hardware problems. In-fection rates vary from 0% to 18%, with the lower rates reported in the more recent studies.24,31,37,38 Painful, irritating hardware requiring plate or pin removal is reported to be as high as 50% to 100%.24,39 Following plate removal, the risk for refracture rang¬es from 0% to 8%.24,31 Adhesive cap-sulitis of the shoulder has been re-ported with surgical treatment in 0% to 7% of cases.24,28
IM devices are associated with unique complications, including mi-gration ofthe pin and hardware irri-tation, resulting in local skin break-down that often requires antibiotics and, ultimately, hardware rem ov-al.39 Figure 7 illustrates skin break-down from an IM pin. Although most ofthese complications are rare, a second surgery for plate or pin re¬moval is sufficiently frequent to be considered when reviewing treat¬ment choices.
6．并发症
非手术治疗可以引发并发症，手术治疗同样会引起。二者都可造成外观上的缺陷，
同时也能引起以下并发症：骨折畸形愈合，不愈合、疼痛、局部的触痛或排异反应以及活动障碍。手术治疗其它的并发症较少，但非手术治疗还可能会遗留神经上的感觉异常、锁骨下血管压迫、血栓、假性动脉瘤、胸廓出口综合症以及臂从神经病变等。
然而一些并发症也是外科手术特有的，例如：感染和内植物问题。手术治疗感染率在0%-18%内变化，最近许多研究报道的感染率有所降低。[24，32，38，39]另有文献报道由于疼痛，钢板的排异而要求拆除钢板或髓内钉的高达50%-100%。[24，40]钢板拆除后再骨折率有将近0%-8%。而有报道[24，28]表明术后肩关节粘连的病例达0%-7%。
IM内固定糸统特有的并发症包括针的滑移和内植物的排异反应，而这种排异反应将造成局部皮肤的破溃常需要抗生素来治疗，最终只能提早拆除内植物。尽管这些并发症很少，回头来看做治疗选择时，再次手术移出钢板或髓内钉应当充分考虑进去。
Results
Whether treated nonsurgically or surgically, most clavicular fractures heal without incident when length and alignment are maintained. Ac-ceptable cosmetic and functional re-sults should be expected. Satisfacto-ry results occur less consistently when the fracture fails to heal or heals with a significant deformity.
Nonunion
Most cases ofnonunion are symp-tomatic, presenting with pain, loss of function, neurologic changes, and/or unsightly clavicular deform i-ty. Although clavicular nonunion has not been clearly defined in the literature, most authors concur that nonunion is present when healing has not occurred by 16 weeks.
Traditional thinking is that cla-vicular fractures treated nonsurgical¬ly almost always heal and that surgi¬cal treatment increases the risk of nonunion. Rowe4 reported a non-union rate of 3.7% in patients who underwent surgery compared with 0.8% in those treated without sur¬gery. Neer17 reported nonunion rates of 0.1% with nonsurgical treatment and 4.6% with surgical treatment. Neer17 suggested that the most im¬portant causal factor for nonunion of a midshaft clavicular fracture is im¬proper open surgery. This may be true to some extent; aggressive soft-tissue stripping, inability to reduce the fracture, and inadequate internal fixation all can lead to poor results.
Several recent studies have re¬ported high union rates with surgical intervention using a variety of inter-nal fixation devices, including plat-ing and IM pin or rod fixation.39,40 In addition, there is evidence that the nonunion rate after nonsurgical treat¬ment may be higher than previously reported, particularly in certain frac¬ture types and in certain patients. In their review of 581 nonsurgically treated fractures, Robinson et al20 re¬ported an overall nonunion rate of
Figure 7
Healed clavicular fracture treated with intramedullary pinning. A, Note incision size and location over fracture and posterolateral prominence. B, Early breakdown of the skin resulting from a prominent pin at the posterolateral insertion site.
4.5% for diaphyseal fractures. Strat-ification of Robinson’s data revealed that women with displaced diaphy¬seal fractures had a nonunion rate ranging from 19% to 33%. When comminution was combined with displacement, the nonunion rate in women increased to a range of 33% to 47%.41 In addition to fracture frag¬ment displacement, female sex, and comminution, other risk factors identified with nonunion include ad-vancing age, lack of cortical apposi-tion, severity of the initial trauma, the extent of fracture fragment dis-placement,25 and, arguably, soft-tissue interposition.42 Early m obiliza¬tion has not been associated with the development of a nonunion, whether treated surgically or non surgically.
A recently published systematic review ofthe literature on nonunion after treatment ofmidshaft clavicu¬lar fractures revealed a 5.9% non¬union rate in nonsurgically managed fractures.8 In the completely dis-placed fractures, the rate increased to 15.1%. In surgically treated displaced fractures, plating of 460 fractures re¬sulted in a nonunion rate of 2.2%, and IM fixation of 152 fractures re-sulted in a nonunion rate of 2.0%.8 These data should be interpreted with caution, however, because mostwere from evidence-based level III, IV, and V studies (ie, observational, retrospective, case series, and expert opinion studies) rather than from level Iand II studies (ie, randomized, prospective studies).
Surgical treatment of nonunion has a high success rate. Techniques include plate fixation with bone graft, IM pin fixation with bone graft, and external fixation. Union rates with each method have been reported to be >92% and as high as 100%.42-45 Plate fixation has the largest support in the literature and is currently the most predictable and recommended treatment for symptomatic nonunion. Other methods may be successful in the hands of an experienced surgeon.
M a lu n ion
Most nonsurgically treated cla-vicular fractures heal with some de-formity. The literature does not clearly define when a deformity is considered to be a malunion; howev-er, the evidence strongly suggests that some clavicular deformities re-sult in unsatisfactory outcomes. The deformity is a three-dimensional problem; the most consistent char-acteristic is shortening with inferior displacement of the medial frag¬ment. Symptomatic patients help define the malunion. Symptoms in¬clude weakness and pain in the in¬volved shoulder, loss of shoulder motion, loss of endurance, neurolog¬ic symptoms consistent with thorac¬ic outlet syndrome and brachial plexus impingement, and cosmetic deformity.46
In 1986, Eskola et al21 noted in 89 patients that shortening >12mm was associated with increased pain. Wick et al22 concluded in a retrospec¬tive study that shortening of2 cm in midshaft clavicular fractures was as¬sociated with an increased risk of pain, limitation of motion, or non¬union. McKee et al9 assessed func¬tional outcome following displaced clavicular fractures and noted signif¬icantly inferior scores for both the upper extremity–specific (DASH) outcome scores (P = 0.02) and the Constant scores (P = 0.01) compared with the general population. They concluded that fractures with >2 cm ofshortening tended to be associated with decreased abduction strength and greater patient dissatisfaction. Hill et al25 reported on completely displaced middle third clavicular fractures and concluded that final shortening ≥2 cm was associated with an unsatisfactory result but not
with nonunion. After closed treat-ment, 31% ofpatients were dissatis-fied with the final result, 54% were unhappy with the appearance, and 15% of fractures failed to unite. Us-ingthe same subjective patient ques-tionnaire as that used by Hill et al,25 Lazarides and Zafiropoulos10 re-ported that final clavicular shorten-ing>18 mm in males and >14mm in females was associated with unsatis-factory results and with increased patient symptoms.
Ledger et al47 showed the effect of clavicular shortening >15 mm on biomechanical parameters of the shoulder. They found a significant increase in upward angulation (mean, 10.7°; P < 0.005) of the SC joint on the injured side compared with the uninjured side. The muscle torque ofthe injured arm was signif-icantly weaker than that ofthe unin-jured arm in extension (P <0.05), ad-duction (P < 0.05), and internal rotation (P < 0.05).47
These studies indicate that al-though clavicular deformities are complex and hard to assess, shorten-ingof1.5 to 2cm, which results in an increased incidence ofclinical symp-toms, is one parameter that can be measured. Further investigation is needed to clearly define the patients as well as the fracture deformity that is likely to be symptomatic with a clavicular malunion. In this way, acute surgical treatment could be of-fered to the patients who are most likely to benefit. In addition, compar¬ative trials are necessary to establish that patients with clavicular frac¬tures that predictably result in defor¬mity have better outcomes when treated surgically rather than nonsur¬gically. Several randomized trials cur¬rently are under way, and one has been completed, assessing the surgi¬cal versus nonsurgical management of acute displaced midshaft clavicu¬lar fractures. The Canadian Ortho¬paedic Trauma Society has shown in a multicenter randomized trial of 132 patients that for displaced fractures of the clavicular shaft, surgical fixa-tion with a plate and screws resulted in an improved functional outcome and a lower rate of malunion and nonunion compared with nonsurgi¬cal treatment at 1 year.11
Treatment of a malunion consists of surgical correction to restore length, angular deformity, and rota-tion of the clavicle. Treatment may or may not involve an intercalary bone graft. Often, after removing the callus of the malunion, it is possible to identify the proximal and distal fragments in order to anatomically reconstruct the clavicle.46,48 The ben¬efit of this technique is that there is no donor-site morbidity for a bone graft. When difficulty in determining the length of the malunited clavicle is anticipated, a preoperative radio-graphic image of both clavicles is helpful. Both IM devices and plates have been used successfully to treat
m alunions.46,48-50 Treatment ofsymp¬tomatic malunions has resulted in improvement of the function of the upper extremity, decreased pain, and increased patient satisfaction.46,50
7．讨论
是非手术治疗还是手术治疗？大多数锁骨骨折没有对位对线维持时也能愈合。外观上的接受程度和功能恢恢复情况应当考虑到。但当骨折不愈合或畸形愈合，那么满意的疗效是很少能持续的。
7.1 骨折不愈合
大多数不愈合是有症状的，如出现疼痛、功能的丧失，神经学上的改变，并/或存在难看的锁骨畸形愈合。尽管锁骨骨折不愈合在文献中没有清楚定义，但大多数学者一致认为16周后骨折未出现愈合则为骨折不愈合。
传统思想认为非手术治疗锁骨骨折通常可以愈合，手术治疗反而增加了不愈合的风险。Rowe[4]研究报道手术治疗的不愈合率为3.7%而非手术治疗为0.8%。NEER[17]报道的非手术治疗的不愈合率为0.1%，手术治疗为4.6%。NEER[17]认为锁骨中段骨折不愈合最重要的发生因素是不恰当的开放手术治疗。这可能由于以下原因造成：对软组织过分的剥离，不能复位骨折，选用不恰当的内植物，所有这些都能导致较差的临床疗效。几项研究报道[40，41]使用各式内植物包括钢板，髓内钉或外固定器进行手术治疗均取得较高的愈合率。另外，有证据认为非手术治疗的不愈合率可能比早期报道的要高，尤其是在某此特殊骨折类型和特殊的患者中。Robinson等[42]回顾了581例非手术治疗的病例，锁骨干骨折不愈合率总体为4.5%。而在Robinson分层数据中表明移位锁骨干骨折的女性患者不愈合率为19%-33%。而当为粉碎性时，不愈合率增加到33%-47%。除了骨折断端移位、女性和粉碎性，其它因素如年龄增长，皮质无对合，损伤的严重程度，骨折的移位程度[25]，和可以确认的骨折断端软组织嵌入[43]都可影响骨折的不愈合率。不论是手术治疗还是非手术治疗，早期的功能锻炼是与不愈合的增加没有关联的。
最近一篇关于锁骨中段骨折不愈合的糸统性回顾文献表明，[8]非手术治疗骨不愈合率为5.9%。而完全移位的骨折概率增加到15.1%。在手术治疗的移位骨折中，钢板治疗460例骨折不愈合率为2.2%，IM治疗的152例骨折则为2.0%。[8]然而，这些数据应当谨慎读解，因为这些大部分来自于III、IV、V型研究设计而不是来自I、II型。
手术治疗骨折不愈合有很高的治愈率。方法包括植骨钢板内固定，植骨髓内钉内固定和外固定器。每种方法的愈合率都大于92%，甚至达到100%。[43-46]在文献中，钢板内固定是最受推崇，也是当前对有症状的骨不愈合最具疗效和最受推荐的治法。其它方法在具有经验的术者操作下也是可以获得成功的。
7.2 畸形愈合
大多数非手术治疗锁骨骨折伴有一些畸形。文献中没有定义当畸形到那种度时将考虑为骨折畸形愈合。然而，一些锁骨的畸形引发不良临床疗效是不容置疑的。这种畸形是一个三维的问题：最多见的特征就是骨折短缩并伴有近端向下方移位。有症状的患者有助于诊断畸形愈合。这些症状包括：肩关节的无力和疼痛，肩关节活动范围的丢失，耐受力的下降，因存在胸廓出口综合征和侵及臂丛引起持续的神经学症状以及外观上畸形。[47]
Eskola等[21]在1986年在89例患者中就注意到伴有>12mm短缩的患者与疼痛增加有关。Wick等在一项回顾性研究中发现[22]锁骨中段短缩2cm的骨折同疼痛，活动受限或者骨不愈合并发症的发生有关。McKee等[9]对移位的锁骨骨折愈合后的功能使用DASH和Constant评分进行分析，两者评分都比正常人明显降低。（P=0.02，P=0.01）他们也得出结论骨折短缩>2cm同患肩外展力量减少和许多患者的不适相关。Hill等认为[25]完全移位但最后短缩≥2cm并未骨折不愈合的锁骨中1/3的骨折与不满意的临床疗效是存在关联的。而保守治疗后，31%的患者对最后的结果不满意，54%的患者对外观不满意，还有15%的骨折无法愈合。Lazarides and Zafiropoulos使用同Hill等同样的客观问卷调查发现，[10]骨折愈合后男性短缩>18mm，女性>14mm的患者临床结果不满意，同时患者症状也有所增加。
Ledger等[48]认为当锁骨短缩>15mm对肩关节的生物力学参数有影响。他们发现与健侧相比较患侧胸锁关节存在明显向上成角（平均10.7度，P<0.005）。而患肩的外展，内收以及内旋的肌力明显比健侧减弱。
这些研究表明了锁骨畸形是复杂的，也是难于评定的，但短缩1.5-2cm可引发临床症状发生率的增加是一种可测的参数。更进一步研究应当清楚地评定锁骨骨折畸形愈合，畸形程度怎样可引发临床症状发生。这样看来，进行急诊手术治疗是最能给患者益处的。另外，我们也有必要建立对照研究以说明进行手术治疗对可能出现畸形愈合的患者比非手术治疗能获得更好的临床疗效。一项关于手术治疗与非手术治疗急性锁骨中段移位骨折对比研究已完成。加拿大骨创伤中心在经过一项关于132例锁骨中段移位骨折患者的多中心随机试验发现，[11]随访一年使用钢板螺钉手术治疗的患者与非手术治疗相比，功能疗效有提高而畸形愈合率和不愈合率明显降低。
手术治疗骨折畸形愈合可以恢复其长度、矫正其畸形成角以及锁骨的旋转。这种治疗可能需要或不需要作骨移植。我们手术时常规都去除畸形愈合处的骨痂，这样可以辨清骨折两端也有助于锁骨的解剖重建。[47，49]术前拍摄双侧锁骨的X片对术中出现无法确定愈合不良的锁骨实际长度很有帮助。在治疗有症状的锁骨畸形愈合方面，IM内固定和钢板内固定都成功地提高上肢功能，减轻了疼痛也提高了患者的满意度。[47，51]
