CAJ | 학술논문

目的：探讨关节镜下纽扣钢板固定术治疗不稳定锁骨远端骨折的临床疗效。方法回顾性分析17例不稳定锁骨远端骨折经关节镜下纽扣钢板固定术后临床结果。通过 Constant 评分,简明肩关节功能测试(simple shoulder text,SST),VAS 疼痛评分对患者在最后一次随访时的肩关节功能进行评价。结果本组患者共17例,男性10例,女性7例。平均年龄42.6岁(27~68岁)。按照Robinson 骨折分型,均为3B 型。17例患者均获得随访,平均随访时间50个月(42~66个月)。16例患者骨折愈合,平均愈合时间3.2个月,1例骨折不愈合。术中发现合并关节内损伤2例,SLAP 损伤1例,Bankart 损伤1例,术中分别予以修复。患者术后 Constant 评分患侧平均93.1分(72~100分),健侧98.3分(90~100分)。SST 患侧平均10.7分(8~12分),健侧11.6分(9~12分)。VAS 评分患侧平均1.9分(0~4分),健侧1.7分(0~5分)。结论关节镜下纽扣钢板固定术具有临床效果良好,创伤小,可同时处理关节内合并损伤,喙锁弹性固定,不需要再次手术等优点。可以作为锁骨远端骨折治疗的一个选择。
목적：탐토관절경하뉴구강판고정술치료불은정쇄골원단골절적림상료효。방법회고성분석17례불은정쇄골원단골절경관절경하뉴구강판고정술후림상결과。통과 Constant 평분,간명견관절공능측시(simple shoulder text,SST),VAS 동통평분대환자재최후일차수방시적견관절공능진행평개。결과본조환자공17례,남성10례,녀성7례。평균년령42.6세(27~68세)。안조Robinson 골절분형,균위3B 형。17례환자균획득수방,평균수방시간50개월(42~66개월)。16례환자골절유합,평균유합시간3.2개월,1례골절불유합。술중발현합병관절내손상2례,SLAP 손상1례,Bankart 손상1례,술중분별여이수복。환자술후 Constant 평분환측평균93.1분(72~100분),건측98.3분(90~100분)。SST 환측평균10.7분(8~12분),건측11.6분(9~12분)。VAS 평분환측평균1.9분(0~4분),건측1.7분(0~5분)。결론관절경하뉴구강판고정술구유림상효과량호,창상소,가동시처리관절내합병손상,훼쇄탄성고정,불수요재차수술등우점。가이작위쇄골원단골절치료적일개선택。
Background The cases of distal clavicular fracture account for 12%-1 5% of all clavicular fracture cases.Distal clavicular fracture combined with coracoclavicular ligament rupture frequently behave as unstable fracture,with the opportunity for fracture non-union in conservative therapy being as high as 21%.Although partial patients with fracture nonunion show mild clinical symptoms,the symptomatic nonunion may affect the functions of shoulder joint.Therefore,most of physicians suggest operative treatment for unstable distal clavicular fracture.The operative treatment can achieve fracture union rate up to 98%.The distal clavicular fracture is characterized by fracture combined with ligament injury, and there are also diversified clinical therapies. The frequently reported internal fixation methods include kirschner wire,tension band,coraco-clavicular screw, anchor,clavicular hook plate,anatomical locking plate as well as suture fixation,etc.After fracture union,the metallic internal implants are frequently required to be taken out through operation. Different therapies have both their advantages and disadvantages.At present,there has been no unified therapy for unstable distal clavicular fracture.Arthroscopic button plate fixation therapy for unstable distal clavicular fracture is a relatively new minimally invasive treatment method,and its technology is originated from arthroscopic button plate fixation for the treatment of dislocation of acromioclavicular joint.We made retrospective analysis on the clinical effects of arthroscopic button plate fixation on distal clavicular fracture and discussed the potential advantages and disadvantages of this therapy.Method Ⅰ.General materials:Twenty-one patients with unstable distal clavicular fracture who received operative treatment in our department during the period from September 2010 to December 2012 are collected,seventeen cases of these meet inclusion criteria,namely 10 male cases and 7 female cases,with an average age of 42.6 years;according to Robinson clavicular fracture classification,all fracture cases are of type 3B fracture.Inclusion criteria:(1)Diagnosed as unstable distal clavicular fracture; (2 ) Received arthroscopic button plate fixation treatment. Exclusion criteria:(1)Diagnosed as unstable distal clavicular fracture,but has not received arthroscopic button plate fixation treatment,including open reduction Clavicle hook plate fixation,anatomic locking plate fixation and open button plate fixation;(2 )Old distal clavicular fracture.Ⅱ.Operative method:operation was performed under general anesthesia.Allow the patient to take sand beach chair posture, with head leaning to the other side.Draw shoulder joint anatomic marks under shoulder arthroscopy, and perform conventional disinfection on affected shoulder and upper limbs.The arthroscope enters the joint cavity from posterior portal;Under direct vision,establish the anterior working portal located in rotator interval. perform intra-articular routine inspection, pay particular attention to inspect whether there is structural damage to glenoid labrum and rotator cuff.If intra-articular injury is discovered during operation,immerely treat it.Under direct vision,establish the anterolateral second observation portal under arthroscope through anterior supraspinatus tendon,and transfer the arthroscope to the second observation portal through exchange rod.Along the upper edge of musculus subscapularis,inward expose the lower surface of coracoid,and use a feller to determine the madial and lateral edges of coracoid.Perform C-arm X-ray machine fluoroscopy to demine the vertical projection position of coracoid on clavicular surface,namely the conical ligament attachment position;open skin by 2 cm,and expose the clavicular upper surface.Place the anterior cruciate ligament guider on the central location of coracoid lower surface,drive guide pin into coracoid through clavicle;perform fluoroscopy to validate that the position of guide pin is corret;through guide pin,use a 4.5 mm hollow drill for drilling,introduce the shuttle wire,and take out guider.Take two 4-hole button plates,remove loop spinalium,and use two No.5 Ethicon suture to perform plate connection as shown in Figure 9.By means of shuttle wire,introduce the button plates to pass through clavicle and coracoid,place one plate under coracoid,place another plate on the surface of clavicle.Perform reduction of fracture.If there are soft tissues entrapped at the fracture end,use probe for release. Maintain fracture reduction,tighten the suture for knotting and fixation,perform fluoroscopy again to validate fracture reduction;perform arthroscopy to validate that the plate under coracoid is completely attached on the lower surface of coracoid.Conventionally close incision.Ⅲ.Postoperative treatment:Use shoulder joint protector to suspend the injured shoulder for 4 weeks.In 4 weeks post operation, allow the shoulder joint to perform passive uplifting and external rotation activities;In the 2nd month after operation,perform intensive joint traction exercise,active assisted shoulder joint uplifting as well as internal and external rotation activities;2 months post operation,when preliminary fracture healing is realized and there is no local pressing pain,start active motion of shoulder joint,gradually recover daily activities as well as muscle strength and endurance training on rotator cuff and shoulder girdle.Ⅳ.Post-operative follow-up:After operation,perform re-examination once per month,take X-ray film,examine the fracture union situation until bony union of fracture.In the final follow-up,make evaluation on patient through shoulder joint constant scoring,simple shoulder joint test (SST),VAS pain scoring and examination on the range of shoulder joint motion.Results All 1 7 cases obtained follow-up,with average follow-up time of 50 months (42-66 months).1 6 cases achieved fracture union,with average union time of 3.2 months;there is 1 case of nonunion.During the operation 2 cases of combined intra-articular injury,1 case of SLAP injury and 1 case of Bankart injury are discovered and respectively repaired.Average postoperative constant score of the patients is 93.1 points (72-100 points),with health side score of 98.3 points (90-100 points).SST affected side score is 10.7 points on average (8-12 points),with health side score of 1 1.6 points (9-12 points).VAS average score is 1.9 points (0-4 points),with health side score of 1.7 points (0-5 points).1 case of fracture nonunion,male,aged 50 at the time of initial operation,right shoulder is injured by falling from electric bicycle in drunk driving,fracture typing is 3B distal clavicle fracture;this patient has pervious history of diabetes,with unsatisfactory blood glucose control.After hospital admission, perform arthroscopic internal fixation with button plate,and postoperative conventional bracing and rehabilitation training;According to postoperative re-examination,internal fixation failure and fracture displacement are discovered;make observation until 4 months after operation;fracture nonunion, local pressing pain and obviously limited shoulder joint functions are discovered.After readmission of the patients,take out the internal implants,take ilium for bone grafting,perform internal fixation with clavicular hook-plate;In 3 months after the operation for the second time,fracture union is realized;12 months later,take out clavicular hook-plate;the shoulder joint functions of the patients are basically recovered to normal level,with Constant score of 91 points,SST score of 1 1 points and VAS score of 1 point.Conclusion Most of unstable distal clavicular fracture cases need operative treatment,but there has been no unified therapy at present.Arthroscope-assisted button plate fixation is a new operation method which has been gradually developing in recent years,which is minimally invasive,being able to treat combined intra-articular injury at the same time,realize elastic fixation of coracoclavicular,without need for reoperation.This new operation method can realize good clinical effects,but has high technical requirements.It can be an option for treatment of distal clavicular fracture.