胡曉川 林輝陽 向明 陳杭 楊國勇

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·論著·

鎖定鋼板結(jié)合縫合錨固定治療NeerⅡB型鎖骨遠(yuǎn)端骨折

胡曉川 林輝陽 向明 陳杭 楊國勇

目的 探討應(yīng)用2.4 mm鎖定鋼板結(jié)合縫合錨固定治療不穩(wěn)定型NeerⅡB型鎖骨遠(yuǎn)端骨折的方法及臨床療效。方法 回顧性分析2011年1月至2013年12月收治并獲完整隨訪的16例不穩(wěn)定型NeerⅡB型鎖骨遠(yuǎn)端骨折患者臨床資料，其中男性12 例，女性4例，年齡23～65歲，平均35歲。致傷原因：跌傷4例，自行車摔傷2例，電動(dòng)自行車摔傷4例，交通事故傷6例，均為新鮮閉合骨折，無神經(jīng)、血管損傷。受傷至手術(shù)時(shí)間3～12 d，平均5 d。沿皮膚Langer線的縱切口，采用2.4 mm L形橈骨遠(yuǎn)端鎖定鋼板切開復(fù)位內(nèi)固定結(jié)合縫合錨增強(qiáng)喙鎖穩(wěn)定性手術(shù)治療。結(jié)果 術(shù)后切口均Ⅰ期愈合。16例患者均獲隨訪，隨訪時(shí)間12～18個(gè)月，平均15個(gè)月。X線片示骨折均愈合，愈合時(shí)間6～12周，平均8周。隨訪期間無內(nèi)固定物失效、斷裂、移位情況發(fā)生。末次隨訪時(shí)Constant肩關(guān)節(jié)功能評(píng)分為86～100分，平均94分。疼痛視覺模擬評(píng)分為0～2分，平均0.2分。結(jié)論 對于不穩(wěn)定型NeerⅡB型鎖骨遠(yuǎn)端骨折，應(yīng)用2.4 mm L形橈骨遠(yuǎn)端鎖定鋼板內(nèi)固定結(jié)合縫合錨增強(qiáng)喙鎖穩(wěn)定性，術(shù)后早期進(jìn)行活動(dòng)鍛煉，可獲滿意療效，是一種可行的有效方法。

肩關(guān)節(jié)；鎖骨骨折，遠(yuǎn)端； 鎖定鋼板；縫合錨；內(nèi)固定

鎖骨遠(yuǎn)端骨折占所有鎖骨骨折的10%～30%[1]。大多數(shù)鎖骨遠(yuǎn)端骨折為無或輕度移位的穩(wěn)定型骨折(NeerⅠ型和NeerⅢ型)，通常保守治療即可獲得滿意的療效。然而對于不穩(wěn)定型NeerⅡB型鎖骨遠(yuǎn)端骨折，治療尚存在爭議，非手術(shù)治療骨折不愈合率高，手術(shù)治療有發(fā)生并發(fā)癥的潛在風(fēng)險(xiǎn)，多數(shù)學(xué)者仍主張手術(shù)治療。眾多的手術(shù)方法可供選擇，各有優(yōu)缺點(diǎn),尚無金標(biāo)準(zhǔn)，且與內(nèi)固定物相關(guān)的并發(fā)癥較常見[2-4]。

近年來，有學(xué)者將橈骨遠(yuǎn)端鎖定鋼板應(yīng)用于NeerⅡ型鎖骨遠(yuǎn)端骨折的手術(shù)治療[5-9]，骨折愈合率高、并發(fā)癥少，早期結(jié)果令人鼓舞，但報(bào)道較少,尚未形成公認(rèn)的手術(shù)方法。我們回顧性分析2011年1月至2013年12月，采用2.4 mm L形橈骨遠(yuǎn)端鎖定鋼板內(nèi)固定結(jié)合縫合錨增強(qiáng)喙鎖穩(wěn)定性手術(shù)治療16例不穩(wěn)定型NeerⅡB型鎖骨遠(yuǎn)端骨折患者的臨床資料，以期為該類型骨折的手術(shù)方法選擇提供參考，現(xiàn)報(bào)道如下。

資 料 與 方 法

一、一般資料

本組患者16例，男性12例，女性4例；年齡23～65歲，平均35歲。左側(cè)6例，右側(cè)10例。致傷原因：跌傷4例，自行車摔傷2例，電動(dòng)自行車摔傷4例，交通事故傷6例，均為新鮮閉合骨折，無神經(jīng)、血管損傷。術(shù)前均行鎖骨正軸位X線，肩關(guān)節(jié)CT平掃+骨三維重建檢查明確為不穩(wěn)定型NeerⅡB型鎖骨遠(yuǎn)端骨折。受傷至手術(shù)時(shí)間3～12 d，平均5 d。

二、手術(shù)方法

全身麻醉聯(lián)合臂叢神經(jīng)阻滯麻醉下，患者取45°沙灘椅位，患肩墊高。沿皮膚Langer線(皮膚彈力纖維走形線)，切口從肩鎖關(guān)節(jié)內(nèi)側(cè)1.5～2.0 cm向前至喙突，長約6.0 cm。顯露三角肌、斜方肌筋膜，沿鎖骨長軸切開筋膜顯露骨折端，術(shù)中注意保持肩鎖韌帶完整性，保護(hù)三角肌和斜方肌止點(diǎn)。從胸大肌內(nèi)側(cè)緣鈍性分離進(jìn)入，將三角肌拉向外側(cè)，即可顯露喙突基底，小心分離，避免損傷臨近血管神經(jīng)，充分暴露喙突基底，探查喙鎖韌帶的完整性。清理骨折端，于鎖骨近折端遠(yuǎn)側(cè)前1/3處相距1.0 cm鉆2個(gè)骨孔；將1枚5.0 mm縫合錨(Mitek Fastinrc，Depuy或Twinx，Smith&Nephew)固定于喙突基底，將縫合錨釘尾的兩股2號(hào)不可吸收線穿過骨孔。向上托起患肢，向前下推壓近折端，向內(nèi)推患肩，復(fù)位骨折后，將縫合錨尾線打結(jié)固定。以1枚1.5 mm克氏針經(jīng)或不經(jīng)肩峰結(jié)合點(diǎn)狀復(fù)位鉗臨時(shí)固定，C臂機(jī)透視確認(rèn)骨折復(fù)位、錨釘位置滿意。

將1枚2.4 mm橈骨遠(yuǎn)端直形或斜L形鎖定加壓鋼板(瑞士Synthes公司或山東威高骨科材料有限公司)置于鎖骨遠(yuǎn)端上方。使用細(xì)針頭確定肩鎖關(guān)節(jié)間隙，在確保最遠(yuǎn)端螺釘不會(huì)進(jìn)入肩鎖關(guān)節(jié)間隙后，再置入螺釘，遠(yuǎn)端3～4枚螺釘，近端2～3枚螺釘。若遠(yuǎn)折端骨塊足夠大，可以用1枚2.4 mm皮質(zhì)骨螺釘行拉力螺釘固定。必要時(shí)可以用2號(hào)不可吸收線縫合，加強(qiáng)固定。對于斷裂的喙鎖韌帶不作特殊處理。仔細(xì)修復(fù)三角肌及斜方肌筋膜。術(shù)中活動(dòng)患肢判斷骨折固定的穩(wěn)定性。

三、術(shù)后處理

術(shù)后頸腕吊帶制動(dòng)患肢6周，術(shù)后即刻活動(dòng)肘關(guān)節(jié)、腕關(guān)節(jié)及手指，術(shù)后2周開始仰臥位肩關(guān)節(jié)被動(dòng)前屈上舉，外旋功能鍛煉，術(shù)后6周開始肩關(guān)節(jié)主動(dòng)輔助功能鍛煉，待X線片示有明顯的骨折愈合征象后開始肩關(guān)節(jié)肌力訓(xùn)練。建議患者術(shù)后6個(gè)月內(nèi)避免從事接觸性體育活動(dòng)。

四、療效評(píng)定標(biāo)準(zhǔn)

于術(shù)后第4、6、8、12周，第6、9、12個(gè)月隨訪，之后每隔6個(gè)月定期隨訪。拍鎖骨正軸位X線片，觀察骨折愈合情況，內(nèi)固定物有無失效、斷裂、移位等。采用Constant肩關(guān)節(jié)功能評(píng)分[10]評(píng)價(jià)肩關(guān)節(jié)功能，疼痛視覺模擬評(píng)分(visual analogu scale,VAS)評(píng)價(jià)疼痛程度。

結(jié) 果

術(shù)后切口均Ⅰ期愈合，無血管及神經(jīng)損傷、感染等并發(fā)癥發(fā)生。16例患者均獲隨訪，隨訪時(shí)間12～18個(gè)月，平均15.0個(gè)月；X線片示骨折均愈合，愈合時(shí)間6～12周，平均8周。隨訪期間無內(nèi)固定物失效、斷裂、移位情況發(fā)生。末次隨訪時(shí)Constant肩關(guān)節(jié)功能評(píng)分為86～100分，平均94分。VAS評(píng)分為0～2分，平均0.2分。10例患者于術(shù)后12～18個(gè)月取出內(nèi)固定物，見圖1，2。

圖1 患者，女性，47歲，左側(cè)NeerⅡB型鎖骨遠(yuǎn)端骨折。A為術(shù)前鎖骨正軸位X線片；B為術(shù)后即刻鎖骨正軸位X線片；C為術(shù)后12個(gè)月鎖骨正軸位X線片；D為手術(shù)切口

討 論

一、病理表現(xiàn)與分型

Neer[11]基于骨折線與喙鎖韌帶和肩鎖關(guān)節(jié)的關(guān)系，將鎖骨遠(yuǎn)端骨折分為3型：Ⅰ型為喙鎖韌帶外側(cè)骨折，肩鎖韌帶完整，通常無明顯移位或輕度移位；Ⅱ型為喙鎖韌帶內(nèi)側(cè)骨折，其中根據(jù)韌帶完整度分為ⅡA型(錐狀韌帶與斜方韌帶完整，附著于骨折遠(yuǎn)端)和ⅡB型(錐狀韌帶撕裂，斜方韌帶完整)；Ⅲ型為喙鎖韌帶外側(cè)骨折，累及肩鎖關(guān)節(jié)面。

二、治療方法

大多數(shù)鎖骨遠(yuǎn)端骨折為無或輕度移位的穩(wěn)定型骨折(NeerⅠ型和NeerⅢ型)，采用頸腕吊帶制動(dòng)4～6周，2周后疼痛緩解后即可開始肩關(guān)節(jié)功能鍛煉，可獲得滿意的療效。然而對于不穩(wěn)定型鎖骨遠(yuǎn)端骨折(NeerⅡB型)的治療尚存在爭議。由于遠(yuǎn)折端較小，常為粉碎性骨折，喙鎖韌帶撕裂，導(dǎo)致水平和垂直方向的不穩(wěn)定，斜方肌和胸鎖乳突肌牽拉近折端向上后移位，加上胸肌和上肢重力的作用，常導(dǎo)致骨折端較大的分離[12-13]。非手術(shù)治療難以對骨折進(jìn)行復(fù)位和固定，骨折不愈合率達(dá)到30%[12]。

盡管有臨床研究報(bào)道非手術(shù)和手術(shù)治療的遠(yuǎn)期肩關(guān)節(jié)功能差異不大，骨不愈合對肩部最終功能和肌力無太大影響，且手術(shù)治療有發(fā)生并發(fā)癥的潛在風(fēng)險(xiǎn)，從而對手術(shù)的指征提出了質(zhì)疑[14-15],但多數(shù)學(xué)者仍主張手術(shù)治療。文獻(xiàn)報(bào)道了眾多的手術(shù)方法包括：鎖骨鉤鋼板、鎖骨遠(yuǎn)端解剖鎖定鋼板、經(jīng)肩峰克氏針、Knowles針、喙鎖螺釘固定、張力帶縫線、改良Weaver-Dunn術(shù)、Endo-button、縫合錨、雙鋼板及關(guān)節(jié)鏡技術(shù)等，各有優(yōu)缺點(diǎn),尚無金標(biāo)準(zhǔn)，且內(nèi)固定物相關(guān)的并發(fā)癥較常見，如骨折不愈合、內(nèi)置物失效斷裂移位、復(fù)位丟失、肩峰骨折、肩峰下骨侵蝕、肩峰撞擊、鋼板周圍鎖骨骨折等[2-4,16-17]。

三、方法和療效

近年來，有學(xué)者將橈骨遠(yuǎn)端鎖定鋼板應(yīng)用于NeerⅡ型鎖骨遠(yuǎn)端骨折的手術(shù)治療，骨折愈合率高、并發(fā)癥少，早期結(jié)果令人鼓舞。Kalamaras等[5]于2008年，首次報(bào)道將2.4 mm橈骨遠(yuǎn)端鎖定鋼板應(yīng)用于9例Neer Ⅱ型鎖骨遠(yuǎn)端骨折，采用鎖骨前方平行于鎖骨的皮膚切口，其中6例采用掌側(cè)T形鋼板(需塑形)，3例采用L形鋼板，6例采用了不可吸收線環(huán)繞喙突和鎖骨遠(yuǎn)端技術(shù)增強(qiáng)。8例患者獲得隨訪10～19個(gè)月，骨折均愈合(6～16周)，1例出現(xiàn)傷口感染，Constant評(píng)分均為優(yōu)。并指出該技術(shù)無肩鎖關(guān)節(jié)的干擾和醫(yī)源性的肩袖損傷和撞擊，鋼板低切跡不需要常規(guī)取出鋼板，固定穩(wěn)定，允許早期活動(dòng)，愈合率高。

圖2 患者術(shù)后12個(gè)月肩關(guān)節(jié)功能。A為肩關(guān)節(jié)前屈上舉；B為肩關(guān)節(jié)外展；C為肩關(guān)節(jié)外旋；D肩關(guān)節(jié)內(nèi)旋

Herrmann等[6]于2009年報(bào)道了8例Neer ⅡB型鎖骨遠(yuǎn)端骨折，橫行皮膚切口，如果三角肌筋膜無創(chuàng)傷性撕脫需從鎖骨上切斷以顯露喙突基底，喙突基底置入1～2枚縫合錨，復(fù)位骨折后以1塊3.5 mm橈骨遠(yuǎn)端鎖定鋼板固定骨折，必要時(shí)以2.0 mm皮質(zhì)骨螺釘固定大骨折塊，縫合錨縫線環(huán)繞鎖骨和鋼板打結(jié)增強(qiáng)喙鎖間穩(wěn)定性，重建喙鎖韌帶功能。7例患者獲得平均8.3個(gè)月(4～16個(gè)月)隨訪，無術(shù)中和術(shù)后早期并發(fā)癥，6周內(nèi)骨折均愈合，臨床或X線片均無垂直或水平方向的不穩(wěn)定征象，Constant評(píng)分5例為優(yōu)，2例為良。

Hohmann等[7]于2012年，報(bào)道了31例Neer Ⅱ型鎖骨遠(yuǎn)端骨折，鎖骨前方橫行皮膚切口，鈍性分離三角肌顯露喙突，置入TightRope縫線裝置，鎖骨上方以2.4 mm橈骨遠(yuǎn)端鎖定鋼板固定，喙鎖韌帶以TightRope縫線增強(qiáng)。29例獲得隨訪，骨折愈合時(shí)間平均(6.3±4.1)周，1例出現(xiàn)傷口感染，1例出現(xiàn)骨折不愈合和鋼板斷裂，Constant評(píng)分24例優(yōu)，5例良。并指出不可吸收線環(huán)繞鎖骨和喙突技術(shù)有縫線侵蝕喙突骨質(zhì)的潛在風(fēng)險(xiǎn)，TightRope系統(tǒng)的優(yōu)點(diǎn)在于可避免骨質(zhì)侵蝕，因?yàn)榭p線是系在鈕扣上而不是在鎖骨和喙突上。

龔偉華等[8]于2009年報(bào)道了9例NeerⅡ型鎖骨遠(yuǎn)端骨折，采用肩峰弧形切口，鎖骨上方以橈骨遠(yuǎn)端鎖定鋼板(未報(bào)告型號(hào))固定，因選用的病例喙鎖韌帶并非完全撕裂，原始移位不甚明顯，術(shù)中檢查LCP完全能滿足骨折固定的需要，未修補(bǔ)喙鎖韌帶。隨訪3～14個(gè)月，傷口均I期愈合，無內(nèi)固定并發(fā)癥。骨折愈合時(shí)間為8～10周，平均9.1周。無骨折延遲愈合、不愈合及畸形愈合。按照Constant肩關(guān)節(jié)功能評(píng)分：患側(cè)為84～94分，平均90分；同期健側(cè)為90～97分，平均95分。

最近，朱彤等[9]比較了橈骨遠(yuǎn)端T形鎖定鋼板與鎖骨鉤鋼板治療NeerⅡ型鎖骨遠(yuǎn)端骨折的療效。鎖骨表面橫行切口，采用橈骨遠(yuǎn)端T形鎖定鋼板(未報(bào)告鋼板的大小)預(yù)彎后置于鎖骨遠(yuǎn)端表面，所有患者均未行斷裂喙鎖韌帶修復(fù)術(shù)。術(shù)后隨訪中未發(fā)現(xiàn)鋼板斷裂和骨折不愈合。結(jié)果顯示橈骨遠(yuǎn)端T形鎖定鋼板治療效果明顯優(yōu)于鎖骨鉤鋼板，前者可避免對肩峰周圍軟組織的侵襲損害。

四、注意事項(xiàng)與技巧

本組患者均采用2.4 mm L形橈骨遠(yuǎn)端鎖定鋼板結(jié)合縫合錨治療NeerⅡB型鎖骨遠(yuǎn)端骨折，療效滿意，與文獻(xiàn)報(bào)道的結(jié)果相似，無骨折延遲愈合、不愈合，無感染，無內(nèi)固定物失效、斷裂、移位情況發(fā)生，但方法有一些不同之處?；诒窘M資料并結(jié)合有關(guān)文獻(xiàn)，我們有如下體會(huì)和建議：(1)可選擇橫切口或縱切口，均可滿足充分顯露的需要，沿皮膚Langer線的縱切口具有以下優(yōu)點(diǎn)[3]：①瘢痕小，切口方向與皮紋線方向一致，可以較大程度減少術(shù)后傷口的皮膚攣縮，從而減小瘢痕的面積，且容易用服裝掩蓋；②避免鎖骨上神經(jīng)損傷，減少術(shù)后麻木。因此，我們推薦采用縱切口，不建議常規(guī)采用上述文獻(xiàn)采用的橫切口。(2)因NeerⅡB型骨折肩鎖韌帶完整，故術(shù)中無須暴露肩鎖關(guān)節(jié)，避免醫(yī)源性破壞肩鎖關(guān)節(jié)穩(wěn)定性和骨折端血運(yùn)。(3)基于NeerⅡB型骨折主要特點(diǎn)：遠(yuǎn)端骨折塊通常較小且粉碎，主要為松質(zhì)骨，不穩(wěn)定、移位大的主要原因是錐狀韌帶的斷裂，2.4 mm鎖骨鋼板螺釘?shù)陌殉至蛷?qiáng)度均有限。因此，我們不建議單獨(dú)應(yīng)用該鋼板，推薦結(jié)合縫合錨增強(qiáng)喙鎖間穩(wěn)定性，避免鋼板失效，通常1枚縫合錨已足夠。已有實(shí)驗(yàn)表明，使用縫合錨固定代替喙鎖韌帶的功能，其強(qiáng)度同喙鎖韌帶相似[18]。(4)喙突縫合錨的置入：我們推薦從胸大肌內(nèi)側(cè)緣(胸三角的外側(cè)邊)鈍性分離進(jìn)入，將三角肌拉向外側(cè)，即可顯露喙突基底，但須小心分離和牽拉，避免損傷臨近的血管神經(jīng)。不建議分離三角肌或剝離三角肌筋膜，因其會(huì)加重軟組織的損傷和破壞骨折端的血運(yùn)。鎖骨骨孔位于喙突上方鎖骨前中1/3，靠后可能會(huì)阻礙隨后鋼板的放置?？p合錨應(yīng)盡量置入喙突基底的中心，以提供最大的錨定力，避免其拔出。(5)復(fù)位：基于NeerⅡB型骨折的移位特點(diǎn)：近折端向后上移位，遠(yuǎn)折端下外移位，復(fù)位時(shí)需向上托起患肢，向前下推壓近折端，向內(nèi)推患肩?？耸厢樅忘c(diǎn)狀復(fù)位鉗有助于維持復(fù)位。復(fù)位后應(yīng)先將縫合錨縫線打結(jié)穩(wěn)定近折端，然后再用鋼板固定遠(yuǎn)近折端。(6)因鎖骨遠(yuǎn)端呈向后的弧形，而近折端有縫合錨線結(jié)的阻礙，通常選擇拐角向后的L形鋼板，再根據(jù)具體骨折形態(tài)選擇直L形或斜L形鋼板，使遠(yuǎn)端有3～4枚螺釘，近端有2～3枚螺釘固定。(7)使用細(xì)針頭確定肩鎖關(guān)節(jié)間隙，有助于確保鋼板最遠(yuǎn)端螺釘不會(huì)進(jìn)入肩鎖關(guān)節(jié)間隙。(8)鋼板遠(yuǎn)端螺釘要獲得足夠把持力需要骨折塊足夠的骨量和較好的骨質(zhì)量。如果遠(yuǎn)折端小、嚴(yán)重粉碎、骨質(zhì)疏松，難以有效復(fù)位鋼板內(nèi)固定，術(shù)前、術(shù)中應(yīng)做好轉(zhuǎn)變手術(shù)方式的準(zhǔn)備。年輕患者為了盡可能保留鎖骨遠(yuǎn)端，可選擇龔曉峰等[19]報(bào)道的縫合錨結(jié)合骨折端縫線環(huán)扎技術(shù)。老年患者可選擇鎖骨遠(yuǎn)端切除改良Weaver-Dunn術(shù)[12]。(9)應(yīng)仔細(xì)修復(fù)三角肌及斜方肌筋膜，因?yàn)槠溆兄卩规i關(guān)節(jié)前后向的穩(wěn)定[19]。

綜上所述，對于NeerⅡB型鎖骨遠(yuǎn)端骨折，應(yīng)用2.4 mm L形橈骨遠(yuǎn)端鎖定鋼板結(jié)合縫合錨增強(qiáng)喙鎖間穩(wěn)定性，術(shù)后早期活動(dòng)鍛煉，可獲滿意療效，是一種可行的有效方法。但由于本組病例數(shù)較少，且隨訪時(shí)間較短，還需要更大樣本量和更長期的隨訪觀察以明確療效。

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(本文編輯：李靜)

Locking plate combined with suture anchor for treatment of NeerⅡ B distal clavicular fractures

HuXiaochuan,LinHuiyang,XiangMing,ChenHang,YangGuoyong.

DepartmentofUpperExtremity,SichuanOrthopaedicHospital,Chengdu610041,China

Correspondingauthor：XiangMing,Email:josceph_xm@sina.com

Background The cases of distal clavicular fracture account for about 10%-30% of all clavicular fracture cases. Most of distal clavicular fracture cases are stable fracture cases without fracture or with minor fractures (Neer I type and Neer Ⅲ type), for which satisfactory curative effects can be achieved through conservative treatment in general. However, there are disputes over treatment methods for the cases of instable Neer ⅡB type distal clavicular fractures. The non-operative therapy is featured by high fracture nonunion rate, while operative treatment involves potential risk of complications. The majority of scholars still advocate operative treatment. Many operation methods are optional and have their own advantages and disadvantages. However, there is no gold standard for operative treatment at present, and the complications related to internal fixtures are frequent.In recent years, some scholars have applied the distal radius locking plate in the operative treatment of Neer Ⅱ type distal clavicular fracture, featuring high fracture union rate, less complications and encouraging early results. However, there are few research reports, and no generally accepted operation method has been formed. During the period from January 2011 to December 12, 2013, our department adopted 2.4 mm L-shaped distal radius locking plate for internal fixation in combination with suture anchor with enhanced coracoclavicular stability in the operative treatment of 16 patients with instable Neer ⅡB type distal clavicular fractures. We hereby make retrospective analysis on the clinical data of these patients, in order to provide references for selecting the operation method for this type of fracture.Methods (1) General materials:This groups includes 12 male cases and 4 female cases; they are aged 23-65, with average age of 35 years. There are 6 cases of left side fracture and 10 cases of right side fracture; The injury causes: 4 cases of falling injury, 2 cases of bicycle injury, 4 cases of electric bicycle injury and 6 cases of traffic accident injury. All these cases suffer from fresh closed fracture, without nerve and vascular injury. Prior to operation, our department performed X-ray examination on clavicular orthoaxis position, CT plan scanning on shoulder joint+ three-dimensional bone reconstruction on these cases and thus made clear that they suffer from instable NeerⅡB type distal clavicular fracture. The duration from injury to operation is 3-12 d, with average duration of 5 d. (2) Operative method:Under general anesthesia in combination with brachial plexus block anesthesia, allow the patient to lie on 45° beach chair position, and raise the shoulder of patient; Perform skin incision along the Langer line of skin (spandex running line of skin), incise forwards from 1.5-2.0 cm inner side of acromioclavicular joint to coracoid, with incision length of about 6.0 cm. Expose deltoid fascia and inclined and square muscle fascia, incise the fasciae along the long axis of clavicle to expose the fracture ends. In the operation, pay attention to keeping the integrity of acromioclavicular ligament and protecting the insertions of deltoid and musculus trapezius.Perform blunt separation from the medial margin of pectoralis major muscle, enter the musculus pectoralis major, pull the deltoid outwards, so that the coracoid base can be exposed. Make separation carefully, avoid causing injury to adjacent vascular nerves, sufficiently expose the coracoid base, and explore the integrity of coracoclavicular ligament. Clean the fracture end, on the position 1/3 before distal side of clavicular fracture end, drill two bone holes at interval of 1.0 cm; Fix one 5.0 mm suture anchor (Mitek FASTIN RC, Depuy or Twinx，Smith & Nephew) on coracoid base, and allow two strands of No.2 non-absorbable sutures for stitching anchor tail to pass through the bone holes. Hold up the affected limbs, push and press the proximal fracture end forwards and downwards, and push the affected shoulder inwards; After reduction of bone fracture, knot and fix the suture anchor tail line. Use one 1.5 mm kirschner wire in combination with reduction forceps to perform temporary fixation through acromion or not through acromion; Through C arm X-ray machine perspective, validate fracture reduction and satisfactory position of anchor rivet.Place one 2.4 mm distal radius straight-shaped or inclined L-shaped locking compression plate (provided by Switzerland Synthes Company or Shandong Weigao Orthopedics material Co.,Ltd) above the distal clavicular. Use a fine needle to determine the acromioclavicular joint clearance; After having ensured that the screws at the furthest end will unlikely enter the acromioclavicular joint clearance, place the screws, with 3-4 screws placed at distal end and 2-3 screws at the proximal end. If the bone block at the distal fracture end is big enough, one 2.4 mm cortical bone screw is used to perform lag screw fixation. When necessary, No.2 non-absorbable suture can be used for stitching and enhancing fixation. No special treatment is made for fractured coracoclavicular ligament. The deltoid fascia and inclined and square muscle fascia are carefully repaired. Move the affected limbs during operation, so as go judge the stability of facture fixation. (3) Postoperative treatment:After operation, use neck-wrist strap to rest the affected limbs for 6 weeks, then immediately exercise elbow joint, wrist joint and finger. At 2 weeks after operation, start passive functional exercises of shoulder joint (including forward bending, uplifting and outward rotation) on supine position; At 6 weeks after operation, start the exercise of active and auxiliary functions of shoulder joint; After obvious fracture union sign has been confirmed through X-ray film examination, start the training on muscle strength of shoulder joint. It is suggested that the patient should avoid contact physical sports in 6 months after operation. (4) Evaluation criteria for curative effects:Respectively make follow-up visit at 4, 6, 8 and 12 weeks after operation, in the sixth, ninth and twelfth months after operation, and then make regular follow-up visit at interval of 6 months; Make X-ray photography on the orthoaxis position of clavicular, observe the fracture union and verify whether there is malfunction, fracture or displacement of internal fixture. Adopt shoulder joint function score such as Constant to evaluate the functions of shoulder joint, and adopt visual analogue pain scale (VAS) to evaluate the pain degree.Results All the postoperative incisions were healed up at Phase I, without occurrence of such complications as vascular injury, nerve injury and infection. All 16 cases obtained follow-up visits, with follow-up survey period of 12-18 months and average period of 15.0 months. As shown in X-ray film, 16 cases of fracture were healed without exception, with healing time of 6～12 weeks and average healing time of 8 weeks. During the follow-up period, there was no malfunction, fracture or displacement of fixture. In the final follow-up visit, the Constant shoulder joint function score was 86-100 points, with average score of 94 points.VAS was 0-2 points, with average value of 0.2 points. For 10 cases, internal fixtures were taken out in 12-18 months after operation.Conclusions For unstable Neer type ⅡB distal clavicular fractures, using 2.4 mm L shape locking compression plate designed for distal radius for open reduction and internal fixation combined with suture anchor augmentation of the coraco-clavicular stability, and early active mobilization can obtain good functional results,it is a feasible and effective method.

Shoulder joint;Clavicular fractures,distal;Locking plate;Suture anchor;Internal fixation

10.3877/cma.j.issn.2095-5790.2015.04.002

公益性行業(yè)科研專項(xiàng)(201302007)

610041成都，四川省骨科醫(yī)院上肢科

向明,Email: josceph_xm@sina.com

2015-03-31)