多枚骨圓針治療不穩(wěn)定型鎖骨遠端骨折

多枚骨圓針治療不穩(wěn)定型鎖骨遠端骨折,廣東省中醫(yī)院骨二科2016級 嚴(yán)偉健指導(dǎo)老師：黃剛,Neer分型,Type：骨折發(fā)生在喙鎖韌帶遠端，導(dǎo)致微小的骨折移位，肩鎖關(guān)節(jié)保持完整；TypeA：骨折發(fā)生在錐形韌帶內(nèi)側(cè)；TypeB：骨折發(fā)生在喙鎖韌帶中間，錐形韌帶斷裂；Type：骨折發(fā)生在喙鎖韌帶遠端，累及肩鎖關(guān)節(jié)；Type：骨折發(fā)生在未成年人，干骺端和骺線分離；Type：小的下方的鎖骨骨折塊連接著喙鎖韌帶。IIA和IIB型中喙鎖韌帶與內(nèi)側(cè)骨折塊分離，會導(dǎo)致骨折不穩(wěn)。,最佳治療方式？,II型鎖骨遠端骨折采用鉤鋼板固定，能夠提高愈合率（98.1%）和臨床效果。但也會出現(xiàn)并發(fā)癥：肩峰端骨質(zhì)溶解、假體周圍骨折、鋼板移位等。,張力帶或髓內(nèi)釘?shù)确绞焦潭?。但是同樣會出現(xiàn)如：肩鎖關(guān)節(jié)炎、螺釘切出等并發(fā)癥。而且鉤鋼板和張力帶需要二次手術(shù)取出。,Methods,2001年11月-2013年3月期間，共納入55例Neer II型鎖骨遠端骨折患者，平均年齡45.1歲（18-81歲）。采用多枚骨圓針進行固定治療。,全麻滿意后，患者取沙灘椅位，術(shù)中避免損傷臂叢神經(jīng)和鎖骨下動脈。沿Langer線由后向前延伸切開顯露骨折斷端。仔細(xì)剝離骨折斷端上緣的骨膜和前方三角肌、斜方肌的止點，清除骨折斷端嵌入的軟組織。復(fù)位鉗維持復(fù)位，克氏針由內(nèi)側(cè)端置入，穿過骨折端，直至外側(cè)骨折塊的對側(cè)皮質(zhì)。然后在外側(cè)肩峰處切開長約1.5cm的切口，3枚2.0mm的骨圓針從肩鎖關(guān)節(jié)向鎖骨后側(cè)皮質(zhì)穿入。,手術(shù)操作,透視下確定骨圓針尖端穿過后側(cè)皮質(zhì)2mm）。術(shù)中根據(jù)患者具體的情況，選擇2-4枚骨圓針固定。如果鎖骨遠端為斜形骨折或間隙較大，可以采用1或2枚加壓螺釘固定以維持復(fù)位。如果骨折粉碎，骨圓針固定后，骨折塊間隙仍然2mm，可取髂骨移植。術(shù)中所有患者的錐形韌帶均不需探查修復(fù)。將骨圓針尾部折彎90，埋在斜方肌和三角肌內(nèi)，可吸收縫線修復(fù)肌肉組織。最后生理鹽水沖洗傷口，留置引流，閉合傷口。,病例,A）55歲老年男性，術(shù)前X線顯示鎖骨遠端骨折，且喙鎖韌帶間隙增寬；（B）和（C）顯示術(shù)中采用3枚骨圓針+2枚加壓螺釘穩(wěn)定固定骨折；（D）術(shù)后2年隨訪可見骨折愈合，喙鎖韌帶間隙未見明顯增寬，肩鎖關(guān)節(jié)可見輕度骨關(guān)節(jié)炎改變；（E）為健側(cè)鎖骨遠端的形態(tài)和喙鎖韌帶間隙。,病例,（A）26歲女性，術(shù)前X線顯示鎖骨遠端斜形骨折；（B）術(shù)中采用3枚骨圓針復(fù)位固定；（C）術(shù)后隨訪可見骨折愈合，且喙鎖韌帶間隙輕度增寬。,Results,術(shù)后平均隨訪30.5月（范圍：24-81月），所有患者均達到骨性愈合。與健側(cè)相比，患側(cè)喙鎖韌帶間隙增寬約6.4%。其中有14例患者發(fā)生單枚骨圓針脫出（平均脫出11.6mm）。術(shù)后ConstantMurley評分平均為94.3分（范圍：85-100分），術(shù)后University ofCalifornia at Los Angeles評分平均為33.1分（范圍：29-35分），Disabilities ofthe arm, shoulder, and hand 評分平均為2.7分（范圍：0-8.3分）。,Advantages,1. anterior-posterior stability ，less damage to the AC joint 2. not damage the subacromial space. the hook plate technique can preserve the biomechanics of the AC joints, complications related to subacromial space are a potential problem. 3. if the acromion（肩峰） is intact,surgeons can use this technique in any type of fracture regardless of the state of the distal fracture fragment.4.technically simple .5.this surgical method is inexpensive 6. no need for general anesthesia to remove the S-pins.,Forbone graft,Although the pain at the donor site usually disappears after 3 weeks, there could be a risk of donor site infection.Although the patients did not complain of donor site pain, the clinical outcomes were worse than those who did not undergo bone graft. related to the use of more pins and the progression of arthritis.,Lateral pin migration,lateral pin migration. Although there was no medial pin migration, which could be fatal, lateral pin migrations could induce loss of reduction or pin protrusion through the skin. In our series, there was no lateral migration until 6 weeks, and migration was limited to only 1 pin. The initiation of active shoulder exercise was likely to have caused the lateral migration. 1.purchasing 2 cortices with S-pins2.bending the S-pins at the acromial end3. performing a secure repair of the deltoid attachment to the acromion 4.short-term regular follow-up,AC joint arthritis,New AC joint arthritis did not occur in innocent AC joint, previous arthritic jointappeared to progress easily. This change was not symptomatic during our follow-up period, but further changes after 24 months could be a potential problem.,2018/3/30,15,Various surgical techniques for unstable distal clavicle fractures can provide good results, but each method has its own indications and complications. A surgeons preference should ultimately determine the technique chosen. Our relatively simple technique produced good results, has widerange of indications, and could be used as a possible surgical opt