多枚骨圆针治疗不稳定型锁骨远端骨折

多枚骨圆针治疗不稳定型锁骨远端骨折,广东省中医院骨二科2016级 严伟健指导老师：黄刚,Neer分型,Type：骨折发生在喙锁韧带远端，导致微小的骨折移位，肩锁关节保持完整；TypeA：骨折发生在锥形韧带内侧；TypeB：骨折发生在喙锁韧带中间，锥形韧带断裂；Type：骨折发生在喙锁韧带远端，累及肩锁关节；Type：骨折发生在未成年人，干骺端和骺线分离；Type：小的下方的锁骨骨折块连接着喙锁韧带。IIA和IIB型中喙锁韧带与内侧骨折块分离，会导致骨折不稳。,最佳治疗方式？,II型锁骨远端骨折采用钩钢板固定，能够提高愈合率（98.1%）和临床效果。但也会出现并发症：肩峰端骨质溶解、假体周围骨折、钢板移位等。,张力带或髓内钉等方式固定。但是同样会出现如：肩锁关节炎、螺钉切出等并发症。而且钩钢板和张力带需要二次手术取出。,Methods,2001年11月-2013年3月期间，共纳入55例Neer II型锁骨远端骨折患者，平均年龄45.1岁（18-81岁）。采用多枚骨圆针进行固定治疗。,全麻满意后，患者取沙滩椅位，术中避免损伤臂丛神经和锁骨下动脉。沿Langer线由后向前延伸切开显露骨折断端。仔细剥离骨折断端上缘的骨膜和前方三角肌、斜方肌的止点，清除骨折断端嵌入的软组织。复位钳维持复位，克氏针由内侧端置入，穿过骨折端，直至外侧骨折块的对侧皮质。然后在外侧肩峰处切开长约1.5cm的切口，3枚2.0mm的骨圆针从肩锁关节向锁骨后侧皮质穿入。,手术操作,透视下确定骨圆针尖端穿过后侧皮质2mm）。术中根据患者具体的情况，选择2-4枚骨圆针固定。如果锁骨远端为斜形骨折或间隙较大，可以采用1或2枚加压螺钉固定以维持复位。如果骨折粉碎，骨圆针固定后，骨折块间隙仍然2mm，可取髂骨移植。术中所有患者的锥形韧带均不需探查修复。将骨圆针尾部折弯90，埋在斜方肌和三角肌内，可吸收缝线修复肌肉组织。最后生理盐水冲洗伤口，留置引流，闭合伤口。,病例,A）55岁老年男性，术前X线显示锁骨远端骨折，且喙锁韧带间隙增宽；（B）和（C）显示术中采用3枚骨圆针+2枚加压螺钉稳定固定骨折；（D）术后2年随访可见骨折愈合，喙锁韧带间隙未见明显增宽，肩锁关节可见轻度骨关节炎改变；（E）为健侧锁骨远端的形态和喙锁韧带间隙。,病例,（A）26岁女性，术前X线显示锁骨远端斜形骨折；（B）术中采用3枚骨圆针复位固定；（C）术后随访可见骨折愈合，且喙锁韧带间隙轻度增宽。,Results,术后平均随访30.5月（范围：24-81月），所有患者均达到骨性愈合。与健侧相比，患侧喙锁韧带间隙增宽约6.4%。其中有14例患者发生单枚骨圆针脱出（平均脱出11.6mm）。术后ConstantMurley评分平均为94.3分（范围：85-100分），术后University ofCalifornia at Los Angeles评分平均为33.1分（范围：29-35分），Disabilities ofthe arm, shoulder, and hand 评分平均为2.7分（范围：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