關(guān)節(jié)鏡下紐扣鋼板固定術(shù)治療不穩(wěn)定鎖骨遠(yuǎn)端骨折

陳建海 黨育 付中國(guó) 姜保國(guó)

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·論著·

關(guān)節(jié)鏡下紐扣鋼板固定術(shù)治療不穩(wěn)定鎖骨遠(yuǎn)端骨折

陳建海 黨育 付中國(guó) 姜保國(guó)

目的 探討關(guān)節(jié)鏡下紐扣鋼板固定術(shù)治療不穩(wěn)定鎖骨遠(yuǎn)端骨折的臨床療效。方法 回顧性分析17例不穩(wěn)定鎖骨遠(yuǎn)端骨折經(jīng)關(guān)節(jié)鏡下紐扣鋼板固定術(shù)后臨床結(jié)果。通過(guò)Constant評(píng)分，簡(jiǎn)明肩關(guān)節(jié)功能測(cè)試(simple shoulder text,SST)，VAS疼痛評(píng)分對(duì)患者在最后一次隨訪(fǎng)時(shí)的肩關(guān)節(jié)功能進(jìn)行評(píng)價(jià)。結(jié)果 本組患者共17例，男性10例，女性7例。平均年齡42.6歲(27～68歲)。按照Robinson骨折分型，均為3B型。 17例患者均獲得隨訪(fǎng)，平均隨訪(fǎng)時(shí)間50個(gè)月(42～66個(gè)月)。16例患者骨折愈合，平均愈合時(shí)間3.2個(gè)月，1例骨折不愈合。術(shù)中發(fā)現(xiàn)合并關(guān)節(jié)內(nèi)損傷 2例， SLAP損傷1例， Bankart損傷1例，術(shù)中分別予以修復(fù)?；颊咝g(shù)后Constant評(píng)分患側(cè)平均93.1分(72～100分)，健側(cè)98.3分(90～100分)。SST患側(cè)平均10.7分(8～12分)，健側(cè)11.6分(9～12分)。VAS評(píng)分患側(cè)平均1.9分(0～4分)，健側(cè)1.7分(0～5分)。結(jié)論 關(guān)節(jié)鏡下紐扣鋼板固定術(shù)具有臨床效果良好，創(chuàng)傷小，可同時(shí)處理關(guān)節(jié)內(nèi)合并損傷，喙鎖彈性固定，不需要再次手術(shù)等優(yōu)點(diǎn)?？梢宰鳛殒i骨遠(yuǎn)端骨折治療的一個(gè)選擇。

鎖骨骨折；關(guān)節(jié)鏡；肩；微創(chuàng)

鎖骨遠(yuǎn)端骨折占鎖骨骨折的12%～15%[1]。鎖骨遠(yuǎn)端骨折合并喙鎖韌帶斷裂常常表現(xiàn)為不穩(wěn)定性骨折，保守治療出現(xiàn)骨折不愈合的機(jī)率高達(dá)21%[2]。盡管有部分骨折不愈合的患者臨床癥狀輕微[2]，但會(huì)影響肩關(guān)節(jié)的功能。因此，多數(shù)醫(yī)師建議對(duì)不穩(wěn)定鎖骨遠(yuǎn)端骨折進(jìn)行手術(shù)治療[3-5]。手術(shù)治療可以獲得高達(dá)98%的骨折愈合率[6]。鎖骨遠(yuǎn)端骨折的特點(diǎn)是既有骨折，又有韌帶損傷，臨床上治療方法多種多樣，常報(bào)道的內(nèi)固定方法包括克氏針、張力帶、喙鎖螺釘、錨釘、鎖骨鉤板、解剖鋼板以及縫線(xiàn)固定等。金屬內(nèi)植物在骨折愈合后常常需要再次手術(shù)取出。各種治療方法優(yōu)、缺點(diǎn)并存，目前尚無(wú)統(tǒng)一的治療方法。

關(guān)節(jié)鏡下紐扣鋼板固定治療鎖骨遠(yuǎn)端骨折是一種比較新的微創(chuàng)治療方法，其技術(shù)來(lái)源于治療肩鎖關(guān)節(jié)脫位的關(guān)節(jié)鏡下紐扣鋼板固定術(shù)[7]。我們回顧性分析關(guān)節(jié)鏡下紐扣鋼板固定術(shù)治療鎖骨遠(yuǎn)端骨折的臨床效果，探討此技術(shù)的潛在優(yōu)、缺點(diǎn)。

資 料 與 方 法

一、一般資料

收集2010年9月至2012年12月在我科接受手術(shù)治療的21例不穩(wěn)定鎖骨遠(yuǎn)端骨折患者，其中17例符合納入標(biāo)準(zhǔn)，男性10例，女性7例，平均年齡42.6歲，按照Robinson鎖骨骨折分型[8]均為3B型骨折。納入標(biāo)準(zhǔn)：(1)診斷為不穩(wěn)定鎖骨遠(yuǎn)端骨折；(2)接受關(guān)節(jié)鏡下紐扣鋼板固定治療術(shù)。排除標(biāo)準(zhǔn)：(1)診斷為不穩(wěn)定鎖骨遠(yuǎn)端骨折，但沒(méi)有進(jìn)行關(guān)節(jié)鏡下紐扣鋼板固定手術(shù)，包括切開(kāi)復(fù)位鎖骨鉤鋼板固定、解剖鎖定鋼板固定、切開(kāi)紐扣鋼板固定；(2) 陳舊性鎖骨遠(yuǎn)端骨折。

二、手術(shù)方法

手術(shù)均在全麻下進(jìn)行?；颊呷∩碁┮误w位(圖1)，頭部偏向健側(cè)。標(biāo)畫(huà)肩關(guān)節(jié)鏡體表標(biāo)記，進(jìn)行常規(guī)患肩及上肢消毒。關(guān)節(jié)鏡從后方通道進(jìn)入關(guān)節(jié)腔，直視下建立前方位于肩袖間隙的工作通道(圖2)。進(jìn)行關(guān)節(jié)內(nèi)常規(guī)檢查，尤其注意檢查有無(wú)盂唇和肩袖結(jié)構(gòu)損傷。如果術(shù)中發(fā)現(xiàn)關(guān)節(jié)內(nèi)損傷即刻給予處理。直視下建立前外側(cè)經(jīng)岡上肌腱前部的關(guān)節(jié)鏡第二觀察通道(圖3)，通過(guò)交換棒將關(guān)節(jié)鏡轉(zhuǎn)移到第二觀察通道(圖4)。沿肩胛下肌上緣向內(nèi)顯露喙突下表面(圖5)，探鉤確定喙突的內(nèi)外側(cè)邊緣。C型臂機(jī)透視確定喙突在鎖骨表面的垂直投影位置，即錐形韌帶止點(diǎn)位置，切開(kāi)皮膚2 cm，顯露鎖骨上表面。將前交叉韌帶導(dǎo)向器放置在喙突下表面中央位置，經(jīng)鎖骨向喙突打入導(dǎo)針，透視確認(rèn)導(dǎo)針位置無(wú)誤(圖6)，經(jīng)導(dǎo)針使用4.5 mm空心鉆鉆孔(圖7)，引入擺渡鋼絲，取出導(dǎo)向器(圖8)。取2枚四孔紐扣鋼板，去除袢，用2枚5號(hào)愛(ài)惜康縫線(xiàn)按照?qǐng)D9所示進(jìn)行鋼板連接。將紐扣鋼板通過(guò)擺渡鋼絲穿過(guò)鎖骨和喙突，1枚位于喙突下，另1枚位于鎖骨表面。復(fù)位骨折，如果骨折端有軟組織崁入，可以使用探鉤進(jìn)行松解(圖10)。維持骨折復(fù)位，收緊縫線(xiàn)進(jìn)行打結(jié)固定。再次透視確認(rèn)骨折復(fù)位(圖11)，關(guān)節(jié)鏡檢查喙突下鋼板完全貼附喙突下表面(圖12)。常規(guī)關(guān)閉切口。

圖1 患者位于沙灘椅體位，頭向健側(cè)傾斜

圖2 關(guān)節(jié)鏡常規(guī)自后方通道插入關(guān)節(jié)腔，建立前方肩袖間隙工作通道 圖3 建立長(zhǎng)頭肌腱后緣的關(guān)節(jié)鏡第二觀察通道

圖4 插入交換棒，經(jīng)交換棒將關(guān)節(jié)鏡轉(zhuǎn)到此通道，以觀察喙突下間隙 圖5 使用射頻刀顯露喙突下表面，確定喙突內(nèi)、外側(cè)邊緣

圖8 經(jīng)空心鉆引入擺渡鋼絲，取出導(dǎo)向器

圖9 用于喙鎖固定的Tightrope內(nèi)植物，部分病例使用此內(nèi)植物，其余病例將2枚紐扣鋼板通過(guò)2根5號(hào)愛(ài)惜康縫線(xiàn)按照Tightrope 縫線(xiàn)連接方法進(jìn)行組裝

圖10 使用探鉤協(xié)助骨折復(fù)位

圖11 骨折復(fù)位，縫線(xiàn)打結(jié)固定完畢，術(shù)中透視像

圖12 關(guān)節(jié)鏡檢查喙突下鋼板完全貼服喙突下表面

圖13 關(guān)節(jié)鏡下紐扣鋼板內(nèi)固定術(shù)前(A)、術(shù)后 1周(B)和術(shù)后4個(gè)月(C)X線(xiàn)片

圖14 鉤板翻修術(shù)后

三、術(shù)后處理

肩關(guān)節(jié)護(hù)具懸吊患肩4周。術(shù)后4周進(jìn)行肩關(guān)節(jié)被動(dòng)上舉、外旋活動(dòng)；術(shù)后第2個(gè)月進(jìn)行強(qiáng)化的關(guān)節(jié)牽拉練習(xí)，主動(dòng)輔助的肩關(guān)節(jié)上舉、內(nèi)外旋活動(dòng)。術(shù)后2個(gè)月后，骨折初步愈合，局部無(wú)壓痛后開(kāi)始肩關(guān)節(jié)主動(dòng)活動(dòng)，肩袖及肩胛帶肌肉力量和耐力練習(xí)，逐步恢復(fù)日常活動(dòng)。

四、術(shù)后隨訪(fǎng)

術(shù)后每個(gè)月復(fù)查一次，拍攝X線(xiàn)片，檢查骨折愈合情況，直至骨折骨性愈合。末次隨訪(fǎng)通過(guò)肩關(guān)節(jié)Constant評(píng)分、簡(jiǎn)明肩關(guān)節(jié)評(píng)分(simple shoulder text,SST)，VAS疼痛評(píng)分，肩關(guān)節(jié)活動(dòng)范圍檢查等對(duì)患者進(jìn)行評(píng)價(jià)。

結(jié) 果

17例患者均獲得隨訪(fǎng)，平均隨訪(fǎng)時(shí)間50個(gè)月(42～66個(gè)月)。16例患者骨折愈合，平均愈合時(shí)間3.2個(gè)月，1例骨折不愈合。術(shù)中發(fā)現(xiàn)合并關(guān)節(jié)內(nèi)損傷2例， SLAP損傷1例， Bankart損傷1例，術(shù)中分別給予修復(fù)。

患者術(shù)后Constant評(píng)分患側(cè)平均93.1分(72～100分)，健側(cè)98.3分(90～100分)。SST患側(cè)平均10.7分(8～12分)，健側(cè)11.6分(9～12分)。VAS評(píng)分患側(cè)平均1.9分(0～4分)，健側(cè)1.7分(0～5分)。

1例骨折不愈合患者，男性，初次手術(shù)時(shí)年齡50歲，酒后騎電動(dòng)車(chē)摔傷右肩，骨折分型為鎖骨遠(yuǎn)端3B型，既往糖尿病史，血糖控制不佳。入院后行關(guān)節(jié)鏡下紐扣鋼板內(nèi)固定術(shù)(圖13)，術(shù)后進(jìn)行常規(guī)制動(dòng)和康復(fù)鍛煉。術(shù)后復(fù)查內(nèi)固定失效，骨折移位，觀察至術(shù)后4個(gè)月，骨折不愈合，局部壓痛，肩關(guān)節(jié)功能明顯受限?；颊咴俅稳朐?，將內(nèi)植物取出，髂骨取骨植骨，鎖骨鉤鋼板內(nèi)固定術(shù)(圖14)。第二次手術(shù)后3個(gè)月骨折愈合，12個(gè)月后取出鎖骨鉤鋼板，患者肩關(guān)節(jié)功能基本恢復(fù)正常，Constant評(píng)分91分，SST評(píng)分11分，VAS評(píng)分1分。

討 論

鎖骨是連接上肢與軀干的唯一骨性結(jié)構(gòu)，上肢通過(guò)肩鎖關(guān)節(jié)和喙鎖韌帶牢固與鎖骨連接，喙鎖韌帶又分為錐形韌帶和斜方韌帶。不穩(wěn)定的鎖骨遠(yuǎn)端骨折最主要特點(diǎn)是喙突與近端鎖骨連接結(jié)構(gòu)破壞，主要表現(xiàn)為喙鎖韌帶斷裂。因此，對(duì)于不穩(wěn)定的鎖骨遠(yuǎn)端骨折的治療，既要考慮骨折因素，同時(shí)要重視喙鎖韌帶損傷的處理。

Robinson等[2]對(duì)不穩(wěn)定的鎖骨遠(yuǎn)端骨折保守治療結(jié)果進(jìn)行分析研究，共101例患者進(jìn)行保守治療，14%因?yàn)闊o(wú)法耐受持續(xù)的疼痛而接受手術(shù)治療，骨折不愈合率高達(dá)21%。Neer[3]提出對(duì)不穩(wěn)定鎖骨遠(yuǎn)端骨折進(jìn)行手術(shù)治療以避免骨折不愈合的發(fā)生。有關(guān)鎖骨遠(yuǎn)端骨折手術(shù)治療方法種類(lèi)很多，包括克氏針張力帶固定[9]、錨釘固定[10]、鎖骨鉤鋼板固定[11-12]、鎖骨遠(yuǎn)端解剖鋼板固定[13]、紐扣鋼板固定[14-15]、鋼板結(jié)合韌帶重建[16]、Bosworth螺釘固定等[17]。手術(shù)后并發(fā)癥如克氏針移位、錨釘縫線(xiàn)斷裂、鎖骨鉤肩峰下刺激癥狀、螺釘斷裂、鎖骨應(yīng)力性骨折等，金屬內(nèi)植物常常需要二次手術(shù)取出。隨著關(guān)節(jié)鏡技術(shù)的發(fā)展，關(guān)節(jié)鏡下喙鎖固定手術(shù)獲得了較多的開(kāi)展[7,14-15]，關(guān)節(jié)鏡手術(shù)的優(yōu)勢(shì)在于微創(chuàng)，重建喙鎖穩(wěn)定性，不需要二次手術(shù)取出內(nèi)植物，同時(shí)處理關(guān)節(jié)內(nèi)合并損傷等。

關(guān)節(jié)鏡下紐扣鋼板固定術(shù)治療不穩(wěn)定鎖骨遠(yuǎn)端骨折，其手術(shù)設(shè)計(jì)理念在于通過(guò)重建喙鎖穩(wěn)定性，將不穩(wěn)定鎖骨遠(yuǎn)端骨折轉(zhuǎn)變成穩(wěn)定的鎖骨遠(yuǎn)端骨折。手術(shù)僅通過(guò)紐扣鋼板固定喙突與鎖骨近端骨折塊，對(duì)于鎖骨遠(yuǎn)近端骨折塊沒(méi)有進(jìn)行固定。隨訪(fǎng)結(jié)果顯示絕大部分患者獲得了與健側(cè)相同的功能水平，說(shuō)明手術(shù)設(shè)計(jì)理念得到了實(shí)現(xiàn)。Pujol等[18]在2008年報(bào)道了4例關(guān)節(jié)鏡下雙紐扣鋼板固定不穩(wěn)定鎖骨遠(yuǎn)端骨折病例，4例均獲得骨性愈合，患者術(shù)后功能恢復(fù)良好。Baumgarten[15]同年報(bào)道1例關(guān)節(jié)鏡下使用Tightrope紐扣鋼板系統(tǒng)治療不穩(wěn)定鎖骨遠(yuǎn)端骨折，骨折在術(shù)后3個(gè)月愈合，患者沒(méi)有功能障礙。Loriaut等[19]2015年5月報(bào)道21例鎖骨遠(yuǎn)端骨折患者接受關(guān)節(jié)鏡下紐扣鋼板固定治療的結(jié)果，81%的患者恢復(fù)傷前工作，Constant評(píng)分平均94分，VAS疼痛評(píng)分平均0.5分，有1例骨折發(fā)生不愈合。本研究的病例數(shù)量和結(jié)果與Loriaut的研究結(jié)果相當(dāng)。Loriaut提出可以將此手術(shù)方式作為治療不穩(wěn)定鎖骨遠(yuǎn)端骨折的首選方式?？紤]到關(guān)節(jié)鏡手術(shù)的學(xué)習(xí)曲線(xiàn)較長(zhǎng)，我們建議此手術(shù)應(yīng)在關(guān)節(jié)鏡技術(shù)成熟的醫(yī)院開(kāi)展。

大多數(shù)的創(chuàng)傷骨科醫(yī)師熟悉切開(kāi)復(fù)位、鎖骨鉤鋼板內(nèi)固定術(shù)，這是一項(xiàng)廣泛使用的技術(shù)，手術(shù)效果可靠，但缺點(diǎn)也很顯著，如術(shù)后較長(zhǎng)時(shí)間的肩關(guān)節(jié)疼痛、鋼板內(nèi)側(cè)鎖骨應(yīng)力性骨折、二次取出內(nèi)固定等。Lin等[20]對(duì)40例鎖骨遠(yuǎn)端骨折或肩鎖關(guān)節(jié)脫位經(jīng)鎖骨鉤鋼板治療的患者進(jìn)行臨床隨訪(fǎng)，通過(guò)體格檢查、X線(xiàn)片和動(dòng)靜態(tài)B超進(jìn)行臨床評(píng)估，結(jié)果發(fā)現(xiàn)15例(37.5%)患者有肩峰下撞擊綜合征，其中6例伴有肩袖損傷，這15例患者的肩關(guān)節(jié)功能明顯低于無(wú)撞擊綜合征的患者，鉤板導(dǎo)致的肩峰下骨磨損發(fā)生在20例(50%)患者中。Lin等認(rèn)為鎖骨鉤板發(fā)生肩峰下撞擊的幾率較高，只有取出內(nèi)植物才能解決問(wèn)題，建議在骨折和/或韌帶愈合后盡早取出內(nèi)植物。Flinkkil?等[21]對(duì)比了Tightrope紐扣鋼板系統(tǒng)(21例)和鎖骨鉤鋼板(19例)治療鎖骨遠(yuǎn)端骨折的臨床效果，結(jié)果每組各有1例骨折不愈合，Constant評(píng)分Tightrope組平均93分，鎖骨鉤鋼板組89分；DASH評(píng)分Tightrope組平均6分，鎖骨鉤鋼板組11分。提示關(guān)節(jié)鏡下紐扣鋼板固定可以獲得與鎖骨鉤鋼板相似的臨床結(jié)果，但避免了鎖骨鉤鋼板的諸多缺點(diǎn)。

Pauly等[22]前瞻性分析肩鎖關(guān)節(jié)脫位并發(fā)關(guān)節(jié)內(nèi)損傷的發(fā)生率，分析了125例肩鎖關(guān)節(jié)脫位患者，其中Rockwood Ⅲ型6例，Ⅴ型119例。關(guān)節(jié)鏡檢查發(fā)現(xiàn)合并關(guān)節(jié)內(nèi)病變38例(30.4%)，確定與外傷有關(guān)的損傷9例(7.2%)，退變性損傷確定與外傷無(wú)關(guān)的18例(14.4%)，無(wú)法確定是否與外傷有關(guān)的11例(8.8%)。肩鎖關(guān)節(jié)脫位與鎖骨遠(yuǎn)端骨折有著類(lèi)似的創(chuàng)傷機(jī)制，在本研究中也發(fā)現(xiàn)2例合并關(guān)節(jié)內(nèi)損傷，術(shù)中一并予以處理，這也是關(guān)節(jié)鏡治療鎖骨遠(yuǎn)端骨折的一個(gè)優(yōu)勢(shì)，開(kāi)放手術(shù)不能發(fā)現(xiàn)關(guān)節(jié)內(nèi)損傷。

Oh等[23]系統(tǒng)分析21項(xiàng)研究的425例鎖骨遠(yuǎn)端不穩(wěn)定骨折病例，結(jié)果發(fā)現(xiàn)不穩(wěn)定鎖骨遠(yuǎn)端骨折手術(shù)治療的不愈合率為1.6%。本研究也有1例鎖骨遠(yuǎn)端骨折不愈合病例，此病例發(fā)生骨折不愈合的主要原因是術(shù)中骨折復(fù)位不良，骨折端反?；顒?dòng)增加，最終將紐扣鋼板之間的縫線(xiàn)磨斷，導(dǎo)致內(nèi)固定失效。反思這例病例，我們認(rèn)識(shí)到進(jìn)行喙鎖固定只是重建了喙鎖垂直方向的穩(wěn)定性，不穩(wěn)定骨折在骨折區(qū)域軟組織(斜方肌與三角肌腱膜)損傷要重于穩(wěn)定性骨折，由于骨折在水平方向還是存在不穩(wěn)定，因此單純喙鎖固定并不能將不穩(wěn)定骨折完全轉(zhuǎn)變成穩(wěn)定性骨折，提示我們應(yīng)該改良固定方式，即增加鎖骨骨折塊間水平方向的固定。

結(jié)論：不穩(wěn)定型鎖骨遠(yuǎn)端骨折多數(shù)需要手術(shù)治療，目前尚無(wú)統(tǒng)一的治療方法。關(guān)節(jié)鏡輔助下的紐扣鋼板固定術(shù)是近年逐漸開(kāi)展的一種新術(shù)式，具有微創(chuàng)，可同時(shí)處理關(guān)節(jié)內(nèi)合并損傷，喙鎖彈性固定，不需要再次手術(shù)等優(yōu)點(diǎn)。這一術(shù)式臨床效果良好，但技術(shù)要求較高，可以作為鎖骨遠(yuǎn)端骨折治療的一個(gè)選擇。

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(本文編輯：李靜)

陳建海，黨育，付中國(guó)，等.關(guān)節(jié)鏡下紐扣鋼板固定術(shù)治療不穩(wěn)定鎖骨遠(yuǎn)端骨折[J/CD]. 中華肩肘外科電子雜志,2015,3(3):133-140.

Arthroscopic button plate fixation therapy for instable distal clavicular fracture

ChenJianhai,DangYu,FuZhongguo,JiangBaoguo.

DepartmentofTraumaandOrthopaedics,PekingUniversityPeople′sHospital,PekingUniversityTrafficMedicineCenter,Beijing100044,China

JiangBaoguo,Email:jiangbaoguo@vip.sina.com

Background The cases of distal clavicular fracture account for 12%-15% 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

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 17 cases obtained follow-up, with average follow-up time of 50 months (42-66 months). 16 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 11.6 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 11 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.

Arthroscopic button plate fixation;Therapy;Clavicular fracture;Distal

10.3877/cma.j.issn.2095-5790.2015.03.002

教育部創(chuàng)新團(tuán)隊(duì)(IRT1201)；衛(wèi)生公益性行業(yè)科研專(zhuān)項(xiàng)基金(201002014)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

姜保國(guó)，Email：jiangbaoguo@vip.sina.com

2015-07-15)