Altamimi Sahal A, McKee Michael D
Upper Extremity Reconstructive Service, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada.
J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8. doi: 10.2106/JBJS.G.01336.
Recent studies have shown a high prevalence of symptomatic malunion and nonunion after nonoperative treatment of displaced midshaft clavicular fractures. We sought to compare patient-oriented outcome and complication rates following nonoperative treatment and those after plate fixation of displaced midshaft clavicular fractures.
In a multicenter, prospective clinical trial, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disabilities of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. There were no differences between the two groups with respect to patient demographics, mechanism of injury, associated injuries, Injury Severity Score, or fracture pattern.
Constant shoulder scores and DASH scores were significantly improved in the operative fixation group at all time-points (p = 0.001 and p < 0.01, respectively). The mean time to radiographic union was 28.4 weeks in the nonoperative group compared with 16.4 weeks in the operative group (p = 0.001). There were two nonunions in the operative group compared with seven in the nonoperative group (p = 0.042). Symptomatic malunion developed in nine patients in the nonoperative group and in none in the operative group (p = 0.001). Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). At one year after the injury, the patients in the operative group were more likely to be satisfied with the appearance of the shoulder (p = 0.001) and with the shoulder in general (p = 0.002) than were those in the nonoperative group.
Operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.
近期研究表明，移位型锁骨中段骨折非手术治疗后，症状性骨不连和骨畸形愈合的发生率较高。我们旨在比较移位型锁骨中段骨折非手术治疗与钢板固定治疗后的患者导向性结局及并发症发生率。
在一项多中心前瞻性临床试验中，132例锁骨中段移位骨折患者通过密封信封随机分为钢板固定手术治疗组（67例患者）和吊带非手术治疗组（65例患者）。结局分析包括标准临床随访、Constant肩关节评分、上肢、肩部和手部功能障碍（DASH）评分及X线平片。111例患者（62例接受手术治疗，49例接受非手术治疗）完成了1年的随访。两组在患者人口统计学、损伤机制、合并损伤、损伤严重程度评分或骨折类型方面无差异。
手术固定组在所有时间点的Constant肩关节评分和DASH评分均显著改善（分别为p = 0.001和p < 0.01）。非手术组影像学愈合的平均时间为28.4周，而手术组为16.4周（p = 0.001）。手术组有2例骨不连，非手术组有7例（p = 0.042）。非手术组有9例患者出现症状性骨畸形愈合，手术组无1例（p = 0.001）。手术组的大多数并发症与内固定物相关（5例患者出现内固定物局部刺激和/或突出，3例伤口感染，1例内固定物机械故障）。受伤1年后，手术组患者对肩部外观（p = 0.001）和总体肩部情况（p = 0.002）的满意度高于非手术组。
与非手术治疗相比，锁骨中段移位骨折的手术固定在随访1年时可改善功能结局，降低骨畸形愈合和骨不连的发生率。取出内固定物仍然是手术组再次干预的最常见原因。本研究支持对活动的成年患者的完全移位锁骨中段骨折进行一期钢板固定。
