Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.
Arch Orthop Trauma Surg. 2013 Jan;133(1):15-22. doi: 10.1007/s00402-012-1631-3. Epub 2012 Oct 19.
Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures.
The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion.
A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion.
Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.
锁骨骨折占所有骨折的近 10%，其中大多数骨折涉及骨干中段。历史上，这些骨折未经手术治疗；然而，最近的数据表明，对于保守治疗的移位、粉碎性中段锁骨骨折，非愈合和症状性畸形愈合的风险增加。通过钢板内固定或克氏针、钉或螺钉髓内固定进行手术干预已被证明可以降低，但不能消除这种风险。识别预测骨折不愈合的危险因素将改善移位、粉碎性中段锁骨骨折的整体治疗效果。
回顾性分析了 2007 年 4 月至 2009 年 3 月期间采用 Knowles 针固定和补充环形扎带治疗移位、粉碎性中段锁骨骨折的 337 例连续患者的病历。记录了损伤机制、损伤侧、Robinson 骨折分类、合并损伤的存在、环形扎带材料以及包括糖尿病、高血压和吸烟在内的患者相关变量。通过单变量和多变量分析评估变量，以确定与骨折不愈合发展显著相关的因素。
共发生 19 例骨折不愈合。年龄增长和补充环形扎带固定时使用钢丝与骨折不愈合风险增加显著相关（p<0.001）。尽管在其他研究中被认为是不愈合的预测因素，但女性性别和骨折严重程度与不愈合无显著相关性。
即使采用髓内固定，移位、粉碎性中段锁骨骨折的治疗仍存在显著的不愈合并发症。使用可吸收缝线代替钢丝进行环形扎带固定，并在老年患者中仔细选择治疗策略，可能会降低不愈合的风险。
