Atsushi Saito: Conservative treatment of clavicular fracture: its anatomical significance. Tsuga Saito Seikeigeka, Chiba Tel

Transcription

1 Robinson Type2B odds / Robinson Type2A Type2B Type2B1 2B Craig Type 14.3 Type / / Robinson Type2B1 Key words: Ⅰ Atsushi Saito: Conservative treatment of clavicular fracture: its anatomical significance. Tsuga Saito Seikeigeka, Chiba Tel Fax Received October 4, 2010, Accepted December 15,

2 X 24 Ⅱ 2 S Mall S 1/3 5 Deltopectoral triangle S 2 % 6 X 1 7 2/

3 /3 HOX CT 13 Krishnan VAS /3 Kirschner 15 MRI Kirschner Ⅲ Orthopaedic Trauma Associaton OTA Gustilo, R. B.: The fracture classification manual, St Luis, 1991, Mosby Rowe 19 Allman

4 42 1/3 1/3 1/3 Neer A B Rockwood Craig 5 Neer 20 CT 20 Craig Rockwood X Rockwood CT 3 D Robinson 1000 Type1 TypeA1 A2 Type1B1 1B2 1/3 Craig Robinson Type2 2A1 2A2 2B1 1 2B Ⅳ 2 % /3 1 1/ / Sarwark 1/ % 1/3 3 5 % 1/ Craig Type A 1 B 1 Type 2 Neer Type A A 10 2 A B /3 Robinson Type2A Type2A 14 Odds P Type2B

5 43 X Ⅴ 2 10 Neer A % % Craig A B X % 40.0% 33.3% 50.5% 83.3%

6 Neer B / Robinson 2A1 7 2A2 17 2B1 18 2B B /3 Robinson 2B1 1 1 Kirschner 20 10% /3 70% 20 2B B1 2 14

7 45 X 16 1 Ⅵ. 3 T 1 28 Bohler X Akimbo /3 8 31,32 94% Robinson 2B Robinson 24 90% 80% % % % % 34 McKee 1/ % DASH , % % 52 64% 56% 43% 37 1/3

8 , SUMMARY Clavicular fractures are among the most common of all fractures. Recent studies have shown that operative treatment results in improved outcome and a lower rate of nonunion in active adult patients; however, superb union rates have also been reported with nonoperative treatment. The aim of this study was to evaluate the clinical results of low-energy fractures of the clavicle treated conservatively in our clinic. A series of 171 consecutive patients range, 0-87 years came to our clinic for ambulatory treatment. The treatment included a figure-of-eight bandage in most patients or a plaster-of-paris cast in selected adults. The method incorporated a pad placed under each axilla with the arms in the akimbo position. During the initial phase of treatment, the patients were instructed to remain supine as the pain subsided; however, their activities of daily living were not restricted. Union of the fractured clavicle occurred in 82 patients 78 middle third, 4 lateral end under 15 years of age. The majority of these 82 fractures occurred in younger 29 from 0-3 years old and older patients 24 from years old, with only 3 fractures in patients 8-9 years old. A clavicular fixation band with a large biscuit-sized felt pad attached to the shoulder strap on the fractured side was effective in an older child with a Neer type distal fracture. Clavicular fractures were also evaluated in 89 adult patients with a median age of 46.5 years range, years. Thirty-two lateral-end fractures occurred in 25 men and 7 women, mean age, 42.7 years with right-sided fractures in 22 and leftsided in 10. The rate of nonunion in 6 patients with Takubo s type classification was 83.3% mean age, 51.5 years. This was higher than the nonunion rates of 14.3% 2/14 patients, 40.0% 2/5 patients, 33.3% 1/3 patients and 50.0% 2/4 patients in Takubo s type, type, type and type fractures, respectively. Many patients with nonunion were asymptomatic or had slight acceptable pain with few limitations of activities of daily living. In the 89 adults that had clavicular fracture, a midshaft fracture occurred in 55 mean age, 36 years old. The majority of these were young and active men 40 men, 15 women. Of these 55 patients, 24, including a patient with bilateral fractures, had a fracture that was classified as Robinson s type 2A1 and 2A2, and 21 patients with type 2B1 and 2B2. Most type 2 A and B fractures were healed uneventfully, but 3 middle-aged women mean age, 49 years old with Oneda s type fracture showed delayed union. One patient required surgery. Two other patients ultimately healed after time periods of up to 24 weeks. A case of distal nonunion type,

9 47 active man fracture required resection of the lateral end of the clavicle with satisfactory results. Medical clavicular fractures were also observed in 3 elderly patients and these fractures were united and the patients were asymptomatic at 12 weeks. This study demonstrated that a watershed of 24 weeks for the diagnosis of nonunion is acceptable. Furthermore, we were unable to predict the risk of nonunion 12 weeks after clavicular fracture. In addition, most of the diaphyseal fractures were healed with traditional, nonoperative treatment. The nonunion of distal-end fractures in elderly patients was not related to pain or limitations in activities of daily living. The nonunion of clavicular fractures was discussed based on anatomy and function. Nonoperative treatment should be the prevailing approach, especially for pediatric and geriatric clavicular fractures. 1 pitfall 2006; 29: Voision JL. Clavicle, a negrected bone, morphology and relation to arm movements and shoulder architecture in primates. Anat Rec 2006; 288A: Ljunggren AE. Clavicular function. Acta Orthop scand 1979; 50: Rojas MR. Montenegro MR. An anatonical and embryological study of the clavicle in cats Felios domestus and sheep Ovis aries during the prenatal period. Acta Anat 1995; 154: Ogata S, Uhthoff HK. The early development and ossification of the human clavicle-an embryologic study. Acta Orthop Scand 1990; 61: ; 18: Wall JJ. Congenital pseudrthrosis of the clavicle. J Bone Joint Surg 1970; 52-A: ; 32: ; 21: ; 21: O Leary E, Elsayed S, Mukherjee A, Tayton K. Familiar pseudarthrosis of the clavicle; does it need treatmet. Acta Orthop Belg 2008; 74: Kreitner KF, Riepert T, Nafe B, Thelen M. Bone age determination based on the study of the median extremity of the clavicle. Eur Radiol 1998; 8: MB Orthop 2007; 20: Krishnan SG, Schiffern SC, Pennington SD, Rimalawi M, Burkhead Jr. WZ. Functional outcomes after total claviculectomy as a salvage procedure, a series of six cases. J Bone Joint Surg 2007; 89-A: tension band wiring Scorpion plate 2008; 43: Sahara W, Sugamoto K, Murai M, Yoshikawa H. Three dimensional clavicular and acromoiclavicular rotations during arm abduction using vertically open MRI. J Orthop Res 2007; 25: Kirschner ; 31: ; 20: Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop 1968; 58: ; 31: Robinson CM. Fracture of the clavicle in the adult, epidemiology and classification. J Bone Joint Surg 1998; 80-B: Oneda T, Takahashi E, Sakurai S. The treatment of clavicle fractures. J Jap Orthop Ass 1965; 38: ; 30: Stanley D, Trowbride EA, Norris SH. The mechanism of clavicular fracture, a clinical and biomechanical analysis. J Bone Joint Surg 1988; 70-B: type MB Orthop 2007; 20: ; 48: Nordqvist A, Peterson C, Redlund-Johnell I. The natural course of lateral clavicle fracture, year follow-up of 110 cases. Acta Orthop Scand 1993; 64: ; 1: Trynin AH. The Bohler clavicular splint in the treatment of clavicular injuries. J Bone Joint Surg 1937; 19: Cook TW. Reduction and external fixation of fracture of clavicle in recumbency. J Bone Joint Surg 1954; 36-A:

10 48 31 Mullick S. Treatment of mid-clavicular fractures. Lancet 1967: Fowler AW. Treatment of fractured clavicle. Lancet 1968; 1: /3 2006; 30: Robinson MC, Court-Brown CM, McQeen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg 2004; 86-A: McKee MC, Pedersen EM, Jone C, Stephen DJG, Kreder HJ, Schemitsch EH, Wild LM, Potter J. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg 2006; 88-A: Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fracrures of the clavicle gives poor results. J Bone Joint Surg 1997; 79-B: The Canadian Orthopedic Trauma Society. Non operative treatment compared with plate fixation of dislaced midshaft clavicular fractures. J Bone Joint Surg 2007; 89-A: ; 20: ; 33: ; 61: ; 72: ; 22: 24-6