AAOS 2013：锁骨骨折进行性移位的临床观察

目的：超过一定程度的锁骨骨折移位会导致骨折愈合后临床功能疗效不佳，因此在诊断锁骨骨折的同时预测骨折断端的最终移位程度具有重要的临床意义。然而，肩关节X线摄片技术存在一定的变异，而且有研究显示部分锁骨骨折在损伤发生后的一段时间内会出现进行性移位。本研究旨在探讨以下三个问题：（1）计算损伤发生后骨折断端进行性移位程度超过1cm的比例；（2）根据观察者之间测定的可靠性来比较不同方法对骨折断端移位程度的差异；（3）于仰卧位和站立位两种体位下所摄X片上测量的骨折断端移位程度的差异。
方法：本研究为回顾性观察研究，共纳入60例按特定影像诊断方案确定为锁骨中段移位性骨折的连续病例。所有在发生7天之内就诊的锁骨中段骨折病例均纳入本项研究。此外，纳入研究的病例需要按本研究所采用的X线摄片方案进行至少一次随访检查。该X线摄片方案包括三个不同X线投照方法所获得的影像片：1）站立位15º头倾锁骨前后位片；2）仰卧位15º头倾锁骨前后位片；3）仰卧位15º头倾全肩带前后位片。由两位经培训的检查者分别测量锁骨垂直移位及短缩程度，并通过比较不同体位及不同时间点的测量结果计算骨折断端的移位程度。为了便于分析术后不同时间点摄片是否影响站立位和仰卧位的断端移位情况，我们将X片结果划分为三组：1）伤后1-6天内摄片者（n= 66）；2）伤后7-21天内摄片者（n=46），以及3）伤后22天或以上摄片者（n = 29）。
结果：60例患者在伤后平均1天时第一次摄片，第二次摄片平均于首次摄片后12天时完成，30例患者首次摄片后41天时进行第三次摄片。6例（10%）患者最后一次X片与首次X片测量结果比较，骨折断端进行性内移程度超过1cm，有13例（22%）骨折断端进行性移位超过1cm。通过比较伤后第一次以及最后一次随访时的X片，结果显示有6例（10%）患者出现大于1cm的骨折断端进行性内移，13例（22%）患者出现大于1cm的骨折断端向侧方移位。根据一致性相关系数结果判断观察者之间对骨折断端内移、侧方移位以及锁骨长度测量结果的可靠性系数分别为0.929，0.982和0.996。对伤后不同时间点（0-6天，7-21天，22+天）不同体位摄片结果的分析显示，站立位X片上骨折断端内移程度大于仰卧位X片的比例分别为11%, 27% 和10%。而站立位X片上骨折断端侧方移位程度大于仰卧位X片结果的比例分别为16%, 19%和9%。统计学分析结果显示，所有时间点站立位与仰卧位骨折断端内移及侧方移位程度均存在显著性差异（P<.05）。这个结果提示随着全国时间的进展，骨折断端移位程度逐步缩小，而这与骨折逐步牢固愈合的过程相一致。
结论：本研究结果提示应该对采用保守治疗的锁骨骨折需要进行密切的随访观察，其原因在于骨折断端有进行性移位的风险。研究结果也提示站立位摄片时，由于重力的作用会导致骨折断端向内及侧方移位。因此，我们建议在可能的情况下避免站立位摄片，从而避免体位原因导致的移位程度变化影响治疗方案的制定。
与骨折相关的拓展阅读：

• 2013AAOS：不同年龄段幼儿肱骨髁上移位骨折的临床特征差异
• Injury：关节外胫骨远端骨折的手术选择：MIPPO vs ORIF
• AAOS：多次细菌培养或可提高骨折内固定术后感染诊断率
• AAOS：抗骨质疏松治疗可降低髋部骨折老年女性的死亡风险
• Osteoporos Int：糖皮质激素使用增加骨折风险
• JCEM：腹部脂肪的减少增加骨折风险
更多信息请点击：有关骨折更多资讯

Progressive Displacement After Clavicle Fracture; An Observational Study 
PURPOSE
Certain amounts of clavicle fracture displacement have been associated with poor functional outcome, making the ability to measure this displacement an important diagnostic goal. There is variability however in radiographic technique on shoulder X-rays. Additionally, it has been shown that a subset of clavicle fractures progressively displace in the peri injury time period. The purpose of this study is to (1) describe the incidence of progressive displacement greater than 1cm in the peri-injury time frame, (2) Compare different methods of measuring clavicle displacement using inter-observer reliability and (3) Determine whether supine vs. upright position during radiography changes measured displacement.
METHODS
A prospective observational study in which 60 consecutive patients diagnosed with a displaced midshaft clavicle fracture had a specific radiographic protocol. All patients presenting with a midshaft clavicle fracture within seven days of injury met inclusion. In addition, inclusion required at least one follow up with protocol defined x-rays. The protocol included three views: 1) Standing 15º cepahalic tilted anteroposterior (AP), 2) Supine 15º cepahalic tilted AP clavicle, 3) Supine 15º cephalic tilted AP panoramic shoulder girdle view. Vertical displacement and clavicle shortening was independently measured by two trained examiners at all time points to detect changes resulting from patient positioning and time from injury. To analyze whether time from injury affected the difference between upright and supine displacement measurements, x-rays were categorized into three groups; 1) x-rays taken on days 0-6 post injury (n= 66), 2) days 7-21 post injury (n=46) and 3) days 22 or greater post injury (n = 29).
RESULTS
Sixty patients had initial films at a mean of one day after injury with the second set of films done at a mean of 12 days after the initial radiographs. Thirty patients had a third set of radiographs done at a mean of 41 days after the initial radiographs. Between the initial and the final follow up x-ray, six patients (10%) had progressive medialization greater than 1cm and 13 patients had progressive translation (22%) greater than 1cm. The interobserver reliability as determined by the concordance correlation coefficient was nearly perfect for the measurement of medialization (0.929), translation (0.982) and length of injured clavicle (0.996). Analysis showed that upright x-rays had 11%, 27% and then 10% greater medialization compared to supine in the respective time categories (0-6 days, 7-21 days, 22+ days). Upright x-rays also showed 16%, 19% and then 9% greater translation than supine in the respective time categories. Statistical analysis comparing medialization and translation from upright to supine at all time points revealed significant differences (P<.05). This data would suggest that the difference between upright and supine displacement measurements diminished over time as would be expected due to consolidation of the fracture. {nextpage}
CONCLUSION
Our data show that close follow up of non-operatively treated clavicle fractures is warranted due to the risk of progressive displacement. The data also show that upright gravity views highlight displacement both for medialization and translation of the fracture. We therefore recommend consideration of a change in radiographic protocol which mandates upright films when possible, since measurements of displacement in this position may affect surgical decision making.