AO丨弹性髓内钉丨锁骨骨干完整弯曲楔形骨折

Flexible intramedullary nail弹性髓内钉

Diaphyseal wedge, intact bending wedge clavicle fracture骨干楔形、完整弯曲楔形锁骨骨折

1. Introduction

Intramedullary nailing of the clavicle is reserved for young and highly active patients who are expected to resume full active function soon after surgery.

锁骨髓内钉留给年轻和高度活跃的患者，他们有望在手术后很快恢复完全的活动功能。

It is also a procedure best reserved for bending- and fragmented-wedge fractures in the middle zone of the clavicle

它也是锁骨中部弯曲和碎片楔形骨折的最佳保留程序

For technical reasons, other fracture patterns are not suitable for nailing.

由于技术原因，其他骨折模式不适合打钉。

This procedure is performed only under image intensifier guidance.

此过程仅在图像增强器引导下执行。

Intramedullary nailing

The goal of treatment for these types of fractures of the shaft of the clavicle is to achieve as anatomical reduction as possible and then splint them with intramedullary fixation. The shape of the nail and the shape of the bone maintain alignment and rotation. Shortening is prevented by bone contact.

这类锁骨干骨折的治疗目标是尽可能达到解剖复位，然后用夹板进行髓内固定。钉子形状和骨骼的形状保持对齐和旋转。骨骼接触可防止缩短。

Implant migration and damage to nearby neurovascular structures are potential complications that can be encountered. However, it is a minimally invasive approach that requires less soft tissue dissection, preserves blood supply and biology to improve healing.

植入物迁移和附近神经血管结构的损伤是可能遇到的潜在并发症。然而，它是一种微创方法，需要较少的软组织解剖，保持血液供应和生物学以改善愈合。

Selection of pin

Stiff pins or thick K-wires should be avoided as the limited diameter of the intramedullary canal of the clavicle and its curved anatomy presents inherent difficulties during insertion and stabilization of the fracture. Thus, the procedure described will be with a flexible titanium intramedullary nail.

应避免使用硬针或粗克氏针，因为锁骨髓内管的有限直径及其弯曲的解剖结构在骨折的插入和稳定过程中存在固有的困难。因此，所描述的程序将使用灵活的钛髓内钉。

2. Patient preparation and approach

Patient preparation

This procedure is normally performed with the patient either in a beach chair or a supine position.

此过程通常在患者坐在沙滩椅或仰卧位时进行。

Approach

For this procedure a nailing approach is used.

对于此过程，使用钉子方法。

3. Reduction and fixation

For intramedullary nailing of clavicular fractures, the following reduction techniques are useful:

对于锁骨骨折的髓内钉，以下复位技术是有用的：

Shoulder manipulation with inline traction and an external rotation moment often helps to reduce the fracture. (The shoulder should be draped free.)

内联牵引和外旋力矩的肩部操作通常有助于减少骨折。（肩膀应该是自由的。）

Pointed reduction clamps can be used either percutaneously or through small stab incisions.尖头复位夹可以经皮使用，也可以通过小刺切口使用。

If a closed reduction cannot be achieved, a small incision directly over the fracture site to perform a limited open reduction is helpful and often necessary.

如果无法实现闭合复位，则直接在骨折部位上方做一个小切口以进行有限的切开复位是有帮助的，并且通常是必要的。

Nail insertion

Using image intensifier, the entry point is obtained using a 2.5 mm drill bit in the anterior cortex of the medial clavicle 1.5-2.0 cm lateral to the sternoclavicular joint.

使用图像增强器，在胸锁关节外侧 1.5-2.0 cm 的内侧锁骨前皮质中使用 2.5 mm 钻头获得进入点。

The entry point is enlarged with a small awl in a lateral direction to allow for ease of insertion.

入口点在横向上用小锥子扩大，以便于插入。

A 2.0 - 3.5 mm titanium elastic nail designed for intramedullary nailing, used for this or other applications, is inserted then with the aid of the universal T-handle chuck. The nail is manually inserted with oscillating movements under image intensifier control and advanced to the fracture site. If significant resistance is encountered, reassess the position of the nail to redirect and complete the passage of the nail.

然后在通用 T 型手柄夹头的帮助下插入一个 2.0 - 3.5 毫米的钛弹性钉，用于髓内钉，用于此或其他应用。在图像增强器的控制下，通过振荡运动手动插入钉子，并将钉子推进到骨折部位。如果遇到明显的阻力，请重新评估钉子的位置以重新定向并完成钉子的通过。

The tip of the nail has a slight curve, which will assist its passage into the lateral fragment.

尖端有一个轻微的弯曲，这将有助于它进入横向碎片。

The tip of the nail is advanced as far lateral as possible without perforating the cortex.

尖端尽可能向外侧推进，但不穿透皮质。

The medial end of the nail is then cut and buried subcutaneously or slightly proud depending on surgeon preference.

然后根据外科医生的喜好，将钉子内侧端切开并埋入皮下或稍微隆起。

A threaded end cap may be used and inserted over the medial end of the nail to prevent backing out of the nail. 

可以使用带螺纹的端盖并将其插入钉子的内侧端，以防止指甲脱离。

Hardware removal is only indicated if the nail is prominent and threatening or irritating the overlaying soft tissue at the entry point or perforating the far cortex.

仅当钉子突出并威胁或刺激进入点处覆盖的软组织或穿透远端皮质时，才需要移除硬件。

4. Aftercare

Wound care

Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed.

手术后两天可以去除主要的手术敷料，允许淋浴，并可以使用轻干敷料。手术后至少两周，当伤口完全愈合并且缝线和订书钉已被移除时，才允许浸泡在浴缸、热水浴缸和游泳池中。

Implant removal

Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration.

通常不需要或不推荐从锁骨上取下骨板。可能会出现锁骨板的症状性突出和撞击。骨折完全愈合后，可能需要考虑移除植入物。

Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport.

恢复接触性运动的运动员只有在绝对必要的情况下才应移除骨板，如果需要，应在赛季结束时完成，以便在恢复运动前获得最大程度的康复。

Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.

许多在植入后 6-12 个月要求从局部症状中移除硬件的患者发现，术后 2 年症状明显减轻，并无限期推迟硬件移除。

Sleeping

The patient should sleep wearing the sling on his/her back or on the non-injured side.

患者应该在他/她的背上或未受伤的一侧佩戴吊兜睡觉。

When sleeping on the side, a pillow can be placed across the chest to support the injured side.

侧睡时，可以在胸前放一个枕头来支撑受伤的一侧。

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm.

仰卧时，应在手臂下方放置一个枕头来支撑受伤的一侧。

It may be more comfortable sleeping in a sitting or semi reclined position.

以坐姿或半躺姿睡觉可能更舒服。

Hygiene

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

淋浴/浴缸中的防滑垫将提高安全性。沐浴时手臂可以轻轻悬挂在患者身边。腋窝卫生很重要。如果没有帮助，可以使用长柄海绵清洗背部和腿部。

Dressing

Loose fitting clothing and button-up shirts are ideal. The affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

宽松的衣服和纽扣衬衫是理想的选择。受影响的手臂可用于扣扣和解扣。首先穿戴受影响的手臂，然后是未受影响的手臂。脱衣服时，先从未受影响的手臂开始，然后是受影响的手臂。

Progressive exercises

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture shows early evidence of healing radiographically.

应提供吊索支撑，直到患者足够舒适以开始肩部使用，和/或骨折在放射学上显示愈合的早期证据。

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.

一旦实现了这些目标，就可以开始进行康复锻炼以恢复运动范围、力量和功能。

The phases of nonoperative treatment are thus:

因此，非手术治疗的阶段是：

Temporary immobilization

Passive/assisted range of motion

Active range of motion

Progressive resistance exercises

临时固定

被动/辅助运动范围

主动活动范围

渐进式抗阻练习

Usually immobilization is maintained for 1-2 weeks for comfort and wound healing purposes. The use of the sling is gradually decreased at this point.
This is followed by gentle range of motion exercises.

为了舒适和伤口愈合的目的，通常保持固定 1-2 周。此时吊索的使用逐渐减少。

接下来是温和的运动练习。

Non-weight-bearing of the affected upper limb is continued for approximately for 6 weeks or until radiographic and clinical evidence of progressive healing.

受影响的上肢不负重持续大约 6 周或直到放射学和临床证据显示逐渐愈合。

Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms.

抗阻练习通常可以在 6 周时开始。根据受伤情况和患者症状，等长运动可能会更早开始。

Phase I: Day one after surgery

After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended:

锁骨手术后，保持未受影响关节的完全活动性以减少手臂肿胀和保持关节活动非常重要。建议进行以下练习：

Straightening and flexion of the elbow

Open and closure of the hand

Squeezing of a soft ball

肘部伸直和弯曲

手的开合

挤压软球

Bending of the wrist forward, backwards and in a circular motion

Movement of an open hand from side to side

手腕向前、向后和做圆周运动弯曲

张开的手从一侧移动到另一侧

Squeezing the shoulder blades together, while shoulders remain relaxed

 将肩胛骨挤压在一起，同时肩膀保持放松

Phase II: Two to six weeks after surgery

Pendular exercises can be started when pain starts to subside.     

当疼痛开始消退时，可以开始摆动练习。

Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.

逐渐发展到被动和辅助的运动范围练习是在耐受的情况下开始的。必须观察肩胛骨稳定以恢复肩部运动的正常动力学。

Activated assisted range of motion exercises are started with:

激活的辅助运动范围练习开始于：

External rotation

Internal rotation

外旋

内部旋转

Flexion with arms on table

Flexion with ball on wall

 用手臂在桌子上弯曲

 用球在墙上弯曲

Sub-maximal isometric exercises with:

Internal rotation

External rotation (1)

Abduction (2)

Extension

次最大等距练习：

内部旋转

外旋 (1)

绑架（2）

扩展

Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals. 

注意：锻炼的时间和进展最终由手术外科医生指导，因为骨骼质量、骨折类型和固定等因素可能因人而异。

Phase III: Six to twelve weeks after surgery

Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.

在等待手术外科医生进行临床和影像学检查之前，现在可以允许负重，并且可以开始逐渐抵抗/加强锻炼。

Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

一旦骨折愈合并且四肢恢复了全部力量，则允许恢复全面活动和/或接触性运动。通常这需要受伤后大约 6 个月。这可能迟早取决于患者因素、骨折愈合的进展和对康复的反应。

If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.

如果骨折愈合的连续 X 线片在 3 个月时没有进展，则可能存在愈合延迟或受损。如果骨折9个月后仍未愈合，应考虑手术干预。