Clinical efficacy evaluation of distal clavicle fracture treated with clavicle hook plate
The distal clavicle fracture is more common among clavicle fractures, and the effect of conservative treatment for this fracture is poor.
Data and methods
The AO shoulder locking plate is an anatomical distal clavicle plate with the distal plate hook placed under the acromion, which not only stabilizes the shoulder joint but also does not damage the rotator cuff, and is suitable for distal clavicle fractures.
2. Clinical data The 32 cases in this group, 24 males and 8 females, aged 21-55 years old, average 33.2 years old, were all closed injuries without combined neurovascular injuries. According to Craig’s typing, 26 cases were type II and 6 cases were type V. There were 20 cases of emergency surgery and 12 cases of elective surgery, with an average operating time of 2.4 days and a maximum of 12 days.
3. Surgical method: After satisfactory brachial plexus anesthesia, the patient was placed in the supine position, the affected side was padded about 30 degrees, the head was turned to the healthy side, and the exposed deltoid and trapezius fascia was taken about 5-6 cm long along the lateral top of the clavicle in a solitary shape outward and backward to the posterior aspect of the acromioclavicular joint, and the fracture end was revealed by cutting the fascia along the long axis of the clavicle to reveal the acromioclavicular joint and the posterior acromion, and attention was paid to protect the integrity of the acromioclavicular joint. The skin of the deltoid muscle was lifted appropriately to fully expose the fracture end, clean the fracture end, and pay attention to the exploration of the rostral collar ligament (5 cases of rupture of the rostral collar ligament in this group were given absorbable sutures of the ruptured ligament on the clavicle periosteum after intraoperative fixation). After satisfactory repositioning, the shoulder locking hook plate was shaped, the hook end of the plate was inserted under the posterior shoulder crest, the position of the plate on the clavicle was adjusted, and screws were fixed, and three or more screws were fixed at the proximal end of the fracture. Repair the damaged ligament and close the surgical incision routinely.
4.Efficacy evaluation Functional evaluation of shoulder lock: Kalsson scale: excellent: no pain, normal muscle strength, shoulder can move freely, anatomical repositioning of shoulder lock joint on X-ray, no subluxation, gap <5mm; good: slight pain, limited function, moderate muscle strength, shoulder range of motion is 90 degrees-180 degrees, X-ray shows shoulder joint gap is 5 Poor: pain that worsened at night, poor muscle strength, shoulder movement <90 degrees in any direction, and shoulder dislocation on x-ray.
Results and discussion
1. Results: The fracture was well repositioned and there was no abnormality in the acromioclavicular joint when the CR was checked within 3 days after the operation. Follow-up 6-18 months, average 11 months, fracture healed in all cases, flat healing time 3 months, no deformity healing, and normal shoulder lock joint position. The Kalsson score was excellent in 30 cases and good in 2 cases six months after surgery.
2. Discussion The acromioclavicular joint can move slightly in all directions, and its stable structure is maintained by the joint capsule, acromioclavicular ligament, rostral ligament, and muscle fibers of the trapezius and deltoid muscles. The surgical steps after distal clavicle fracture are firstly the precise repositioning and firm fixation of the bony structure, followed by soft tissue repair [2], after internal fixation that is, to achieve strong fixation of the fracture end, and at the same time to avoid joint motion disorders due to long-term braking of the shoulder joint; in addition, the micromotion of the shoulder joint should be restored.
The traditional gristle tension band fixation has achieved good results, but the fixation with fine gristle is not firm, and the thick needle is easy to cause bone splitting, and the penetration fixation is easy to cause shoulder stiffness and pain, secondary to osteoarthritis of the acromioclavicular joint. Also, because of the lack of stability of fixation, forearm suspension is needed for 4-6 weeks, which makes it difficult for patients to perform early rehabilitation exercises and functional exercises, and the prognosis is that patients have reduced shoulder mobility.
The clavicle hook plate consists of a 4-6 hole plate and a hook of each, and its anatomical design conforms to the shape of the clavicle, with an expanded distal end of the plate and two nail holes in the transverse shape to fix the distal end of the fracture, which conforms to the expanded structure of the distal clavicle. The hook is inserted under the acromion and fixed by the clavicle screw, which provides a stable and continuous repositioning of the acromioclavicular joint through the “leverage” of the clavicle plate, and finally provides a stable and tension-free environment for the healing of the acromioclavicular and marginal clavicular ligaments, improving the healing quality of the combined acromioclavicular ligament injury patients. . After fixation, the internal fixation did not affect the shoulder joint activity and provided micro-movement for the acromioclavicular joint, which reduced the shear force on the internal fixation during the shoulder joint activity and decreased the chance of internal fixation fracture, which solved the contradiction between firm fixation of the clavicle fracture and shoulder joint activity and provided conditions for early shoulder joint activity. Again, the clavicle hook is implanted below the acromion, which is less damaging to the rotator cuff than other internal fixation methods and provides a foundation for shoulder joint recovery. Due to the obvious advantages of the clavicle hook plate, it is now more and more commonly used at home and abroad [3-5]. Patients with combined fractures in the acromion area that make the acromion area unstable are contraindicated for surgery.
3. Common complications and analysis
Clavicle hook plate treatment of distal clavicle fractures also has corresponding complications, and postoperative pain, impingement syndrome, decubitus, rotator cuff tear, and proximal fracture of the clavicle hook plate are often reported [6].
All patients in this group had 1 case of postoperative clavicle hook prolapse under the acromion, the patient had good fracture healing, good shoulder joint movement, no complaints of discomfort, and the clavicle hook prolapse was found in the postoperative review in 3 months. 2 cases had mild shoulder pain and mild limitation of shoulder abduction (see Figure 2), and were diagnosed as traumatic arthritis. The postoperative CR examination revealed that the clavicle hook was not well attached and the distal end of the hook was sagging. In one case, intraoperative C-arm fluoroscopy revealed that the distal end of the clavicle hook was hooked into the acromion, which was then adjusted to a normal position.
Surgical points.
1, the clavicle hook should be placed under the acromion as far as possible posteriorly during surgery, so that the acromion is maximally stabilized and the clavicle hook can be prevented from prolapsing due to shoulder joint activities. In this group of prolapsed cases, the patient was a GraigV type patient with a small distal fracture block, and the distal transverse two screws were not given intraoperatively, which affected the stability of the clavicle hook to some extent and led to the prolapse of the clavicle hook.
2, The acromion perforation needs to be strictly positioned, and the lateral hook of the hook plate should be close to the subacromial cortex and should not pass through the acromioclavicular joint so as not to damage the subacromial bursa and produce pain.
3.The template shaped clavicle hook plate should be applied during surgery to increase the plate adhesion.
4.Combine with intraoperative C-arm fluoroscopy to understand the position of the clavicle hook to ensure the surgical effect.
5.Follow the principle of internal fixation, fix at least 3 screws at the proximal end of the fracture, and for patients with larger bone masses at the distal end of the fracture, fixation by plate using screws is required.
6.It should be noted that the acromioclavicular joint is a micro-movement joint, and the internal fixation has friction and impact with the surrounding tissues when the joint is moving, causing pain and limited movement of the patient’s shoulder joint, and the internal fixation can be removed early after the fracture heals.
7. For patients with combined rostral collateral ligament rupture, it is recommended to give ligament repair after the completion of internal fixation to avoid distal fracture upstroke after healing. Ye Biqian et al [7] focused on ligament repair and reconstruction, removing the internal fixation as early as possible when conditions allow, supplemented by local physiotherapy, and achieved very good results.
In conclusion, the treatment of distal clavicle fracture with a clavicle hook plate has the characteristics of small trauma, firm fixation, few complications, allowing early movement of the shoulder joint and good functional recovery, and satisfactory results can be obtained.