骨科英文书籍精读（57）｜锁骨骨折（2）
Treatment
MIDDLE THIRD FRACTURES
There is general agreement that undisplaced fractures should be treated non- operatively. Most will go on to unite uneventfully with a non-union rate below 5 percent and a return to normal function.
Non-operative management consists of applying a simple sling for comfort. It is discarded once the pain subsides (between 1–3 weeks) and the patient is then encouraged to mobilize the limb as pain allows. There is no evidence that the traditional figure-of-eight bandage confers any advantage and it carries the risk of increasing the incidence of pressures sores over the fracture site and causing harm to neurological structures; it may even increase the risk of non-union.
There is less agreement about the management of displaced middle third fractures. Treating those with shortening of more than 2cm by simple splintage is now believed to incur a considerable risk of symptomatic mal-union – mainly pain and lack of power during shoulder movements (McKee et al., 2006) – and an increased incidence of non-union. There is, therefore, a growing trend towards internal fixation of acute clavicular fractures associated with severe displacement. Methods include plating (specifically contoured locking plates are available) and intramedullary fixation.
LATERAL THIRD FRACTURES
Most lateral clavicle fractures are minimally displaced and extrarticular. The fact that the coracoclavicular ligaments are intact prevents further displacement and non-operative management is usually appropriate.
Treatment consists of a sling for 2–3 weeks until the pain subsides, followed by mobilization within the limits of pain.
Displaced lateral third fractures are associated with disruption of the coracoclavicular ligaments and are therefore unstable injuries. A number of studies have shown that these particular fractures have a higher than usual rate of non-union if treated nonoperatively. Surgery to stabilize the fracture is often recommended. However the converse argument is that many of the fractures that develop non-union do not
cause any symptoms and surgery can therefore be reserved for patients with symptomatic non-union. Operations for these fractures have a high complication rate and no single procedure has been shown to be better than the others. Techniques include the use of a coracoclavicular screw, plate and hook plate fixation and suture and sling techniques with Dacron graft ligaments.
MEDIAL THIRD FRACTURES
Most of these rare fractures are extra-articular. They are mainly managed non-operatively unless the fracture displacement threatens the mediastinal structures. Initial fixation is associated with significant
complications, including migration of the implants into the mediastinum, particularly when K-wires are used. Other methods of stabilization include suture and graft techniques and the newer locking plates.
---from 《Apley’s System of Orthopaedics and Fractures》P687-688
重点词汇整理：
uneventfully/,ʌni'ventfəli/adv. 太平无事地
discard /dɪˈskɑːrd/n. 抛弃；被丢弃的东西或人vt. 抛弃；放弃；丢弃
figure-of-eight bandage 八字绷带
contour /ˈkɑːntʊr/n. 轮廓；等高线；周线；电路；概要vt. 画轮廓；画等高线
intramedullary /,intrə,me'dʌləri/adj. [解剖] 髓内的
coracoclavicular screw, plate and hook plate fixation and suture and sling techniques with Dacron graft ligaments.技术包括使用喙锁骨螺钉、钢板和钩板固定，以及使用涤纶移植物韧带缝合和吊带技术。
Dacron /'dekrɑn/涤纶
mediastinal /,mi:diæs'tainəl/adj. 纵隔的
migration /maɪˈɡreɪʃn/n. 迁移；移民；移动
百度翻译：
治疗
中三分之一骨折
普遍认为未移位的骨折应该采用非手术治疗。大多数人将完全愈合，不愈率低于5%，功能恢复正常。
非手术治疗包括使用简单的吊带以获得舒适性。一旦疼痛消退(1-3周)，它就会被丢弃，然后鼓励患者在疼痛允许的情况下活动肢体。没有证据表明传统的八字形绷带有任何优势，它有可能增加骨折部位压疮的发生率，并对神经结构造成伤害；它甚至可能增加骨不连的风险。
对于移位的中三分之一骨折的治疗，意见较少。用简单夹板治疗短缩超过2厘米的骨折现在被认为会招致相当大的症状性骨不连风险-主要是肩部活动时疼痛和力量不足(McKee等人，2006年)-以及增加骨不连的发生率。因此，对于伴有严重移位的急性锁骨骨折进行内固定的趋势越来越明显。方法包括钢板固定(有特殊形状的锁定钢板可供选择)和髓内固定。
外侧三分之一骨折
大多数锁骨外侧骨折是轻微移位和关节外骨折。喙锁韧带完整可防止进一步移位，非手术治疗通常是合适的。治疗包括吊带2-3周，直到疼痛消退，然后在疼痛范围内活动。
移位的外侧三分之一骨折与喙锁韧带断裂有关，因此是不稳定的损伤。许多研究表明，如果非手术治疗，这些特殊骨折的不愈合率比通常高。因此一般建此种骨折议行手术治疗。然而，相反的论点是，许多发生骨不连的骨折不会引起任何症状，因此手术可以留给有症状性骨不连的患者。这些骨折的手术有很高的并发症发生率，而且没有一种手术被证明比其他手术更好。技术包括使用喙锁骨螺钉、钢板和钩板固定，以及使用涤纶移植物韧带缝合和吊带技术。
内侧三分之一骨折
这些罕见的骨折大多是关节外骨折。除非骨折移位威胁到纵隔结构，否则主要采用非手术治疗。初始固定与重大并发症有关，包括植入物向纵隔内移位，尤其是使用克氏针时。其他稳定方法包括缝合和移植技术以及较新的锁定钢板。