骨科英文书籍精读（56）｜锁骨骨折（1）
The great bugbear of upper limb injuries is stiffness-particularly of the shoulder but sometimes of the elbow and hand as well. Two points should be constantly borne in mind:
· Whatever the injury, and however it is treated, all the joints that are not actually immobilized – and especially the finger joints – should be exercised from the start.
· In elderly patients it is sometimes best to disregard the fracture and concentrate on regaining movement.
FRACTURES OF THE CLAVICLE
In children the clavicle fractures easily, but it almost invariably unites rapidly and without complications. In adults this can be a much more troublesome injury. In adults clavicle fractures are common, accounting for 2.6–4 percent of fractures and approximately 35 percent of all shoulder girdle injuries. Fractures of the midshaft account for 69–82 percent, lateral fractures for 21–28 percent and medial fractures for 2–3 percent.
Mechanism of injury
A fall on the shoulder or the outstretched hand may break the clavicle. In the common mid-shaft fracture, the outer fragment is pulled down by the weight of the arm and the inner half is held up by the sternomastoid muscle. In fractures of the outer end, if the ligaments are intact there is little displacement; but if the coracoclavicular ligaments are torn, or if the fracture is just medial to these ligaments, displacement may be severe and closed reduction impossible.
Clinical features
The arm is clasped to the chest to prevent movement. A subcutaneous lump may be obvious and occasionally a sharp fragment threatens the skin. Though vascular complications are rare, it is prudent to feel the pulse and gently to palpate the root of the neck. Outer third fractures are easily missed or mistaken for acromioclavicular joint injuries.
Imaging
Radiographic analysis requires at least an anteroposterior view and another taken with a 30 degree cephalic tilt. The fracture is usually in the middle third of the bone, and the outer fragment usually lies below the inner. Fractures of the outer third may be missed, or the degree of displacement underestimated, unless additional views of the shoulder are obtained. With medial third fractures it is also wise to obtain x-rays of the sternoclavicular joint. In assessing clinical progress, remember that ‘clinical’ union usually precedes ‘radiological’ union by several weeks.
CT scanning with three-dimensional reconstructions may be needed to determine accurately the degree of shortening or for diagnosing a sternoclavicular fracture-dislocation, and also to establish whether a fracture has united.
Classification
Clavicle fractures are usually classified on the basis of their location: Group I (middle third fractures), Group II (lateral third fractures) and Group III (medial third fractures). Lateral third fractures can be further sub-classified into (a) those with the coracoclavicular ligaments intact, (b) those where the coracoclavicular ligaments are torn or detached from the medial segment but the trapezoid ligament remains intact to the distal segment, and (c) factures which are intra-articular. An even more detailed classification proposed by Robinson (1998) is useful for managing data and comparing clinical outcomes.
---from 《Apley’s System of Orthopaedics and Fractures》P687-688
重点词汇整理：
bugbear /ˈbʌɡber/n. 怪物；棘手的难题；恐惧或烦恼的原因
invariably /ɪnˈveriəbli/adv. 总是；不变地；一定地
shoulder girdle上肢带骨
girdle /ˈɡɜːrdl/n. 腰带；围绕物；妇女紧身褡vt. 围绕；绕…而行；用带子捆扎
outstretch /,aut'stretʃ/v. 伸展，伸出；超出……的范围
held up举起（提出，支持）
sternomastoid muscle胸骨乳突肌
coracoclavicular ligaments 喙锁韧带
clasp /klæsp/n. 扣子，钩子；握手
vt. 紧抱；扣紧；紧紧缠绕vi. 扣住
subcutaneous lump 皮下肿块 /ˌsʌbkjuˈteɪniəs/adj. 皮下的；皮下用的
prudent /ˈpruːdnt/adj. 谨慎的；精明的；节俭的
palpate /pælˈpeɪt/adj. （有）触须的v. 触诊
acromioclavicular joint 肩锁关节 /ə,krəumiəuklə'vikjulə/adj. 肩锁的
anteroposterior /,ætərəupɔs'tiəriə/adj. 前后的
30 degree cephalic tilt头侧倾斜30度 /sɪˈfælɪk/adj. [动] 头的
underestimate/ˌʌndərˈestɪmeɪt/n. 低估vt. 低估；看轻
sternoclavicular joint胸锁关节 /,stə:nəuklə'vikjulə/
adj. 胸锁的；胸骨锁骨的
CT scanning with three-dimensional reconstructions CT扫描与三维重建 /daɪmenʃənl,dɪmenʃənl/adj. 空间的；尺寸的
trapezoid ligament斜方韧带 /ˈtræpəzɔɪd/n. [数] 梯形；[数] 不规则四边形adj. 梯形的；[数] 不规则四边形的
intra-articular /,intrəɑ:'tikjulə/adj. 关节内的
谷歌翻译：
上肢损伤最令人头疼的是僵硬--特别是肩膀，但有时手肘和手肘也会僵硬。应该始终牢记两点：·无论受伤的是什么，无论如何治疗，所有实际上没有固定的关节-特别是手指关节-都应该从一开始就进行锻炼。·对于老年患者，有时最好忽略骨折，专注于恢复活动。
锁骨骨折
儿童锁骨很容易骨折，但几乎总是能迅速愈合，而且没有并发症。对于成年人来说，这可能是一种更麻烦的伤害。在成人中，锁骨骨折很常见，占骨折的2.6-4%，约占所有肩带损伤的35%。中段骨折占69%~82%，外侧骨折占21%~28%，内侧骨折占2%~3%。
损伤机制
摔倒在肩膀或伸出的手上可能会折断锁骨。在常见的中段骨折中，外侧部分被手臂的重量拉下，内侧部分由胸锁乳突肌支撑。在外端骨折中，如果韧带完整，几乎没有移位；但如果喙锁韧带撕裂，或骨折仅位于这些韧带的内侧，移位可能严重，不可能闭合复位。
临床表现
手臂紧握在胸部以防止移动。皮下肿块可能很明显，偶尔会有尖锐的碎片威胁皮肤。虽然血管并发症很少见，但谨慎的做法是摸摸脉搏，并轻轻触诊颈部根部。外侧三分之一骨折容易漏诊或误诊为肩锁关节损伤。
影像学表现
X线分析至少需要正位和另一张头颅倾斜30度的照片。骨折通常在骨头的中间三分之一，而外部的碎片通常位于内部以下。除非获得更多的肩部切面，否则可能会漏掉外三分之一的骨折，或者低估了移位的程度。对于内侧三分之一骨折，明智的做法是拍摄胸锁关节的X光片。在评估临床进展时，请记住“临床”愈合通常比“放射”愈合早几周。
CT扫描和三维重建可能需要准确地确定骨折缩短的程度或诊断胸锁骨折脱位，并确定骨折是否愈合。
骨折分型
锁骨骨折通常根据其位置进行分类：I组(中三分之一骨折)、II组(外侧三分之一骨折)和III组(内侧三分之一骨折)。外侧三分之一骨折可进一步细分为(A)喙锁韧带完整的骨折，(B)喙锁韧带从内侧段撕裂或分离，但远端梯形韧带保持完整的骨折，以及(C)关节内骨折。Robinson(1998)提出的更详细的分类对于管理数据和比较临床结果是有用的。