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鎖骨骨折

著者: 小林 誠1) 横浜労災病院運動器外傷センター

著者: 松下 隆2) 帝京大学 整形外科学教室

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2019/04/05
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小林 誠 : 特に申告事項無し[2021年]
松下 隆 : 未申告[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、鎖骨中1/3骨折の治療について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 活動性の高い若年者に多い骨折である。
  1. 女性よりも、より活動性の高い男性に多い。
  1. 中1/3の骨折は高エネルギー外傷で起こる。
  1. 外側1/3の骨折は単純な転倒でも生じ、年齢層がやや高い。
  1. 内側1/3の骨折は頻度が低い。
  1. 肩に加わった外力により鎖骨に圧迫力がかかり、力学的に弱い部位が破綻する。
  1. 皮下にすぐ触れる割に開放骨折は少ない。
問診・診察のポイント  
問診:
  1. 受傷機転を確認する。

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文献 

著者: Dean C Taylor, Kevin L Krasinski
雑誌名: J Bone Joint Surg Am. 2009 Feb;91(2):462-73.
Abstract/Text
PMID 19181993  J Bone Joint Surg Am. 2009 Feb;91(2):462-73.
著者: C Michael Robinson, Charles M Court-Brown, Margaret M McQueen, Alison E Wakefield
雑誌名: J Bone Joint Surg Am. 2004 Jul;86-A(7):1359-65.
Abstract/Text BACKGROUND: Nonunion is a rare complication of a fracture of the clavicle, but its occurrence can compromise shoulder function. The aim of this study was to evaluate the prevalence of and risk factors for nonunion in a cohort of patients who were treated nonoperatively after a clavicular fracture.
METHODS: Over a fifty-one-month period, we performed a prospective, observational cohort study of a consecutive series of 868 patients (638 men and 230 women with a median age of 29.5 years; interquartile range, 19.25 to 46.75 years) with a radiographically confirmed fracture of the clavicle, which was treated nonoperatively. Eight patients were excluded from the study, as they received immediate surgery. Patients were evaluated clinically and radiographically at six, twelve, and twenty-four weeks after the injury. There were 581 fractures in the diaphysis, 263 fractures in the lateral fifth of the clavicle, and twenty-four fractures in the medial fifth.
RESULTS: On survivorship analysis, the overall prevalence of nonunion at twenty-four weeks after the fracture was 6.2%, with 8.3% of the medial end fractures, 4.5% of the diaphyseal fractures, and 11.5% of the lateral end fractures remaining ununited. Following a diaphyseal fracture, the risk of nonunion was significantly increased by advancing age, female gender, displacement of the fracture, and the presence of comminution (p < 0.05 for all). On multivariate analysis, all of these factors remained independently predictive of nonunion, and, in the final model, the risk of nonunion was increased by lack of cortical apposition (relative risk = 0.43; 95% confidence interval = 0.34 to 0.54), female gender (relative risk = 0.70; 95% confidence interval = 0.55 to 0.89), the presence of comminution (relative risk = 0.69; 95% confidence interval = 0.52 to 0.91), and advancing age (relative risk = 0.99; 95% confidence interval = 0.99 to 1.00). Following a lateral end fracture, the risk of nonunion was significantly increased only by advancing age and displacement of the fracture (p < 0.05 for both). On multivariate analysis, both of these factors remained independently predictive of nonunion (p < 0.05), and, in the final model, the risk of nonunion was increased by a lack of cortical apposition (relative risk = 0.38; 95% confidence interval = 0.25 to 0.57) and advancing age (relative risk = 0.98; 95% confidence interval = 0.97 to 0.99).
CONCLUSIONS: Nonunion at twenty-four weeks after a clavicular fracture is an uncommon occurrence, although the prevalence is higher than previously reported. There are subgroups of individuals who appear to be predisposed to the development of this complication, either from intrinsic factors, such as age or gender, or from the type of injury sustained. The predictive models that we developed may be used clinically to counsel patients about the risk for the development of this complication immediately after the injury.

PMID 15252081  J Bone Joint Surg Am. 2004 Jul;86-A(7):1359-65.
著者: Roberto Postacchini, Stefano Gumina, Pasquale Farsetti, Franco Postacchini
雑誌名: Int Orthop. 2010 Jun;34(5):731-6. doi: 10.1007/s00264-009-0850-x. Epub 2009 Aug 10.
Abstract/Text A series of 91 patients (59 males, 32 females, mean age 41 years) with middle-shaft clavicle fracture were assessed at a mean of 8.7 years after injury. Based on Allman's classification, fractures were placed in group Ia, Ib and Ic. The majority (66%) were allocated to groups Ib or Ic. Clinical evaluation was made using the Constant score and simple shoulder test. On post-injury radiographs, we measured the amount of overlapping of the fracture fragments (OV) both in centimetres and as percentage of the length of the clavicle and the mean distance between cranio-caudally displaced fragments (DS). The mean Constant scores were 87.1% and 85.6% in groups Ib and Ic, respectively. In patients with a Constant score > or =90%, the mean OV was 7.7% and the average DS was 1.59 cm. In those with a Constant score of 81-89% the average OV and DS were 12% and 1.6 cm, respectively, with the greatest OV being 12.9. In the nine patients whose Constant score was > or =80% the mean OV was 13.2 and the average DS was 1.7; however, the majority of patients had an OV > 15% and DS > or = 2 cm. In these nine patients the mean Constant score was significantly lower than that in the group with a score of > or =90%. The simple shoulder test showed that 20% of patients were dissatisfied with the outcome; a low score was associated with a severe degree of OV or DS. Fracture nonunion occurred in five cases (5.5%). We conclude that there is a clear-cut indication for surgery in patients with OV > or = 15% or DS > or = 2.3 cm as well as in those with an OV > or = 13% associated with a DS > or = 2 cm. This holds particularly for young and middle-aged patients.

PMID 19669643  Int Orthop. 2010 Jun;34(5):731-6. doi: 10.1007/s00264-0・・・
著者: Canadian Orthopaedic Trauma Society
雑誌名: J Bone Joint Surg Am. 2007 Jan;89(1):1-10. doi: 10.2106/JBJS.F.00020.
Abstract/Text BACKGROUND: Recent studies have shown a high prevalence of symptomatic malunion and nonunion after nonoperative treatment of displaced midshaft clavicular fractures. We sought to compare patient-oriented outcome and complication rates following nonoperative treatment and those after plate fixation of displaced midshaft clavicular fractures.
METHODS: In a multicenter, prospective clinical trial, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disability of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. There were no differences between the two groups with respect to patient demographics, mechanism of injury, associated injuries, Injury Severity Score, or fracture pattern.
RESULTS: Constant shoulder scores and DASH scores were significantly improved in the operative fixation group at all time-points (p = 0.001 and p < 0.01, respectively). The mean time to radiographic union was 28.4 weeks in the non-operative group compared with 16.4 weeks in the operative group (p = 0.001). There were two nonunions in the operative group compared with seven in the nonoperative group (p = 0.042). Symptomatic malunion developed in nine patients in the nonoperative group and in none in the operative group (p = 0.001). Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). At one year after the injury, the patients in the operative group were more likely to be satisfied with the appearance of the shoulder (p = 0.001) and with the shoulder in general (p = 0.002) than were those in the nonoperative group.
CONCLUSIONS: Operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.

PMID 17200303  J Bone Joint Surg Am. 2007 Jan;89(1):1-10. doi: 10.2106・・・
著者: K Andersen, P O Jensen, J Lauritzen
雑誌名: Acta Orthop Scand. 1987 Feb;58(1):71-4.
Abstract/Text Seventy-nine out-patients with midclavicular fractures were included in a prospective, randomized trial comparing treatment with a figure-of-eight bandage and a simple sling. Sixty-one patients completed the study and were reevaluated clinically and radiographically after 3 months. We found that treatment with a simple sling caused less discomfort and perhaps fewer complications than with the figure-of-eight bandage. The functional and cosmetic results of the two methods of treatment were identical and alignment of the healed fractures was unchanged from the initial displacement.

PMID 3554886  Acta Orthop Scand. 1987 Feb;58(1):71-4.
著者: L A Kashif Khan, Timothy J Bradnock, Caroline Scott, C Michael Robinson
雑誌名: J Bone Joint Surg Am. 2009 Feb;91(2):447-60. doi: 10.2106/JBJS.H.00034.
Abstract/Text Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union, and the functional outcomes are good after nonoperative treatment. Nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits than previously reported. However, it remains difficult to predict which patients will have these complications. Since a satisfactory functional outcome may be obtained after operative treatment of a clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment of these injuries. Displaced lateral-end fractures have a higher risk of nonunion after nonoperative treatment than do shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in elderly individuals. The results of operative treatment are more unpredictable than they are for shaft fractures.

PMID 19181992  J Bone Joint Surg Am. 2009 Feb;91(2):447-60. doi: 10.21・・・
著者: Sarah Woltz, Pieta Krijnen, Inger B Schipper
雑誌名: J Bone Joint Surg Am. 2017 Jun 21;99(12):1051-1057. doi: 10.2106/JBJS.16.01068.
Abstract/Text BACKGROUND: The aim was to analyze whether patients with a displaced midshaft clavicular fracture are best managed with plate fixation or nonoperative treatment with respect to nonunion, secondary operations, and functional outcome, by evaluating all available randomized controlled trials (RCTs) on this subject.
METHODS: A systematic search of electronic databases (PubMed, MEDLINE, Embase, and Web of Science) was performed to identify RCTs comparing nonoperative treatment with plate fixation for displaced midshaft clavicular fractures. Risk of bias of the studies was assessed. Outcomes evaluated were nonunion, shoulder function (Constant score and Disabilities of the Arm, Shoulder and Hand [DASH] score), and secondary operations.
RESULTS: Six RCTs (614 patients) were included. The risk of nonunion was lower in the operatively treated patients (relative risk [RR] = 0.14, 95% confidence interval [CI] = 0.06 to 0.32). One-third of the patients with a nonunion did not receive further treatment. Secondary operations for adverse events were performed less often in the operatively treated patients (RR = 0.42, 95% CI = 0.25 to 0.71). When plate removal operations were also included, a secondary operation was performed in 17.6% in the operative group and 16.6% in the nonoperative group (RR = 1.01, 95% CI = 0.64 to 1.59). Constant and DASH scores after 1 year were somewhat better after plate fixation, with mean differences of 4.4 points (95% CI, 0.9 to 7.9 points) and 5.1 points (95% CI, 0.1 to 10.1 points), respectively.
CONCLUSIONS: Plate fixation significantly reduces the risk of nonunion, but does not have a clinically relevant advantage regarding final functional outcome. Secondary operations are common after both treatments. Overall, there is not enough evidence to support routine operative treatment for all patients with a displaced midshaft clavicular fracture.
LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PMID 28632595  J Bone Joint Surg Am. 2017 Jun 21;99(12):1051-1057. doi・・・
著者: Rahul Banerjee, Brian Waterman, Jeff Padalecki, William Robertson
雑誌名: J Am Acad Orthop Surg. 2011 Jul;19(7):392-401.
Abstract/Text Most clavicle fractures heal without difficulty. However, radiographic nonunion after distal clavicle fracture has been reported in 10% to 44% of patients. Type II distal clavicle fractures, which involve displacement, are associated with the highest incidence of nonunion. Several studies have questioned the clinical relevance of distal clavicle nonunion, however. Nonsurgical and surgical management provide similar results. The decision whether to operate may be influenced by the amount of fracture displacement and the individual demands of the patient. Surgical options to achieve bony union include transacromial wire fixation, a modified Weaver-Dunn procedure, use of a tension band, screw fixation, plating, and arthroscopy. Each technique has advantages and disadvantages; insufficient evidence exists to demonstrate that any one technique consistently provides the best results.

PMID 21724918  J Am Acad Orthop Surg. 2011 Jul;19(7):392-401.
著者: Joo Han Oh, Sae Hoon Kim, Jung Ha Lee, Seung Han Shin, Hyun Sik Gong
雑誌名: Arch Orthop Trauma Surg. 2011 Apr;131(4):525-33. doi: 10.1007/s00402-010-1196-y. Epub 2010 Oct 22.
Abstract/Text The Neer type II distal clavicle fracture is notorious for its high nonunion rate, and surgical treatment is usually recommended. We reviewed articles from January 1990 to September 2009, and among them, 425 cases from 21 studies were included. According to the 425 cases in the literature, sixty patients were treated nonsurgically and 365 surgically. From 365 patients who were treated surgically, 105 were identified as receiving the coracoclavicular stabilization, 162 hook plate, 42 intramedullary fixation, 16 interfragmentary fixation, and 40 K-wire plus tension band wiring. The nonsurgical treatment resulted in 20 (33.3%) nonunions and 4 (6.7%) other complications. The surgical treatment resulted in 6 (1.6%) nonunions, 81 (22.2%) complications other than nonunion. The nonunion rate was significantly high with nonsurgical treatment (p < 0.001), and the complication rate was statistically high with surgery (p = 0.002). With surgical treatment, the nonunion rate was not significantly different among the modalities (p = 0.391). The complication rate was significantly higher in cases of the hook plate (40.7%) and the K-wire plus tension band wiring (20.0%) than those of the coracoclavicular stabilization (4.8%), the intramedullary (2.4%) and the interfragmentary fixation (6.3%). For the nonsurgical treatment, the functional outcomes were generally acceptable despite the high nonunion rate. The nonsurgical treatment could be considered as the first line treatment after sufficient counsel with the patient. The nonunion rate is high, however, the functional outcome is acceptable in most of the cases with nonunion. If the surgical treatment is considered, the intramedullary screw fixation, CC stabilization and interfragmentary fixation would be preferred because of their low complication rate.

PMID 20967548  Arch Orthop Trauma Surg. 2011 Apr;131(4):525-33. doi: 1・・・

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