手術及保守治療對鎖骨中段骨折病患於多平面上舉時肩關節運動之影響

Effects of Surgical and Conservative Treatment for Mid-Shaft Clavicle Fractures on the Kinematics of the Shoulder Complex During Multi-Plane Elevation

洪立維(Li-Wei Hung)

指導教授 ： 呂東武

國立臺灣大學/工學院/醫學工程學研究所/博士(2021年)

https://doi.org/10.6342/NTU202103812

摘要

鎖骨中段骨折占肩關節傷害的35％至44％。以往認為鎖骨骨折不癒合機率極低，所以皆以保守方式治療。近年越來越多文獻支持以手術治療鎖骨骨折，以恢復鎖骨長度方式進而恢復肩關節功能。然而研究指出，部分患者即使手術後，關節恢復還是不如預期，其中最常被報告的是肩胛骨活動不良。過去的研究方法，因為肩胛骨皮膚移動誤差問題，無法在體外精確量測其活動，對於鎖骨骨折術後病患的肩胛骨活動細節並不清楚，所以目前對鎖骨中段骨折的最佳治療方式尚未定論。本研究使用光學運動分析系統搭配可調整式肩胛骨定位器，可克服皮膚運動誤差，並精確量化不同治療方式對中段鎖骨骨折病患在多平面手臂抬高過程的肩關節骨骼運動力學。本研究招募手術組、保守治療組與控制組各15名受試者，在他們手臂抬高的各階段，測量肩關節骨骼的活動。結果發現，兩個實驗組的肩部功能都已恢復到與控制組相當。然而，即使兩組骨折病患關節活動角度和控制組沒有顯著差異，實驗結果發現在他們患側和健側的鎖骨與肩胛骨在手臂抬高過程中的各平面都有程度不同的內轉與前引，此運動偏差可能造成對旋轉肌腱進一步的磨損甚至是永久性的傷害。本實驗結果支持鎖骨骨折病患在康復過程中監測多平面肩部運動力學的必要性，並建議病患在健側與患側都需要進行復健訓練以改善肩關節之運動控制。本研究亦針對以上數據進行主成分分析，在龐大的數據維度中找出十個主成分，並發現在不同的治療方式的受試者之間只有一個主成分有顯著差異。各主成分與臨床醫學的關聯則是未來研究上重要的課題。

關鍵字

鎖骨骨折 ； 動作分析 ； 手術治療 ； 保守治療 ； 主成分分析

並列摘要

Midshaft clavicle fractures account for 35% to 44% of shoulder girdle injuries. In the past, conservative treatment was preferred for midshaft clavicle fracture for the low nonunion rate. Currently, there is consensus on conservative treatment for midshaft clavicle fracture without displacement. While there is increasing evidence to support surgical repair, poor functional outcomes have been reported. The most common reported pathology is scapular dyskinesia. However, the detail of scapular motion was not understand for the limitation of skin motion artifact. And therefore, no consensus concerning whether surgery or conservative treatment is best for displaced midshaft clavicle fracture. The purpose of the current study was to quantify the effects of different treatments for midshaft clavicle fractures on the 3D bone poses of the shoulder complex during multi-plane elevations using computerized optical motion analysis with the new three-pointed scapular locator. The 3D poses of the shoulder bones during arm elevations were measured in 15 patients treated for midshaft clavicle fractures by open reduction and internal fixation, 15 patients treated by conservative managements, and in 15 healthy controls. No significant between-side differences were found in the clavicle length after surgical or conservative treatments. Both patient groups were found to have recovered general shoulder function by the time of the motion experiment with normal ranges of the subjective outcome measures. However, residual kinematic deviations of the shoulder complex in different arm elevation planes were found on both the affected and unaffected side, with similar clavicle lengths, maximum arm elevations, and scapulothoracic, claviculothoracic, and AC joint kinematics between sides. The results suggest that shoulder kinematics in multi-plane arm elevations should be monitored for any signs of compromised bone motions following treatment, and that rehabilitative training may be needed on both sides to improve the bilateral movement control of the shoulder complex. The movement patterns of principal component also showed a trend of bilateral symmetrical compensation on the both affected and unaffected sides of the patient groups. Furthermore, the patterns of principal component for the movements of shoulder complex allowed statistical comparisons between groups without redundancy and preserved kinematic information in a non-arbitrary manner. Therefore, PCA may be used in future studies investigating muscle synergy patterns relate to the kinematic data of the shoulder complex after surgical treatment for clavicle fractures.

並列關鍵字

clavicle fracture ； motion analysis ； surgical treatment ； conservative treatment ； principal component analysis

參考文獻

1. Prescher, A., Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle. European journal of radiology, 2000. 35(2): p. 88-102.

2. Wang, Q., et al., Motor control training for the shoulder with smart garments. Sensors, 2017. 17(7): p. 1687.

3. Sonawane, K., et al., Uncovering secrets of the beauty bone: A comprehensive review of anatomy and regional anesthesia techniques of clavicle surgeries. Open Journal of Orthopedics and Rheumatology, 2021. 6(1): p. 019-029.

4. Carter, H.V. and H. Gray, Anatomy of the human body. Bartleby. com: Gray's Anatomy, Plate, 1918. 392.

5. Ornitz, D.M. and P.J. Marie, FGF signaling pathways in endochondral and intramembranous bone development and human genetic disease. Genes development, 2002. 16(12): p. 1446-1465.