Influencing factors and construction of a predictive model for postoperative complications of Craig type I clavicle fractures in adolescents

doi:10.11958/20253733

Abstract

Abstract:

Objective To investigate the influencing factors of postoperative complications in adolescents with Craig type Ⅰ clavicle fractures, analyze the protective effect of retrograde elastic intramedullary nailing, and develop/validate a predictive model for postoperative complications. Methods A total of 180 adolescent patients with Craig type Ⅰ clavicle fractures were selected. The patients were followed up for 1 year after surgery, and they were divided into the complication group (56 cases) and the non-complication group (124 cases) based on whether complications occurred. The clinical data of the two groups were compared, and the influencing factors of postoperative complications were analyzed using multivariate Logistic regression, and a nomogram prediction model was constructed accordingly. The predictive efficacy of each factor and the combined model was evaluated using the receiver operating characteristic (ROC) curve. Results Compared with the non-complication group, the intraoperative blood loss and serum N-terminal peptide cross-linking (NTX) level were higher in the complication group, while the Constant-Murley shoulder joint score, serum type Ⅰ procollagen N-terminal propeptide (PⅠNP) and the proportion of retrograde elastic nail internal fixation were lower in the complication group (P<0.05). Multivariate Logistic regression analysis revealed that high intraoperative blood loss and high NTX level were independent risk factors for postoperative complications, while retrograde elastic nail internal fixation, high Constant-Murley score and high PⅠNP level were protective factors (P<0.05). Based on this, a predictive model was constructed. The model passed the Omnibus test (P<0.01) and fitted well (Hosmer-Lemeshow test, χ² = 10.047, P = 0.262). ROC curve analysis showed that the combined predictive model of surgical method, intraoperative blood loss, Constant-Murley score, PⅠNP and NTX had the best discrimination efficacy, with an area under the curve (AUC) of 0.949 (95% CI: 0.914-0.984), which was significantly higher than any single predictive factor (P<0.05), and its prediction sensitivity and specificity were 91.1% and 87.9%, respectively. Conclusion The constructed combined predictive model has good discrimination and predictive efficacy for postoperative complications in adolescents with Craig type Ⅰ clavicle fractures, and can provide a quantitative tool for clinical risk assessment.

Key words: clavicle, fractures, fracture fixation, intramedullary, adolescent, postoperative complications, retrograde elastic nailing, risk factors, predictive model

CLC Number:

R687.3

Figures/Tables 7

References 20

[1]	Sayed M, Sutar S, Kamel F, et al. Temporal trends in the management of midshaft clavicle fractures:a systematic review[J]. Cureus, 2025, 17(11):e96532. doi:10.7759/cureus.96532.
[2]	Lin B, Dong Y, Wei L, et al. Clinical efficacy of endobutton combined with mini-plate in the treatment of Neer IIB(IIC)type distal clavicle fracture[J]. Acta Orthop Traumatol Turc, 2025, 59(1):39-44. doi:10.5152/j.aott.2025.24023.
[3]	Varady N H, Jones R H, Bram J T, et al. Safety of accelerated return to play after anatomic open reduction and internal fixation of adolescent clavicle fractures[J]. Orthop J Sports Med, 2025, 13(9):23259671251374299. doi:10.1177/23259671251374299.
[4]	王烁, 龙大伟, 杨辉宝. 超声下逆行弹性髓内钉固定治疗儿童肱骨下段骨折的疗效[J]. 实用骨科杂志, 2025, 31(9):832-836.
	Wang S, Long D W, Yang H B, et al. Ultrasound-guided retrograde elastic intramedullary nail fixation for distal humeral fractures in children[J]. Journal of Practical Orthopaedics, 2025, 31(9):832-836. doi:10.3760/cma.j.issn.1008-5572.2025.09.113.
[5]	Kim D W, Kim D H, Kim B S, et al. Current concepts for classification and treatment of distal clavicle fractures[J]. Clin Orthop Surg, 2020, 12(2):135-144. doi:10.4055/cios20010.
[6]	郑宪友. 锁骨骨折治疗:2023美国骨科医师学会(AAOS)临床实践指南解读[J]. 中国修复重建外科杂志, 2024, 38(8):942-946.
	Zheng X Y. Treatment of clavicle fracture:Interpretation of the 2023 American Academy of Orthopaedic Surgeons(AAOS)Clinical Practice Guidelines[J]. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(8):942-946. doi:10.7507/1002-1892.202404101.
[7]	Bae K, Ryu S, Choi S H, et al. Operative treatment of adolescent diaphyseal clavicle fracture:elastic stable intramedullary nail versus plate fixation[J]. Medicina(Kaunas), 2025, 61(8):1494. doi:10.3390/medicina61081494.
[8]	田子睿, 姚敏, 王拥军, 等. 中文版Constant-Murley肩关节评分量表的研制与应用[J]. 中医正骨, 2019, 31(5):20-21,25.
	Tian Z R, Yao M, Wang Y J, et al. Development and application of Chinese version of Constant-Murley shoulder scoring scale[J]. J Trad Chin Orthop Traum, 2019, 31(5):20-21,25. doi:10.3969/j.issn.1001-6015.2019.05.005.
[9]	Hamid M, Younis Z, Mannan M, et al. Adolescent clavicle fractures:a management dilemma?[J]. Cureus, 2025, 17(1):e77961. doi:10.7759/cureus.77961.
[10]	Ahmad T, Khan K, Khan K, et al. Functional outcomes and complications of non-surgical management for midshaft clavicle fractures[J]. Cureus, 2025, 17(10):e95788. doi:10.7759/cureus.95788.
[11]	陈笑天, 王晓盼, 赵培帅, 等. 钛弹性钉辅助耻骨上支逆行通道螺钉植入手术技巧及临床疗效[J]. 中国修复重建外科杂志, 2023, 37(4):431-437.
	Chen X T, Wang X P, Zhao P S, et al. Surgical technique and effectiveness of titanium elastic nail assisted retrograde channel screw implantation in superior pubic branch[J]. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(4):431-437. doi:10.7507/1002-1892.202212093.
[12]	陈伟, 杨玉亭, 王艳, 等. 有限元分析弹性髓内钉治疗尺桡骨干双骨折不同进针点的力学差异[J]. 中国组织工程研究, 2026, 30(15):3772-3779.
	Chen W, Yang Y T, Wang Y, et al. Finite element analysis of mechanical differences between different entry points of elastic intramedullary nail in treatment of double fractures of radioulnar shaft[J]. Chinese Journal of Tissue Engineering Research, 2026, 30(15):3772-3779. doi:10.12307/2026.329.
[13]	Zhang W, Chen J. Elastic stable intramedullary nailing(ESIN)for displaced midshaft clavicle fractures in adolescents(12-18 years):a study of early functional outcomes and safety[J]. J Orthop Surg Res, 2025, 20(1):507. doi:10.1186/s13018-025-05923-9.
[14]	Cao R, Tan J, Zhang Y, et al. Finite element analysis of antegrade and retrograde internal intramedullary nailing for mid-shaft clavicle fracture[J]. BMC Musculoskelet Disord, 2025, 26(1):172. doi:10.1186/s12891-025-08426-0.
[15]	Rybaczek M, Kowalski P, Mariak Z, et al. Safety in spine surgery:risk factors for intraoperative blood loss and management strategies[J]. Life(Basel), 2025, 15(10):1615. doi:10.3390/life15101615.
[16]	杨正洋, 王野, 刘大君, 等. 股骨近端防旋髓内钉与骨水泥半髋关节置换术治疗老年不稳定股骨粗隆间骨折围术期失血量的比较[J]. 创伤外科杂志, 2025, 27(8):594-601.
	Yang Z Y, Wang Y, Liu D J, et al. Comparison of perioperative blood loss between proximal femoral nail anti-rotation and cemented hemiarthroplasty for unstable intertrochanteric fractures in the elderly[J]. J Trauma Surg, 2025, 27(8):594-601. doi:10.3969/j.issn.1009-4237.2025.08.006.
[17]	Perut F, Roncuzzi L, Gómez-Barrena E, et al. Association between bone turnover markers and fracture healing in long bone non-union:a systematic review[J]. J Clin Med, 2024, 13(8):2333. doi:10.3390/jcm13082333.
[18]	马广恩, 张磊, 董思奇, 等. 钛质弹性髓内钉内固定治疗儿童胫骨干骨折术后应激反应与疗效观察[J]. 中国骨与关节损伤杂志, 2025, 40(12):1328-1331.
	Ma G E, Zhang L, Dong S Q, et al. Postoperative stress response and efficacy observation of titanium elastic intramedullary nail internal fixation for pediatric tibial shaft fractures[J]. Chin J Bone Joint Injury, 2025, 40(12):1328-1331. doi:10.7531/j.issn.1672-9935.2025.12.024.
[19]	莫贤跃, 黄勇斌, 姜权, 等. 弹性髓内针固定治疗大龄儿童移位型锁骨中段骨折[J]. 临床骨科杂志, 2022, 25(2):219-221.
	Mo X Y, Huang Y B, Jiang Q, et al. Titanium elastic nails internal fixation foRthe treatment of displaced middle clavicle fractures in oldeRchildren[J]. Journal of Clinical Orthopaedics, 2022, 25(2):219-221. doi:10.3969/j.issn.1008-0287.2022.02.022.
[20]	苏驰, 张彦, 盛志中, 等. 顺行弹性髓内钉微创内固定治疗大龄儿童完全移位锁骨中段骨折疗效观察[J]. 中国骨与关节损伤杂志, 2025, 40(3):309-311.
	Su C, Zhang Y, Sheng Z Z, et al. Clinical observation of antegrade elastic intramedullary nail minimally invasive internal fixation for completely displaced midshaft clavicular fractures in older children[J]. Chin J Bone Joint Injury, 2025, 40(3):309-311. doi:10.7531/j.issn.1672-9935.2025.03.021.

组别	n	年龄/ 岁		男性		BMI/ （kg/m²）		受伤至手术的时间/d	手术时间/ min		术中出血量/mL		螺钉数量/个			住院时间/d		Constant-Murley肩关节评分/分
非并发症组	124	14.58±1.76		64（51.61）		19.36±1.36		5.59±2.18	83.10±14.82		103.49±22.11		8.23±2.00			10.02±3.24		71.31±10.05
并发症组	56	14.52±1.80		26（46.43）		19.27±1.36		5.32±2.28	84.57±15.61		125.27±22.52		8.50±2.07			10.16±3.45		63.07±10.38
t或χ²		0.220		0.415		0.418		0.752	0.605		6.084^＊＊		0.842			0.272		5.039^＊＊
组别			PⅠNP/ （μg/L）		NTX/ （μg/L）		家族骨折病史			术后抗生素		术后抗凝药		术后镇痛药			骨折位置
组别			PⅠNP/ （μg/L）		NTX/ （μg/L）		家族骨折病史			术后抗生素		术后抗凝药		术后镇痛药			中段		远端
非并发症组			55.98±8.24		70.30±14.04		30（24.19）			18（14.25）		56（45.16）		70（56.45）			88（70.97）		36（29.03）
并发症组			45.32±8.60		89.45±14.33		12（21.43）			6（10.71）		26（46.43）		33（58.93）			38（67.86）		18（32.14）
t或χ²			7.928^＊＊		8.417^＊＊		0.165			0.483		0.025		0.097			0.178
组别		手术方式					受伤原因								AO分型
组别		逆行弹性钉内固定			传统内固定		跌倒		撞击		交通事故		其他			A型		15-B型		15-C型
非并发症组		76（61.29）			48（38.71）		44（35.48）		33（26.61）		28（22.58）		19（15.32）			48（38.71）		46（37.10）		30（24.19）
并发症组		15（26.79）			41（73.21）		28（50.00）		12（21.43）		8（14.29）		8（14.29）			20（35.71）		18（32.14）		18（32.14）
χ²		18.374^＊＊					3.802									1.272

组别	n	年龄/ 岁		男性		BMI/ （kg/m²）		受伤至手术的时间/d	手术时间/ min		术中出血量/mL		螺钉数量/个			住院时间/d		Constant-Murley肩关节评分/分
非并发症组	124	14.58±1.76		64（51.61）		19.36±1.36		5.59±2.18	83.10±14.82		103.49±22.11		8.23±2.00			10.02±3.24		71.31±10.05
并发症组	56	14.52±1.80		26（46.43）		19.27±1.36		5.32±2.28	84.57±15.61		125.27±22.52		8.50±2.07			10.16±3.45		63.07±10.38
t或χ²		0.220		0.415		0.418		0.752	0.605		6.084^＊＊		0.842			0.272		5.039^＊＊
组别			PⅠNP/ （μg/L）		NTX/ （μg/L）		家族骨折病史			术后抗生素		术后抗凝药		术后镇痛药			骨折位置
组别			PⅠNP/ （μg/L）		NTX/ （μg/L）		家族骨折病史			术后抗生素		术后抗凝药		术后镇痛药			中段		远端
非并发症组			55.98±8.24		70.30±14.04		30（24.19）			18（14.25）		56（45.16）		70（56.45）			88（70.97）		36（29.03）
并发症组			45.32±8.60		89.45±14.33		12（21.43）			6（10.71）		26（46.43）		33（58.93）			38（67.86）		18（32.14）
t或χ²			7.928^＊＊		8.417^＊＊		0.165			0.483		0.025		0.097			0.178
组别		手术方式					受伤原因								AO分型
组别		逆行弹性钉内固定			传统内固定		跌倒		撞击		交通事故		其他			A型		15-B型		15-C型
非并发症组		76（61.29）			48（38.71）		44（35.48）		33（26.61）		28（22.58）		19（15.32）			48（38.71）		46（37.10）		30（24.19）
并发症组		15（26.79）			41（73.21）		28（50.00）		12（21.43）		8（14.29）		8（14.29）			20（35.71）		18（32.14）		18（32.14）
χ²		18.374^＊＊					3.802									1.272

变量	β	SE	Wald χ²	P	OR（95%CI）
手术方式	1.924	0.587	10.752	0.001	6.848（2.168~21.628）
术中出血量	0.046	0.014	11.436	0.001	1.047（1.020~1.076）
Constant-Murley 肩关节评分	-0.090	0.032	7.755	0.005	0.914（0.858~0.974）
PⅠNP	-0.130	0.034	14.292	<0.001	0.878（0.821~0.939）
NTX	0.087	0.021	16.257	<0.001	1.090（1.045~1.137）
常数项	-1.448	3.350	0.187	0.666	0.235

变量	β	SE	Wald χ²	P	OR（95%CI）
手术方式	1.924	0.587	10.752	0.001	6.848（2.168~21.628）
术中出血量	0.046	0.014	11.436	0.001	1.047（1.020~1.076）
Constant-Murley 肩关节评分	-0.090	0.032	7.755	0.005	0.914（0.858~0.974）
PⅠNP	-0.130	0.034	14.292	<0.001	0.878（0.821~0.939）
NTX	0.087	0.021	16.257	<0.001	1.090（1.045~1.137）
常数项	-1.448	3.350	0.187	0.666	0.235

变量	AUC	95%CI	截断值	敏感度/%	特异度/%	约登指数
手术方式	0.673	0.588~0.757	-	61.3	73.2	0.345
术中出血量	0.749	0.673~0.825	112.7 mL	76.8	67.7	0.445
Constant- Murley 肩关节评分	0.714	0.634~0.793	70分	61.3	76.8	0.381
PⅠNP	0.818	0.752~0.884	50.70 μg/L	76.6	76.8	0.534
NTX	0.820	0.754~0.885	79.55 μg/L	69.6	76.6	0.462
联合预测	0.949	0.914~0.984	-	91.1	87.9	0.790