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Clavicle Fractures

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Topic updated on 07/13/16 4:12pm
Introduction
  •  Epidemiology
    • incidence
      • clavicle fractures make up ~4% of all fractures
    • demographics
      • often seen in young active patients
  • Pathophysiology
    • mechanism
      • direct blow to lateral aspect of shoulder
      • fall on an outstretched arm or direct trauma
    • pathoanatomy
      • in displaced fractures, the sternocleidomastoid muscle pulls the medial fragment posterosuperiorly, while pectoralis and weight of arm pull the lateral fragment inferomedially  
      • open fractures buttonhole through platysma
  • Associated injuries
    • are rare but include
      • ipsilateral scapular fracture
      • scapulothoracic dissociation
        • should be considered with significantly displaced fractures
      • rib fracture
      • pneumothorax
      • neurovascular injury
  • Pediatric Clavicle fractures
    • fracture patterns include
      • medial clavicle physeal injury
      • distal clavicle physeal injury
Relevant Anatomy
  • Acromioclavicular Joint Anatomy
  • AC joint stability
    • acromioclavicular ligament
      • provides anterior/posterior stability
      • has superior, inferior, anterior, and posterior components
      • superior ligament is strongest, followed by posterior
    • coracoclavicular ligaments (trapezoid and conoid)
      • provides superior/inferior stability
      • trapezoid ligament inserts 3 cm from end of clavicle
      • conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
        • conoid ligament is strongest
    • capsule, deltoid and trapezius act as additional stabilizers

 

Classification
  • Allman Classification with Neer's Modification 
Group I - Middle third (80-85%)
Nondisplaced
  • Less than 100% displacement
Nonoperative
Displaced
  • Greater than 100% displacement
  • Nonunion rate of 4.5%
Operative
Group II - Neer Classification of Lateral third (10-15%)
Type I
  • Fracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or interligamentous
  • Usually minimally displaced
  • Stable because conoid and trapezoid ligaments remain intact
Nonoperative
Type IIA
  • Fracture occurs medial to intact conoid and trapezoid ligament
  • Medial clavicle unstable
  • Up to 56% nonunion rate with nonoperative management
Operative  

Type IIB
  • Fracture occurs either between ruptured conoid and intact trapezoid ligament or lateral to both ligaments torn
  • Medial clavicle unstable
  • Up to 30-45% nonunion rate with nonoperative management
Operative 

Type III
  • Intraarticular fracture extending into AC joint
  • Conoid and trapezoid intact therefore stable injury
  • Patients may develop posttraumatic AC arthritis
Nonoperative
x
Type IV
  • A physeal fracture that occurs in the skeletally immature
  • Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum
  • Clavicle pulls out of periosteal sleeve
  • Conoid and trapezoid ligaments remain attached to periosteum and overall the fracture pattern is stable
Nonoperative
x
Type V
  • Comminuted fracture
  • Conoid and trapezoid ligaments remain attached to comminuted fragment
  • Medial clavicle unstable
Operative
x
Group III - Medial third (5-8%)

Anterior displacement

  • Most often non-operative
  • Rarely symptomatic

Nonoperative

Posterior displacement
  • Rare injury (2-3%)
  • Often physeal fracture-dislocation (age < 25)
  • Stability dependent on costoclavicular ligaments
  • Must assess airway and great vessel compromise
  • Serendipity radiographs and CT scan to evaluate
  • Surgical management with thoracic surgeon on standby
Operative

Presentation
  • Symptoms
    • shoulder pain
  • Physical exam
    • deformity
    • perform careful neurovascular exam
    • tenting of skin (impending open fracture)
Imaging
  • Radiographs
    • standard AP view of bilateral shoulders
      • to measure clavicular shortening
    • 45° cephalic tilt determine superior/inferior displacement
    • 45° caudal tilt determines AP displacement
  • CT
    • may help evaluate displacement, shortening, comminution, articular extension, and nonunion
    • useful for medial physeal fractures and sternoclavicular injuries
Treatment
  • Nonoperative
    • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks
      • indications
        • nondisplaced Group I (middle third)
        • stable Group II fractures (Type I, III, IV)
        • nondisplaced Group III (medial third)
        • pediatric distal clavicle fractures (skeletally immature)
      • outcomes
        • nonunion (1-5%)  
          • risk factors for nonunion
            • Group II (up to 56%)
            • comminution
            • 100% displacement & shortening (>2 cm)
            • advanced age and female gender
        • poorer cosmesis  
        • decreased shoulder strength and endurance
          • seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • unstable Group II fractures (Type IIA, Type IIB, Type V)
          • open fxs
          • displaced fracture with skin tenting
          • subclavian artery or vein injury
          • floating shoulder (clavicle and scapula neck fx)
          • symptomatic nonunion
          • posteriorly displaced Group III fxs
          • displaced Group I (middle third) with >2cm shortening 
        • relative and controversial indications
          • brachial plexus injury (questionable b/c 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
      • outcomes
        • advantages of ORIF
          • improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement 
          • improved functional outcome / less pain with overhead activity 
          • faster time to union
          • decreased symptomatic malunion rate
          • improved cosmetic satisfaction
          • improved overall shoulder satisfaction
          • increased shoulder strength and endurance
        • disadvantages of ORIF
          • increased risk of need for future procedures
            • implant removal
            • debridement for infection
    • coracoclavicular ligament repair vs reconstruction
      • indications
        • group IIb fractures
        • group III fractures
Techniques
  • Sling Immobilization
    • technique
      • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
      • after 2-4 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-10 weeks
      • no attempt at reduction should be made
  • Open Reduction Internal Fixation
    • technique
      • plate and screw fixation
        • superior vs anterior plating
          • superior plating biomechanically higher load to failure and bending
          • superior plating better for inferior bony comminution
          • superior plating has higher risk of neurovascular injury during drilling
        • limited contact dynamic compression plate
          • 3.5mm reconstruction plate
          • locking plates
          • precontoured anatomic plates
          • lower profile needing less chance for removal surgery
        • intramedullary screw or nail fixation
          • higher complication rate including hardware migration
        • hook plate
          • AC joint spanning fixation
      • postoperative rehabilitation
        • sling for 7-10 days followed by active motion
        • strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
        • full activity including sports at ~ 3 month
  • Coracoclavicular ligament repair
    • technique
      • coracoclavicular ligament primary repair (most common)
        • most add supplementary suture (mersilene tape, fiberwire, ethibond) tied around coracoid and either into or around clavicle  
  • Coracoclavicular ligament reconstruction
    • see AC separation Techniques section 
      • techniques include
        • modified Weaver-Dunn
        • free tendon graft
Surgical Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • treatment of nonunion
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
  • Operative treatment
    • hardware prominence
      • ~30% of patient request plate removal
      • superior plates associated with increased irritation
    • neurovascular injury (3%)
      • superior plates associated with increased risk of subclavian artery or vein penetration
      • subclavian thrombosis
    • nonunion (1-5%)
    • infection (~4.8%)
    • mechanical failure (~1.4%)
    • pneumothorax
    • adhesive capsulitis
      • 4% in surgical group develop adhesive capsulitis requiring surgical intervention

 

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Qbank (12 Questions)

TAG
(SBQ12.3) A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury?
Topic Review Topic
FIGURES: A   B        

1. Decreased chance of nonunion with nonoperative treatment
2. Improved Constant and DASH scores with operative treatment at all time points
3. Increased symptomatic malunion rate with operative treatment
4. No change in shoulder abduction strength
5. Increased time to union with operative treatment

PREFERRED RESPONSE ▶
TAG
(SBQ12.23) A 25-year-old patient is involved in a motor vehicle accident. An isolated orthopaedic injury is sustained to the upper extremity with no compromise of skin integrity or neurovascular function. A radiograph of the injury is shown in Figure A. The patient is interested in pursuing surgical intervention. What is a reported outcome of surgery when compared to nonoperative management at 1 year postoperatively? Topic Review Topic
FIGURES: A          

1. Increased rates of symptomatic nonunion
2. Similar rates of symptomatic nonunion
3. No differences in cosmetic results
4. Increased functional outcome scores
5. Improved range of motion of the shoulder

PREFERRED RESPONSE ▶
TAG
(OBQ12.202) A 23-year-old male right hand dominant minor league hockey player sustains the injury shown in Figure A and B. The patient is apprised of the risks and benefits of both conservative and surgical treatments. He chooses to undergo surgical intervention and wishes to minimize the chance of requiring a second operation. Which of the following is the most appropriate surgical procedure for this patient? Topic Review Topic
FIGURES: A   B        

1. Distal clavicle resection
2. Transacromial wire fixation with possible coracoclavicular ligament reconstruction
3. Coracoclavicular screw fixation
4. Hook plate fixation with coracoclavicular ligament reconstruction
5. Small fragment plate fixation with possible coracoclavicular ligament reconstruction

PREFERRED RESPONSE ▶
TAG
(OBQ11.118) A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true? Topic Review Topic
FIGURES: A          

1. No difference in shoulder function
2. Higher risk of nonunion with operative management
3. Higher risk of symptomatic malunion with nonoperative management
4. Earlier return to sport with nonoperative management
5. No difference in union rates

PREFERRED RESPONSE ▶
TAG
(OBQ10.101) A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion? Topic Review Topic
FIGURES: A          

1. Open reduction and internal fixation with plating
2. Open reduction and percutaneous pinning
3. Closed reduction and percutaneous pinning
4. Closed reduction and external fixation
5. Nonoperative treatment with a sling and early range of motion

PREFERRED RESPONSE ▶
TAG
(OBQ08.54) Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively? Topic Review Topic

1. Sling immobilization
2. Displacement and comminution
3. Age less than 40 years old
4. Immediate motion exercises
5. Male

PREFERRED RESPONSE ▶
TAG
(OBQ08.168) A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. What is the most appropriate management of the clavicular injury? Topic Review Topic
FIGURES: A          

1. Closed reduction and figure of 8 splinting
2. Open reduction and plate fixation
3. Open reduction and percutaneous pinning
4. Simple sling to involved side
5. Sling with abduction pillow to involved side

PREFERRED RESPONSE ▶
TAG
(OBQ08.219) A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. After nine months of conservative treatment, he continues to complain of pain. A current radiograph is shown in Figure A. What is the most appropriate treatment? Topic Review Topic
FIGURES: A          

1. Addition of a bone stimulator
2. Figure of eight brace
3. Closed reduction and percutaneous pinning
4. Open reduction and intramedullary nailing
5. Open reduction and compression plating

PREFERRED RESPONSE ▶
TAG
(OBQ07.1) A 45-year-old male falls onto his left shoulder while biking. An injury radiograph is shown in Figure A. He elects for nonoperative treatment. What is the most likely clinical outcome? Topic Review Topic
FIGURES: A          

1. Symmetric cosmesis of shoulders
2. Decreased shoulder motion
3. Symptomatic nonunion
4. Shoulder instability
5. Decreased shoulder strength and endurance

PREFERRED RESPONSE ▶
TAG
(OBQ07.25) A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace? Topic Review Topic
FIGURES: A          

1. Decreased sleep disturbance
2. Decreased personal care and hygiene impairment
3. Decreased rates of malunion
4. Improved long-term clinical outcomes
5. No advantage, equivalent result between a simple sling and figure-of-eight brace

PREFERRED RESPONSE ▶
TAG
(OBQ07.275) Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture? Topic Review Topic

1. younger patients
2. female gender
3. simple fracture pattern
4. sling immobilization
5. early range-of-motion

PREFERRED RESPONSE ▶



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