FRACTURES OF

THE CLAVICLE ASER ADEL MANSOUR

Msc.orthopedic surgeryDammam medical complex

INTRODUCTION The clavicle assumes a gentle S-shape, the medial

end convex forward and the lateral end concave forward. This shape has been likened to the musical symbol the clavicula, hence the name.

The clavicle is responsible for bracing the shoulder girdle and propping it away from the sternum and thoracic cage. This allows the shoulder to reach into cross-body and internal rotation positions without suffering medial collapse.

The clavicle increases the strength of shoulder girdle movements . Also, this strut function affords cosmesis and posture to the shoulder girdle.

Clavicles are the most common

broken bone in the human body.

4-10% of all adult fractures.

35-45% of all fractures of

shoulder girdle area.

Frequency

Etiology Historically, clavicle fractures were

thought to result from a fall onto an outstretched hand,

More recent work has revealed that, in actuality, the most common mechanism for clavicle fractures is a fall directly onto the shoulder,

Stanley et al found that about 70% of clavicle fractures were the result of trauma from traffic accidents.

Pathophysiology Because of its subcutaneous position, the

clavicle may be fractured easily, The fracture is often an isolated injury. However, clavicle fractures are also common

in the context of high-energy injury or multiple traumatic injuries.

In these situations, it is important to examine the patient for other associated injuries, such as rib fractures, scapula fractures, other fractures about the shoulder girdle, pulmonary contusion, pneumothorax, hemothorax, and closed head injuries.

The midshaft part of the clavicle is a transition zone between the flattened shape of the lateral part and the more tubular-to-triangular medial shape. It is the thinnest segment of the clavicle and is not stabilized by ligaments. Unlike the midshaft, both the lateral side and the medial side of the clavicle are stabilized by strong ligamentous and muscular structures. The midshaft is left relatively unprotected; thus, most fractures occur in the midshaft 65-75% (Moseley 1968, Rowe 1968).

The displacing forces on a midshaft clavicle fracture

The displacing forces on a lateral clavicle fracture.

classification The most common classification

system is that of Allman, in which the clavicle is divided into thirds.

Group I fractures are middle third injuries,

Group II fractures are lateral third injuries,

Group III fractures are medial third injuries.

classification Neer made a significant revision to the Allman

classification scheme. Lateral clavicle fractures were further divided into 3 types;

Type I fractures occurred medial to the coracoclavicular ligaments.

Type II fractures occurred at the level of coracoclavicular ligaments, with the trapezoid remaining intact with the distal segment it subdivided to type IIA and IIB.

Type III injuries occurred distal to the coracoclavicular ligament and entered the acromioclavicular (AC) joint.

Type I fracture of the distal clavicle (group II). The intact ligaments hold the fragments in place.

A type II distal clavicle fracture. In type IIA, both conoid and trapezoid ligaments are on the distal segment, while the proximal segment, without ligamentous attachments, is displaced

A type IIB fracture of the distal clavicle. The conoid ligament is ruptured while the trapezoid ligament remains attached to the distal segment. The proximal fragment is displaced.

The displaced midshaft fractures in the Edinburgh classification for clavicle fractures (Robinson 1998, Khan et al. 2009)

Diagnosis

Signs and symptoms: Pain, particularly with upper extremity

movement Swelling Often, after the swelling has subsided,

the fracture can be felt through the skin. Sharp pain when any movement is made. Referred pain: dull to extreme ache in

and around clavicle area, including surrounding muscles.

Radiographs:Recommended radiographic views of the clavicle include anteroposterior view, which needs to include both the sternoclavicular joint and the shoulder girdle.Additional views that may assist with radiographic diagnosis include 45-degree cephalad and caudal views.Stress views may be used to identify patterns of displacement and are particularly helpful in the context of fractures of the distal clavicle.

Treatment

Nonoperative Treatment consists of sling support for 6 weeks. During

this period, the patient does perform pendulum exercises for shoulder motion and active range of motion of the elbow and hand. After 6 weeks, the patient begins passive assisted motion of the shoulder and progresses to active range of motion as tolerated.

Use of the sling may be discontinued as pain allows.

figure-of-eight bandage, where the latter has been reported to be less comfortable and to offer no advantage over the simple sling.

Surgical Treatment Indications:

1. Open fractures.2. Tenting of the skin by a sharp clavicle edge.3. Neurovascular injury. 4. Floating shoulder("in association with a

glenoid/scapula fracture ").5. Non union.6. A persistent wide separation of the

fragments with interposition of soft tissue.7. Shortning of 1.5- 2cm and 1cm in atheletics

SURGICAL OPTIONS1) Middle 1/3 fracture:

1. Anatomic precontoured plates.2. Locking plates.3. Intramedullary: * k.wire. *Tense nail. * Intramedullary compression

clavicular nail.

* Cannulated screws4. External fixation

anatomic precontoured plates.

Intramedullary compression clavicular nail

Tense nail

Pin placement in external fixation of clavicular fractures

2) Distal clavicle fractures:

1. Coracoclavicular screw fixation.2. Clavicle Hook - plates.3. Tension-band fixation. 4. Intramedullary screw fixation.5. Transacromial K-wire or Knowles pin fixation .6. Coracoclavicular ligament repair with

augmentation and supplementary wire fixation.

7. Dynamic transfer of the coracoid to the clavicle.

8. Arthroscopic technique using the TightRope system

Coracoclavicular screw fixation

Clavicle Hook-Plate

1. Clavicle Hook - plate

arthroscopic technique using the TightRope system

. 2010 ; 81(3): 273–2Acta Orthop June79.

Complictions General:

1. Injury of Subclavian Vessels.2. Pneumothorax-Hemothorax in 3% of clavicle

fractures3. Brachial Plexus Injury early or late4. Posttraumatic Arthritis usually appears in

fractures with intra-articular extension into the acromioclavicular joint

5. Reflex sympathetic dystrophy,6. Symptomatic malunions, 7. Nonunions

Surgical complication

1. Infection: less than one percent.

2. Scarring and Joint Stiffness .

3. Blood Vessel or Nerve Injury

4. Nonunion.5. Implant faliure.

Risk Factors for Nonunionof Midshaft Clavicle Fractures

Clavicle shortening > 15-20 mm.

Female sex. Fracture comminution. Fracture displacement. Greater extent of initial

trauma. Older age

Surgical Treatment

Non-Surgical Treatment

Factors

average 16 weeks

average 28 weeks Time for Healing

Displaced fractures may heal with significant shortening, which may have an impact on shoulder position and function

Impact on shoulder function

Lower Higher Non-union risk

Surgical Scar. the hardware may be slightly prominent

May have large lump ordeformity in clavicle

Cosmetic Issues

Numbness below the incision

No significant changes insensation

Skin Sensation

infection risk ofapproximately 1%,

None Infection Risk

Why Surgical Intervention??

At the American Academy of Orthopaedic Surgeons 2006 Annual Meeting, March 22-26, Chicago, Illinois, Hall and coworkers presented a paper entitled "A Multicenter Prospective Randomized Clinical Trial of Non-operative Versus Operative treatment of Midshaft Clavicle Fractures,The study authors concluded that operative treatment provided statistically significant clinical and functional improvement over nonoperative treatment of displaced midshaft clavicle fractures.

The primary open reduction and internal

fixation by means of plate osteosyntheses may

be superior to primary closed treatment (

Canadian Orthopaedic Trauma Society 2007).

A recent report of a prospective

randomized trial described an incidence of

adverse events of 37%; however, the

proportion of complications in the

nonoperative group was 63% (Canadian

Orthopaedic Trauma Society 2007).

ESIN(Elastic stable intramedullary

nailing) of displaced midshaft clavicular

fractures resulted in a lower rate of nonunion

and delayed union, a faster return to daily

activities, and a better functional outcome.

Clavicular shortening was significantly lower,

and overall satisfaction was higher in the

operative group. Smekal V. et. al J Orthop

Trauma.  2009; 23(2):106-12 ). And (

McKee MD. Orthop Clin North Am. 2010

Apr;41(2):225-31).

 

Plate fixation of displaced midshaft clavicle fracture reliably restores length and alignment. It resulted in shorter time to union with low complication rates. Symptomatic malunion in adolescents may be more common than earlier thought after significantly displaced fractures. Corrective osteotomy with plate fixation can restore clavicle anatomy and eliminate symptoms associated with malunion.(Vander Have KL.et al. J Pediatr Orthop. 2010 Jun;30(4):307-12).

10%–15% of all pediatric fractures. Mid-shaft clavicle fractures account for

nearly 90% of clavicle fractures. Most pediatric clavicle fractures are now

treated with a sling for 2–3 weeks or until the child no longer has pain. Follow-up radiographs should generally be obtained at approximately 4–6 weeks, and contact sports and activities are restricted for 8–10 weeks

Because of abundant callus formation, clavicle fractures usually heal with a palpable and visible bump . To avoid anxiety, parents should be made aware of the bump that will form at the initial examination. The callus bump will become less prominent as the bone remodels over a period of 6–12 months.

Indications for operative intervention inchildren are an open fracture, one in which skin is tented or threatened, complicated comminuted fractures, or fractures with an associated neurovascular injury

THANK

YOU!