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Distal Clavicle Fractures 2013 AOSSM Meeting Chicago, IL - July 13, 2013 J.R. Rudzki, MD Washington Orthopaedics & Sports Medicine Clinical Assistant Professor, Dept . of Orthopaedic Surgery George Washington University School of Medicine

Distal Clavicle Fractures

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Page 1: Distal Clavicle Fractures

Distal Clavicle

Fractures

2013 AOSSM Meeting

Chicago, IL - July 13, 2013

J.R. Rudzki, MDWashington Orthopaedics & Sports Medicine

Clinical Assistant Professor, Dept. of Orthopaedic Surgery

George Washington University School of Medicine

Page 2: Distal Clavicle Fractures

Disclosure

Arthrex – Consultant

AJSM, JBJS, CORR – Reviewer

AAOS – Evaluation Committee, BOC

AOSSM – Enduring Education Committee

Page 3: Distal Clavicle Fractures

Group I – middle-third fractures

Group II – distal-third fractures

Group III – proximal-third fractures

Type I – minimal displacement

(interligamentous)

Type II – medial to CC ligaments

A. Conoid & trapezoid attached

B. Conoid torn, trapezoid attached

Type III – articular surface fractures

Distal Clavicle Fractures Introduction

Reproduced with permission from

Nuber & Bowen, JAAOS 1997

Type IV–ligaments intact to periosteum

(children), with displacement of

proximal fragment

Type V–comminuted, ligaments not

attached proximally or distally, but

to inferior, comminuted fragment

Similar Concepts to

A-C Injuries

Page 4: Distal Clavicle Fractures

The Critical Concept

Which injuries need to be

treated as fractures by:

• ORIF/osteosynthesis

Which injuries need to be

treated as ligament injuries by:

• Ligament repair/reconstruction

Page 5: Distal Clavicle Fractures

The Critical Concept

Which injuries need both:

• ORIF/osteosynthesis

• Ligament repair/reconstruction

Several methods can achieve

successful outcomes

Page 6: Distal Clavicle Fractures

Limitations of Literature

Difficult to define optimal management

Numerous• Small sample sizes; variable inclusion/exclusion criteria

• Short Follow-Up

• Retrospective Reviews, Case Series, Surveys…• Recall Bias • Selection Bias

• Non-validated Outcomes Instruments• Detection Bias

• Susceptibility Bias

Page 7: Distal Clavicle Fractures

Newer Studies

Better Data

Enhanced Understanding of

Anatomy & Biomechanics

2013

Broader Array of Repair

& Reconstructive Options

Technological

Advances

More impt than ever to be clear on

indications for surgery &

best approach for each patient

Page 8: Distal Clavicle Fractures

Type I• Interligamentous fracture

• Minimally displaced

• Treated non-op with

typically excellent results• Nordqvist, Act Orth Scand,1993

Distal Clavicle Fractures Classification

• Neer described incidence of

osteolysis & AC arthrosis

• Arthroscopic distal clavicle

resection may be performed

if symptoms persistent

Page 9: Distal Clavicle Fractures

Type II - A & B

• Type A: trapezoid & conoid ligaments

are attached to distal fragment

ConoidTrapezoid

Distal Clavicle Fractures Classification

• Type B: fracture plane is between

trapezoid & conoid ligaments, & medial

fragment is displaced.

• Greater risk for non-union due to loss of

restraint of C-C ligament

Page 10: Distal Clavicle Fractures

Type III• Intra-articular AC fracture

• No ligamentous injury

• Potential confusion w/

1st degree AC separation

Distal Clavicle Fractures Classification

Page 11: Distal Clavicle Fractures

Type IV• Displaced fracture, C-C ligaments

remain intact attached

to periosteal sleeve

(childhood injury)

Distal Clavicle Fractures Classification

• Displaced, comminuted

fracture with ligaments

attached to butterfly fragment

Type V

Page 12: Distal Clavicle Fractures

Type IV15 y/o elite male hockey player

Distal Clavicular Physeal Closure

Age 19

- XR ~ 4wks after presumed

AC separation

Page 13: Distal Clavicle Fractures

Indications for Treatment:

Controversy regarding Type II

• Classically, type II injuries

associated with higher rates

of nonunion

• 33% - Neer, J Trauma, 1963

• Several authors have

reported increased rates of

non-union for this injury

pattern:• Edwards DJ, Injury, 1992

• Nordqvist, Acta Orth Scan, 1993

• Robinson, JBJS, 2004~30-40%

Page 14: Distal Clavicle Fractures

Indications for Treatment:

Controversy regarding Type II

• Several authors have advocated

surgical intervention based on:• Degree of displacement

• Age & Activity-Level

• Edwards DJ, Injury, 1992

• Nordqvist, Acta Orth Scan, 1993

• Rokito, Bull HJD, 2002-3

• Robinson, JBJS, 2004

~2-50%

• Despite higher rates of non-

union, incidence of symptoms

& need for delayed surgical

reconstruction is controversial

Ballmer, JBJS-Br, 1991; Edwards, Injury, 1992; Yamaguchi, Int Orth, 1998; Flinkkila, Acta Orth

Scand, 2002; Nourissat, Arthroscopy, 2007; Kalamaras, JSES, 2008; Checchia, JSES, 2008

More data

is needed

Page 15: Distal Clavicle Fractures

20 years, 21 articles, 425 cases: 365 surgical cases & 60 nonop tx

Surgical Tx: Nonop Tx:• CC Stabilization – 105

• Hook Plate – 162

• IM Fixation – 16

• K Wire/Tension Band – 40

1.6% Nonunion

22% Complications

33% Nonunion

6.7% Complications

Complication rate with hook plate or K wire (40 vs 20%)

Complication rate with CC

stabilization (4.8%)

Page 16: Distal Clavicle Fractures

JSES, 2010

38 patients treated with hook plate or locked plate & suture

• Union achieved in 95%

• Complication rate 15.8%

Hook plate patients treated in

delayed fashion had higher rate

of complications P = <0.05

Page 17: Distal Clavicle Fractures

Type IIA&B Operative

Surgical Treatment Options:

• Modified Weaver-Dunn

• Transacromial K-wire fixation

• Knowles Pins/Malleolar Screws

• CC Ligament Slings– Mersilene Tape, PDS Braids, FiberTape

• Bosworth CC Screw Fixation

• Plate Fixation

• Arthroscopic Endobutton FixationNourissat, Arthroscopy, 2007

Kalamaras, JSES, 2008

Checchia, JSES, 2008

Page 18: Distal Clavicle Fractures

Type IIA&B Operative Outcomes

Treatment

Clavicular plates for large

distal fragments• Flinkkila, 2002: compared K-wire versus hook

plate fixation - same union rate; higher

complication rate with K-wires

• Tambe, 2005: 10% non-union rate with plate

fixation & 28% rate of acromial osteolysis

• Muramatsu, 2007: 100% union rate @ 4 mos.

w/ hook-plate, Mean Constant Score = 89

Page 19: Distal Clavicle Fractures

CC ligament slings• Mersiline tape: associated w/ clavicle & coracoid fx

• PDS suture: associated w/ loss of reduction Clayer, 1997

• Suture Anchor/Ethibond Sling & K-Wires: Bezer, 2005

Bosworth Screw• Yamaguchi, 1998:

• 11 pts, 100% union @ 10 wks

• 100% return of shoulder fxn to

pre-injury level

• Requires Screw Removal

Type IIA&B Operative Outcomes

Treatment

Page 20: Distal Clavicle Fractures

Modified Weaver-Dunn

• Removal of distal fragment

• Transfer of CA ligament to

clavicle

• Can reinforce with palmaris

or semi-tendonosis graft,

suture anchor, or screw

Type IIA&B Operative Outcomes

Treatment

Non-anatomic Procedure

Page 21: Distal Clavicle Fractures

Severely displaced

5mm;

no bony contact

Mild to moderate

displacement

Acute fixation/stabilization

Large distal fragment

ORIF

Small fragment

• Locking or Hook Plate ORIF• Consider Tendon Graft, suture or

endobutton CC reinforcement

• Open Anatomic Reconstruction

• Arthroscopic Endobutton

• Modified Weaver-Dunn

Union Non-union

Asymptomatic

Mod Weaver-Dunn,

Anatomic, or Arthroscopic

CC Reconstrxn

+ Graft

Pain

or limited

function

Conservative Mgmt

Type II Distal Clavicle Fractures

Page 22: Distal Clavicle Fractures

Better understanding of anatomy, numerous techniques

available, better plates, arthroscopic approaches

Why not fix all of them?

Operative Management Complications

• Loss of Reduction

• Implant Migration

• Clavicle & Coracoid Fracture

• Articular Injury

• Nonunion, Malunion

• Infection

• Neurovascular Injury

• Stiffness

• Hardware Prominence?

• Need for Removal?

Page 23: Distal Clavicle Fractures

Why not fix all of them?

Operative Management Complications

Page 24: Distal Clavicle Fractures

55 y/o RHD male physician went over handlebars of bike

Treatment Options:

• Hook Plate

• Combined Clavicle/Coracoid

Fixation Device

• Transacromial Fixation

• ? +/- Graft Augment ?

Page 25: Distal Clavicle Fractures

Arthroscopic Procedure

Page 26: Distal Clavicle Fractures
Page 27: Distal Clavicle Fractures

4 week follow-up

Page 28: Distal Clavicle Fractures

JSES, 2013

21 specimens: • 7 tightrope

• 7 locking plate

• 7 plate & tightrope

Increased: - stiffness

- max. resistance to compression

Decreased displacement

Further Study is Needed

Page 29: Distal Clavicle Fractures

Arthroscopic Endobutton Fixation

Checchia SL, et al. J Shoulder Elbow Surg, 2008

Nourissat G, et al. Arthroscopy, 2007

Page 30: Distal Clavicle Fractures

5 year follow-up

Page 31: Distal Clavicle Fractures

Sling for 4-6 Weeks

Passive Supine ER & ER with

elbow supported begin immediately

Passive Supine Fwd Elev

Pendulums at 6 wks

Pulleys when Passive Fwd Elev =

90°

Operative Management Rehab Considerations

Page 32: Distal Clavicle Fractures

Key Take-Home Points

Distal Clavicle Fractures Summary

• Distal clavicle fractures are less common• Important to consider in young athletes when

assessing AC joint injury

• Majority can be treated conservatively

• Some displaced type IIb fractures may

warrant surgical intervention • Important to consider potential complications,

need for hardware removal, & re-injury when

choosing surgical approach

Page 33: Distal Clavicle Fractures

2013 AOSSM Meeting

Chicago, IL - July 13, 2013

J.R. Rudzki, MDClinical Assistant Professor, Dept. of Orthopaedic Surgery

George Washington University School of Medicine

Thank You

Distal Clavicle Fractures

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JSES, 201112 pts, 100% union

Page 37: Distal Clavicle Fractures

JSES, 2003