Clavicle fractures

Clavicle fractures
Features of clavicle: 1. First bone to ossify
2. Last ossification centre to fuse (at 22 to 25 years)
3. It is the only long bone to ossify in intramembranous ossification without a cartilaginous state
4. The clavicle is the only bone connecting the axial skeleton to the appendicular skeleton.
5. The medial third is tubular and the lateral third is flat
6. The junction of medial two third and lateral one thirds is a junction of two cross sectional
configurations, hence a weak area 7. Middle third of clavicle is not supported
by muscles or ligaments which again makes it susceptible to fracture Mechanism of injury: Direct fall onto the
shoulder is the most common mode of violence to produce a clavicular fracture Clinical Features:
1. Splinting of the affected extremity with the arm held in adduction across the chest.
supported by the normal extremity is common. 2. Crepitus may be felt
3. Tenting of the skin due to the proximal fragment
4. Look for evidence of associated injuries. Diminished breath sounds with hyper resonance
on percussion may herald an underlying pneumothorax. 5. Look for associated neurovascular injuries
Allmann Classification Group I: Fracture of the middle third
Group II: Fracture of the distal third • Type I: Displaced secondary to a fracture
medial to the coracoclavicular • Type II A: Conoid and trapezoid attached
to the distal segment • Type IIB: Conoid torn, trapezoid attached
Group III: Fracture of the proximal third • Type I: Minimal displacement
• Type II: Displaced • Type III: Intra-articular
• Type IV: Epiphyseal separation • Type V: Comminuted.
X-Rays: Middle third fractures and proximal third
fractures: AP view and 45° caudal tilt view
Distal third fractures: According to Neer the following views are
essential: 1. AP view of both shoulders with 10 lb weight
tied to the wrists (similar to AC joint stress view)
2. Anterior 45° oblique view. This provides a true lateral view of the scapula, the distal
fragment is displaced anteriorly and the proximal fragment is displaced posteriorly.
3. Posterior 45° oblique view. CT scan:
1. May be essential in proximal third fractures to differentiate medial epiphyseal injury
from sternoclavicular joint dislocation 2. In distal third fractures it helps to rule
out intra articular involvement Treatment:
Nonoperative Treatment • Sling immobilisation
• Figure-of-eight bandages are commonly used.
Operative Treatment (Indications) • Neurovascular injury
• Impending skin compromise • Open fractures
• Scapulothoracic dissociation • Group II, type II fractures (high nonunion
rate) • Floating shoulder (clavicular # and glenoid
neck #): clavicle alone is operated Recently, relative indications for surgical
treatment have been expanded to include: 1. high-energy closed fractures with>15 to
20 mm of shortening, 2. fractures with complete displacement, and
3. Fractures with comminution. (Canadian Orthopaedic Trauma Society: J Bone
Joint Surg Am 2007;89:1-10.). More Randomised Controlled trials are necessary to determine
the outcome of these indications. CM Robinson et al.. from Bristol in an RCT in 2013 however
indicated that operative treatment for clavicle fractures should be reserved for the classic
indications only. Many authors have indicated that operating on an acute clavicle fracture
increases the complication rates as well as the reoperation rates Pearls and Pitfalls- ORIF for clavicle fractures:
• 3.5mm LCDCP or Low profile reconstruction plates are ideal. Pins are not recommended
because of danger of migration of pins into the thorax. Recently, a Rockwood pin is being
used that doesn’t migrate. • Plates should be precontoured to save
operative time. Precontoured clavicle plates are becoming commercially available. Also
are locking plates for the clavicle • Incision is placed on the superior surface
(or anterior surface) of the bone with the patient in a beach chair or semi sitting position.
• Plates are placed on the superior surface or the anterior surface
• Anteriorly placed plates are supposed to produce less complications like injury
to underlying neurovascular structures (as when the plate is placed superiorly and drilled.)
• They occupy the widest part of the clavicle and hence offer better stability and are associated
with less prominence • An 8 hole plate is typically used, lag
screws are used whenever possible • Plate must be bent to the shape of an
‘S’, when viewed on edge and without bend when viewed with screw holes in plane view.
• Anterior plates require more contouring. • A minimum of 3 screws should be placed
on either side • Screws are placed in a posterosuperior
direction. • Care should be taken while drilling, and
a protective instrument should be placed to avoid injury to critical structures
• In cases of malunion/nonunion where there is shortening an intercalary bone graft may
be necessary • Malrotation may be addressed by apposing
the superior flat surfaces together. Complications
1. Malunion: Defined as union of the fracture in a shortened, angulated, or displaced position
with weakness, rapid fatigability, pain with overhead activity, neurologic symptoms (numbness
and paresthesia of the hand and forearm with elevation of the limb), and shoulder asymmetry. 2. Neurovascular injury (Laceration of subclavian
vessels or brachial plexus) 3. Non-union. This is rare. It occurs in
a) Group II type II fractures, b) Following ORIF, or
c) Due to soft tissue interposition Some studies quote a higher incidence of non-union
in middle third clavicle fractures (as high as 10-15%) especially when there is a shortening
more than 20mm, though traditionally the risk of nonunion has been 4-5%. Most authors agree
that incidence of nonunion is around 4-5% especially when large number of patients are
included in the study. 4. Post traumatic arthritis (in intraarticular
fractures involving the medial and lateral ends) Indications for surgery in middle third clavicle
# malunion/non union after initial conservative management include (Robinson et al. JBJS 1998,
80B: 476-484): – 1. Malunion or non union with shortening (>15mm)
2. Angular deformity (>30) or translation>1cm
3. Symptoms consistent with Thoracic outlet syndrome
4. Chronic pain with repeated overhead or resisted activity
5. Pain when using shoulder straps or backpacks 6. Dissatisfaction with the appearance or
asymmetry of the shoulders 7. Substantial disability detected on patient-oriented
limb specific health measures Contraindications for operative management
• Active infection in the area • Previous soft-tissue irradiation to the
operative area • Burns over the clavicular area
• A high risk of poor patient compliance, especially due to drugs or alcohol
• An elderly patient with a sedentary lifestyle

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