Clavicle fractures


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  • 2) Shoulder joint being formed by the: GH, SC, AC, ST jnts
  • Direct blow: Shown to account for 85 to 94% of the injuries by biomechanical analysis as well as several studies
  • Hill: retrospective review of 242 clavicle # cases ; 52 mid shaft for 38 months 8 NU; 16 unsatisfact Ali khan 12 plates all united Zenni 25 IM all united
  • So when do we treat conservatively? RCTS: As much as there 200 methods of closed reduction techniques described in the literature …
  • 89 fractures: only one deep infection
  • Clavicle fractures

    1. 1. Clavicle Fractures
    2. 2. INTRODUCTION Clavicle one of the most commonly fractured bones 2.6% - 5% of all fractures 35% - 45% of shoulder girdle fractures  Postacchini F, Gumina S, De Santis P, Albo F: Epidemiology of clavicle fractures.J Shoulder Elbow Surg 2002;11:452-456.  Nordqvist A, Petersson C: The incidence of fractures of the clavicle.Clin Orthop Relat Res 1994;300:127-132. Midshaft clavicle fractures account for 69% - 80%  Albo F: Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-456.  Nordqvist A, Petersson C: The incidence of fractures of the clavicle. Clin Orthop Relat Res 1994;300:127- 132.  Robinson CM: Fractures of the clavicle in the adult: Epidemiology and classification. J Bone Joint Surg Br 1998;80:476-484.  Rowe CR: An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29- 42.  Nowak J, Mallmin H, Larsson S: The aetiology and epidemiology of clavicular fractures: A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;31:353-358.
    3. 3. Clavicle  “S”-shaped bone  Medial - sternoclavicular joint  Lateral - acromioclavicular joint and coracoclavicular ligaments  Muscle attachments:  Medial: sternocleidomastoid  Lateral: Trapezius, pectoralis major
    4. 4. APPLIED BASIC SCIENCE Osseous anatomy and muscular/ligamentous attachments play a pivotal role in determining fracture patterns # most common at junction of outer and middle 3rd  Thinnest part of bone  not protected by muscle/ligamentous attachments Deformity:  SCM pulls proximal fragment superiorly and posteriorly  weight of arm and pectoralis muscles pull distal segment medially and inferiorly
    5. 5. MECHANISM OF INJURY Traditionally thought to occur from “FOOSH” Various mechanisms 1. Direct blow onto the point of the shoulder – Shown to account for 85 to 94% of clavicle fractures • Stanley D, Trowbridge EA, Norris SH: The mechanism of clavicular fracture: A clinical and biomechanical analysis. J Bone Joint Surg Br 1988;70:461-464. • Nordqvist A, Petersson C: The incidence of fractures of the clavicle. Clin Orthop Relat Res 1994;300:127-132. • Robinson CM: Fractures of the clavicle in the adult: Epidemiology and classification. J Bone Joint Surg Br 1998;80:476-484. • Nowak J, Mallmin H, Larsson S: The aetiology and epidemiology of clavicular fractures: A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;31:353-358. 1. Direct blow to clavicle – seat belt strap injuries – 10 to 13% 1. FOOSH 2 to 5% others Sports injury motor vehicle accidents
    6. 6. Physical Examination Inspection  Evaluate deformity and/or displacement  Beware of rare inferior or posterior displacement of distal or medial ends of clavicle  Compare to opposite side.
    7. 7. Physical Examination  Palpation  Evaluate pain  Look for instability with stress
    8. 8. Physical Examination Neurovascular examination Evaluate upper extremity motor and sensation Measure shoulder range-of-motion
    9. 9. RADIOGRAPHIC ASSESSMENT• AP view• 10 -15° cephalic tilt view  # pattern  Comminution  Displacement  Shortening• ± Chest, shoulder, c-spine
    10. 10. Middle Third Clavicle Fractures
    11. 11. ClassificationCraig Classification Group I: Fracture of the middle third Group II: Fracture of the distal third. Subclassified according to the location of coracoclavicular ligaments relative to the fracture as follows: Type I: Minimal displacement: interligamentous fracture between conoid and trapezoid or between the coracoclavicular and acromiocavicular ligaments Type II: Displaced secondary to a fracture medial to the coracoclavicular ligaments – higher incidence of non-union
    12. 12. IIA: Conoid and trapezoid attached to the distal segment (see Figure 2.1) IIB: Conoid torn, trapezoid attached to the distal segment (see Figure 2.2)Type III: Fracture of the articular surface of the acromioclavicular joint with noligamentous injury – may be confused withfirst degree acromioclavicular jointseparationGroup III: Fracture of the proximal third:Type I: Minimal displacementType II: Significant displaced (ligamentousrupture)Type III: IntraarticularType IV: Epiphyseal separationType V: Comminuted
    13. 13. Treatment Options  Nonoperative  Sling  Brace  Surgical  PlateFixation  Screw or Pin Fixation
    14. 14. Simple Sling vs.Figure-of-8 Bandage Prospective randomized trial of 61 patients Simple sling  Less discomfort Functional and cosmetic results identical Alignment of healed fractures unchanged from the initial displacement in both groups Andersen et al., Acta Orthop Scand 58: 71-4, 1987.
    15. 15. CHANGING TRENDS IN MANAGEMENT OF ACUTE CLAVICULAR MIDSHAFT FRACTURES Traditionally been treated non-operatively, even when substantially displaced Early reports suggested non-union was extremely rare  4 (0.8%) out of 556 (3.7% with surgery)  Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. CORR 1968  3 (0.1%) out of 2235 (4.6% with surgery)  most important causal factor for nonunion of a midshaft clavicular fracture is improper open surgery  Neer CS 2nd. Nonunion of the clavicle. JAMA 1960 Recent studies on non-operative mx report:  Higher non-union rate (15%)  Higher rate (32%) of unsatisfactory patient outcome  Hill et al. Closed treatment of middle-third clavicle fractures gives poor results. JBJSB 1997 Several recent studies reported high union rates with surgical intervention using a variety of internal fixation devices  Ali Khan MA, Lucas HK: Plating of fractures of the middle third of the clavicle. Injury 1978  Zenni EJ Jr, Krieg JK, Rosen MJ: Open reduction and internal fixation of clavicular fractures. JBJSA 1981
    16. 16. NON-OPERATIVE MANAGEMENT Historically, has been the mainstay for clavicular fractures Indicated for non-displaced or minimally displaced midshaft clavicular fracture Consist of:  Most commonly, a sling or figure-of-8 brace applied in the acute setting  immobilization typically for 2 to 6 weeks  Gradual return to normal activites Andersen K, Jensen PO, Lauritzen J: Treatment of clavicular fractures: Figure-of-eight versus a simple sling. Acta Orthop Scand 1987;58:71-74.  Prospective, randomized study involving 61 patients  26% of patients treated with a figure-of-8 bandage were dissatisfied compared with 7% of those treated with a sling  There was no difference in overall healing and alignment of the fractures indicating that a figure-of-8 bandage does little to obtain or maintain reduction
    17. 17. Nonoperative Treatment There is new evidence that the outcome of nonoperative management of displaced middle-third clavicle fractures is not as good as traditionally thought, with many patients having significant functional problems.
    18. 18. MANAGEMENT OF ACUTE MIDHSAFT CLAVICLEFRACTURE: LITERATURE EVIDENCE FRACTURE DISPLACEMENT / SHORTENING 1. Nowak J, Holgersson M, Larsson S: Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004 • Prospective study 245 patients with 9-10 years follow-up  Displacement without bony contact, especially with comminuted transverse fracture, and an elderly patients, strongly predictive of long term sequelae and persistent symptoms 1. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE: Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004 • Prospective review of 581 midshaft clavicular fractures • 4.5 % non-union rate  Fracture displacement, fracture comminution, female gender, advanced age significantly increase risk of non-union
    19. 19. MANAGEMENT OF ACUTE MIDHSAFT CLAVICLEFRACTURE: LITERATURE EVIDENCEFRACTURE DISPLACEMENT / SHORTENING3. Wick M, Müller EJ, Kollig E, Muhr G: Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001 • Retrospective analysis of 39 clavicle non-union / delayed union  Shortening of 2 cm in midshaft clavicular fractures was associated with an increased risk of pain, limitation of motion, or nonunion3. McKee MD et al: Deficits following non-operative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006 • Prospective study of 30 cases with displaced midshaft clavicle #s (mean follow-up 55 months) • assessed functional outcome and noted significantly inferior scores for both the upper extremity–specific (DASH) outcome scores and the Constant scores compared with the general population.  fractures with >2 cm of shortening tended to be associated with decreased abduction strength and greater patient dissatisfaction
    20. 20. Deficits following nonoperative treatment of displaced midshaft clavicular fractures  The strength of the injured shoulder was 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all).  The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability.McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.
    21. 21. MANAGEMENT OF ACUTE MIDHSAFT CLAVICLEFRACTURE: LITERATURE EVIDENCEFRACTURE DISPLACEMENT / SHORTENING5. Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997 • Retrospective review of 52 midshaft clavicular fractures  final shortening ≥2 cm was associated with an unsatisfactory result but not with non-union6. Ledger M, Leeks N, Ackland T, Wang A: Short malunions of the clavicle: An anatomic and functional study.J Shoulder Elbow Surg 2005 • Evaluated the effects of clavicular malunion (15mm shortening) in 10 subjects using CT with #D recon, shoulder score assessments and biomechanical testing  Significant increase in upward angulation of the SC joint and an increased scapular version compared with the uninjured side  Significantly weaker muscle strength than that of the uninjured arm  Significant poorer shoulder scores outcome These studies indicate that although clavicular deformities are complex and hard to assess, shortening of 1.5 to 2 cm results in an increased incidence of clinical symptoms
    22. 22.  Thus,displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.
    23. 23. Definite Indications for SurgicalTreatment of Clavicle Fractures  1) Open fractures  2) Associated neurovascular injury
    24. 24. Relative Indications for AcuteTreatment of Clavicle Fractures  1) Widely displaced fractures  2) Multiple trauma  3) Displaced distal-third fractures
    25. 25. Relative Indications for AcuteTreatment of Clavicle Fractures  4) Floating shoulder  5) Seizure disorder  6) Cosmetic deformity  7) Earlier return to work.
    26. 26. SURGICAL MANAGEMENT PLATING Advantages of surgery  Early mobilisation  Better early pain relief Incision  Directly over clavicle along Langer’s line  Sabre cut incision  Preservation of supra-clavicular nerves  Inferior incision  Coupe et. al.: A new approach for plate fixation of midshaft clavicular fractures. Injury 2005  Proposed to prevent wound complications and improve cosmesis
    27. 27. Plate Fixation Traditionalmeans of ORIF Plate applied superiorly or inferiorly  Inferior plating associated with lower risk of hardware prominence Used for acute displaced fractures and nonunions.
    28. 28. Risk Factors for theDevelopment of ClavicularNonunions Location of Fracture  (outer third) Degree of Displacement  (marked displacement) Primary Open Reduction
    29. 29. Principles for the Treatment ofClavicular Nonunions Restore length of clavicle  May need intercalary bone graft Rigid internal fixation, usually with a plate Iliac crest bone graft  Role of bone-graft substitutes not yet defined.
    30. 30. Clavicle non-union- autologous bonegraft not a necessary augment 15 patients with symptomatic non-union after nonoperative treatment of a midshaft clavicle fracture of the clavicle Hypertrophic non-union had excessive callus morselized Atrophic non-union had freshening of ends of bone Use of titanium pre-contoured plate All patients – radiographic and clinical union , returned to work and regular sports Suggested distant bone graft unnecessary with preparation of bone ends and adequate fixation J F Baker, et al. Acta Orthop Belgium 2010;76:725-729
    31. 31. The role of autologous bone graft insurgical treatment of hypertrophic non-union of mid shaft clavicle 51 patients treated with 3.5 LC-DCP without bone graft, 30(Grp 1) had previous surgery and 21 (Grp 2 ) had non-operative treatment follow-up for 20 months Decortication of bone ends, medullary canal was reamed with drill All had uneventful union No statistical difference between the two groups postoperative function scores, union time or patient demographics HK Huang MD, et al. J Chinese Medical A 2012;75:216-210
    32. 32. Intramedullary Fixation Large threaded cannulated screws Flexible elastic nails K-wires  Associated with risk of migration Useful when plate fixation contra- indicated  Bad skin  Severe osteopenia Fixation less secure
    33. 33. Complications of ClavicularFractures and its Treatment  Nonunion  Malunion  Neurovascular Sequelae  Post-Traumatic Arthritis
    34. 34. Principles for the Treatment ofClavicular Nonunions Restore length of clavicle  May need intercalary bone graft Rigid internal fixation, usually with a plate Iliac crest bone graft  Role of bone-graft substitutes not yet defined.
    35. 35. Clavicular Malunion Symptoms of pain, fatigue, cosmetic deformity. Initially treat with strengthening, especially of scapulothoracic stabilizers. Consider osteotomy, internal fixation in rare cases in which nonoperative treatment fails. Correction of malunion with thoracic outlet sx
    36. 36. Neurologic Sequelae Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms. Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.
    37. 37. Osteotomy for ClavicularMalunion 15 patients with malunion after nonoperative treatment of a displaced midshaft clavicle fracture of the clavicle. Average clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm). Mean time from the injury to presentation was three years (range, 1 to 15 years). Outcome scores revealed major functional deficits. All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7
    38. 38. Osteotomy forClavicular Malunion At follow-up (mean 20 months postoperatively) the osteotomy site had united in 14 of 15 patients. All 14 patients satisfied with the result. Mean DASH score for all 15 patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001). Mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01). There was 1 nonunion, and 2 patients had elective removal of the plate. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7
    39. 39. Techniques for Acute OperativeTreatment of Distal ClavicleFractures Kirschner wires inserted into the distal fragment Dorsal plate fixation CC screw fixation Tension-band wire or suture Transfer of coracoid process to the clavicle Clavicular Hook Plate
    40. 40.  Formost techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.
    41. 41. • The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.
    42. 42. Hook Plate - Results Recent series of distal clavicle fractuers treated with the Hook Plate document high union rates of 88% - 100%. Complications are rare but potentially significant, including new fracture about the implant, rotator cuff tear, and frequent subacromial impingement.
    43. 43. Preferred Technique forFixation of Acute Distal ThirdClavicle Fractures  Horizontalincision  Manual reduction of fracture  Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.
    44. 44. Indications for Late Surgeryfor Distal Clavicle Fractures  Pain  Weakness  Deformity
    45. 45. Techniques for Late Surgeryfor Distal Clavicle Fractures  Excision of distal clavicle  With or without reconstruction of coracoclavicular ligaments (Modified Weaver-Dunn procedure)  Reduction and fixation of fracture
    46. 46. SUMMARY1. Most mid-shaft clavicular fractures heal without incident when length and alignment are maintained Nondisplaced and minimally displaced fractures should be treated nonsurgically, preferably with a sling for patient comfort • acceptable cosmetic and functional results, as well as union rates can be expected2. The risk of complications from non-surgical management may be significantly higher: • those with completely displaced (1.5 to 2cm) and comminuted fractures • Possibly those who are female or of advanced age The current literature suggests that surgical stabilization, with either plates or IM device, should be considered the preferred treatment option for these more complex acute midshaft clavicular fractures
    47. 47. Thank You