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Clavicle fractures
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Clavicle fractures


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by dr. hardik pawar

by dr. hardik pawar

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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
  • Transcript

    • 1. Clavicle Fractures
    • 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. Clavicle  “S”-shaped bone  Medial - sternoclavicular joint  Lateral - acromioclavicular joint and coracoclavicular ligaments  Muscle attachments:  Medial: sternocleidomastoid  Lateral: Trapezius, pectoralis major
    • 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. 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. 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. Physical Examination  Palpation  Evaluate pain  Look for instability with stress
    • 8. Physical Examination Neurovascular examination Evaluate upper extremity motor and sensation Measure shoulder range-of-motion
    • 9. RADIOGRAPHIC ASSESSMENT• AP view• 10 -15° cephalic tilt view  # pattern  Comminution  Displacement  Shortening• ± Chest, shoulder, c-spine
    • 10. Middle Third Clavicle Fractures
    • 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. 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. Treatment Options  Nonoperative  Sling  Brace  Surgical  PlateFixation  Screw or Pin Fixation
    • 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. 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. 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. 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. 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. 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. 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. 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.  Thus,displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.
    • 23. Definite Indications for SurgicalTreatment of Clavicle Fractures  1) Open fractures  2) Associated neurovascular injury
    • 24. Relative Indications for AcuteTreatment of Clavicle Fractures  1) Widely displaced fractures  2) Multiple trauma  3) Displaced distal-third fractures
    • 25. Relative Indications for AcuteTreatment of Clavicle Fractures  4) Floating shoulder  5) Seizure disorder  6) Cosmetic deformity  7) Earlier return to work.
    • 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. 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. Risk Factors for theDevelopment of ClavicularNonunions Location of Fracture  (outer third) Degree of Displacement  (marked displacement) Primary Open Reduction
    • 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. 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. 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. 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. Complications of ClavicularFractures and its Treatment  Nonunion  Malunion  Neurovascular Sequelae  Post-Traumatic Arthritis
    • 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. 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. 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. 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. 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. 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.  Formost techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.
    • 41. • The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.
    • 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. Preferred Technique forFixation of Acute Distal ThirdClavicle Fractures  Horizontalincision  Manual reduction of fracture  Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.
    • 44. Indications for Late Surgeryfor Distal Clavicle Fractures  Pain  Weakness  Deformity
    • 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. 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. Thank You