by dr. hardik pawar

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. Classification
Craig 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 no
ligamentous injury – may be confused with
first degree acromioclavicular joint
separation
Group III: Fracture of the proximal third:
Type I: Minimal displacement
Type II: Significant displaced (ligamentous
rupture)
Type III: Intraarticular
Type IV: Epiphyseal separation
Type 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 CLAVICLE
FRACTURE: 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 CLAVICLE
FRACTURE: LITERATURE EVIDENCE
FRACTURE DISPLACEMENT / SHORTENING
3. 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 nonunion
3. 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 CLAVICLE
FRACTURE: LITERATURE EVIDENCE
FRACTURE DISPLACEMENT / SHORTENING
5. 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-union
6. 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 Surgical
Treatment of Clavicle Fractures
 1) Open fractures
 2) Associated neurovascular injury

24. Relative Indications for Acute
Treatment of Clavicle Fractures
 1) Widely displaced fractures
 2) Multiple trauma
 3) Displaced distal-third fractures

25. Relative Indications for Acute
Treatment 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.

32. Risk Factors for the
Development of Clavicular
Nonunions
 Location of Fracture
 (outer third)
 Degree of Displacement
 (marked displacement)
 Primary Open Reduction

33. Principles for the Treatment of
Clavicular 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.

34. Clavicle non-union- autologous bone
graft 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

35. The role of autologous bone graft in
surgical 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

36. 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

37. Complications of Clavicular
Fractures and its Treatment
 Nonunion
 Malunion
 Neurovascular Sequelae
 Post-Traumatic Arthritis

38. Principles for the Treatment of
Clavicular 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.

39. 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

40. 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.

41. Osteotomy for Clavicular
Malunion
 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

42. Osteotomy for
Clavicular 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

43. Techniques for Acute Operative
Treatment of Distal Clavicle
Fractures
 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

44.  Formost techniques of clavicular fixation,
coracoclavicular fixation is also needed to
prevent redisplacement of the medial
clavicle.

45. • The Hook Plate (Synthes USA, Paoli, PA)
was specifically designed to avoid this
problem of redisplacement.

47. 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.

48. Preferred Technique for
Fixation of Acute Distal Third
Clavicle Fractures
 Horizontalincision
 Manual reduction of fracture
 Dorsal tension band suture and
reconstruction/augmentation of
coracoclavicular ligaments.

49. Indications for Late Surgery
for Distal Clavicle Fractures
 Pain
 Weakness
 Deformity

50. Techniques for Late Surgery
for Distal Clavicle Fractures
 Excision of distal clavicle
 With or without reconstruction of
coracoclavicular ligaments (Modified
Weaver-Dunn procedure)
 Reduction and fixation of fracture

51. SUMMARY
1. 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
expected
2. 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

52. Thank You