Clavicle fractures

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Clavicle fractures

  1. 1. CLAVICLE FRACTURES Kevin R. Stone, M.D. The Stone Clinic, San Francisco, CA
  2. 2. CLAVICLE FRACTURES prevalence <ul><li>Clavicle Fractures: 10% of all fractures </li></ul><ul><li>44% all shoulder fractures </li></ul><ul><li>75% are middle third of the clavicle </li></ul>
  3. 3. 1/3 rd CLAVICLE FRACTURES Clinical Findings and Questions <ul><li>Is non-operative care really OK? </li></ul><ul><li>How much displacement and/or overlap is too much? </li></ul><ul><li>Deficits of short or mal-aligned healing? </li></ul><ul><li>Goal: Good enough or Normal? </li></ul>
  4. 4. CLAVICLE FRACTURES Clinical Findings and Questions <ul><li>Do slings figure 8 or immobilization matter? </li></ul><ul><li>Are 40 degrees of clavicle rotation restored </li></ul><ul><li>Why is healing so variable? </li></ul><ul><ul><li>Thin bone </li></ul></ul><ul><ul><li>little cancellous bone </li></ul></ul><ul><ul><li>minimal tissue coverage </li></ul></ul><ul><ul><li>lots of motion </li></ul></ul><ul><ul><li>…how little we really know. </li></ul></ul>
  5. 5. CLAVICLE FRACTURES published outcome studies <ul><li>Hill: non-operative: </li></ul><ul><ul><li>15% nonunion </li></ul></ul><ul><ul><li>31% patient unsatisfactory with pain or plexus irritation </li></ul></ul><ul><ul><li>No loss of motion or strength at 38 months </li></ul></ul><ul><ul><li>Initial shortening of >20mm or final shortening of >20mm led to poor result </li></ul></ul><ul><ul><li>Sling, activity, communition, mechanism of injury, age, gender did not matter </li></ul></ul><ul><li>Other studies: Neer 0.1%; Rowe 0.8%; Eskola 3%; White 13% </li></ul>
  6. 6. CLAVICLE FRACTURES operative indications <ul><li>Angulation with skin tenting </li></ul><ul><li>Shortening >2cm (1.5?) </li></ul><ul><li>Driven athlete with competition near </li></ul><ul><li>(bike racers) </li></ul><ul><li>Overhead athlete with shoulder </li></ul><ul><li>mechanics concerns </li></ul><ul><li>Cosmetic concerns (bump, length) </li></ul>
  7. 7. OPERATIVE TECHNIQUE Intra-medullary fixation (modified from Cave 1958) <ul><li>Beach chair patient positioning </li></ul><ul><li>C-arm Fluoro on top </li></ul><ul><li>Cosmetic Incision </li></ul><ul><li>Bone clamps </li></ul><ul><ul><li>Deformity is downward lateral displacement </li></ul></ul><ul><ul><li>due to shoulder </li></ul></ul><ul><ul><li>Upward backward medial due </li></ul></ul><ul><ul><li>sternocleidomastoid </li></ul></ul>
  8. 8. OPERATIVE TECHNIQUE Intra-medullary fixation (continued) <ul><li>Guide pin double point and overdrill both </li></ul><ul><li>directions </li></ul><ul><ul><li>Flat to prismatic bone with “thick compacta” minimal medullary space </li></ul></ul><ul><li>Reduce and screw </li></ul>
  9. 9. OPERATIVE TECHNIQUE Intra-medullary fixation
  10. 10. OPERATIVE TECHNIQUE Intra-medullary fixation
  11. 11. OPERATIVE TECHNIQUE Intra-medullary fixation
  12. 12. OPERATIVE TECHNIQUE Intra-medullary fixation
  13. 13. OPERATIVE TECHNIQUE Intra-medullary fixation
  14. 14. CLAVICLE FRACTURE Open reduction with IM Fixation: problems <ul><li>Screw length </li></ul><ul><li>Bump </li></ul><ul><li>Break out </li></ul><ul><li>Infection </li></ul><ul><li>Screw removal </li></ul><ul><li>Screw migration </li></ul>
  15. 15. CLAVICLE FRACTURES Patient Example: SF <ul><li>37 year old, male </li></ul><ul><li>Drummer </li></ul><ul><li>Cyclist </li></ul><ul><li>History of injury: </li></ul><ul><ul><li>Head over handlebars </li></ul></ul><ul><ul><li>Clavicle fractured in 3 places </li></ul></ul>
  16. 16. CLAVICLE FRACTURES Patient Example: SF <ul><li>Right shoulder displaced </li></ul><ul><li>Angulated mid shaft </li></ul><ul><li>clavicular fracture (>2cm) </li></ul>
  17. 17. Patient Example: SF <ul><li>Open reduction internal fixation of clavicle </li></ul><ul><li>Intermedullary 65 AO screw and washer </li></ul>Post-op X-ray, day 1 Post-op X-ray, 4 weeks
  18. 18. CLAVICLE FRACTURES Patient Example: JC <ul><li>36 year old male </li></ul><ul><li>Amateur cyclist </li></ul><ul><li>Previous shoulder dislocation 1 yr prior </li></ul><ul><li>History of injury: </li></ul><ul><ul><li>Bicycle racing accident: “took out his front end” </li></ul></ul><ul><ul><li>Flipped, landed on head and shoulder. </li></ul></ul>
  19. 19. CLAVICLE FRACTURES Patient Example: JC Pre-op x-ray
  20. 20. CLAVICLE FRACTURES Patient Example: JC Post-op x-ray Open reduction and internal fixation Problem - Proud Screw
  21. 21. Patient Example: JC 2 Mo. Post-op x-ray Hardware Removal 8 Mo. Post-op
  22. 22. CLAVICLE FRACTURES Patient Example: MM <ul><li>47 year old male </li></ul><ul><li>Software engineer </li></ul><ul><li>Cyclist </li></ul>
  23. 23. CLAVICLE FRACTURES Patient Example: MM X-ray Immediately Post Trauma Non-operative care or operative fixation??? AP Oblique
  24. 24. CLAVICLE FRACTURES Patient Example: MM 1 Mo. Post Trauma X-ray Non-operative care Oblique AP
  25. 25. CLAVICLE FRACTURES Summary <ul><li>Non-Operative treatment can lead to excellent healing and alignment </li></ul><ul><ul><li>However there can be complications </li></ul></ul><ul><li>Operative fixation can lead to excellent healing and alignment </li></ul><ul><ul><li>However there can be complications </li></ul></ul>
  26. 26. Thank you

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