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1. Clavicle fracture-
MANAGEMENT
BY
M J FELIX EMERSON

2.  More than 200 methods have been described to treat fractures of the
clavicle

3. NON OPERATIVE
 Group I, middle one-third, clavicle fractures can generally be treated
nonoperatively.
 A figure-of-eight bandage with or without plaster reinforcement has long
been recommended and is one very good treatment option

4.  The goal of this method is to reoppose the bone ends as much as possible
by simultaneously raising the lateral fragment upward and backward while
depressing the medial fragment.
 The advantage of a figure-of-eight brace is that it leaves the ipsilateral
hand free for use while splinting the fracture helps keep the patient's
shoulders back and the clavicle out to length, minimizing the chance of
the bone healing in a shortened position.
 The disadvantages of this method include the difficulty many patients
have keeping the brace adjusted properly and the potential skin problems
caused by the brace, as well as impairment of patients' agility, personal
hygiene needs, and comfort while sleeping.

6.  Alternatively, middle-third clavicle fractures may be treated with an arm
sling.
 Although a sling does nothing to correct shortening or displacement at the
fracture site, it is often more comfortable and convenient for patients than
a figure-or-eight brace and yet leads to the same rate of union and
excellent function as can be achieved with more restrictive treatment
methods

8. COMPLICATIONS
 Treated nonoperatively, the vast majority of middle-third clavicle fractures
heal uneventfully and with little or no functional limitations.
 The nonunion rate for middle-third clavicle fractures ranges from 1-5%.
 Higher rates of nonunion in middle-third clavicle fractures have been
associated with high-energy fractures, wide displacement (1to 2 cm),
refracture, soft tissue interposition by the trapezius muscle.

9. Indications for Primary Fixation of
Midshaft Clavicle Fractures
Fracture Specific
 Displacement >2 cm
 Shortening >2 cm
 Increasing comminution (>3 fragments)
 Segmental fractures
 Open fractures
 Impending open fractures with soft tissue compromise
 Scapular malposition and winging on initial examination

10. Associated Injuries
 Vascular injury requiring repair
 Progressive neurologic deficit
 Ipsilateral upper extremity injuries/fractures
 Multiple ipsilateral upper rib fractures
 “Floating shoulder”
 Bilateral clavicle fractures

11. Patient Factors
 Polytrauma with requirement for early upper extremity weight
bearing/arm use
 Patient motivation for rapid return of function (e.g., elite sports or the self-
employed professional)

12. “FLOATING SHOULDER”
 The combination of ipsilateral fractures of the clavicle and scapular neck
has traditionally been called the “floating shoulder,” which has been
considered to be an unstable injury that may require operative fixation.
 This injury pattern can be considered to be a subgroup of the “double
disruption of the superior shoulder suspensory complex (SSSC)

14. SSSC
 This includes the bone and soft tissue circle, or ring, of the glenoid,
coracoid process, coracoclavicular ligament, clavicle (especially its distal
part), AC joint, and the acromion.
 This complex is extremely important biomechanically, as it maintains the
anatomic relationship between the upper extremity and the axial skeleton.
 The clavicle is the only bony connection between the two, and the
scapula is suspended from it by the coracoclavicular and AC ligaments.
 Thus, any injury that disrupts this ring at two or more levels is considered
inherently unstable.

15. OPERATIVE TECHNIQUES
Middle-Third Fractures
 Three types of fixation are available for middle-third clavicle fractures:
intramedullary devices, plates, and external fixators.

16. INTRAMEDULLARY FIXATION
 Intramedullary fixation can be accomplished with smooth or threaded K-
wires, Steinman pins, Knowles pins, Hagie pins, or cannulated screws.
 The advantages of using intramedullary devices are several: less surgical
dissection and soft tissue stripping is needed, and the hardware is less
prominent.
 Disadvantages include possible pin migration and poor rotational control
during elevation of the extremity above shoulder level.

19. `
 Most techniques using intramedullary devices utilize the S-shaped curve of the
clavicle for hardware placement.
 A small anterior incision, exposure of the bone ends, and retrograde insertion
of the chosen pin or device. Once the fracture is reduced, the pins are
advanced back across the fracture into the anterior cortex of the medial
fragment.
 Two 2-mm smooth K-wires inserted retrograde into the medial fragment and
then antegrade into the lateral fragment.
 Recently, modifications to the technique have included a radiographically
guided completely “closed” technique
 If these pins back out, they are very prominent and easy to remove. Two wires
are used to prevent rotation.
 Removal of K-wires is recommended once the fracture has healed. In
contrast, Knowles pins and screws do not need to be removed unless
hardware-related symptoms develop.

20. PLATE FIXATION
 Biomechanically, plate fixation is superior to intramedullary fixation because it better
resists the bending and torsional forces that occur during elevation of the upper
extremity above shoulder level.
 Patients treated with plate fixation can be allowed full range of motion once their soft
tissues have healed.
 Disadvantages of plate fixation include the necessity for increased exposure and soft-
tissue stripping;potential damage to the supraclavicular nerves, which cross through
the surgical field; slightly higher infection rates ; and the risk of refracture after plate
removal.
 Despite these shortcomings, plate fixation utilizing careful surgical technique and
appropriate use of autogenous bone grafting is an excellent method of treatment for
these injuries.

23.  A 3.5-mm AO/ASIF dynamic compression plate (DCP) or a low-contact
dynamic compression plate with at least three screws (six cortices) in both
the medial and lateral fragment and an interfragmentary lag screw
whenever the fracture pattern allows it.
 No difference between using 3.5-mm DCPs and 3.5-mm AO/ASIF
reconstruction plates; both provided acceptable fixation and rigidity.
 One-third of tubular plates have a high rate of fatigue failure when used
for clavicle fractures and should be avoided.
 The 3.5mm DCPs should be precontoured and placed superiorly (best) or
anteriorly (second best). Autogenous bone graft should be used in
comminuted fractures with bone loss.

24. External fixation of the clavicle
its indications are few
 It may be indicated for severe open fractures with poor quality of overlying
skin.
 External fixation may also be indicated for treatment of clavicle fractures
in the face of infection or infected nonunions following plate removal.
 Even in these cases, plate fixation should be considered first and used
whenever possible.

26. DISTAL THIRD
CLAVICLE
FRACTURES
The treatment of distal-
third clavicle fractures is
based on their
classification.

27.  Type I fractures are stable because of the intact surrounding ligaments
and can be treated effectively with sling immobilization and progressive
use of the shoulder as pain allows.
 Most type I fractures heal within 4 to 6 weeks with little to no residual
shoulder dysfunction

28.  Type II fractures are more difficult to
treat nonoperatively because of the
deforming forces.
 The trapezius pulls upward and
posteriorly on the medial fragment,
which is no longer tethered by the
coracoclavicular ligaments and thus
becomes widely displaced from the
lateral fragment.

29. Several surgical treatment options are possible
 Transacromial K-wires with or without a tension band
 Coracoclavicular screw
 Plate fixation –Hook Plate
 Coracoclavicular banding or taping with or without acromioclavicular
fixation utilizing dacron or other synthetic materials

33.  The choice of one technique over another should be based on the size of
the distal fragment, patient and fracture anatomy, and surgeon's
preference.
 If there is a noncomminuted, 2- to 3-cm distal piece, then a small-fragment
AO T-plate or
 Two K-wires with a tension band placed outside the acromioclavicular joint
are good choices for fixation.

34. On the other hand, comminuted and/or small distal fragments require
 Transacromial wire fixation
 coracoclavicular screw fixation or
 coracoclavicular ligament repair.

35.  Type III fractures (those with intraarticular extension) of the distal clavicle
generally can be treated nonoperatively with a sling for support and
gradual return to normal use of the extremity as pain allows.
 If the fracture is unstable, however, then treatment should be similar to
that for type II fractures.
 In severely comminuted fractures, primary excision can be performed with
repair or reconstruction of the coracoclavicular ligaments using the
Weaver-Dunn procedure as necessary to stabilize the clavicle.

36. WEAVER DUNN PROCEDURE
 Resection of the distal 2 cm of distal clavicle
 Detaching the acromial end of the coracoacromial ligament, and possibly
shortening it.
 Attaching the remaining ligament to the remaining clavicle with sutures.

37.  Type IV fractures occur in skeletally immature patients and can mimic an
AC joint dislocation.
 Most heal well with nonoperative treatment unless severely displaced.
 If operative treatment is necessary, then open reduction and suture repair
of the periosteal sleeve is recommended.
 Type V fractures can be treated by following the same principles used to
treat type II injuries.

38. Medial-Third Clavicle Fractures
 Most medial clavicle fractures are stable because of the surrounding
ligamentous attachments.
 So treated nonoperatively with a sling for comfort and return to normal
function.
 Surgical treatment of medial clavicle fractures is rarely indicated and limited to
cases in which there is wide displacement of the fracture fragments or
impingement on vital neurovascular structures.
 When treated operatively, the fracture may be fixed using heavy sutures
passed through drill holes in the bone or, alternatively, with a small low-profile
plate.
 Pin fixation should be avoided because of the possibility for hardware
migration into subjacent vital organs.

39. PAEDIATRIC CLAVICLE
FRACTURE MANAGEMENT

40. NEWBORN
 Clavicular fractures in newborn may be difficult to identify.
 To minimize pain, newborns with clavicular fractures demonstrate
pseudoparalysis of the affected arm, characterized by voluntary splinting
or immobilization of the ipsilateral arm.
 This pseudoparalysis is similar in presentation to a brachial plexus birth
injury.

41.  Treatment of the birth-related clavicle fracture is nonoperative.
 If the infant appears to be in significant discomfort, the affected arm can
be immobilized to the body for a short period of time, typically less than 2
weeks.
 The parents should be warned not to disturb the upper extremity by
unnecessary movements in the acute period.
 In addition, they should be informed that the infant will develop a
noticeable mass over the fracture site that will typically resolve within 6
months.443

42. Interventions for Clavicle
Fractures Iin Children
Immobilization
Closed Reduction and
Immobilization
Operative Reduction and
Internal Fixation
Middle third X X (adolescent and young
adults)
Distal third X(Type I,II,III) Rare(Type IV,V,VI)
Medial third X X(Posterior displacement)
Sternoclavicular
dislocation, anterior
X X
Sternoclavicular
dislocation, posterior
X—Urgent X—Urgent

43. Distal Third
Fractures
Classified by DAMERON and ROCKWOOD

44.  Most investigators agree that nondisplaced or minimally displaced injuries
of the distal clavicle (types I, II, and III) are treated without surgery.These
injuries are managed with a sling immobilization.
 The treatment of displaced types IV, V, and VI distal clavicle fractures
remains controversial.
 In the young, operative management involves periosteal repair and
internal fixation in the older patient to prevent permanent deformity.
 Any intra-articular fracture fragment displacement, similar to an adult
injury, requires anatomic reduction and fixation.

45. MEDIAL THIRD CLAVICULAR INJURIES
 Most pediatric injuries in the medial clavicle are fractures through the
physis
 Acute posteriorly displaced injuries are more commonly treated with
operative reduction and repair.

46. POSTOPERATIVE MANAGEMENT
 Have patients wear a sling for the first 1 to 2 weeks for comfort but remove
it twice a day to perform pendulum exercises and active-assisted ROM
exercises below shoulder level.
 After 3 to 4 weeks, when the wound is completely healed and the patient
is comfortable, institute active-assisted ROM exercises above shoulder
level and full return to activities of daily living.
 Most patients resume all normal activities 8 to 12 weeks postoperatively.

47. COMPLICATIONS
 Occurs mostly due to poor technique and soft tissue handling.
 Whatever approach is chosen, take great care to avoid excessive soft-
tissue stripping,
 Try to achieve solid fixation and
 Plan on acute bone grafting for fractures that are highly comminuted or
where there is bone loss.
 When exposing middle-third clavicle fractures, be cognizant of the small
supraclavicular nerves that cross through the operative field and try to
preserve them.

48. Other reported complications from the operative treatment include
 Pin migration
 Coracoid fracture
 Wound-healing problems
 K-wire failure and
 Infection

49.  To prevent pin migration, always bend the ends of the pins.
 Minimize wound-healing problems and infection by not undermining skin
flaps, by handling soft tissues carefully and by waiting for acutely
damaged skin to improve before operating.
 Use stout K-wires, such as two 2-mm pins as opposed to smaller pins, to
decrease the chance for hardware failure. Never use threaded wires.

50. RECENT
ADVANCES
SONOMA CRx NAIL

51. CRx Plates and Screws Slings
Rehabilitation Shorter Long Long
Healing Saves muscle and blood supply
Blood supply damage
impairs bone healing
Collarbone shortening and
misalignment
Return to function Full return to function Full return to function
15% chance bones will not
fuse together; 30% chance
the patient will not like the
result
Pain Minimal postoperative pain
Postoperative pain due
to skin being pushed
against the plate
Pain can last from just a few
weeks to indefinitely
Appearance In many cases, 3 tiny scars
5"-8" scar, plate can be
seen and felt
Possible bump, slumping of
shoulder
% of patients who have
implant removed
<1% 18% n/a
Post-removal rehabilitation Sometimes not needed Yes n/a
Post-removal fracture risk Low 7% n/a

52. The greatest glory in living lies
not in never falling, but in rising
every time we fall.
Ralph Waldo Emerson

53. THANK YOU.