1. The patient is a 75-year-old Thai man who fell off his bicycle 6 hours prior, injuring his left elbow and clavicle. 2. Radiographs show a fracture of the left shaft of the clavicle. 3. Clavicle fractures are commonly classified using the Allman or Neer classifications to determine appropriate treatment. Non-displaced or stable fractures are typically treated non-operatively while displaced or unstable fractures often require surgical fixation.

1. Extern conference
By extern กันต์นภัส กิตยารักษ์

2. Case
Patient profile : ชายไทยคู่ อายุ 75 ปี
Chief complain : จักรยานล้ม 6 ชม. ก่อนมาโรงพยาบาล
Present illness : 6 ชมก่อนมา ปั่นจักรยานตกหลุม ล้มตกจากจักรยาน
ศอกซ้าย และซี่โครงด้านซ้ายกระแทกพื้น เจ็บบริเวณศอก และไหปลาร้าด้านซ้าย
ทันที หายใจแล้วเจ็บที่ซี่โครงซ้าย หัวไม่กระแทก ไม่สลบ จาเหตุการณ์ได้ ไม่ปวด
ท้อง NPO 8.00 น.
Past illness :
• u/d type2 DM on glipizide(5) 1x2 po ac
• No drug/food allergy

3. Physical examination
GA : good consciousness, well co-operate, on figure
of eight from COMH
HEENT : not pale conjunctivae, anicteric sclearae
RS : clear breath sound equal both lungs
Heart : normal s1 s2, no murmur
Abd : normoactive bowel sound, soft, not tender, old
surgical scar at right upper quadrant
Ext : lacerated wound at left elbow 1 cm with active
bleeding, swelling left clavicle limit ROM due to pain

4. CXR

5. Film shoulder AP

6. Film shoulder transcapular

7. Film left clavicle

8. Film left clavicle, serendipity view

9. Film left elbow AP

10. Film left elbow lateral

11. Diagnosis
• CFx left shaft clavicle

12. Management
• On figure of eight

13. Clavicle fracture

14. Introduction
Clavicle fractures are common injuries
• 10% of all fractures
• 44% of injuries to the shoulder girdle (clavicle + scapula)

15. Anatomy
• S-shaped bone
between the sternum
and the glenohumeral
joint. Bound to scapula
by the AC & CC
ligaments

16. Function
• Power and stability of arm
• Motion of the shoulder girdle
• Muscle attachment
• Protect neurovascular structure

17. Mechanism of injury
Trauma
• Fall against lateral shoulder
• Fall on outstretched hand
• Direct blow to clavicle
Non-trauma
• Tumor
• Ricket
• Osteogenesis imperfect
• Physical abuse

18. Mechanism of displacement

19. Clinical presentation
• Pain/ swelling/ bruising/ stepping/ deformity at site of
injury
• Decrease movement of the affect limb
• The affected arm will usually be held by the opposite
limb to support the weight
Complication
• Neurovascular injury
• Pneumothorax, subcutaneous emphysema
• Open fracture

20. Radiographs
• Chest x-ray
• Clavicle in different angles
o Anteroposterior – evaluate superior-inferior
displacement
oSerendipity view ( 40 degree cephalic tilt) – evaluate
anterior-posterior displacement
• CT

21. Normal
Posterior
displacement
Anterior displacement

22. Classification and treatment
Allman classification
• Group I : middle one third –
the shaft (common in
young, active patients)
• Group II : lateral one third –
the acromial end (common
in older or osteoportic
patients)
• Group III : medial one third
– the sternal end

23. Group I :
middle one third – the shaft
Non-operative
• Less than 100% displaced
Operative
• 2 cm. Shortening
• 100% displaced – nonunion risk

24. Group II :
lateral one third – the acromial end
Neer classification
• relationship of the fracture to CC ligament and AC
joint
• Operative in unstable type (floating medial
segment)

25. Neer classification
Type I • Fracture is lateral to coracoclavicular ligaments
• Conoid and/or trapezoid ligament remain intact
• Minimal displacement
• Stable

26. Neer classification
Type IIA • Fracture occurs medial to coracoclavicular ligaments
• Conoid and trapezoid ligment remain intact
• Significant medial clavicle displacement
• Unstable
o Up to 56% nonunion rate with nonoperative
management
Type IIB • Two fracture patterns
1. Fracture occurs either between the coracoclavicular
ligaments
o Conoid ligament torn
o Trapezoid ligament intact
2. Fracture occurs lateral to coracoclavicular ligaments
o Conoid ligament torn
o Trapezoid ligament torn
• Signficant medial clavicle dispalcement
• Unstable
o Up to 30-45% nonunion rate with nonoperative
management

27. Neer classification
Type III • Intra-articular fracture extending into AC joint
• Conoid and trapezoid ligaments remain intact
• Minimal displacement
• Stable
o Patients may develop post-traumatic AC arthritis
Type IV • Physeal fracture that occurs in the skeletally immature
• Conoid and trapezoid ligaments remain intact
• Displacement of lateral clavicle occurs superiorly through a
tear in the thick periosteum
o Clavicle pulls out of periosteal sleeve
• Unstable
Type V • Comminuted fracture pattern
• Conoid and trapezoid ligaments remain intact
• Significant medial clavicle displacement
• Unstable

28. Group III :
medial one third – the sternal end
Non-operative
• Anterior displacement
Operative
• Posterior displacement
oRare injury
oRisk of pneumothorax, airway injury, great vessels
injuries
oSerendipity radiograph and CT scan to evaluate surgical
management

29. Summary of management
Non-operative : the majority of clavicular fraction
can be treated conservatively with good outcomes.
• Group I : non-displaced
• Group II : stable type
• Group III : anterior displacement
Technique
• Figure-of-eight, Arm sling
• Gentle ROM exercises at 2 – 4 weeks

30. Summary of management
Operative : Indication
• Group I : displaced
• Group II : unstable type
• Group III : posterior displacement
• Open fracture
• Symptomatic nonunion
• Great vessels injuries +- brachial plexus injury
• Floating shoulder (clavicle and neck of scapula fx)
• Bilateral fracture/ multiple fractures
• Wide displaced fracture (>= 2 cm.)

31. Summary of management
Operative : Technique
• Plate fixation
• Intramedullary fixation
• External fixation
• CC ligament replace/ reconstruction
Post-op rehab
• Sling for 7 - 10 days followed by active motion
• Strengthening at 6 weeks when pain free motion
• Full activity including sports at ~3 months