This document discusses classifications and treatments for clavicle fractures. It notes that midshaft fractures make up 80% of clavicle fractures. For midshaft fractures, displaced fractures may be treated surgically or non-surgically. A Cochrane review found no difference in outcomes between surgery and conservative treatment, though some studies found surgery resulted in fewer non-unions but more complications. The document concludes that treatment should be individualized based on the patient and fracture characteristics.

1. ORTHOPAEDIC DEPARTMENT
SÖDERSJUKHUSET, STOCKHOLM, SWEDEN
HENRIK ILLERSTRÖM, M.D.
CLAVICLE FRACTURES

2. Clavicle Fractures

3. Clavicle Fractures Classification
• Allman: Medial – Midshaft – Lateral/distal
• Nordqvist & Petersson
• Craig
• Edingburgh
• Neer

4. Clavicle Fractures
• 3% of all fractures
• Midshaft fractures 80%
• Distal (or lateral) fractures 15%
• Medial fractures <5%

5. Medial Clavicle Fractures
• Risk for neurovascular damage
• Often epiphyseal separation (open until 30 y)
• Stability of fracture by the costo-clavicular lig.
• Preferably no surgery if undisplaced and no risk
for underlying structures

6. Lateral Clavicle Fractures
• Undisplaced fractures – have an intact
periosteal sleeve and are stable due to intact
conoid and trapezoid ligaments.
• If there is a intra-articular component that can
lead to AC-joint arthritis. Best treated with lateral
clavicle resection.

7. Lateral Clavicle Fractures
• Displaced fractures usually needs surgery
• Conservative treatment => 33% non-union
• Operative treatment => 6% non-union (Review -
Oh et al 2011)
• Increased incidence among elderly – tolerate
non-union reasonably well

8. Lateral Clavicle Fractures
• Hook-plate – removal after union >3months

9. Lateral Clavicle Fractures
• Contured locking plates, >2-3 screws in lateral
fragment

10. Lateral Clavicle Fractures
• Coraco-clavicular screw
• Sutures and or ligament grafts
• Needles and pins…

11. And now to the controversial part…

12. Mid Shaft Clavicular Fractures

13. Mid Shaft Clavicular Fractures
2 weeks

14. Mid Shaft Clavicular Fractures
• Undisplaced – non-operatively
• Conservative treatment – sling or figure of 8
bandage. No evidence for either. (Andersen et al
1987, Cochrane-Lenza et al 2009)
• Displaced – surgery or not…

15. Displaced Mid Shaft Clavicular
Fractures surgery or not?
• Cochrane review (Lenza et al 2013) of 8 RCTs
show low evidence. No difference between
surgery or conseravtive treatment. No QoL
• McKee 2012, meta-analysis of 6 RCTs show
lower rate of non-union and symtomatic
malunion and earlier functional return compared
to conseravtive treatment. Little evidence for
significantly improved long-term functional
outcome for surgery vs conservative treatment

16. More
• RCT Virtanen ET al 2012 no difference at one
year follow-up Constant and DASH scores. Poor
scores associated with non-union
• RCT Robinson et al 2013 showed significantly
less reported dissatisfaction after surgery but no
difference in Constant/DASH scores. High NNT,
>6 to prevent 1 non-union

17. Displaced Mid Shaft Clavicular
Fractures – surgical methods
• Plates
– Stable,Comminution
– Prominence
– Wound complications
• Pins
– Less invasive
– Less prominence
– Less control/stability

18. Displaced Mid Shaft Clavicular
Fractures – Conclusion
• Individualize for each patient
• Early return – Surgery
• Large displacement >2cm, Z-fragment – Surgery
• Communition – Plate
• No surgery – high risk for non-union (up to 23%)
• Surgery – high risk of complications (up to 48%)
– mostly hardware related (McKee 2012)

19. Thank you!