Clavicle fracture- MANAGEMENT

BY M J FELIX EMERSON

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

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

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.

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

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.

Indications for Primary Fixation of Midshaft Clavicle FracturesFracture 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

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

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)

“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)

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.

OPERATIVE TECHNIQUES

Middle-Third Fractures

Three types of fixation are available for middle-third clavicle fractures: intramedullary devices, plates, and external fixators.

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.

` 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.

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.

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.

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.

DISTAL THIRD CLAVICLE FRACTURES

The treatment of distal-third clavicle fractures is based on their classification.

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

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.

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

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.

On the other hand, comminuted and/or small distal fragments require Transacromial wire fixation

coracoclavicular screw fixation or

coracoclavicular ligament repair.

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.

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.

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.

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.

PAEDIATRIC CLAVICLE FRACTURE MANAGEMENT

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.

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

Interventions for Clavicle Fractures Iin Children

ImmobilizationClosed Reduction and

ImmobilizationOperative Reduction and

Internal FixationMiddle 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

Distal Third FracturesClassified by DAMERON and ROCKWOOD

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.

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.

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.

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.

Other reported complications from the operative treatment include

Pin migration

Coracoid fracture Wound-healing problems

K-wire failure and

Infection

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.

RECENT ADVANCESSONOMA CRx NAIL

  CRx Plates and Screws SlingsRehabilitation 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 painPostoperative 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

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

Ralph Waldo Emerson

THANK YOU.