Clavicle Fractures - Dushan Atkinson 25/11/2005

One of the most common type of fractures
4% of all adult fractures (Nordqvist & Petersson, 1994)
44% of shoulder girdle fractures. (Robinson 1998)
Trimodal age distribution 76% median age 13 yrs, 21 % age 47, 3% age 59yrs

Anatomy

1 ^st bone to ossify (5 ^th week gest); last ossification centre (SCJ) fuses 22-25yrs
Only long bone to ossify my intramembranous ossification (no cartilagestage)
Flat (prism) outer third is attachment of trapezius and deltoid, andanchored to scapula by ACJ and CC ligaments
Medial third, tubular, protects brachial plexus, subclavian and axillaryvessels, and lung and is strong in axial load.
Junction of the 2 (transition) is vulnerable to #. Esp on axial loading,
Middle third has no muscle or ligament attachments distal to subclavius,and is vulnerable

Function

Osseous strut, maintaining width ofshoulder, and only bony connection between thorax and shoulder. Protects NVstructures and assists respiration with its ligamentous attachment to 1st riband sternum. Angles 30 deg up and 35 deg back and rotates 50 deg on its axiswhen arm in full abduction.

Mechanism of injury

Fall onto shoulder 87%, FOOSH 6%, direct trauma 7%, also seizures, path#’s

Clinically

Arm in adduction supported by other arm
NV exam
Fracture end may tent skin
Chest exam: pneumothorax
Associated injury: head, neck, coracoid, ribs, ACJ, SCJ

Radiology

AP xray and 45 degree caudal tilt views

For distal third #s (Neer) AP loadbearing, 45 degree anterior oblique, and 45 degree posterior oblique views(shoulder flat on xray plate), provides lateral of scapula and shows relativeAP positions of fragments

Serendipity view – 45 cephalid tilt for SCJ and medial clavicle, fordislocation

CT better for SCJ visualisation
NB check for scapula # - floating shoulder

Classification

Allman (JBJS. A 1967) AP x- ray based. Arbitrary

Group 1 - Middle third (midshaft ) #s 80% - ends secured by lig and muscle attachments
1A - undisplaced 1B - displaced 1C – comminuted

Upward displacement of medial frag produced by sternocleidomastoid muscle. Distal fragment is pulled downward by weight of limb

Group 2 - Distal third 15% Subclassified (Neer 1968 clin orthop) in relation to CC ligaments:

Type 1 - minimal displacement, # usually between trapezoid + conoid, and CAC.
Type 2 – displaced due to # medial to CC ligament (higher chance of non-union)

Type 2A – conoid and trapezoid ligs attached to distal fragment
Type 2B- conoid torn .trapezoid attached to distal fragment

Type 3 - intra-artic ACJ # with noligamentous rupture (almost ACJ sprain)

Group 3 - Medial third <5%

Type 1 – if costoclavicular ligs ok.
Type 2 – displaced
Type 3 – intra-articular
Type 4 – epiphyseal separation
Type 5 - comminuted

Historical outcomes (30-40 yrs ago)

Given the complications, implant migration, and technical difficulty, Non-operative treatment has been the rule!

BUT Non-unions do exist, though not all non-unions or malunions are symptomatic.

WHAT ARE TODAYS FIGURES?

OVERALL

“Estimating the risk of N-U following non-op treatment of a clavicular fracture” (Robinson JBJS.2004

Prospective analysis of 868 patients with clavicular fractures

Collar and cuff x 2 weeks (Neer– patients were immobilized for 6 weeks)
Then encouraged to start active shoulder movements and physiotherapy.
4.5% non-union rate for diaphyseal fractures
11.5% non-union rate for distal #s - 24.5% non-union for Group 2Type 2 #s

Overall nonunion rate 6.2% Higher than previous reports

Non-union associated with increasing age, comminution, female and amount of displacement

Literature Search (PubMed)

All English articles containing the words clavicular fracture from1999-2005

85 articles reviewed – 45 articles analysed

2 prospective results of non op treatment; 1 retrospective
10 distal third fractures
8(7) middle third fractures
8 floating shoulders
15 nonunions
2 malunions
11 review articles, 25 case studies, 7 skeletally immature, 1 basic science
1 published twice.....

Midshaft Malunions of the Clavicle. Surgical Technique (JBJS.2004) 15 patients
Midshaft Malunions of the Clavicle (JBJS. 2003) the same 15 patients

1)

• Operative Treatment (AllmanGroup 2 Neer Type II lateral fractures) 159 pooled patients

29 various plating tech. (17 hook plate, 12 Wolter plate)
32 Knowles pinning
34 K wire fixation with tension band wiring
64 Coracoclavicular fixation (14 CC ORIF, 12 PDS tension suture, 23 Mersilene tape, 15 Dacron and screw)

3.1% nonunion rate (5 pts. Flinkkila 2 k-wire, 2 hookplate, 1 k-wire Kao)
12.6% complication rate (20pts Flinkkila 12/22 k-wires, 1/17 pts,1/11 Kao)
41.5% re-op rate (66 out of 159, mostly forremoval of metalwork)
14 - 25% Re-op due toadverse events (infection, k-wire migration, re-#)

• Nonoperative Treatment 117 pts.

24 % nonunion rate (Robinson 21/101, zuckermann7/16)

• “Primary nonoperative treatment of displaced lateral fractures of the clavicle”. Robinson JBJS Am. 2004

“Nonoperative treatment ofmost displaced lateral fractures of the clavicle in middle-aged andelderly patients achieves a good medium-term functional result.Symptoms that were severe enough to warrant a delayed reconstructiveprocedure developed in only 14% of the patients. Asymptomaticnonunion does not appear to adversely affect the functional outcomein the medium term” (6 yrs).

• “A Comparison of Nonoperative and Operative Treatment of Type II Distal Clavicle Fractures” (Zuckerman. Bull Hosp Jt Dis.2003)

Retrospective 30 patients 4-5year follow up
0/14 ORIF nonunions
7/16 non-op nonunions 44% - on xray
5 no pain, 1 mild pain, 1 moderate pain

All patients were satisfied with their shoulders.

Operative and nonoperative treatment yield similar results with regard to pain, function and strength.

A successful clinical outcome can be achieved with nonoperative treatment even if non-union occurs.

2)