Clavicle Fractures - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Clavicle Fractures

Classification of

Clavicle Fractures

• Group I : Middle third
  • Most common (80% of clavicle fractures)
• Group II: Distal third
  • 10-15% of clavicle injuries
• Group III: Medial third
  • Least common (approx. 5%)

Treatment Options

• Nonoperative
  • Sling
  • Brace
• Surgical
  • Plate Fixation
  • Screw or Pin Fixation

Nonoperative Treatment

• “Standard of Care” for most clavicle fractures.
• Continued questions about the need to wear a specialized brace.

Simple Sling vs.

Figure-of-8 Bandage

• Prospective randomized trial of 61 patients
• Simple sling
  • Less discomfort
• Functional and cosmetic results identical
• Alignment of healed fractures unchanged from the initial displacement in both groups

Andersen et al., Acta Orthop Scand 58: 71-4, 1987.Docsity.com

Nonoperative Treatment

• It is difficult to reduce clavicle fractures by closed means.
• Most clavicle fractures unite rapidly despite displacement
• Significantly displaced mid-shaft and distal- third injuries have a higher incidence of nonunion.

Nonoperative Treatment

• There is new evidence that the outcome of nonoperative management of displaced middle-third clavicle fractures is not as good as traditionally thought, with many patients having significant functional problems.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures

• A patient-based outcome questionnaire and muscle- strength testing were used to evaluate 30 patients after nonoperative care of a displaced midshaft fracture of the clavicle.
• At a minimum of twelve months (mean 55 mos), outcomes were measured with the Constant shoulder score and the DASH patient questionnaire. In addition, shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures

• The strength of the injured shoulder was 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all).
• The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

• Displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.

Definite Indications for Surgical

Treatment of Clavicle Fractures

• 1. Open fractures
• 2. Associated neurovascular injury

Relative Indications for Acute

Treatment of Clavicle Fractures

• 1. Widely displaced fractures
• 2. Multiple trauma
• 3. Displaced distal-third fractures

Relative Indications for Acute

Treatment of Clavicle Fractures

• 4. Floating shoulder
• 5. Seizure disorder
• 6. Cosmetic deformity
• 7. Earlier return to work.

Clavicular Displacement

• < 5 mm shortening: acceptable results at 5 years (Nordqvist et al, Acta Orthop Scand 1997;68:349-51.

• 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years (Hill et al, JBJS 1997;79B: 537-9)

Plate Fixation

• Traditional means of ORIF
• Plate applied superiorly or inferiorly
  • Inferior plating associated with lower risk of hardware prominence
• Used for acute displaced fractures and nonunions.

Intramedullary Fixation

• Large threaded cannulated screws
• Flexible elastic nails
• K-wires
  • Associated with risk of migration
• Useful when plate fixation contra- indicated - Bad skin - Severe osteopenia
• Fixation less secure

Complications of Clavicular Fractures

and its Treatment

• Nonunion
• Malunion
• Neurovascular Sequelae
• Post-Traumatic Arthritis

Risk Factors for the Development of

Clavicular Nonunions

• Location of Fracture
  • (outer third)
• Degree of Displacement
  • (marked displacement)
• Primary Open Reduction

Principles for the Treatment of

Clavicular Nonunions

• Restore length of clavicle
  • May need intercalary bone graft
• Rigid internal fixation, usually with a plate
• Iliac crest bone graft
  • Role of bone-graft substitutes not yet defined.

Clavicular Malunion

• Symptoms of pain, fatigue, cosmetic deformity.
• Initially treat with strengthening, especially of scapulothoracic stabilizers.
• Consider osteotomy, internal fixation in rare cases in which nonoperative treatment fails.

Correction of malunion with thoracic outlet sx

Neurologic Sequelae

• Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms.
• Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

Osteotomy for Clavicular Malunion

• 15 patients with malunion after nonoperative treatment of a displaced midshaft clavicle fracture of the clavicle. Average clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm).
• Mean time from the injury to presentation was three years (range, 1 to 15 years).
• Outcome scores revealed major functional deficits.
• All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

Osteotomy for

Clavicular Malunion

• At follow-up (mean 20 months postoperatively) the osteotomy site had united in 14 of 15 patients.
• All 14 patients satisfied with the result.
• Mean DASH score for all 15 patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001).
• Mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01).
• There was 1 nonunion, and 2 patients had elective removal of the plate.

Classification of Distal Clavicular

Fractures

(Group II Clavicle Fractures)

• Type I-nondisplaced
  • Between the CC and AC ligaments with ligament still intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Docsity.com

Classification of Distal Clavicular

Fractures

• Type II
  • Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace superiorly
  • Highest rate of nonunion (up to 30%)
  • Two Types