2. INTRODUCTION
Clavicle one of the most commonly fractured bones
2.6% - 5% of all fractures
35% - 45% of shoulder girdle fractures
Postacchini F, Gumina S, De Santis P, Albo F: Epidemiology of clavicle fractures.J Shoulder
Elbow Surg 2002;11:452-456.
Nordqvist A, Petersson C: The incidence of fractures of the clavicle.Clin Orthop Relat Res
1994;300:127-132.
Midshaft clavicle fractures account for 69% - 80%
Albo F: Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-456.
Nordqvist A, Petersson C: The incidence of fractures of the clavicle. Clin Orthop Relat Res 1994;300:127-
132.
Robinson CM: Fractures of the clavicle in the adult: Epidemiology and classification. J Bone Joint Surg Br
1998;80:476-484.
Rowe CR: An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-
42.
Nowak J, Mallmin H, Larsson S: The aetiology and epidemiology of clavicular fractures: A prospective study
during a two-year period in Uppsala, Sweden. Injury 2000;31:353-358.
3. Clavicle
“S”-shaped bone
Medial - sternoclavicular joint
Lateral - acromioclavicular joint and
coracoclavicular ligaments
Muscle attachments:
Medial: sternocleidomastoid
Lateral: Trapezius, pectoralis major
4. APPLIED BASIC SCIENCE
Osseous anatomy and
muscular/ligamentous attachments play
a pivotal role in determining fracture
patterns
# most common at junction of outer and
middle 3rd
Thinnest part of bone
not protected by muscle/ligamentous
attachments
Deformity:
SCM pulls proximal fragment superiorly
and posteriorly
weight of arm and pectoralis muscles
pull distal segment medially and
inferiorly
5. MECHANISM OF INJURY
Traditionally thought to occur from “FOOSH”
Various mechanisms
1. Direct blow onto the point of the shoulder
– Shown to account for 85 to 94% of clavicle fractures
• Stanley D, Trowbridge EA, Norris SH: The mechanism of clavicular fracture: A
clinical and biomechanical analysis. J Bone Joint Surg Br 1988;70:461-464.
• Nordqvist A, Petersson C: The incidence of fractures of the clavicle. Clin Orthop
Relat Res 1994;300:127-132.
• Robinson CM: Fractures of the clavicle in the adult: Epidemiology and
classification. J Bone Joint Surg Br 1998;80:476-484.
• Nowak J, Mallmin H, Larsson S: The aetiology and epidemiology of clavicular
fractures: A prospective study during a two-year period in Uppsala, Sweden. Injury
2000;31:353-358.
1. Direct blow to clavicle
– seat belt strap injuries
– 10 to 13%
1. FOOSH
2 to 5%
others
Sports injury
motor vehicle accidents
6. Physical Examination
Inspection
Evaluate deformity and/or
displacement
Beware of rare inferior or
posterior displacement of
distal or medial ends of
clavicle
Compare to opposite side.
7. Physical Examination
Palpation
Evaluate pain
Look for instability with stress
11. Classification
Craig Classification
Group I: Fracture of the middle third
Group II: Fracture of the distal third. Subclassified according
to the location of coracoclavicular ligaments relative
to the fracture as follows:
Type I: Minimal displacement: interligamentous
fracture between conoid and trapezoid or
between the coracoclavicular and acromiocavicular
ligaments
Type II: Displaced secondary to a fracture medial to
the coracoclavicular ligaments – higher
incidence of non-union
12. IIA: Conoid and trapezoid attached to
the distal segment (see Figure 2.1)
IIB: Conoid torn, trapezoid attached to the
distal segment (see Figure 2.2)
Type III: Fracture of the articular surface of
the acromioclavicular joint with no
ligamentous injury – may be confused with
first degree acromioclavicular joint
separation
Group III: Fracture of the proximal third:
Type I: Minimal displacement
Type II: Significant displaced (ligamentous
rupture)
Type III: Intraarticular
Type IV: Epiphyseal separation
Type V: Comminuted
14. 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.
15. CHANGING TRENDS IN MANAGEMENT OF ACUTE
CLAVICULAR MIDSHAFT FRACTURES
Traditionally been treated non-operatively, even when substantially
displaced
Early reports suggested non-union was extremely rare
4 (0.8%) out of 556 (3.7% with surgery)
Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. CORR 1968
3 (0.1%) out of 2235 (4.6% with surgery)
most important causal factor for nonunion of a midshaft clavicular fracture is
improper open surgery
Neer CS 2nd. Nonunion of the clavicle. JAMA 1960
Recent studies on non-operative mx report:
Higher non-union rate (15%)
Higher rate (32%) of unsatisfactory patient outcome
Hill et al. Closed treatment of middle-third clavicle fractures gives poor results. JBJSB 1997
Several recent studies reported high union rates with surgical
intervention using a variety of internal fixation devices
Ali Khan MA, Lucas HK: Plating of fractures of the middle third of the clavicle. Injury 1978
Zenni EJ Jr, Krieg JK, Rosen MJ: Open reduction and internal fixation of clavicular fractures.
JBJSA 1981
16. NON-OPERATIVE MANAGEMENT
Historically, has been the mainstay for clavicular fractures
Indicated for non-displaced or minimally displaced midshaft
clavicular fracture
Consist of:
Most commonly, a sling or figure-of-8 brace applied in the acute
setting
immobilization typically for 2 to 6 weeks
Gradual return to normal activites
Andersen K, Jensen PO, Lauritzen J: Treatment of clavicular
fractures: Figure-of-eight versus a simple sling. Acta Orthop
Scand 1987;58:71-74.
Prospective, randomized study involving 61 patients
26% of patients treated with a figure-of-8 bandage were
dissatisfied compared with 7% of those treated with a sling
There was no difference in overall healing and alignment of the
fractures indicating that a figure-of-8 bandage does little to obtain
or maintain reduction
17. 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.
18. MANAGEMENT OF ACUTE MIDHSAFT CLAVICLE
FRACTURE: LITERATURE EVIDENCE
FRACTURE DISPLACEMENT / SHORTENING
1. Nowak J, Holgersson M, Larsson S: Can we predict long-term sequelae
after fractures of the clavicle based on initial findings? A prospective
study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004
• Prospective study 245 patients with 9-10 years follow-up
Displacement without bony contact, especially with comminuted
transverse fracture, and an elderly patients, strongly predictive of long
term sequelae and persistent symptoms
1. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE:
Estimating the risk of nonunion following nonoperative treatment of a
clavicular fracture. J Bone Joint Surg Am 2004
• Prospective review of 581 midshaft clavicular fractures
• 4.5 % non-union rate
Fracture displacement, fracture comminution, female gender, advanced
age significantly increase risk of non-union
19. MANAGEMENT OF ACUTE MIDHSAFT CLAVICLE
FRACTURE: LITERATURE EVIDENCE
FRACTURE DISPLACEMENT / SHORTENING
3. Wick M, Müller EJ, Kollig E, Muhr G: Midshaft fractures of the clavicle
with a shortening of more than 2 cm predispose to nonunion. Arch
Orthop Trauma Surg 2001
• Retrospective analysis of 39 clavicle non-union / delayed union
Shortening of 2 cm in midshaft clavicular fractures was associated with
an increased risk of pain, limitation of motion, or nonunion
3. McKee MD et al: Deficits following non-operative treatment of displaced
midshaft clavicular fractures. J Bone Joint Surg Am 2006
• Prospective study of 30 cases with displaced midshaft clavicle #s (mean
follow-up 55 months)
• assessed functional outcome and noted significantly inferior scores for both
the upper extremity–specific (DASH) outcome scores and the Constant
scores compared with the general population.
fractures with >2 cm of shortening tended to be associated with
decreased abduction strength and greater patient dissatisfaction
20. 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.
21. MANAGEMENT OF ACUTE MIDHSAFT CLAVICLE
FRACTURE: LITERATURE EVIDENCE
FRACTURE DISPLACEMENT / SHORTENING
5. Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle
third fractures of the clavicle gives poor results. J Bone Joint Surg Br
1997
• Retrospective review of 52 midshaft clavicular fractures
final shortening ≥2 cm was associated with an unsatisfactory result but not with
non-union
6. Ledger M, Leeks N, Ackland T, Wang A: Short malunions of the clavicle:
An anatomic and functional study.J Shoulder Elbow Surg 2005
• Evaluated the effects of clavicular malunion (15mm shortening) in 10 subjects using
CT with #D recon, shoulder score assessments and biomechanical testing
Significant increase in upward angulation of the SC joint and an increased scapular
version compared with the uninjured side
Significantly weaker muscle strength than that of the uninjured arm
Significant poorer shoulder scores outcome
These studies indicate that although clavicular deformities are
complex and hard to assess, shortening of 1.5 to 2 cm results in an
increased incidence of clinical symptoms
22. Thus,displaced midshaft clavicle fractures
can cause significant, persistent disability,
even if they heal uneventfully.
23. Definite Indications for Surgical
Treatment of Clavicle Fractures
1) Open fractures
2) Associated neurovascular injury
25. Relative Indications for Acute
Treatment of Clavicle Fractures
4) Floating shoulder
5) Seizure disorder
6) Cosmetic deformity
7) Earlier return to work.
26. SURGICAL MANAGEMENT
PLATING
Advantages of surgery
Early mobilisation
Better early pain relief
Incision
Directly over clavicle along Langer’s line
Sabre cut incision
Preservation of supra-clavicular nerves
Inferior incision
Coupe et. al.: A new approach for plate fixation of midshaft
clavicular fractures. Injury 2005
Proposed to prevent wound complications and improve
cosmesis
27. Plate Fixation
Traditionalmeans of ORIF
Plate applied superiorly or inferiorly
Inferior plating associated with lower risk of
hardware prominence
Used for acute displaced fractures and
nonunions.
28.
29.
30.
31.
32. Risk Factors for the
Development of Clavicular
Nonunions
Location of Fracture
(outer third)
Degree of Displacement
(marked displacement)
Primary Open Reduction
33. 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.
34. Clavicle non-union- autologous bone
graft not a necessary augment
15 patients with symptomatic non-union after nonoperative
treatment of a midshaft clavicle fracture of the clavicle
Hypertrophic non-union had excessive callus morselized
Atrophic non-union had freshening of ends of bone
Use of titanium pre-contoured plate
All patients – radiographic and clinical union , returned to work
and regular sports
Suggested distant bone graft unnecessary with preparation of
bone ends and adequate fixation
J F Baker, et al. Acta Orthop Belgium 2010;76:725-729
35. The role of autologous bone graft in
surgical treatment of hypertrophic non-
union of mid shaft clavicle
51 patients treated with 3.5 LC-DCP without bone graft, 30(Grp
1) had previous surgery and 21 (Grp 2 ) had non-operative
treatment follow-up for 20 months
Decortication of bone ends, medullary canal was reamed with
drill
All had uneventful union
No statistical difference between the two groups postoperative
function scores, union time or patient demographics
HK Huang MD, et al. J Chinese Medical A 2012;75:216-210
36. 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
38. 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.
39. 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
40. 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.
41. 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
42. 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.
McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7
43. Techniques for Acute Operative
Treatment of Distal Clavicle
Fractures
Kirschner wires inserted into the distal
fragment
Dorsal plate fixation
CC screw fixation
Tension-band wire or suture
Transfer of coracoid process to the clavicle
Clavicular Hook Plate
44. Formost techniques of clavicular fixation,
coracoclavicular fixation is also needed to
prevent redisplacement of the medial
clavicle.
45. • The Hook Plate (Synthes USA, Paoli, PA)
was specifically designed to avoid this
problem of redisplacement.
46.
47. Hook Plate - Results
Recent series of distal clavicle fractuers
treated with the Hook Plate document high
union rates of 88% - 100%. Complications
are rare but potentially significant, including
new fracture about the implant, rotator cuff
tear, and frequent subacromial impingement.
48. Preferred Technique for
Fixation of Acute Distal Third
Clavicle Fractures
Horizontalincision
Manual reduction of fracture
Dorsal tension band suture and
reconstruction/augmentation of
coracoclavicular ligaments.
49. Indications for Late Surgery
for Distal Clavicle Fractures
Pain
Weakness
Deformity
50. Techniques for Late Surgery
for Distal Clavicle Fractures
Excision of distal clavicle
With or without reconstruction of
coracoclavicular ligaments (Modified
Weaver-Dunn procedure)
Reduction and fixation of fracture
51. SUMMARY
1. Most mid-shaft clavicular fractures heal without incident when length and
alignment are maintained
Nondisplaced and minimally displaced fractures should be treated
nonsurgically, preferably with a sling for patient comfort
• acceptable cosmetic and functional results, as well as union rates can be
expected
2. The risk of complications from non-surgical management may be
significantly higher:
• those with completely displaced (1.5 to 2cm) and comminuted fractures
• Possibly those who are female or of advanced age
The current literature suggests that surgical stabilization, with either plates
or IM device, should be considered the preferred treatment option for
these more complex acute midshaft clavicular fractures
2) Shoulder joint being formed by the: GH, SC, AC, ST jnts
Direct blow: Shown to account for 85 to 94% of the injuries by biomechanical analysis as well as several studies
Hill: retrospective review of 242 clavicle # cases ; 52 mid shaft for 38 months 8 NU; 16 unsatisfact Ali khan 12 plates all united Zenni 25 IM all united
So when do we treat conservatively? RCTS: As much as there 200 methods of closed reduction techniques described in the literature …