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Introduction
  •  Epidemiology
    • incidence
      • 75-80% of all clavicle fractures will occur in the middle third segment
    • demographics
      • most often seen in young, active patients
  • Pathophysiology
    • mechanism
      • fall on an outstretched arm or direct trauma to lateral aspect of shoulder
    • pathoanatomy
      • displaced fractures
        • the sternocleidomastoid muscle pulls the medial fragment posterosuperiorly
        • pectoralis and weight of arm pull the lateral fragment inferomedially  
      • open fractures buttonhole through platysma
  • Associated injuries
    • are rare but include
      • ipsilateral scapular fracture
      • scapulothoracic dissociation
        • should be considered with significantly displaced fractures
      • rib fracture
      • pneumothorax
      • neurovascular injury
  • Pediatric Clavicle fractures
    • fracture patterns include
      • medial clavicle physeal injury
      • distal clavicle physeal injury
Relevant Anatomy
  • Acromioclavicular Joint Anatomy
  • AC joint stability
    • static stabilizers
      • acromioclavicular ligament
        • provides anterior/posterior stability
        • has superior, inferior, anterior, and posterior components
          • superior ligament is strongest, followed by posterior
      • coracoclavicular ligaments (trapezoid and conoid)
        • provides superior/inferior stability
          • trapezoid ligament inserts 3 cm from end of clavicle
          • conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
        • conoid ligament is strongest
      • capsule
    • dynamic stabilizers
      • deltoid and trapezius 
Classification
  • Neer's Classification   
Neer Classification - Middle third clavicle fracture
Nondisplaced
  • Less than 100% displacement
Nonoperative
Displaced
  • Greater than 100% displacement
  • Nonunion rate of 4.5%
Operative

 

  • AO classification  
AO Classification - Middle third clavicle fracture
Type A=Simple              
  • A1 = spiral
  • A2 = oblique
  • A3 = transverse
Nonoperative or Operative   
Type B=Wege
  • A1 = spiral wedge
  • A2 = bending wedge
  • A3 = fragmented wedge
Nonoperative or Operative  
Type C=Complex
  • A1 = complex spiral
  • A2 = segmental
  • A3 = irregular
Operative 


Presentation
  • Symptoms
    • anterior shoulder pain
  • Physical exam
    • deformity
    • perform careful neurovascular exam
    • tenting of skin (impending open fracture)
Imaging
  • Radiographs 
    • views 
      • sitting/standing upright, standard AP view of bilateral shoulders
    • additional views 
      • 15° cephalic tilt (ZANCA view) determine superior/inferior displacement 
        • may consider having the patient hold 5 to 10 lbs weight in affected hand
  • CT 
    • views 
      • coronal, saggital, axial
      • 3D reconstruction views
    • findings 
      • may help evaluate displacement, shortening, comminution, articular extension, and nonunion
      • vascular injury 
Treatment
  • Nonoperative
    • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks
      • indications
        • minimally displaced Group I (middle third)
          • shortening and displacement <2cm
          • no neurologic deficit
          • no significant displacement to the superior shoulder suspensory complex (<10mm displacement)  
      • outcomes
        • nonunion (1-5%)  
          • risk factors for nonunion
            • comminution
            • 100% displacement & shortening (>2 cm)
            • advanced age and female gender
        • poorer cosmesis  
        • decreased shoulder strength and endurance
          • seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • open fxs
          • displaced fracture with skin tenting
          • subclavian artery or vein injury
          • floating shoulder (clavicle and scapula neck fx)
          • symptomatic nonunion 
          • symptomatic malunion
        • relative and controversial indications
          • displaced Group I (middle third) with >2cm shortening 
          • bilateral, displaced clavicle fractures
          • brachial plexus injury (questionable b/c 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
      • outcomes
        • advantages of ORIF
          • improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement 
          • improved functional outcome / less pain with overhead activity 
          • faster time to union
          • decreased symptomatic malunion rate
          • improved cosmetic satisfaction
          • improved overall shoulder satisfaction
          • increased shoulder strength and endurance
        • disadvantages of ORIF
          • increased risk of need for future procedures
            • implant removal
            • debridement for infection
Techniques
  • Sling Immobilization
    • technique
      • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
      • after 2-4 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-10 weeks
      • no attempt at reduction should be made
  • Closed Reduction, Intramedullary Fixation 
    • equipment options
      • cannulated screw
      • specialized screw systems (e.g, Dual Trak)
      • titanium elastic nail
      • Hagle pin
    • approach
      • beach chair or supine
      • posterolateral incision
    • contraindications
      • substantial comminution
      • segmental fractures
    • advantages
      • smaller incision
      • less soft-tissue disruption
      • less prominent hardware
      • avoids the supraclavicular cutaneous nerves commonly injured with plating
    • disadvantages
      • higher complication rate including hardware migration
      • biomechanically inferior to plating
  • Open Reduction, Plate and Screw Fixation
    • equipment
      • most common
        • limited contact precontroured, dynamic compression plate 
        • k-wires for preliminary fixation
      • others
        • 3.5mm reconstruction plate 
        • locking plates 
    • approach
      • beach chair or supine
      • direct superior vs anterior incision
    • biomechanics
      • superior vs anteroinferior plating
        • higher load to failure (superior plating > anterointerior plating)
        • plate strength with inferior bone comminunion (anteroinferior plating > superior plating) 
        • lower risk of neurovascular injury (anteroinferior plating > superior plating)
        • lower removal of deltoid attachment (superior plating > anterointerior plating)
    • outcomes
      • time to union
        • operative (16.4 weeks) vs. non-operative (28.4 weeks) 
  • Postoperative Rehabilitation
    • early
      • sling for 7-10 days followed by active motion
    • late
      • strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
      • full activity including sports at ~ 3 month
Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • risk factors
        • fracture comminution (e.g, Z deformity)
        • fracture displacement
        • female
        • advancing age
        • smoker
      • treatment of nonunion
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
    • malunion
      • definition
        • shortening >3cm, angulation >30 degrees, translation >1cm
      • complaints
        • increased fatigue with overhead activities
        • thoracic outlet syndrome
        • dissatisfaction with appearance
        • difficulty with shoulder straps, backpacks and the like
      • treatment
        • clavicle osteotomy with bone grafting, if symptomatic
  • Operative treatment
    • hardware prominence
      • ~30% of patient request plate removal
      • superior plates associated with increased irritation
    • neurovascular injury (3%)
      • superior plates associated with increased risk of subclavian artery or vein penetration
      • subclavian thrombosis
    • nonunion (1-5%)
    • infection (~4.8%)
      • risk factors
        • illicit drug use
        • diabetes
        • previous shoulder surgery
    • mechanical failure (~1.4%)
    • pneumothorax
    • adhesive capsulitis
      • 4% in surgical group develop adhesive capsulitis requiring surgical intervention
 

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