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Introduction
  •  Epidemiology
    • incidence
      • 10-15% of clavicle fracture occur in the distal third segment
    • demographics
      • more commonly in older or osteoportic patients
      • less common in pediatric patients 
  • Pathophysiology
    • mechanism
      • similar mechanism to mid-shaft clavicle fractures
        • usually occur after a direct, compressive force applied to the shoulder after a fall or trauma
    • pathoanatomy
      • fracture displacement corresponds to
        • fracture location  (e.g, extra-articular vs. articular)
        • fracture pattern  (e.g, simple vs. comminuted)
        • integrity of the coracoclavicular ligments 
          • conoid [medial] and trapzoid [lateral] provide primary resistence to superior displacement of the lateral clavicle
        • age (e.g, pediatric patients usually have an intact periosteal sleeve)
  • Associated injuries
    • are rare but include
      • floating shoulder
      • scapulothoracic dissociation
        • should be considered with significantly displaced or widened fractures
        • rib fracture
        • pneumothorax
        • neurovascular injury
Relevant Anatomy
  • AC joint stability consist of 
    • static stabilizing factors
      • acromioclavicular ligament
        • function
          • provides anterior + posterior translation stability
        • components
          • superior
          • inferior
          • anterior
          • posterior 
        • clinical significance
          • superior and posterior ligaments are most important
      • coracoclavicular ligaments (trapezoid and conoid)
        • function
          • provides superior + inferior translation stability
        • components
          • trapezoid ligament  (lateral)
            • inserts 3 cm from end of clavicle
          • conoid ligament (medial)
            • inserts 4.5 cm from end of clavicle
        • clinical significance
          • conoid ligament is strongest
      • capsule
    • dynamic stabilizing factors
      • deltoid and trapezius act as additional stabilizers
Classification
  • Two most common classification systems
    • Neer Classification 
Neer Classification of Lateral third Clavicle Fractures  (10-15%)  
Type 1                  
  • Fracture is LATERAL to coracoclavicular ligaments
  • Conoid and/or trapezoid ligament remain INTACT
  • Minimal displacement
  • STABLE
Nonoperative 
Type IIA
  • Fracture occurs MEDIAL to coracoclavicular ligaments
  • Conoid and trapezoid ligment remain INTACT
  • Significant medial clavicle displacement
  • UNSTABLE 
    • Up to 56% nonunion rate with nonoperative management
Operative  

Type IIB
  • Two fracture patterns
    • (1) Fracture occurs either BETWEEN the coracoclavicular ligaments 
      • Conoid ligament TORN
      • Trapezoid ligament INTACT
    • (2) Fracture occurs LATERAL to coracoclavicular ligaments 
      • Conoid ligmanet TORN
      • Trapezoid ligament TORN
  • Signficant medial clavicle dispalcement
  • UNSTABLE
    • Up to 30-45% nonunion rate with nonoperative management
Operative 

Type III
  • INTRA-ARTICULAR fracture extending into AC joint
  • Conoid and trapezoid ligaments remain INTACT 
  • Minimal displacement
  • STABLE injury
    • Patients may develop posttraumatic AC arthritis
Nonoperative
x
Type IV
  • PHYSEAL fracture that occurs in the skeletally immature
  • Conoid and trapezoid ligaments remain INTACT 
  • Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum
    • Clavicle pulls out of periosteal sleeve
  • STABLE
Nonoperative
Type V
  • COMMINUTED fracture pattern
  • Conoid and trapezoid ligaments remain INTACT
  • Significant medial clavicle displacement
  • Usually UNSTABLE
Operative

  • AO Classification
AO Classification
Type A           
  • Undisplaced fracture, CC ligaments intact
    • A1 = extraarticular
    • A2 = intraarticular
Nonoperative 
      

Type B

  • Displaced fracture, CC ligaments intact
    • A1 = extraarticular
    • A2 = comminuted
Nonoperative or Operative  

Type C
  • Displaced fracture, CC ligaments disrupted
    • A1 = extraarticular
    • A2 = intraarticular
Operative 
 

 

 
Presentation
  • Symptoms
    • tip of shoulder pain
  • Physical exam
    • AC joint deformity
    • tenting of skin (impending open fracture)
    • perform careful neurovascular exam
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
Treatment
  • Nonoperative
    • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks 
      • indications
        • stable fractures (Neer Type I, III, IV) 
        • pediatric distal clavicle fractures (skeletally immature)
      • outcomes
        • nonunion (1-5%)
          • risk factors for nonunion
            • Neer group II (up to 56%)
              • disrupted CC ligaments 
            • advanced age and female gender
        • poor cosmesis  
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • open, or impending open, fractures  
          • subclavian artery or vein injury
          • floating shoulder (e.g., distal clavicle and scapula neck fx with >10mm of displacement)
          • symptomatic nonunion
        • relative 
          • unstable fracture patterns (Type IIA, Type IIB, Type V)
          • brachial plexus injury (questionable b/c 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
        • outcomes
          • advantages of ORIF
            • higher union rates
            • faster time to union
            • improved functional outcome / less pain with overhead activity
            • decreased symptomatic malunion rate 
            • improved cosmetic satisfaction
          • disadvantages of ORIF
            • increased risk of need for future procedures (e.g, removal of hook plate)
            • symptomatic hardware
            • infection
Techniques
  • Sling Immobilization
    • technique
      • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
      • after 2-3 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-8 weeks
      • no attempt at reduction should be made
  • Open Reduction Internal Fixation
    • technique
      • limited contact dynamic compression plate  
        • position
          • beach chair or supine
        • approach
          • superior approach to AC joint
          • temporary fixation with k wires
        • equipment
          • locking plates 
          • precontoured anatomic plates 
        • fixation
          • need larger distal fragment for multiple locking screws 
          • >3 or 4 bicortical screws into medial fragment to reduce the risk of screw pull out  
      • hook plate  
        • position
          • beach chair or supine
        • approach
          • superior approach to AC joint
          • temporary fixation with k wires
        • equipment
          • hook plates vary in hook depth and number of holes
          • proper hook depth ensures the AC joint is not over- or under-reduced
        • fixation
          • hook plates are generally used when there is insufficent bone in the distal fragment for conventional clavicle plate fixation
          • the hook should be placed posterior to AC joint and positioned as far lateral as possible to avoid hook escape  
          • >3 or 4 bicortical screws should be placed into the proximal (medial) fragment to reduce the risk of screw pull out 
      • Other types of fixation
        • AC joint spanning fixation
          • usually used as an alternative to hook plates
        • tension band wire
        • intramedullary screw  
        • coracoclavicular ligament reconstruction   
    • 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
        • hardware removal considered usually after 3 months
Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • risks
        • comminution
        • Z deformity
        • female
        • older
        • smoker
        • distal clavicle higher risk than middle third
      • treatment of nonunion
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
  • Operative treatment
    • hardware prominence
      • ~30% of patient request plate removal
      • superior plates associated with increased irritation
    • hardware removal
      • mostly with hook plates
    • neurovascular injury (3%)
      • superior plates associated with increased risk of subclavian artery or vein penetration
      • subclavian thrombosis
    • nonunion (1-5%)
    • infection (~4.8%)
    • mechanical failure (~1.4%)
    • pneumothorax
    • adhesive capsulitis
      • 4% in surgical group develop adhesive capsulitis requiring surgical intervention
 

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