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A 23-year-old male right hand dominant minor league hockey player sustains the injury shown in Figure A and B. The patient is apprised of the risks and benefits of both conservative and surgical treatments. He chooses to undergo surgical intervention and wishes to minimize the chance of requiring a second operation. Which of the following is the most appropriate surgical procedure for this patient?
Distal clavicle resection
Transacromial wire fixation with possible coracoclavicular ligament reconstruction
Coracoclavicular screw fixation
Hook plate fixation with coracoclavicular ligament reconstruction
Small fragment plate fixation with possible coracoclavicular ligament reconstruction
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Small fragment plate fixation with possible coracoclavicular ligament reconstruction is the most appropriate treatment for a displaced distal clavicle fracture in a patient that wishes to avoid a second procedure.
The Neer classification describes lateral third distal clavicle fractures. Type II fractures (where the proximal fragment is detached from the CC ligaments and the distal fragment remains attached to the scapula via the AC joint capsule) and Type V (where a inferior clavicular fragment remains attached to the CC ligaments) are often displaced and are believed to have a higher rate of nonunion. Treatment of distal third as well as midshaft clavicle nonunions is best treated with open reduction and internal fixation of the nonunion.
Banerjee et al performed a Level 5 review of the management of distal clavicle fractures. They recommend primary nonsurgical management of type I, type III, and nondisplaced type II distal clavicle fractures. For patients with displacement, the authors offer surgical treatment but counsel them that the current evidence suggests equivalent outcomes between surgical and nonsurgical treatment.
Oh et al. performed a Level 4 systematic review of 425 cases from 21 studies. With surgical treatment, the nonunion rate was not significantly different among the modalities (p = 0.391). The complication rate was significantly higher in cases of the hook plate (40.7%) and the K-wire plus tension band wiring (20.0%) than those of the coracoclavicular stabilization (4.8%), the intramedullary (2.4%) and the interfragmentary fixation (6.3%).
Jin et al present a Level 4 review of 17 patients that underwent CC screw fixation of their distal clavicle fracture. They routinely removed the CC screw at 8 weeks as a second procedure and noted that all but one patient had a good outcome based on the UCLA score.
Figures A and B demonstrate displaced Type V distal clavicle fractures. Illustration A and B demonstrate an example of the use of a hook plate for distal clavicle fixation. Illustration C shows an example of a CC screw fixation and Illustration D demonstrates a distal clavicle plate fixation. Illustration E depicts the Neer classification for distal clavicle fractures. Illustration F displays a distal clavicle fracture ORIF with small fragment locking plate.
Answer 1: Isolated distal clavicle excision may lead to instability if the fragments are attached to the CC ligaments.
Answer 2: Transacromial wire fixation has a high rate of secondary procedure for wire removal and concern for hardware breakage and migration.
Answer 3: Coracoclavicular screw fixation routinely requires a secondary procedure for removal of the screw.
Answer 4: Hook plate fixation has a high rate of secondary procedure for plate removal to prevent acromial osteolysis.
Banerjee R, Waterman B, Padalecki J, Robertson W
J Am Acad Orthop Surg. 2011 Jul;19(7):392-401. PMID: 21724918 (Link to Abstract)
Banerjee, JAAOS 2011
Oh JH, Kim SH, Lee JH, Shin SH, Gong HS
Arch Orthop Trauma Surg. 2011 Apr;131(4):525-33. PMID: 20967548 (Link to Abstract)
Oh, AOTS 2011
Jin CZ, Kim HK, Min BH.
J Trauma. 2006 Jun;60(6):1358-61. PMID: 16766986 (Link to Abstract)
Jin, JTACS 2006
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