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Introduction
  •  Epidemiology
    • incidence
      • common; 15% pediatric upper extremity injuries
    • demographics
      • birth fractures
        • 0.5% normal deliveries;1.6% breech deliveries
      • traumatic
        • most often seen in active patients
  • Pathophysiology
    • mechanism
      • fall on an outstretched arm or direct trauma to lateral aspect of shoulder
      • birth fractures (account for 90% of obstetric fractures)
      • if there is no history of trauma consider congenital pseudarthrosis of clavicle (typically on right except in patients with dextrocardia)
    • 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
      • neurovascular injury
      • brachial plexus injury
    • associated topics on orthobullets
      • pediatric
        • medial clavicle physeal injury  
        • clavicle shaft fracture - pediatric (80%)
        • distal clavicle physeal injury
      • adolescent and adult
        • sternoclavicular dislocation 
        • clavicle shaft fracture 
        • distal third clavicle fracture 
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
        • conoid ligament is strongest
      • capsule
    • dynamic stabilizers
      • deltoid and trapezius 
Classification
 
Allman Classification   
Type I Middle third (most common)
Type II Distal to the coracoclavicular ligaments (lateral 1/3)
Type III Proximal (medial) third

Presentation
  • Symptoms
    • pain
  • Physical exam
    • deformity
    • perform neurovascular exam
    • tenting of skin, assess if skin is at risk (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
Treatment
  • Nonoperative
    • observation / care with lifting
      • indications
        • newborn birth fractues
      • outcomes
        • union occurs at approx 1 wk
    • sling or shoulder immobilizer with progressive motion
      • indications
        • <12 years of age
          • due to high remodeling potential almost all fractures in this age group are treated nonoperatively
      • outcomes
        • nonunion/malunion rare in <12 yo
        • may have prominent area of callous which generally becomes less apparent over 6-12 mo
  • Operative
    • open reduction internal fixation
      • indications
        • controversial: adolescent fractures with significant shortening(>2cm)
        • absolute
          • open fxs
          • displaced fracture with soft-tissue at risk from tenting
          • subclavian artery or vein injury
Techniques
  • Sling Immobilization
    • technique
      • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces) or shoulder immobilizer
      • after 2-4 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-10 weeks
      • no attempt at reduction should be made
  • 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
        • specially designed intramedulary rods
    • approach
      • beach chair or supine
      • direct superior vs anterior incision
  • 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/malunion are rare 
  • Operative treatment
    • hardware prominence (up to 59%) (Li et al JPO 2018); plate removal commonly performed
    • discomfort
    • anterior chest wall numbness
    • refracture 
    • infection/ wound dehiscence(~5%)
 

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