Updated: 7/17/2019

Clavicle Shaft Fractures

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Introduction
  • Overview
    • clavicle shaft fractures are common traumatic injuries that occur in the middle third of the clavicle
      • treatment is somewhat controversial but may be nonoperative or operative based on the degree of displacement and patient factors
    • other fractures of the clavicle include
      • adult distal third clavicle fx 
      • pediatric medial clavicle physeal injury 
      • pediatric distal clavicle physeal injury 
  • Epidemiology
    • incidence
      • clavicle fractures account for 2.6-4% of all adult fractures
    • demographics
      • often seen in young, active patients
      • most common in males < 30 years old
    • location
      • 75-80% of all clavicle fractures will occur in the middle third segment
  • Pathophysiology
    • mechanism of injury
      • fall on an outstretched arm or direct trauma to the shoulder
    • pathoanatomy
      • 75-80% of all clavicle fractures will occur in the middle third segment
        • the junction of the outer and middle thirds is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments
          • it is therefore prone to fracture, particularly with axial loading
      • displaced fractures
        • medial fragment: sternocleidomastoid muscle pulls the medial fragment posterosuperiorly
        • lateral fragment: pectoralis and weight of arm pull the lateral fragment inferomedially  
      • open fractures usually the result of the medial fragment as it "buttonholes" through the platysma
  • Associated conditions
    • rare but may include
      • ipsilateral scapular fracture
      • scapulothoracic dissociation
        • should be considered with significantly displaced/widened fracture fragments
      • rib fracture
      • pneumothorax
      • neurovascular injury
Classification
 
 Neer Classification
Nondisplaced
 • < 100% displacement
 nonoperative
Displaced  • > 100% displacement
 • nonunion rate of 4.5%
 operative
 
 
AO Classification
Type A = Simple
 • A1 = spiral
 • A2 = oblique
 • A3 = transverse 
nonoperative vs. operative
Type B = Wedge
 • B1 = spiral wedge
 • B2 = bending wedge
 • B3 = fragmented wedge
nonoperative vs. operative
Type C = Complex
 • C1 = complex spiral
 • C2 = segmental
 • C3 = irregular
operative
 
Presentation
  • Symptoms
    • anterior shoulder pain
  • Physical exam
    • may have deformity
    • may have skin tenting (impending open fracture)
    • important to perform careful neurovascular exam
Imaging
  • Radiographs 
    • recommended views 
      • upright AP of bilateral shoulders
      • 15° cephalic tilt (zanca view)
        • helps to determine superior/inferior displacement
        • may consider having the patient hold 5-10 lbs of weight in the affected hand
  • CT 
    • views 
      • coronal, saggital, axial
      • 3D reconstruction views
    • findings 
      • may help evaluate displacement, shortening, comminution, articular extension, vascular injury, and nonunion
Treatment
  • Nonoperative
    • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks
      • indications
        • < 2cm shortening and displacement
        • < 1cm displacement of the superior shoulder suspensory complex
        • no neurovascular injury
  • Operative
    • closed reduction and intramedullary fixation vs. open reduction internal fixation
      • indications
        • absolute
          • open fractures
          • displaced fracture with skin tenting
          • subclavian artery or vein injury
          • floating shoulder (clavicle and scapular neck fracture)
          • symptomatic nonunion 
          • symptomatic malunion
        • relative and controversial indications
          • displaced with > 2cm shortening 
          • bilateral displaced clavicle fractures
          • brachial plexus injury (questionable because 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
Techniques
  • Sling Immobilization
    • technique
      • immobilize using sling or figure-of-eight brace
        • prospective studies have not shown a difference in functional or cosmetic outcomes between sling and figure-of-eight braces
      • no attempt at reduction should be made
      • after 2-4 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-10 weeks
    • outcomes 
      • nonunion (1-5%)  
        • risk factors 
          • comminution
          • > 100% displacement
          • > 2cm shortening
          • advanced age
          • female gender
      • poorer cosmesis  
      • decreased shoulder strength and endurance
        • seen with displaced midshaft clavicle fractures healed with > 2cm of shortening
  • Closed Reduction and Intramedullary Fixation 
    • contraindications
      • substantial comminution
      • segmental fractures
    • approach
      • beach chair or supine
      • posterolateral incision
    • instrumentation
      • cannulated screw
      • specialized screw systems (e.g, Dual Trak)
      • titanium elastic nail
      • Hagle pin
    • 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, hardware breakage, temporary brachial plexus palsy, and skin breakdown over the entry portal
      • biomechanically inferior to plating
  • Open Reduction Internal Fixation
    • approach
      • beach chair vs. supine
      • direct superior vs. anterior incision
    • instrumentation
      • most common
        • limited contact, pre-controured, dynamic compression plate 
        • k-wires for preliminary fixation
      • other options
        • 3.5mm reconstruction plate 
        • locking plates 
    • technique
      • superior vs. anteroinferior plating
        • higher load to failure (superior plating > anterointerior plating)
        • decreased 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)
    • advantages
      • improved results with ORIF for clavicle fractures with > 2cm shortening and > 100% displacement 
      • improved functional outcomes/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
      • increased risk of need for future procedures
        • implant removal
        • debridement for infection
    • 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 months
Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • risk factors
        • fracture comminution (Z deformity)
        • fracture displacement 
        • female gender
        • advanced age
        • smoker
      • treatment 
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
    • malunion
      • definition
        • shortening > 3cm
        • angulation > 30°
        • translation > 1cm
      • presentation
        • 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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Questions (21)
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(OBQ10.101) A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion? Review Topic

QID: 3195
FIGURES:
1

Open reduction and internal fixation with plating

90%

(1256/1388)

2

Open reduction and percutaneous pinning

1%

(13/1388)

3

Closed reduction and percutaneous pinning

1%

(13/1388)

4

Closed reduction and external fixation

0%

(1/1388)

5

Nonoperative treatment with a sling and early range of motion

7%

(98/1388)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(SBQ12TR.23) A 25-year-old patient is involved in a motor vehicle accident. An isolated orthopaedic injury is sustained to the upper extremity with no compromise of skin integrity or neurovascular function. A radiograph of the injury is shown in Figure A. The patient is interested in pursuing surgical intervention. What is a reported outcome of surgery when compared to nonoperative management at 1 year postoperatively? Review Topic

QID: 3938
FIGURES:
1

Increased rates of symptomatic nonunion

3%

(118/4135)

2

Similar rates of symptomatic nonunion

7%

(304/4135)

3

No differences in cosmetic results

2%

(77/4135)

4

Increased functional outcome scores

81%

(3361/4135)

5

Improved range of motion of the shoulder

6%

(256/4135)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(SBQ12TR.3) A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury?
Review Topic

QID: 3918
FIGURES:
1

Decreased chance of nonunion with nonoperative treatment

4%

(228/5375)

2

Improved Constant and DASH scores with operative treatment at all time points

70%

(3738/5375)

3

Increased symptomatic malunion rate with operative treatment

1%

(74/5375)

4

No change in shoulder abduction strength

18%

(974/5375)

5

Increased time to union with operative treatment

6%

(340/5375)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ07.275) Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture? Review Topic

QID: 936
1

younger patients

8%

(54/720)

2

female gender

54%

(387/720)

3

simple fracture pattern

8%

(59/720)

4

sling immobilization

6%

(40/720)

5

early range-of-motion

24%

(175/720)

ML 4

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PREFERRED RESPONSE 2

(OBQ07.1) A 45-year-old male falls onto his left shoulder while biking and an injury radiograph is shown in Figure A. He elects for nonoperative treatment. What is the most likely clinical outcome at one year after injury? Review Topic

QID: 662
FIGURES:
1

Symmetric cosmesis of shoulders

5%

(51/1056)

2

Decreased shoulder motion

4%

(47/1056)

3

Symptomatic nonunion

14%

(146/1056)

4

Shoulder instability

0%

(0/1056)

5

Decreased shoulder strength and endurance

76%

(806/1056)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ07.25) A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace? Review Topic

QID: 686
FIGURES:
1

Decreased sleep disturbance

2%

(16/815)

2

Decreased personal care and hygiene impairment

3%

(26/815)

3

Decreased rates of malunion

2%

(19/815)

4

Improved long-term clinical outcomes

0%

(2/815)

5

No advantage, equivalent result between a simple sling and figure-of-eight brace

92%

(747/815)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ08.219) A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. After nine months of conservative treatment, he continues to complain of pain. A current radiograph is shown in Figure A. What is the most appropriate treatment? Review Topic

QID: 605
FIGURES:
1

Addition of a bone stimulator

0%

(3/745)

2

Figure of eight brace

0%

(2/745)

3

Closed reduction and percutaneous pinning

0%

(1/745)

4

Open reduction and intramedullary nailing

8%

(59/745)

5

Open reduction and compression plating

91%

(677/745)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ11.118) A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true? Review Topic

QID: 3541
FIGURES:
1

No difference in shoulder function

7%

(256/3613)

2

Higher risk of nonunion with operative management

2%

(67/3613)

3

Higher risk of symptomatic malunion or nonunion with nonoperative management

83%

(3001/3613)

4

Earlier return to sport with nonoperative management

0%

(17/3613)

5

No difference in union rates

7%

(262/3613)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ08.168) A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. What is the most appropriate management of the clavicular injury? Review Topic

QID: 554
FIGURES:
1

Closed reduction and figure of 8 splinting

1%

(16/2075)

2

Open reduction and plate fixation

96%

(2001/2075)

3

Open reduction and percutaneous pinning

0%

(4/2075)

4

Simple sling to involved side

2%

(41/2075)

5

Sling with abduction pillow to involved side

0%

(4/2075)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ08.54) Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively? Review Topic

QID: 440
1

Sling immobilization

0%

(8/1994)

2

Displacement and comminution

93%

(1864/1994)

3

Age less than 40 years old

1%

(10/1994)

4

Immediate motion exercises

4%

(87/1994)

5

Male

1%

(14/1994)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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