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
Technique Guide CPT Codes: 23515 Open treatment of clavicular fracture, includes internal fixation, when performed Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Clavicle Shaft Fracture ORIF Orthobullets Team Trauma - Clavicle Shaft Fractures
QUESTIONS 1 of 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 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: A 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: A B 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 Select Answer to see Preferred Response 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: A 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: A 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: A 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: A 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: A 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Titanium elastic IM nailing for Middle-Third Clavicle Fractures - What are your thoughts? Trauma - Clavicle Shaft Fractures What implant would you use for this clavicle fracture? Trauma - Clavicle Shaft Fractures
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