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Introduction
  •  Epidemiology
    • incidence
      • 75-80% of all clavicle fractures will occur in the middle third segment
    • demographics
      • most often seen in young, active patients
  • Pathophysiology
    • mechanism
      • fall on an outstretched arm or direct trauma to lateral aspect of shoulder
    • pathoanatomy
      • 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 "buttonhole" through platysma
  • Associated injuries
    • are rare but may include:
      • ipsilateral scapular fracture
      • scapulothoracic dissociation
        • should be considered with significantly displaced/widened fracture fragments
      • rib fracture
      • pneumothorax
      • neurovascular injury
  • Pediatric Clavicle fractures
    • fracture patterns include
      • medial clavicle physeal injury
      • distal clavicle physeal injury
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
          • trapezoid ligament inserts 3 cm from end of clavicle
          • conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
        • conoid ligament is strongest
      • capsule
    • dynamic stabilizers
      • deltoid and trapezius 
Classification
 
Neer Classification - Middle third clavicle fracture   
Nondisplaced
  • Less than 100% displacement
Nonoperative
Displaced
  • Greater than 100% displacement
  • Nonunion rate of 4.5%
Operative

AO Classification - Middle third clavicle fracture 
Type A=Simple              
  • A1 = spiral
  • A2 = oblique
  • A3 = transverse
Nonoperative or Operative   
Type B=Wege
  • A1 = spiral wedge
  • A2 = bending wedge
  • A3 = fragmented wedge
Nonoperative or Operative  
Type C=Complex
  • A1 = complex spiral
  • A2 = segmental
  • A3 = irregular
Operative 

Presentation
  • Symptoms
    • anterior shoulder pain
  • Physical exam
    • deformity
    • perform careful neurovascular exam
    • tenting of skin (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
  • CT 
    • views 
      • coronal, saggital, axial
      • 3D reconstruction views
    • findings 
      • may help evaluate displacement, shortening, comminution, articular extension, and nonunion
      • vascular injury 
Treatment
  • Nonoperative
    • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks
      • indications
        • minimally displaced Group I (middle third)
          • shortening and displacement <2cm
          • no neurologic deficit
          • no significant displacement to the superior shoulder suspensory complex (<10mm displacement)  
      • outcomes
        • nonunion (1-5%)  
          • risk factors for nonunion
            • comminution
            • 100% displacement & shortening (>2 cm)
            • advanced age and female gender
        • poorer cosmesis  
        • decreased shoulder strength and endurance
          • seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • open fxs
          • displaced fracture with skin tenting
          • subclavian artery or vein injury
          • floating shoulder (clavicle and scapula neck fx)
          • symptomatic nonunion 
          • symptomatic malunion
        • relative and controversial indications
          • displaced Group I (middle third) with >2cm shortening 
          • bilateral, displaced clavicle fractures
          • brachial plexus injury (questionable b/c 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
      • outcomes
        • advantages of ORIF
          • improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement 
          • improved functional outcome / 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 of ORIF
          • increased risk of need for future procedures
            • implant removal
            • debridement for infection
Techniques
  • Sling Immobilization
    • technique
      • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
      • after 2-4 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-10 weeks
      • no attempt at reduction should be made
  • Closed Reduction, Intramedullary Fixation 
    • equipment options
      • cannulated screw
      • specialized screw systems (e.g, Dual Trak)
      • titanium elastic nail
      • Hagle pin
    • approach
      • beach chair or supine
      • posterolateral incision
    • contraindications
      • substantial comminution
      • segmental fractures
    • 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
      • biomechanically inferior to plating
  • 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 
    • approach
      • beach chair or supine
      • direct superior vs anterior incision
    • biomechanics
      • superior vs anteroinferior plating
        • higher load to failure (superior plating > anterointerior plating)
        • 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)
    • 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 month
Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • risk factors
        • fracture comminution (e.g, Z deformity)
        • fracture displacement 
        • female
        • advancing age
        • smoker
      • treatment of nonunion
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
    • malunion
      • definition
        • shortening >3cm, angulation >30 degrees, translation >1cm
      • complaints
        • 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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Technique Guides (1)
Questions (22)
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(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%

(226/3140)

2

Higher risk of nonunion with operative management

2%

(57/3140)

3

Higher risk of symptomatic malunion or nonunion with nonoperative management

83%

(2604/3140)

4

Earlier return to sport with nonoperative management

0%

(11/3140)

5

No difference in union rates

7%

(234/3140)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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%

(45/988)

2

Decreased shoulder motion

4%

(42/988)

3

Symptomatic nonunion

13%

(131/988)

4

Shoulder instability

0%

(0/988)

5

Decreased shoulder strength and endurance

77%

(764/988)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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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

91%

(1089/1203)

2

Open reduction and percutaneous pinning

1%

(11/1203)

3

Closed reduction and percutaneous pinning

1%

(13/1203)

4

Closed reduction and external fixation

0%

(1/1203)

5

Nonoperative treatment with a sling and early range of motion

7%

(82/1203)

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%

(108/3892)

2

Similar rates of symptomatic nonunion

7%

(277/3892)

3

No differences in cosmetic results

2%

(67/3892)

4

Increased functional outcome scores

82%

(3188/3892)

5

Improved range of motion of the shoulder

6%

(233/3892)

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%

(216/5132)

2

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

70%

(3587/5132)

3

Increased symptomatic malunion rate with operative treatment

1%

(69/5132)

4

No change in shoulder abduction strength

18%

(919/5132)

5

Increased time to union with operative treatment

6%

(321/5132)

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%

(52/654)

2

female gender

53%

(347/654)

3

simple fracture pattern

8%

(55/654)

4

sling immobilization

5%

(34/654)

5

early range-of-motion

25%

(161/654)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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

3%

(17/666)

2

Decreased personal care and hygiene impairment

4%

(25/666)

3

Decreased rates of malunion

2%

(15/666)

4

Improved long-term clinical outcomes

0%

(2/666)

5

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

90%

(602/666)

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%

(3/625)

2

Figure of eight brace

0%

(2/625)

3

Closed reduction and percutaneous pinning

0%

(1/625)

4

Open reduction and intramedullary nailing

10%

(60/625)

5

Open reduction and compression plating

89%

(556/625)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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%

(15/1972)

2

Open reduction and plate fixation

96%

(1902/1972)

3

Open reduction and percutaneous pinning

0%

(4/1972)

4

Simple sling to involved side

2%

(39/1972)

5

Sling with abduction pillow to involved side

0%

(3/1972)

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%

(7/1911)

2

Displacement and comminution

94%

(1788/1911)

3

Age less than 40 years old

1%

(10/1911)

4

Immediate motion exercises

4%

(81/1911)

5

Male

1%

(14/1911)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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