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Updated: Feb 14 2024

Clavicle Fractures - Midshaft

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  • Summary
    • Midshaft Clavicle fractures are common traumatic injuries caused by a direct impact to the shoulder girdle and is most commonly seen in young, active adults.
    • Diagnosis can be made radiographically with AP and cephalic tilt clavicle x-rays. 
    • Treatment is nonoperative or operative based on patient activity and demands, along with degree of displacement, shortening, and comminution. 
  • Epidemiology
    • Incidence
      • common
        • incidence
          • 1 in 1000 people per year
        • prevalence 
          • 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
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • fall onto lateral aspect of shoulder (85%)
        • direct impact to clavicle 
      • pathoanatomy
        • junction of the outer and middle third is the thinnest part of the bone
          • prone to fracture with axial loading
        • only area not protected by or reinforced with muscle and ligamentous attachments
        • displaced fractures
          • medial fragment pulled posterosuperiorly by sternocleidomastoid muscle 
          • lateral fragment pulled inferomedially by pectoralis major and and weight of arm
        • open fractures usually result from medial fragment "buttonholing" through platysma
    • Associated conditions
      • medical 
        • pneumothorax
        • closed head injury
      • orthopedic
        • ipsilateral scapular fracture (floating shoulder)
        • scapulothoracic dissociation
          • traction injury 
          • significantly distracted/widened fracture fragments
          • widened interval between scapula and spine
          • brachial plexus or vascular injury 
        • neurovascular injury
  •  ANATOMY
    • Osteology
      • Shape
        • S-shaped bone
        • flat laterally, tubular centrally, and prismatic medially 
    • Articulations 
      • sternoclavicular joint
        • four primary stabilizers
          • posterior capsular ligament
          • anterior sternoclavicular ligament
          • costoclavicular ligament
          • intra-articular disc
      • acromioclavicular joint
        • two primary stabilizers
          • coracoclavicular ligament 
          • acromioclavicular ligament 
    • Muscles
      • sternocleidomastoid
        • pulls medial segment proximally
        • clavicular head originates superiorly on medial third
        • inserts on mastoid process 
      • deltoid 
        • stabilizes distal clavicle and assists with shoulder abduction
          • shortening of clavicle decreases lever arm of deltoid  
        • originates from anterior lateral third clavicle, acromion, and scapular spine 
        • inserts on deltoid tuberosity
      • trapezius
        • originates from occiput and C-T spine spinous process
        • inserts on lateral posterosuperior third of clavicle, acromion, and scapular spine
      • pectoralis major
        • pulls medially causing shortening 
        • clavicular head originates from anteroinferior surface of medial half of clavicle
        • inserts on crest of greater tubercle of humerus, lateral to bicipital groove
      • subclavius
        • protects NV structures which pass deep to muscle and displace clavicle inferiorly 
        • originates from 1st rib and costal cartilage 
        • inserts on undersurface of clavicle
      • sternohyoid
        • originates on sternal end of clavicle
        • inserts on hyoid bone
      • platysma
        • violated with skin tenting
        • originates from pectoral fascia
        • inserts mandible 
    • Ligaments
      • coracoclavicular (CC) ligaments
        • provide superior/inferior stability to AC joint
        • two components 
          • trapezoid (lateral) 
            • inserts 3 cm medial to distal clavicle
          • conoid (medial) 
            • inserts 4.5 cm medial to distal clavicle
    • Blood Supply
      • subclavian vessel
        • passes posterior and underneath clavicle near junction of medial and middle third
        • subclavian vein closest to clavicle and anterior to artery and plexus
    • Nervous System
      • supraclavicular nerves
        • cutaneous nerves that run vertically over clavicle and supply superior chest wall
      • brachial plexus
    • Biomechanics
      • middle third is weakest portion of clavicle 
        • thinnest and narrowest
        • transitional of the bone in both curvature and in cross-sectional anatomy
        • only area not supported by ligamentous or muscular attachments
  • Classification
      • Neer Classification (simple)
      • Nondisplaced
      • < 100% displacement
      • Nonoperative
      • Displaced
      • > 100% displacement
      • 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
    • History
      • popping or cracking sound near shoulder after fall
    • Symptoms
      • acute onset of anterior shoulder pain or directly over clavicle
    • Physical exam
      • inspection
        • tender, swelling, crepitus and deformity over clavicle
        • skin tenting (impending open fracture)
      • neurovascular exam
        • assess subclavian vessels and brachial plexus 
  • Imaging
    • Radiographs
      • recommended views
        • clavicle series
          • upright AP clavicle
            • supine may underappeciate displacement with gravity eliminated
          • 15° cephalic tilt (zanca view)
            • eliminates overlapping scapula 
        • shoulder series
          • evaluate for other injuries (ie proximal humerus, scapula)
      • optional views
        • upright chest x-ray 
          • compare shortening with contralateral side
          • evaluate for pneumothorax 
      • findings
        • superior displacement of medial fragment
        • inferior displacement of lateral fragment
        • shortening
      • measurements 
        • shortening 
          • two methods
            • AP clavicle - distance between the corresponding ends of the medial and lateral fragments
            • AP chest - direct comparison of length of clavicle to the contralateral side
              • shortening >2cm associated with decrease shoulder strength and endurance
        • displacement
          • displacement relative to width of clavicle (percent)
            • >100% displacement is a risk factor for nonunion
    • CT 
      • indications  
        • assess fracture pattern for preop planning 
          • comminution, shortening, articular extension, nonunion
        • vascular injury 
        • medial clavicle fracture
        • SC joint dislocation
      • views
        • axial, coronal and 3D reconstruction most useful
        • with contrast if concern for vascular injury 
  • Differential
    • Adult distal third clavicle fx
      • older, osteoporotic patient
      • x-ray may show increased CC distance 
    • Sternoclavicular dislocation
      • high energy mechanism 
      • may present with dysphagia, stridor, asymmetric pulses, paresthesias due to compression of surrounding structures 
      • serendipity view or CT best demonstrate displacement 
    • Acromioclavicular Joint Injury
      • pain and prominence more lateral over AC joint
      • zanca or axillary views shows displaced distal clavicle relative to acromion 
  • Treatment
    • Nonoperative
      • sling immobilization
        • indications
          • < 2cm shortening and displacement
          • < 1cm displacement of the superior shoulder suspensory complex
          • closed and no neurovascular injury
          • low demand patient 
        • techniques
          • sling
          • figure-of-8 strap
            • elevate and extend shoulder to bring distal fragment to the proximal fragment
        • outcomes 
          • figure-of-8 associated with more pain, shortening, and lower compliance than sling
          • no difference in functional or cosmetic outcomes between sling and figure-of-eight braces
    • Operative
      • open reduction internal fixation (ORIF)
        • indications
          • absolute
            • open fractures
            • displaced fracture with skin tenting
            • subclavian artery or vein injury
            • floating shoulder (clavicle and scapular neck fracture)
          • 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
          • intramedullary fixation
          • open reduction internal fixation with plate and screws
        • outcomes
          • operative fixation has higher union rate (>94%)
          • similar or better functional outcomes than nonoperative
          • faster time to union - operative (16.4 weeks) vs. non-operative (28.4 weeks) 
  • Techniques
    • Sling Immobilization
      • technique
        • immobilize using sling or figure-of-eight brace
          • no attempt at reduction should be made
        • rehab 
          • gentle passive ROM exercises at 2 weeks
          • strengthening exercises begin at 6 weeks
          • return to sports at 4-6 months
      • advantage
        • overall good outcomes
        • avoid surgical/hardware complications
      • disadvantage
        • higher nonunion rate compared to operative management
        • slower time to union 
      • complications
        • malunion
        • poor cosmesis 
        • decreased shoulder strength and endurance
          • displaced midshaft clavicle fractures healed with > 2cm of shortening
    • Plate Fixation
      • approach
        • beach chair vs. supine
        • direct superior vs. anterior incision
      • technique
        • plate configuration 
          • anterior plating
          • superior plating (compared to anterior plating) 
            • higher load to failure
            • increased plate strength with inferior bone comminution 
            • increased risk of neuromuscular injury 
            • decreased removal of deltoid attachment 
          • dual plating
            •  low rate of symptomatic hardware removal (0-3.7%)
            • biomechanically equivalent or superior to single 3.5mm plate 
        • plate options
          • limited contact, pre-controured, 3.5mm dynamic compression plate
          • 3.5mm reconstruction plate
          • 2.0mm, 2.4mm and 2.7mm plates can be used and combined for dual 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 nonunion and malunion rate
        • improved cosmetic satisfaction
        • improved overall shoulder satisfaction
        • increased shoulder strength and endurance
      • disadvantage
        • increased risk of need for future procedures
          • implant removal
          • debridement for infection
      • complications 
        • hardware irritation
        • infection
        • neurovascular injury 
        • supraclavicular nerve injury 
        • hardware failure
        • pneumothorax
      • 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
    • Intramedullary Fixation (IMN)
      • technique 
        • positioning
          • beach chair or supine
        • approach
          • percutaneous or mini-open 
        • implant choices
          • intramedullary nail
            • goal size of intramedullary nail is 30-40% of midshaft diameter
          • cannulated screws
          • titanium elastic nail
          • Hagle pin
      • advantages
        • smaller incision
        • less soft-tissue disruption
        • avoids supraclavicular nerves that are commonly injured with plating
        • best for simple patterns 
      • disadvantages 
        • higher complication rate
          • hardware migration, implant irritation, secondary procedures
        • biomechanically inferior to plating
        • unable to lock and control rotation 
        • typically requires hardware removal at 6 months
      • contraindications
        • substantial comminution
        • segmental fractures
      • complications
        • hardware migration 
        • loss of reduction 
  • Complications
    • Nonoperative treatment
      • nonunion (~15%)
        • risk factors
          • fracture comminution (Z deformity)
          • fracture displacement
          • female gender
          • advanced age
          • smoker
        • predictors at 6 week
          • motion at fracture site, no callus on x-ray, DASH >40 
            • 0 - 3% nonunion 
            • 2 or 3 - 60% nonunion 
        • treatment 
          • if asymptomatic, no treatment necessary
          • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
      • malunion (~20%)
        • definition
          • shortening > 3cm
          • angulation > 30°
          • translation > 1cm
        • presentation
          • pain and increased fatigue with overhead activities
          • thoracic outlet syndrome
          • dissatisfaction with appearance
          • difficulty with shoulder straps and backpacks
        • treatment
          • clavicle osteotomy with bone grafting, if symptomatic
    • Operative treatment
      • hardware prominence
        • 8-30% of patient request plate removal
        • superior plates associated with increased irritation
      • neurovascular injury 
        • superior plates associated with increased risk of subclavian artery or vein penetration
        • subclavian thrombosis
      • supraclavicular nerve injury 
        • most common complication 
          • 83% incidence of numbness noted at 2 weeks postop 
            • can improve over time with ~50% having persistent numbness at 1 year
      • 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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