Updated: 4/3/2021

Midshaft Clavicle Fractures

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Introduction
  • Description
    • clavicle shaft fractures are common traumatic injuries seen in young adults that occur in the middle third of the clavicle
      • treatment is controversial but may be nonoperative or operative based on the degree of displacement and patient factors.
  • 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
    • associated injuries are rare but may include
      • ipsilateral scapular fracture
      • scapulothoracic dissociation
        • should be considered with significantly distracted/widened fracture fragments
      • rib fracture
      • pneumothorax
      • neurovascular injury
      • closed head injury
Classification
 
 Neer Classification
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
  • 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
Differential
  • Adult distal third clavicle fx 
  • Pediatric medial clavicle physeal injury 
  • Pediatric distal clavicle physeal injury
  • Acromioclavicular Joint Injury 
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 plating (compared to anteroinferior plating)
        • higher load to failure
        • increased plate strength with inferior bone comminunion
        • increased risk of neurovascular injury
        • decreased removal of deltoid attachment
    • 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 (10-15%)   
      • 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
      • supraclavicular nerve injury
    • 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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