Updated: 7/24/2019

Distal Third Clavicle Fractures

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https://upload.orthobullets.com/topic/12770/images/neer_distal_clavicle-145630ebe331246639b.jpg
https://upload.orthobullets.com/topic/12770/images/lateral_clavicle_orif.jpg
https://upload.orthobullets.com/topic/12770/images/clavicle_hook_plate.jpg
https://upload.orthobullets.com/topic/12770/images/hook_plate.jpg
Introduction
  • Overview
    • distal third clavicle fractures are traumatic injuries
      • treatment is based on the type of injury and its stability
    • 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
      • more commonly in older or osteoportic patients
      • less common in pediatric patients 
    • location
      • 10-15% of all clavicle fractures occur in the distal third segment
  • Pathophysiology
    • mechanism
      • similar mechanism to midshaft clavicle fractures
        • usually occurs after a direct compressive force is applied to the shoulder, i.e. after a fall or trauma
    • pathoanatomy
      • fracture displacement corresponds to
        • fracture location (e.g, extra-articular vs. articular)
        • fracture pattern (e.g, simple vs. comminuted)
        • integrity of the coracoclavicular ligments 
          • conoid (medial) and trapezoid (lateral) provide primary resistance to superior displacement of the lateral clavicle
        • age (e.g, pediatric patients usually have an intact periosteal sleeve)
  • Associated conditions
    • rare but may include
      • floating shoulder
      • scapulothoracic dissociation
        • should be considered with significantly displaced or widened fractures
      • rib fracture
      • pneumothorax
      • neurovascular injury
Anatomy
  • Acromioclavicular joint anatomy
  • AC joint stability
    • static stabilizers
      • acromioclavicular ligament
        • provides anterior/posterior stability
        • components
          • superior
          • inferior
          • anterior
          • posterior 
        • superior ligament is strongest, followed by posterior
      • coracoclavicular ligaments (trapezoid and conoid)
        • provides superior/inferior stability
        • components
          • trapezoid ligament (lateral)
            • inserts 3 cm from end of clavicle
          • conoid ligament (medial)
            • inserts 4.5 cm from end of clavicle in the posterior border
        • conoid ligament is strongest
      • capsule
    • dynamic stabilizers
      • deltoid
      • trapezius 
Classification
 
 Neer Classification
Type I
 • fracture is LATERAL to coracoclavicular ligaments
 • conoid and/or trapezoid ligament remain INTACT
 • minimal displacement
 • STABLE
 nonoperative
Type IIA  • fracture occurs MEDIAL to coracoclavicular ligaments
 • conoid and trapezoid ligment remain INTACT
 • significant medial clavicle displacement
 • UNSTABLE
          • up to 56% nonunion rate with nonoperative management
 operative
 
Type IIB  • two fracture patterns
          (1) fracture occurs either BETWEEN the coracoclavicular ligaments
                    • conoid ligament TORN
                    trapezoid ligament INTACT
          (2) fracture occurs LATERAL to coracoclavicular ligaments 
                    • conoid ligament TORN
                    trapezoid ligament TORN

 • signficant medial clavicle dispalcement
 • UNSTABLE
          up to 30-45% nonunion rate with nonoperative management
 operative

Type III  • INTRA-ARTICULAR fracture extending into AC joint
 • conoid and trapezoid ligaments remain INTACT
 • minimal displacement
 • STABLE
          • patients may develop posttraumatic AC arthritis
 nonoperative

Type IV  • PHYSEAL fracture that occurs in the skeletally immature
 • conoid and trapezoid ligaments remain INTACT
 • displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum (clavicle pulls out of periosteal sleeve)
 • STABLE
 nonoperative
Type V
 • COMMINUTED fracture pattern
 • conoid and trapezoid ligaments remain INTACT
 • significant medial clavicle displacement
 • usually UNSTABLE
 operative
 
AO Classification 
Type A = nondisplaced + intact CC ligaments
 • A1 = extraarticular
 • A2 = intraarticular
nonoperative
Type B = displaced + intact CC ligaments
 • B1 = extraarticular
 • B2 = comminuted
nonoperative vs. operative
Type C = displaced + torn CC ligaments
 • C1 = extraarticular
 • C2 = intraarticular
operative
 
Presentation
  • Symptoms
    • anterior shoulder pain
  • Physical exam
    • AC joint deformity
    • may have tenting of skin (impending open fracture)
    • perform careful neurovascular exam
Imaging
  • Radiographs
    • recommended views
      • upright AP view 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, and nonunion
Treatment
  • Nonoperative
    • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks 
      • indications
        • stable fractures (Neer Type I, III, IV) 
        • pediatric distal clavicle fractures (skeletally immature)
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • open or impending open fractures  
          • subclavian artery or vein injury
          • floating shoulder (distal clavicle and scapula neck fractures with > 10mm of displacement)
          • symptomatic nonunion
        • relative 
          • unstable fracture patterns (Neer Type IIA, IIB, V)
          • 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
          • Neer group II (up to 56%)
            • disrupted CC ligaments
          • advanced age
          • female gender
      • poorer cosmesis
  • Open Reduction Internal Fixation
    • technique
      • limited contact dynamic compression plate  
        • position
          • beach chair vs. supine
        • approach
          • superior approach to AC joint
          • temporary fixation with k wires
        • instrumentation
          • locking plates 
          • precontoured anatomic plates 
        • technique
          • need larger distal fragment for multiple locking screws 
          • > 3-4 bicortical screws into medial fragment to reduce the risk of screw pull-out  
      • hook plate  
        • position
          • beach chair vs. supine
        • approach
          • superior approach to AC joint
          • temporary fixation with k wires
        • instrumentation
          • hook plates vary in hook depth and number of holes
          • proper hook depth ensures the AC joint is not over- or under-reduced
        • technique
          • hook plates are generally used when there is insufficent bone in the distal fragment for conventional clavicle plate fixation
          • the hook should be placed posterior to AC joint and positioned as far lateral as possible to avoid hook escape  
          • > 3-4 bicortical screws should be placed into the proximal (medial) fragment to reduce the risk of screw pull-out 
      • other options
        • AC joint spanning fixation
          • usually used as an alternative to hook plates
        • tension band wire
        • intramedullary screw  
        • coracoclavicular ligament reconstruction   
    • advantages 
      • higher union rates
      • faster time to union
      • improved functional outcome/less pain with overhead activity
      • decreased symptomatic malunion rate 
      • improved cosmetic satisfaction
    • disadvantages
      • increased risk of need for future procedures (e.g, removal of hook plate)
      • symptomatic hardware
      • infection
    • 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
        • hardware removal considered usually after 3 months
Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • risk factors
        • comminution
        • Z deformity
        • female
        • older
        • smoker
        • distal third clavicle > middle third clavicle
      • treatment
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
    • AC joint arthritis
  • Operative treatment
    • hardware prominence
      • ~30% of patient request plate removal
      • superior plates associated with increased irritation
    • hardware removal
      • most common with hook plates
    • neurovascular injury (3%)
      • superior plates associated with increased risk of subclavian artery or vein penetration
      • subclavian thrombosis
    • nonunion (1-5%)
    • infection (~4.8%)
    • mechanical failure (~1.4%)
    • pneumothorax
    • adhesive capsulitis
      • 4% in surgical group develop adhesive capsulitis requiring surgical intervention
 

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Questions (2)

(OBQ12.202) A 23-year-old male right hand dominant minor league hockey player sustains the injury shown in Figure A and B. The patient is apprised of the risks and benefits of both conservative and surgical treatments. He chooses to undergo surgical intervention and wishes to minimize the chance of requiring a second operation. Which of the following is the most appropriate surgical procedure for this patient? Review Topic

QID: 4562
FIGURES:
1

Distal clavicle resection

5%

(224/4493)

2

Transacromial wire fixation with possible coracoclavicular ligament reconstruction

2%

(88/4493)

3

Coracoclavicular screw fixation

1%

(46/4493)

4

Hook plate fixation with coracoclavicular ligament reconstruction

14%

(643/4493)

5

Small fragment plate fixation with possible coracoclavicular ligament reconstruction

77%

(3466/4493)

ML 3

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