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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
  •  Epidemiology
    • incidence
      • 10-15% of clavicle fracture occur in the distal third segment
    • demographics
      • more commonly in older or osteoportic patients
      • less common in pediatric patients 
  • Pathophysiology
    • mechanism
      • similar mechanism to mid-shaft clavicle fractures
        • usually occur after a direct, compressive force applied to the shoulder 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 trapzoid [lateral] provide primary resistence to superior displacement of the lateral clavicle
        • age (e.g, pediatric patients usually have an intact periosteal sleeve)
  • Associated injuries
    • are rare but include
      • floating shoulder
      • scapulothoracic dissociation
        • should be considered with significantly displaced or widened fractures
        • rib fracture
        • pneumothorax
        • neurovascular injury
Relevant Anatomy
  • AC joint stability consist of 
    • static stabilizing factors
      • acromioclavicular ligament
        • function
          • provides anterior + posterior translation stability
        • components
          • superior
          • inferior
          • anterior
          • posterior 
        • clinical significance
          • superior and posterior ligaments are most important
      • coracoclavicular ligaments (trapezoid and conoid)
        • function
          • provides superior + inferior translation stability
        • components
          • trapezoid ligament  (lateral)
            • inserts 3 cm from end of clavicle
          • conoid ligament (medial)
            • inserts 4.5 cm from end of clavicle
        • clinical significance
          • conoid ligament is strongest
      • capsule
    • dynamic stabilizing factors
      • deltoid and trapezius act as additional stabilizers
Classification
  • Two most common classification systems
    • Neer Classification 
Neer Classification of Lateral third Clavicle Fractures  (10-15%)  
Type 1                  
  • 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 ligmanet 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 injury
    • Patients may develop posttraumatic AC arthritis
Nonoperative
x
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
AO Classification
Type A           
  • Undisplaced fracture, CC ligaments intact
    • A1 = extraarticular
    • A2 = intraarticular
Nonoperative 
      

Type B

  • Displaced fracture, CC ligaments intact
    • A1 = extraarticular
    • A2 = comminuted
Nonoperative or Operative  

Type C
  • Displaced fracture, CC ligaments disrupted
    • A1 = extraarticular
    • A2 = intraarticular
Operative 
 

 

 
Presentation
  • Symptoms
    • tip of shoulder pain
  • Physical exam
    • AC joint deformity
    • tenting of skin (impending open fracture)
    • perform careful neurovascular exam
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
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)
      • outcomes
        • nonunion (1-5%)
          • risk factors for nonunion
            • Neer group II (up to 56%)
              • disrupted CC ligaments 
            • advanced age and female gender
        • poor cosmesis  
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • open, or impending open, fractures  
          • subclavian artery or vein injury
          • floating shoulder (e.g., distal clavicle and scapula neck fx with >10mm of displacement)
          • symptomatic nonunion
        • relative 
          • unstable fracture patterns (Type IIA, Type IIB, Type V)
          • brachial plexus injury (questionable b/c 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
        • outcomes
          • advantages of ORIF
            • higher union rates
            • faster time to union
            • improved functional outcome / less pain with overhead activity
            • decreased symptomatic malunion rate 
            • improved cosmetic satisfaction
          • disadvantages of ORIF
            • increased risk of need for future procedures (e.g, removal of hook plate)
            • symptomatic hardware
            • infection
Techniques
  • Sling Immobilization
    • technique
      • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
      • after 2-3 weeks begin gentle range of motion exercises
      • strengthening exercises begin at 6-8 weeks
      • no attempt at reduction should be made
  • Open Reduction Internal Fixation
    • technique
      • limited contact dynamic compression plate  
        • position
          • beach chair or supine
        • approach
          • superior approach to AC joint
          • temporary fixation with k wires
        • equipment
          • locking plates 
          • precontoured anatomic plates 
        • fixation
          • need larger distal fragment for multiple locking screws 
          • >3 or 4 bicortical screws into medial fragment to reduce the risk of screw pull out  
      • hook plate  
        • position
          • beach chair or supine
        • approach
          • superior approach to AC joint
          • temporary fixation with k wires
        • equipment
          • hook plates vary in hook depth and number of holes
          • proper hook depth ensures the AC joint is not over- or under-reduced
        • fixation
          • 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 or 4 bicortical screws should be placed into the proximal (medial) fragment to reduce the risk of screw pull out 
      • Other types of fixation
        • AC joint spanning fixation
          • usually used as an alternative to hook plates
        • tension band wire
        • intramedullary screw  
        • coracoclavicular ligament reconstruction   
    • 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
        • hardware removal considered usually after 3 months
Complications
  • Nonoperative treatment
    • nonunion (1-5%)
      • risks
        • comminution
        • Z deformity
        • female
        • older
        • smoker
        • distal clavicle higher risk than middle third
      • treatment of nonunion
        • if asymptomatic, no treatment necessary
        • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)  
  • Operative treatment
    • hardware prominence
      • ~30% of patient request plate removal
      • superior plates associated with increased irritation
    • hardware removal
      • mostly 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)
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(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%

(168/3285)

2

Transacromial wire fixation with possible coracoclavicular ligament reconstruction

2%

(61/3285)

3

Coracoclavicular screw fixation

1%

(32/3285)

4

Hook plate fixation with coracoclavicular ligament reconstruction

14%

(476/3285)

5

Small fragment plate fixation with possible coracoclavicular ligament reconstruction

77%

(2530/3285)

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