Dr. Ebraheim’s educational animated video describes fractures of the clavicle.
The concoid ligament is medial. The trapezoid is lateral.
These ligaments are the primary stabilizers to superior or vertical translation of the distal clavicle.
Three types based on the integrity of the CC ligament complex and involvement of the AC joint.
•Type I: conoid and trapezoid ligament are intact to the medial fragment. The fracture is lateral to the CC ligaments and the medial fragment is stable.
•Type II: the medial fragment is not supported by the CC ligament. they are either torn or the fracture is medial to the ligaments. The lateral fragment may contain the ligaments entirely and the medial fragment displaces superiorly. This is the fracture type that is displaced and has disruption, it is the least stable fracture type and has the highest risk of nonunion. Consider surgery for type II displaced fracture of the lateral third of the clavicle.
•Type III: fracture extends into the AC joint.
The sternocleidomastoid muscle will pull the medial fragment superiorly and the pectoralis muscle with gravity and the weight of the arm will pull the distal fragment inferiorly.
•Check for deformities and tenting of the skin. •May be impending open fracture. •Watch for distracted clavicle. •May have scapulothoracic dissociation. •Check for possible neurovascular deficit (check for brachial plexus injury). •Be aware that the neurovascular bundle is very close to the clavicle (subclavian vessels are about 1 cm from the clavicle).
X-rays: get x-rays of both shoulders. In the x-rays, you are going to look for shortening, comminution and the z-type fracture.
Risk factors for nonunion: smoker, older female, displacement and comminution. Fracture of the lateral third of the clavicle with displacement of the medial fragment. .
Absolute indications for surgery: open fracture, vascular injury and fragment is tenting the skin. The majority of patients improve spontaneously.
Conservative treatment: most clavicle fractures can be treated without surgery. Patient with undisplaced clavicle fractures usually heals well. It is difficult to reduce and maintain reduction in clavicle fractures. Healing will occur despite the degree of displacement. if the fracture is significantly displaced, then there is a higher incidence of nonunion and this displaced fracture can cause significant, persistent weakness and disability even if the fracture heals. Used for minimally or nondisplaced fractures of the clavicle. The fracture will probably heel with a small bump (callus of healing). Movement of the shoulder and the arm is not a risk factor for nonunion.
•Comminuted fracture (use buttress plate)•Segmented fracture •z-type fracture •fracture shortening more than 2 cm •fracture displacement more than 100%
nonoperative treatment in these cases will lead to decreased endurance and strength, but the range of motion will remain the same in operative or nonoperative cases.
What type of hardware or surgical implant should be used in fixation of clavicle fractures?
Reduction: 1- superior plate fixation, 2- anteroinferior plate fixation,surgery is usually not easy. Surgery begins by defining the location of the AC joint. Also surgery is dependant on getting good x-rays in the operating room.
Superior plate fixation: no dissection of the deltoid muscle from the clavicle. The superior plate has a mechanical advantage being on the tension surface of the clavicle.
Anteroinferior plate fixation: has the advantage of using longer screws with a safe screw trajectory and less hardware prominence. Has disadvantage of deltoid dissection from the clavicle. The anteroinferior plate may be better tolerated by the patient, especially those who carry loads on their shoulders such as backpacks.
It is better to use a contoured plate. About 30% of the clavicle fixation plates are removed after the fracture has completely healed.
Complications of clavicle fractures: nonunion, malunion.
Complications of clavicle fractures due to fixation
1-Symptomatic hardware (most common complication, will need reoperation)
2-Infraclavicular numbness: complication due to injury of the supraclavicular nerve. There are three supraclavicular branches span out to cover the entire clavicle subcutaneous surface, lateral ,medial & intermediate. Injury to these branches may cause chest wall numbness below the incision. Injury to those branches may occur due to the incision or from traction during surgery.
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