05. acute midshaft clavicular fracture

8/10/2019 05. Acute Midshaft Clavicular Fracture

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A c u t e M i d s h a f t

C l a v i c u l a r F r a c t u r e

A b s t r a c t

Clavicular fractures represent 2.6% to 5% of all fractures, and

m iddle third fractures account for 69% to 82% of fractures of th e

clavicle. The junction of the out er and m iddle third is the th innest

part of the bone and is the only area not protected by or reinforced

w ith muscle and l igamento us at t achments. These anato m ic

features make it prone to fracture, particularly w ith a fall on th e

point of the shoulder, w hich results in an axial load to t he clavicle.

Optimal treatment of nondisplaced or minimally displaced

midshaft fracture is w ith a sling or figure-of-8 dressing; the

nonunion rate is very low . How ever, w hen m idshaft cla vicular

fractures are com pletely displaced or comm inuted, and w hen th ey

occur in elderly patients or fema les, the risk of nonunion , cosmetic

deformit y, and poor outcom e may be markedly higher. Thus, some

surgeons propose surgical st abilizat ion of a com plex m idshaft

clavicular fracture w ith either plate-and-screw fixation or

intram edullary devices. Further random ized, prospective t rials are

needed to provide bett er data on w hich t o base treatm ent decisions.

Th e c l a v i c l e i s o n e o f th e mo s tcomm only fractured bones; cla-vicular fractures represent 2.6% to

5% of all fractures.1,2 The incidence

of clavicular fractu re in adults is es-

tim at ed to be 71 in 100,000 for men

and 30 in 100,000 for w omen, w ith

the incidence of m idshaft fractures

decreasing w ith increasing age. Mid-

shaft fractures account for 69% to

82% o f a l l c l a v ic u l a r f ra c tu res.1-5

Midshaft fractures are m ore comm on

in children and youn g adults. The in-

cidence of high-energy clavicular

f ra c tu r es w i th c o mmi n u ti o n , d i s-

placement, an d shortening appears to

be increasing.2

Tr a di t i o n a ll y , f ra c tu r es o f th e

c la v ic le h a v e b ee n t r ea t e d w i t h

c l os ed r ed u cti o n . M o r e th a n 200

meth o d s h a v e b een d es c ri b ed f o r

closed reduction, y et a classic t ext-

book recognizes that reduction is

practically impossible to maintain,

and a certain am ount of deformit y is

to be expected, generally compatible

w ith satisfactory return of function

in the shoulder. 6 T h e s a me tex t-

b o ok s ta tes th a t ev en c o mp letel y

displaced fractures generally do

w ell w ith non-operative ma nage-

ment. . . . 6

How ever, most previous studies

describing the results of clavicular

fracture h ave used surgeon-based or

radiographic outcome m easures th at

equat e union w ith success. Very few

studies on clavicular fracture have

been published using patient-based

outcomes such as the Medical Out-

comes Study 36-Item Short Form

(Quality Metric, Lincoln, RI) or t he

Di s a b i l i t i es o f th e Ar m, S h o u l d er

and H and q uestionnaire (D ASH; In-

stit ute for Work and Healt h, Toron-

ta, C anada, and the American Acad-

Kyle J. Jeray, M D

Dr. Jeray is Program Director,

Orthopaedic Surgery Education,

Greenville Hospital System, Greenville,

SC.

Neither Dr. Jeray nor the department

with which he is affiliated has received

anything of value from or owns stock in a

commercial company or institution

related directly or indirectly to the

subject of this article.

Reprint requests: Dr. Jeray, Greenville

Hospital System, University Medical

Center, Orthopaedic Surgery Education,

701 G rove Road, 2nd Floor ERC

Support Tower, Greenville, SC 296 05.

J Am Acad O rthop Surg2007;15:239-

248

Copyright 20 07 by the American

Academy of Orthopaedic Surgeons.

Volume 15, Number 4, April 2007 2 3 9


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em y o f O rt h opa edi c Su rgeo ns

[AAOS]). Recent studies have indi-

cated that outcomes are not alw ays

e xc el le nt , pa r t ic u la rl y i n h i gh -energy fractures.7-11 These studies

r a is e th e q u est i o n w h eth er a c u te

midsha ft clavicular fractures should

be internally fixed.

A n a to m y a n d F u n c t io n

The clavicle is t he first bone t o ossify

in t he f if th w eek of fetal l i fe, and it

is the only lon g bone to ossify by in-

tramem branous ossif ication. Initial

grow th up to age 5 years arises fromthe ossification center in the central

portion of the clavicle, w ith contin-

ued grow th occurring at th e epiphy-

seal plates at the m edial and lat eral

ends of the bone. The m edial grow th

plate, typically t he only plate seen ra-

d i o gr a p h i c a l l y , a c c o u n ts f o r u p to

80% of longitudinal growt h. The me-

dial grow th plate is the last physis to

close, generally at age 22 to 25 years.

The clavicle is subcutaneous, w ith

only the supraclavicular nerves cross-

ing th e bone. How ever, several fascial

layers and muscles attach to the bone

itself and help to create the predict-able deformit y seen w ith fractures.

The proximal fragment is pulled su-

periorly and posteriorly by the ster-

nocleidomastoid muscle. The distal

segment sags forw ard and rotates in-

feriorly because of t he w eight of th e

upper extremity and, to a lesser ex-

tent, t he pull of the pectoralis mus-

cle on the hum erus.

Th e c l a v i cl e i s a s tr u t th a t c o n -

n ec t s t h e u ppe r e xt r em i t y t o t h e

trunk and is the only l ink to the ax-ial skeleton . It also provides protec-

t i o n f o r th e a d ja c en t a x i ll a r y a n d

subclavicular neurovascular struc-

tures and the apex of the lungs. Lat-

erally, the clavicle is secured by the

acromioclavicular (AC) and coraco-

clavicular ligam ents w here it articu-

lates w ith the acromion. Medially,

the clavicle articulates w ith t he ster-

num and is strongly secured to the

first rib by the intra-articular ster-

noclavicular (SC)joint cartilage, the

oblique fibers of the costoclavicular

ligaments, and the subclavius mus-

c l e. Th e c l a v ic l e i s S -s h a ped a n d

double-curved, concave ventrally on

its lateral half and convex ventrally

o n i ts m edi al h alf. Th e c ro ss-sectional geometry changes from flat

laterally to tubular centrally to trian-

gular m edially (Figure 1).

The shape of the clavicle an d the

l iga m en t ou s a n d m u sc le a t t a ch -

men ts p l a y a r o l e i n f r a c tu r e p a t-

terns. The junct ion of th e outer and

middle thirds is the thinnest part of

the bone and is t he only area not pro-

tect ed by or reinforced w ith m uscle

and ligam entous atta chment s, there-

by rendering it prone to fract ure, par-

ticularly w ith axial loading.12 This

h el ps t o e xpl a in w h y t h e m i d dl e

t h i r d i s t h e m o s t c o m m o n s i t e o f

fracture, occurring at the junction

w here the bone geometry changes

from flat to t ubular.

The mot ion of the clavicle is ulti-

ma t ely l i n ked to th e s u rr ou n d in g

m otion of th e scapula because of the

anatom ic attachm ent to the scapula

through the AC joint and t o the ster-

num t hrough the SC joint. Motion of

the clavicle occurs w ith elevationand abduction of the arm. D uring el-

evation, w ith respect to the SC joint,

the clavicle undergoes elevation of

11 to 15, retraction of 15 to 29,

and posterior long-axis rotation of

15 to 31, w ith the m agnitude and

p la n es v a r y i n g a mo n g s u bjects .13

Other studies suggest that rotation

ma y be as much as 50 and elevation

as high as 30. 14 More importantly,

clavicle rotation is relatively small

until hum eral elevation exceeds 90;

thus, early rehabilitation t hat av oids

over-the-shoulder activity w ill sig-

nificantly l imit rotational forces at

the site of a clavicular fracture.15

M e c h a n is m o f I n ju r y

M i ds h af t c la v ic ul a r f ra c t u re s

h a v e tr a d i t i o n a l l y b een th o u gh t to

occur from a fall on an outstretched

h a n d . H o w ev er , a b i omec h a n i ca l

analysis of t he forces demonstrated

Figure1

Anatomy and cross-sectional geometry of the clavicle. (Adapted with permissionfrom Craig EV: Fractures of the shoulder: Part II. Fractures of the clavicle, inRockwood CA, Green DP, Bucholz RW [eds]: Rockwood and Greens Fracturesin Adults, ed 3. Philadelphia, PA: JB Lippincott, 1991, vol 1, pp 928-990.)

Acute Midshaft Clavicular Fracture

2 4 0 Journal of the American Academy of Orthopaedic Surgeons


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that a direct injury from the shoul-

der (rather tha n the hand) that pro-

d uc es a f orc e e q u al t o t h e b od y

w eigh t w o u l d exc eed th e c ri t i c a l

b u c kl i n g l o a d a n d r es u l t i n a mi d -

shaft clavicular fracture.16 Several

studies have demonstrated that a di-rect fall or blow ont o the point of the

shoulder accounts for 85%to 94%of

th e injuries.2,3,5,16,17 When the forces

are transmitted through the arm, as

w ith a fall on an out stretched hand,

the forces are not directly delivered

to t he clavicle; thus, they are unlike-

l y to p r o d u c e a mi d s h a f t f r a c tu r e.

This m echanism account s for 2% to

5%of all midshaft fractures. A direct

blow t o the clavicle, such as from a

hockey st ick or a seat belt shoulder-

strap injury, also may produce a frac-

tu re and ac count s for 10% to 13% of

m i d sh a ft f ra c t u re s i n m o s t s t u d-

ies.16 Although rare, direct force on

the t op of the shoulder ma y drive the

mi d s h a ft c l a v ic l e a ga i n st th e f i rs t

rib, resulting in a fracture.

C l a s s i f i c a t i o n

C l a v i c u l a r f ra c tu res h a v e b een

classified by Allma n 18 into t hree ana-

tom ic regions, wit h the middle third

being group I. The classification sys-tem of the Orthopaedic Trauma As-

sociation separates diaphyseal cla-

v i c u l a r f r a c tu r es i n to th r ee ty p es :

06-A (sim ple), 06-B (w edge) an d 06-C

(complex).19 Each type is further bro-

ken dow n in to th ree groups.

The system developed by Robin-

so n 3 divides midshaft clavicular frac-

tures into type 2A (cortical align-

m ent fract ure)an d ty pe 2B (displaced

fracture). In an effort to provide di-

rection for treatm ent and prognosis,

Robinson further divides these into

subgroup types 2A1 (nondisplaced),

2A2 (angulated), 2B1 (simple or

w edge comm inut ed), and 2B2 (isolat -

ed or comminuted segmental) (Fig-

ure 2). Robinsons classification sys-

tem h a s d emo n s tr a ted s a t i s fa c to ry

levels of interobserver and intraob-

server reliability and reproducibility.

H o w e ve r, a d di t i on a l s t u di es a re

needed t o determine w hether this

classif ication system w ill reliablypr ed ic t t r ea t m e n t a n d f un c t io n a l

outcomes.

C l in i c a l E v a l u a tio n

O f ten w i th c l a v ic u l a r f ra c tu re, a

bruise or abrasion is seen, eith er over

th e point of the shoulder (indicat ing

a direct blow ) or over t he midline

(suggesting a seat belt sh oulder-strap

injury). The shoulder has a droop,

the scapula appears slightly internal-

ly rotated, and the shoulder appears

s h o rten ed r el a t i v e to th e o pp os i te

side. This characteristic deformity is

produced by the pull of m uscles at -

ta c h ed to th e c l a v i c l e . I mmed i a te

sw elling ma y obscure the deformity

of t he bone, w hich w il l be seen on

r a di o gr a ph s i f th e f ra c tu r e i s d i s-

placed. Palpation over the area w ill

reveal tenderness, and gentle manip-

u l a t i o n ma y p ro d uc e c r epi tu s a n d

mo ti o n a t th e f r a c tu re s i te. A n o n -d i sp la c ed o r mi n i ma l l y d i sp la c ed

fracture ma y be suspected w hen pain

and/or skin ch anges are present over

the clavicle.

Bec a u se mi d d le th i r d f ra c tu r es

frequently occur w ith high-energy

t r a um a , a c om p le t e e xa m i n a t i on

should be performed t o a void m iss-

ing associat ed injuries. Skeleta l inju-

ries include fracture-dislocation s of

the SC and AC joints or, in younger

patient s, physeal injuries. C hest w all

trauma may result in high rib frac-

tures, scapular neck and body frac-

tu r es , a n d a p n eu mo th o r a x o r h e-

mothorax. Although acute brachial

plexus injury is rare, the ulnar nerve

is at h ighest risk because of its loca-

tion adjacent to t he middle third of

the clavicle. When a nerve injury is

identif ied, a thorough vascular ex-

a m i na t io n a n d ev a lu a t io n o f t h e

scapulothoracic articulation should

Figure2

Robinsons classification system for midshaft clavicular fractures. (Reproduced withpermission from Robinson CM: Fractures of the clavicle in the adult: Epidemiologyand classification.J Bone Joint Surg B r1998;80:476-484.)

Kyle J. Jeray, MD



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be undertaken to avoid missing an

associated injury. Penetrating trau-

ma is typically the cause of vascular

injury. How ever, vascular injury canoccur from blunt trauma, resulting

in spasm or thrombosis of the sub-

clavian vessels.

R a d i o g r a p h i cE v a l u a t i o n

To determine the fracture pattern

a n d d i sp la c emen t, r a di o gr a ph s i n

tw o p ro ject i o n s a r e n ecess a ry . A

standa rd anteroposterior view should

be accompanied by a 45 cephalic tilt

view (Figure 3). The sh oulder girdle

a n d u ppe r l u ng f ie ld s s h ou l d b e

carefully assessed to avoid m issing

associat ed fract ures or a subtle pneu-

m otho rax. The radiographic evalua-

tion should assess the fracture pat-

t e rn , p res en c e o f c om m i n ut i o n,

displacement , and shortening or dis-

traction of t he fracture.

Several radiographic findings ca n

help guide the surgeons choice of

tr ea tm en t . D i s pl a c emen t w i th o u t

b on y c on t a c t , e spe ci a ll y w i t h a

transversely displaced fragment, is a

r is k f a c to r s tr o n gl y p redi c t i v e o flong-term sequelae.7 Additional ra-

diographic parameters predictive of

increased risk for pain, limit at ion of

m o t i o n, o r n o n un i on i n cl u de a n

overall displacement of the fracture

ends >1.5 cm. This displacement in-

c l u des s h o rten i n g, d i str a c t i on , o r

separation of the ends in the an teri-

or or posterior direction in an y radio-

graphic view.20-22 A second view, at

l ea s t 45 o f f p la n e f r o m th e f i rs t ,

h elp s t o f u rth er d el i n ea te th e d i s-

placement . Oft en, the displacement

is difficult t o assess on a single radio-

graph. For exam ple, as seen in Figure

3, both view s reveal distraction at

the fracture site of at least 1.5 cm.

M a n a g e m e n t

I n d i c a t i o n s

The primary goal in treatm ent is

to restore shoulder function to the

preinjury level. By allow ing the clav-

icle to heal w ith m inimal deformity,

loss of mot ion and pain can be min-

imized. Indications for nonsurgicaltreatm ent include a nondisplaced or

minimally displaced midshaft clav-

icular fracture. Indications for surgi-

cal treatm ent include open fractures

and fractures associated w ith skin

compromise or w ith neurologic or

vascular in jury.

Relative surgical indications in-

clude certain multiple-system trau-

matized patients, a floating shoulder,

and a painful malunion or nonunion.

More recently, relative indications

for surgical treatm ent ha ve been ex-

panded to include high-energy closed

f ra c t u re s w i t h >15 t o 20 m m o f

shortening, fractures w ith complete

d i sp la c emen t, a n d f ra c tu r es w i th

comminution.23-26 Although t hese re-

cently adopted indications ha ve re-

ceived att ention in t he current lit er-

ature, articles dating as far back as

the 1960s have described similar sur-

gical indicationsincluding Neers

Figure3

Standard radiographic anteroposterior view (A)and 45 cephalic t ilt view (B). Both are necessary to determine the extent offracture displacement.




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article,17 w hich is often cited as sup-

p or t f o r n o n s u r gi c a l ma n a gemen t.

Random ized controlled trials, one of

w hich has recently been complet-

ed ,11 a n d a n o th er th a t i s c u r r en tl y

under w ay, are n ecessary to deter-

mine w hether these relative indica-tions should be considered routine

a n d , i f s o , i n w h i c h p a t i en ts w i th

w hich fracture t ypes.

N o n s u r g ic a l Tr e a tm e n t

H i s to ri c a ll y , n o n s ur gi c a l t r ea t-

m e nt h a s b een t h e m a in st a y f or

c l a v ic u l a r f ra c tu r es . I t h a s v a r ied

from plaster shoulder spica casts to

benign neglect. Most commonly, a

sling or figure-of-8 brace is applied

in the acute setting. With either de-

vice, imm obilization is t ypically for

2 to 6 w eeks, based on t he patient s

l ev el o f c o mf o r t . O f ten , mi l d d i s -

c om f o rt c a n l in ge r i n a d ul t s f or

3 m o n t h s. R et u r n t o a t h l et i c s o r

h ea v y l ab or i s p er m it t ed 4 t o 6

w eeks after clinica l an d radiograph-

ic union has occurred. Light w ork

w i th r es tr ic ted o v er h ea d a c t i v ity

can begin once the patient s com fort

allow s, usually in 2 t o 4 w eeks after

fracture healing.

In a pr os pe ct i v e, r an do m i z edstudy,27 26% of patient s treated w ith

a figure-of-8 bandage w ere dissatis-

f i ed c o mp a red w i th 7% o f th o s e

tr ea ted w i th a s l in g. Th e p a t i en ts

treat ed wit h a sling reported less dis-

com fort. There w as n o difference in

overall healing and alignment of the

f ra c tu r es , i n d ic a t i n g th a t a f igu re-

of-8 bandage does little to obtain or

maintain reduction.

S u r g i c a l T e c h n i q u e sP l a t e s

Open reduction an d internal fixa-

tion using plates and screw s can be

done w ith the patient in either the

supine or t he beach-chair position,

w ith the h ead and neck t i l ted aw ay

f ro m th e s u rgic a l s i te . A b u mp i s

placed behind the scapula t o aid in

th e reduct ion. The arm is prepped in

th e f i el d to a l l o w f o r tra c t i o n a n d

ma nipulation to assist in t he reduc-

tion . Traditiona lly, a skin incision is

ma d e o v er th e c l a v ic l e f o ll o w i n g

Langers lines, as th e skin perm its. A

new ly described alt ernat ive is to in -

cise the inferior skin aft er pulling it

over the fracture site. 28 As the skin is

released, it w ill fall 1 to 2 cm below

the clavicle and prevent the w oundfrom being in cont act w ith t he plat e

o n th e c l a v i c l e . T h e a i m i s to i m-

prove cosmesis and prevent w ound

c o mp li c a t i on s . Th e d i ss ec t i o n i s

t a k en d ow n t o b on e w i t h c a re t o

identify the cutaneous supraclavic-

ular nerves. When necessary, they

can be sacrif iced. I t is im portant to

inform the patient before surgery of

the possibility of a patch of numb-

ness in the skin inferior to t he clav-

icle.

Minim izing subperiosteal strip-

ping with gentle handling of the skin

and soft tissue helps avoid complica-

tion s. The plate usua lly is placed on

the t ension side of the bonefor the

clavicle, th e ant erosuperior position

(Figure 4). Biomechanically, this

position provides t he best stabili-

t y. 29 How ever, clin ically successful

treatm ent w ith ant eroinferior place-

m ent a lso has been described.30 The

a n tero i n feri o r p os i t i on , a l th o u gh

less favorable biomechanically,29 a l-

low s for drilling in a direction aw ay

f ro m t h e s ub cl a vi a n v es se ls a n d

lung. It also keeps the plate from be-

ing placed under the incision. This

position theoretically is less likely to

cause irritation, thereby decreasingth e need for plate remova l. How ever,

the anteroinferior position demands

additional soft-tissue stripping and a

m o r e d if fi cu l t c on t o u ri n g o f t h e

plate compared w ith t he ant erosupe-

rior position .

Ideally, a 3.5-mm dynam ic com -

p ress i on p la te o r p la te o f s i mi l a r

s tr en gth s h ou l d b e u s ed , w i th a t

least six cortices on each side. Semi-

tu b u l a r pl a tes a r e n o t a s r i gid a n d

should not be used.24,31 Reconstruc-

tion plates are more easily contoured

and have been used w ith success;

how ever, t hey account for several

failures to obtain union a nd w ould

not be the authors f irst choice. 24,31

P r ec on t o u re d pl a t es o f s ui t a bl e

thickn ess offer the advanta ge of ease

of placement w ithout m anipulation

of the plate. Locked plates are not

n ecess a ry f o r th e a c u te p l a t i n g o f

nonosteoporotic clavicular fractures;

Figure4

Anteroposterior radiograph demonstrating clavicle plating in the anterosuperiorposition, using a 3.5-mm limited-contact dynamic compression plate.

Kyle J. Jeray, MD



6/10

t h e re i s n o s ig ni fi ca n t a d va n t a ge

o v er c o n v en ti o n a l p la t i n g, a n d th e

cost is higher.

O n c e p l a t i n g i s c o mp l eted , th e

fascia is repaired over the plate, i f

p os si bl e, a n d th e s kin i n c is i on i s

closed. Suture closure is preferable

to sta ples. With a sufficient ly sta bleconstruct, un restricted shoulder m o-

tion is allow ed, w ith the exception

of overhead lifting for 6 w eeks. Of-

ten, t he pain relief associated w ith

stabilizing the fracture is dram atic,

and efforts to l im it t he patients ac-

tivity may be needed. Pain relief is

cited as one of the potentia l benefits

of surgical intervention.

I n t ra m e d u l la r y F i x a t io n

A n a l t er n at i v e t o pl a t in g i s i n -tr a medu l l a ry (I M ) f i x a t i on . M a n y

variat ions of IM im plants hav e been

described over the past 40 years, in-

cluding H agie pins, modified H agie

pins, Kn ow les pins, H erbert screw s,

Steinmann pins, elastic nails, can-

c el lo us s crew s , a n d K irs ch n er

wires. 32-36 Modifications in t he tech-

nique h ave led to a resurgence of in-

terest in IM fixation of these frac-

tures. The potential benefits of IM

fixation compared w ith plate f ixa-

tion include less soft-tissue st ripping

at the fracture site, better cosmesis

w ith a smaller skin incision, easier

hardw are removal, and less w eak-

ness of the bone after hardw are re-

moval. Biomechanically, how ever,

the a bility t o resist t orsional forcesw ith IM fixation is much less than

th a t w i th a p la te . M i gra t i o n o f th e

pins also has been a major concern.

N ew er designs, w hich include lock-

ing nuts on t he lateral end of the IM

devices, prevent medial pin m igra-

t i o n . New er tec h n i q u es th a t a v o i d

penetration of t he m edial fragment

cortex also prevent medial migration

of th e devices.34

P a ti en t p os i t i on i n g i s s i mi la r t o

that for plate f ixation. A small inci-sion is made over the fracture site,

exposing t he fractu re ends. The m e-

dial segment is prepared by drilling

into th e medullary canal, but the an-

terior medial cortex is not violated.

The distal segment is drilled retro-

grade through the canal, exiting th e

posterior lateral cortex. The pin is

inserted retrograde t hrough the ca-

nal and exits through th e posterolat-

eral hole and out t he skin. Next, the

fractu re is reduced, and th e pin is ad-

vanced ant egrade across the fracture

into th e medullary canal of the m e-

dial segment . The Rockw ood C lavi-

cle Pin (DePuy Orthopaedics, War-

s a w , I N) h a s tw o n u ts th a t go o v er

th e threaded end of the inserted pinp os tero l a ter a ll y . O n c e th e p in i s

across the fracture, the first nut is in-

serted posterolaterally, com pressing

th e fracture, follow ed by th e second

n u t , w h i c h i s c o ld -w eld ed to th e

first. Figure 5 show s th e Rock w ood

C lavicle Pin in place. Some of the IM

techniques vary slightly depending

on th e device, and not all of the tech-

niques allow for fracture compres-

sion.

P a t i en t s a re a l lo w e d t o b eg in

shoulder mot ion imm ediately post-

operatively. When rotational stabil-

ity is a concern, forw ard elevation

should be restricted to 90 and ab-

duction to 90 for the first 4 w eeks.

Th e R o c kw o o d p in s h o ul d b e r e-

m oved at 8 to 14 w eeks. In some sit-

uation s, this can be done under local

anesthesia in the off ice; h ow ever,

most Rockw ood pins need to be re-

moved in t he operating room. Some

of the other IM devices, such as Her-

bert screw s, do not need to be re-moved.

As wit h plating, a m ajor benefit is

ea rl y r etu r n to a c t i v i t i es . S ev era l

studies have reported athletes re-

tu r n i n g to th ei r s po r t a c t i v i t i es b y

2 to 3 w eeks.35,37

C o m p l ic a t io n s

C omplications can occur from non-

surgical treatm ent as w ell as surgical

treatment. Both can produce a cos-

metic deformity (Figure 6). Both can

result in m alunion, nonunion, pain,

l o c a l ten d er n es s o r i r r i ta t i o n , a n d

l im i t a t i o n o f m o t i o n. O t h e r r a re

complications follow ing surgical or

nonsurgical treatment are residual

nerve paresthesia; subclavian ves-

s el c o mp ress i on , th r o mb o si s , a n d

p seu do a n eu r y sm; th o r a ci c o u tl et

syndrome; and brachial plexus neu-

ropathy.

Figure5

Anteroposterior radiograph demonstrating the Rockwood Clavicle Pin (DePuyOrthopaedics). Note that the anteromedial cortex is not violated, preventing the pinfrom migrating medially.




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S o me c o mp l i c a t i o n s a r e u n i q u e

to surgical intervention, such as in-

fection and hardw are problems. In-

fection rat es vary from 0% to 18%,w ith th e low er rates reported in th e

m ore recent studies.24,31,37,38 Painful,

irritat ing hardw are requiring plate or

pin removal is reported to be as h igh

as 50% to 100%. 24,39 Follow ing plate

removal, t he risk for refracture rang-

es from 0% to 8%.24,31 Adhesive cap-

sulitis of t he shoulder has been re-

p or ted w i th s u rgic a l t r ea tm en t i n

0% to 7% of ca ses.24,28

IM devices a re a ssociated w ith

unique complications, including mi-

gration of th e pin and h ardw are irri-

tation, resulting in local skin break-

down that often requires antibiotics

a n d , u l t i ma tel y, h a r dw a r e r emo v -

a l. 39 Figure 7 illustrates skin break-

d ow n f ro m a n IM pi n . Al t h ou gh

most of these complications are rare,

a second surgery for plate or pin re-

moval is sufficiently frequent t o be

considered w hen review ing treat-

ment choices.

R e s u l t s

Wh eth er tr ea ted n o n s ur gi c a ll y o r

surgically, most clavicular fracturesheal w ithout incident w hen length

and alignment are maintained. Ac-

ceptable cosmetic a nd functiona l re-

sults should be expected. Satisfact o-

r y r es u lts o c cu r l es s c o n si s ten tl y

w h en th e f ra c tu r e f a i l s to h ea l o r

heals w ith a significant deformity.

N o n u n i o n

Most cases of nonunion are symp-

tom atic, presenting w ith pain, loss

o f f u n cti o n , n eu ro l ogic c h a n ges,

and/or unsightly clavicular deformi-

ty . Alth o u gh c l a v ic u l a r n o n u n i o n

has not been clearly defined in the

literature, most authors concur that

nonunion is present w hen healing

has not occurred by 16 w eeks.

Traditional thinking is that cla-

vicular fractures treated nonsurgical-

ly almost alw ays heal and that surgi-

c a l t r ea tm en t i n c rea ses th e r is k o f

nonunion. Row e4 r ep or ted a n o n -

union rate of 3.7% in patients w ho

underw ent surgery compared w ith

0.8% in those t reated w ithout sur-

gery. Neer17 reported nonun ion rat esof 0.1% w ith nonsurgical t reatm ent

and 4.6% w ith surgical treatment.

Neer17 s u gges ted th a t th e m o s t i m-

portan t causal fact or for nonunion of

a m idshaft clavicular fracture is im-

proper open surgery. This ma y be

true to som e extent; aggressive soft-

tissue stripping, inability to reduce

the fracture, and inadequate internal

fixation all can lead to poor results.

Several recent studies have re-

ported high union rates w ith surgical

intervention using a variety of inter-

nal f ixation devices, including plat-

ing and IM pin or rod fixation. 39,40 In

addition, there is evidence that the

nonunion rat e after nonsurgical treat-

ment m ay be higher tha n previously

reported, particularly in certain frac-

ture ty pes and in certain patients. In

their review of 581 nonsurgically

treated fractures, Robinson et al 20 re-

ported an overall nonunion rate of

Figure6

A,Healed clavicular fracture managed nonsurgically. The bump, shortened shoulder width, and subtle droop are evident.B,A healed clavicular fracture treated with plate and screws, showing prominence of the anterior-superiorpositioned plate.

Kyle J. Jeray, MD



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4.5% for diaphyseal fractu res. Strat-

ification of Robinsons data revealed

that w omen w ith displaced diaphy-

s ea l f ra c tu r es h a d a n o n u n i on r a te

ranging from 19% t o 33%. When

c o mmi n u ti o n w a s c o mb i n ed w i th

displacement, th e nonunion rate in

w omen increased to a range of 33%

to 47%.41 In addition to fracture frag-

ment displacement, female sex, and

c om m i n u t i on , o t h er r is k f a ct o rsidentified wit h nonunion include ad-

vancing age, lack of cortical apposi-

t i o n , s everi ty o f th e i n i t i a l t r a u ma ,

the extent of fracture fragment dis-

placement,25 a n d, a rg ua b ly , s of t -

tissue int erposition.42 Early mobiliza-

tion has not been associated with the

development of a nonunion, w hether

treated surgically or nonsurgically.

A recently published system atic

review of the literature on nonunion

after treatm ent of midshaft clavicu-

lar fractures revealed a 5.9% non-

union rate in nonsurgically m anaged

fractures.8 I n t h e c o mpl etel y d i s-

placed fractu res, the rate increased to

15.1%. In surgically treat ed displaced

fractures, plating of 460 fractures re-

sulted in a nonunion rate of 2.2%,

and IM fixation of 152 fractures re-

sulted in a nonunion rate of 2.0%.8

Th ese d a ta s h o ul d b e i n terp reted

w ith caut ion, however, because most

w ere from evidence-based level III,

IV, a nd V stu dies (ie, observation al,

retrospective, ca se series, an d expert

o pi n i on s tu d ies) r a th er th a n f ro m

level I and II studies (ie, random ized,

prospective studies).

S u rgic a l t r ea tm en t o f n o n u n io n

has a high success rate. Techniques

i n cl u de pl a t e f ix a t io n w i t h b on e

g ra f t , IM pi n f ix a t io n w i t h b on e

gra f t , a n d exter n a l f i x a t i on . U n i o nrates w ith each m ethod have been

reported to be >92% and as high as

100%.42-45 P l at e f ix at i on h a s t h e

largest support in the literature and

i s c u rr en tl y th e mo s t p redi c ta bl e

a n d r ec om m e nd ed t r ea t m e n t f or

sy m pt om a t ic n on un io n. O t her

meth o d s ma y b e s u c c es s f u l i n th e

han ds of an experienced surgeon.

M a lu n io n

M o s t n o n s ur gi c a ll y tr ea ted c l a -

vicular fractu res heal w ith some de-

f or m i t y. Th e l it e ra t u re d oe s n o t

clearly define w hen a deformity is

considered to be a m alunion; how ev-

er, the evidence strongly suggests

that some clavicular deformities re-

sult in unsat isfactory outcomes. The

d ef o rmi ty i s a th r ee-d i men si o n a l

problem; the most consistent char-

acteristic is shortening wit h inferior

d is pl a ce m en t o f t h e m e di a l f ra g-

m e n t . S y m pt o m a t i c pa t i en t s h el p

define the malunion. Sym ptoms in-

clude w eakness and pain in the in-

v o l ved s h o ul d er , l o ss o f s h o ul d er

mot ion, loss of endurance, neurolog-

ic symptoms consistent with thorac-

i c o u t le t s y n dr om e a n d b ra c h ia l

plexus impingement, and cosmetic

deformity.46

In 1986, Eskola et al21 n o ted i n

89 patient s tha t short ening >12 m mw as a ssociated w ith increased pain.

Wick et a l22 concluded in a retrospec-

tive study th at shortening of 2 cm in

midshaft clavicular fractures wa s as-

sociated w ith an increased risk of

p a in , l i mi ta t i o n o f mo ti o n , o r n o n -

union. McKee et al9 assessed func-

tional outcome follow ing displaced

clavicular fractures and not ed signif-

icantly inferior scores for both the

upper extremit yspecific (D ASH)

outcome scores (P = 0.02) and t he

C onstant scores (P= 0.01)com pared

w ith the general population. They

concluded that fractures wit h >2 cm

of shortening tended to be associated

w ith decreased abduction strength

and greater patient dissatisfaction.

H i l l et a l 25 reported on completely

d i sp la c ed mi d d le th i r d c l a v ic u l a r

f r a c tu r es a n d c o n c l u d ed th a t f i n a l

shortening 2 c m w a s a s so ci a t ed

w ith an unsatisfactory result but not

Figure7

Healed clavicular fracture treated with intramedullary pinning.A,Note incision size and location over fracture and posterolateral

prominence. B,Early breakdown of the skin resulting from a prominent pin at the posterolateral insertion site.




9/10

w ith nonunion. After closed treat-

m ent, 31% of patients w ere dissatis-

fied w ith th e final result, 54% w ere

unhappy w ith the appearance, a nd

15% of fractures failed to unit e. U s-

ing the sam e subjective patient q ues-

t i o nn a i re a s t h a t u se d b y H i l l e ta l, 25 Lazarides and Z afiropoulos10 re-

ported tha t f inal clavicular shorten-

ing >18 m m in m ales and >14 mm in

females was associated with unsatis-

factory results and w ith increased

patient symptoms.

Ledger et a l47 show ed the effect of

c l a v ic u l a r s h o r ten i n g >15 mm o n

b io m e ch a n ic a l pa ra m e t er s o f t h e

shoulder. They found a significant

i nc rea se i n u pw a rd a n gu la t io n

(mean, 10.7; P < 0.005) of the SC

joint on the injured side com pared

w ith the un injured side. The m uscle

torque of the injured arm w as signif-

icantly w eaker tha n that of the unin-

jured arm in extension (P< 0.05), ad -

d uc t i on (P < 0. 05), a n d i n tern a l

rotation (P< 0. 05).47

Th ese s tu d ies i n d i c a te t h a t a l -

th o u gh c l a v ic u l a r d ef o rmi t i es a r e

complex and ha rd to assess, shorten-

ing of 1.5 to 2 cm, w hich results in an

increased incidence of clinical sy m p-

to ms , i s o n e p a r a meter th a t c a n b emeasured. Further investigation is

needed to clearly define the patient s

as w ell as the fracture deformit y t hat

i s l i kel y t o b e s y m p to ma ti c w i th a

c l a v ic u l a r m a l u n i on . I n th i s w a y ,

acute surgical treatm ent could be of-

fered to the patients w ho are most

likely to benefit. In addition, compar-

ative t rials are necessary to establish

th a t p a t i en ts w i th c l a v ic u l a r f r a c-

tures that predictably result in defor-

m i t y h a v e b et t e r o u t co m e s w h en

treated surgically rath er tha n nonsur-

gically. Several randomized trials cur-

r en tl y a r e u n d er w a y , a n d o n e h a s

been completed, assessing the surgi-

cal versus nonsurgical management

of acute displaced midshaft clavicu-

lar fractures. The Canadian Ortho-

paedic Trauma Society has show n in

a m ulticent er random ized trial of 132

patients that for displaced fractures

of the clavicular shaft, surgical fixa-

tion w ith a plate and screw s resulted

in an im proved functional outcom e

a n d a l o w er r a te o f ma l u n i o n a n d

nonunion compared w ith nonsurgi-

cal treatment at 1 year.11

Treatment of a ma lunion consists

o f s ur gi ca l c or re ct i o n t o r es t or elength, angular deformity, a nd rota-

tion of t he clavicle. Treatm ent m ay

o r ma y n o t i n v o l v e a n i n ter c a l a r y

bone graft. Oft en, after rem oving the

callus of the ma lunion, it is possible

to i d en ti f y t h e p ro x ima l a n d d i s ta l

fragments in order to anatomically

reconstruct the clavicle.46,48 The ben -

efit of th is technique is that t here is

no donor-site morbidity for a bone

graft. When difficulty in determ ining

the length of the m alunited clavicle

is anticipated, a preoperative radio-

gr a p h i c i ma ge o f b o th c l a v i c l es i s

helpful. Both IM devices and plates

have been used successfully t o treat

malunions.46,48-50 Treatm ent of sym p-

to ma t i c m a l u n io n s h a s r es u lted i n

improvement of the function of the

upper extrem ity, decreased pain, a nd

increased patient satisfaction.46,50

Su m m a r y

The frequency of comminuted anddisplaced m idshaft clavicular frac-

tures t hat result from high-energy

injuries is in creasing. Non displaced

and minimally displaced fractures

s h o ul d b e tr ea ted n o n s ur gi c a ll y ,

preferably w ith a sling for patient

comfort; th e rates of nonunion, pain,

cosmetic deformity, and loss of func-

tion are low . How ever, for specific

groups of patients, the risk of com-

plications from nonsurgical m anage-

men t ma y b e s i gn i f i c a n tl y h i gh er .

These patients include t hose w ith

c o mp letel y d i sp la c ed a n d c o mmi -

nuted fractures and, possibly, those

w ho are female or of advanced a ge.

The current literature suggests that

s u rgic a l s ta b il i za t i on , w i th eith er

plates an d screw s or w ith an IM de-

vice, should be considered as t he pre-

f er red t r ea tm en t o pti o n f o r th es e

mo r e c o mp l ex a c u te mi d s h a f t c l a -

vicular fractures. Further random-

ized, prospective studies a re needed

to determine w hether the benefits of

surgical fixation outw eigh the risks

and, if so, in w hich t ypes of pat ients

and for w hich t ypes of midshaft cla-

vicular fracture.

R e f e r e n c e s

Evid ence-based M edici ne: Level I/II

prospective studies are references

5, 7, 8, an d 27. The rem ain ing refer-

ences a re level III/IV case-con t rol co -

hort studies or level V, expert opinion.

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05. acute midshaft clavicular fracture

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