38 clavicle fractures€¦ · with middle third fractures of the clavicle treated by a sling or a...

$: 38 ClaviCle FraCtures€¦ · with middle third fractures of the clavicle treated by a sling or a figure-of-eight bandage. Rowe160 showed an overall inci-dence of nonunion of 0.8%$
ClaviCle FraCtures

1427

38

• IntroductIon 1427

• Assessment 1429Mechanisms of Injury 1429Associated Injuries 1430Signs and Symptoms 1432Imaging and Other Diagnostic Studies 1435Classification 1437Outcome Measures 1437

• PAthoAnAtomy And APPlIed AnAtomy 1440Bony Anatomy 1440Ligamentous Anatomy 1441Muscular Anatomy 1441Neurovascular Anatomy 1441

• treAtment oPtIons 1442Nonoperative Treatment 1443Operative Treatment 1444

• mAnAgement of exPected Adverse outcomes And unexPected comPlIcAtIons 1459Infection 1459Nonunion 1459Malunion 1461Neurovascular Injury 1464Hardware Failure 1465Hardware Prominence 1466Refracture 1467Scapular Winging 1467

• Author’s Preferred method of treAtment 1469

• controversIes And future dIrectIons 1469Patient Selection for Operative Intervention 1469Method of Fixation 1469Timing of Surgical Intervention 1470

• summAry 1470

Michael D. McKee

IntroductIon to clAvIcle frActures Clavicle fractures are common injuries in young, active indi-viduals, especially those who participate in activities or sports where high-speed falls (bicycling, motorcycles) or violent collisions (football, hockey) are frequent, and they account for approximately 2.6% of all fractures.29–32,46,112,116,122,123,126 In contrast to most fractures, Robinson155 reported in an epidemiologic study that the annual incidence in males was highest in the under 20 age group, decreasing with each subsequent age cohort (Fig. 38-1). The incidence in females was more constant, with peaks seen in the teenager (sports, motor vehicle accidents) and the elderly (osteoporotic frac-tures from simple falls). The annual incidence of fractures in their Scottish population was 29 per 100,000 persons per year.155

The majority of clavicular fractures (80% to 85%) occur in the midshaft of the bone, where the typical compressive forces applied to the shoulder and the narrow cross section of the bone combine and result in bony failure.7–16,18–24,26–32,107,155,179 Distal third fractures are the next most common type (15% to 20%), and, although they can result from the same mechanisms of injury as that seen with midshaft fractures, they tend to occur in more elderly individuals from simple falls.56,153,156,157,193 Medial third fractures are the rarest (0% to 5%), perhaps due to the difficulty in accurately imaging (and identifying) them.167,185 One recent study of 57 such fractures reported that patients were typically men in their fifth decade and the usual mech-anism of injury was from a motor vehicle accident.185 These authors also noted a relatively high (20%) associated mortality from concomitant head and chest injuries.

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1428 Section two Upper Extremity

Older studies suggested that a fracture of the shaft of the clavicle, even when significantly displaced, was an essen-tially benign injury with an inherently good prognosis when treated nonoperatively.112–116 In a landmark 1960 study Neer115 reported nonunion in only three of 2,235 patients with middle third fractures of the clavicle treated by a sling or a figure-of-eight bandage. Rowe160 showed an overall inci-dence of nonunion of 0.8% in 566 clavicle fractures treated in a similar fashion. Thus, what was felt to be the most seri-ous complication following clavicular fracture, nonunion, appeared to be extremely rare. Also, malunion of the clavicle (which occurred radiographically on a predictable basis in displaced fractures), was described as being of radiographic interest only, with little or no functional consequences. This thinking dominated the approach to clavicle fractures for decades.

More recently, there has been increasing evidence that the outcome of the nonoperatively treated (especially displaced or shortened) midshaft fracture is not as optimal as was once thought.14,42,59,68,85,99,103,123–125 In 1997, Hill et al.68 were the first to use patient-oriented outcome measures to examine 66 consecutive patients with displaced midshaft clavicle fractures and they found an unsatisfactory outcome in 31%, as well as a nonunion rate of 15%. In a meta-analysis of the literature from

1975 to 2005, Zlowodzki et al.209 found that the nonunion rate for nonoperatively treated displaced midshaft clavicle fractures was 15.1%, exponentially higher than that previously described (Table 38-1). Other recent epidemiologic and prospective stud-ies have supported these findings.14,42,68,99,121,123,124,153–155 In addi-tion, the malunion of the clavicle has been clearly shown by multiple authors to be a distinct clinical entity with character-istic signs and symptoms that can be significantly improved by corrective osteotomy.7,9,21,24,41,84,102,103 Potential explanations for the increased complication rate seen following the nonoperative care of these fractures may be due to changing injury patterns (especially from “extreme” sports such as mountain bicycling, snowboarding, and all-terrain vehicle riding), increased expec-tations of the modern patient, comprehensive follow-up (includ-ing patient-oriented outcome measures) and focusing on adults (eliminating children with their inherently good prognosis and remodeling potential).71,76,96,101,125,143,154,181,195,205

Good results with a high union rate and a low complica-tion rate have been reported from a variety of techniques for primary fixation of displaced fractures of the clavicle, dispelling some of the pessimism that surrounded prior studies where a poor understanding of soft tissue handling, a selection bias of patients, and inadequate implants combined to produce infe-rior results.2,15,23,41,53,63,82,91,119,140–142 Zlowodzki’s209 systematic

Figure 38-1 the epidemiology of clavicle fractures in edinburgh, Scotland. (Adapted from Robinson cM, court-Brown cM, McQueen MM, et al. estimating the risk of nonunion following nonoperative treat-ment of a clavicle fracture. J Bone Joint Surg Am. 2004;86-A(7):1359–1365.)

Inci

denc

e/10

0,00

0 po

pula

tion/

yr

160

140

120

100

80

60

40

20

0

Age cohorts

MaleFemale

13–20 yrs 20–29 yrs 30–39 yrs 40–49 yrs 50–59 yrs 60–69 yrs 70–79 yrs >80 yrs

Table 38-1 a Meta-analysis of Nonoperative Treatment, intramedullary Pinning, and Plate Fixation for Displaced Midshaft Fractures of the Clavicle (Published 1975–2005)

Treatment Method Percentage with Nonunion infections (Total) infections (Deep) Fixation Failures

nonoperative (n = 159) 15.1 0 0 0

Plating (n = 460) 2.2 4.6 2.4 2.2

intramedullary pinning (n = 152) 2.0 6.6 0 3.9

Adapted from Zlowodzki M, Zelle BA, cole PA, et al. treatment of midshaft clavicle fractures: Systematic review of 2144 fractures: on behalf of the evidence-Based orthopaedic trauma working Group. J Orthop Trauma, 2005;19(7):504–507.


chAPteR 38 Clavicle Fractures 1429

review showed a relative risk reduction of 86% (from 15.1% to 2.2%) for nonunion with primary plate fixation compared to nonoperative treatment. In addition, a recent meta-analysis by McKee et al. of six randomized clinical trials of operative versus nonoperative care for displaced midshaft clavicle frac-tures demonstrated a reduction of nonunion and symptomatic malunion from 46/200 cases (23%) in the nonoperative group to 3/212 cases (1.4%) in the operative group (Fig. 38-2).105

While there is increasing interest in, and enthusiasm for, primary fixation of clavicle fractures, it is vital to remember that the majority of these fractures can and should be treated nonoperatively. The current research in this area should not provoke a swing of the operative pendulum into indiscrimi-nate fixation of all clavicle injuries. Clinical and basic science research in this field adds objective information to this topic and is directed at prompting a thoughtful assessment of each injury based on these data and each case’s individual merits such as the function and expectations of the patient, the loca-tion of the fracture, and the degree of displacement or com-minution. Treatment is then based upon this assessment, the evidence-based facts now available, and a rational balance of the potential risks and benefits of surgery, rather than an extreme operative or nonoperative approach.

Assessment of clAvIcle frActures

Mechanisms of Injury for Clavicle FracturesA direct blow on the point of the shoulder is the commonest reported mechanism of injury that produces a midshaft fracture of the clavicle.15,107,155,179 This can occur in a number of ways, including being thrown from a vehicle or bicycle, during a sports event, from the intrusion of objects or vehicle structure during a motor vehicle accident, or falling from a height (Fig. 38-3). A recent prospective trial of over 130 completely displaced midshaft fractures of the clavicle identified motor vehicle/ motorcycle accidents, bicycling accidents, skiing/ snowboarding

Figure 38-2 A forest plot comparing the nonunion rate between nonoperative (control) and operative (experimental) groups from multiple randomized trials of clavicle fracture fixation for displaced mid-shaft fractures. operative intervention results in a significantly decreased nonunion rate compared to nonoperative treatment (p = 0.002). the size of the squares is proportionate to the size of the study, and the diamond is the pooled data. (Adapted from: McKee Rc, whelan DB, Sche mitsch eh, et al. operative versus nonoperative care of displaced midshaft clavicular fractures: A meta-analysis of ran-domized clinical trials. J Bone Joint Surg Am. 2012;94(8):675–684, with permission.)

COTS 2007

Study or Subgroup Events Total Total WeightRisk Ratio

IV, Random, 95% Cl IV, Random, 95% CIRisk RatioNonoperativeOperative

Events

Judd 2009Smekal 2009Smith 2000Virtanen 2010Witzel 2007

210000

622930302635

16151680

492830352533 Not estimable

Total eventsHeterogeneity: Tau2 = 0.00; Chi2 = 3.35, df = 4 (p = 0.50); I2 = 0%Test for overall effect: Z = 4.38 (p < 0.0001)

3 46

0.01 0.1Favors experimental Favors control

1 10 100

Total (95% CI) 212 200 100.0% 0.11 [0.04, 0.29]

49.0%13.4%12.2%12.9%12.6%

0.10 [0.02, 0.41]0.97 [0.06, 14.70]0.09 [0.01, 1.57]0.04 [0.00, 0.56]0.06 [0.00, 0.93]

B

A

Figure 38-3 a: Mechanism of injury. clavicle fractures are usually produced by a fall directly on the involved shoulder. b: correspond-ing clinical photograph demonstrating posterior skin abrasion follow-ing displaced midshaft clavicle fracture.



falls or collisions, sports injuries, and falls as the most commonly involved mechanisms.15 As the shoulder girdle is subjected to compression force directed from laterally, the main strut main-taining position is the clavicle and its articulations (Fig. 38-4). As the force exceeds the capacity of this structure to withstand it, failure can occur in one of the three ways. The acromioclavicular (AC) articulation may fail, the clavicle may break, or the sterno-clavicular (SC) joint may dislocate. SC injuries are rare and typi-cally associated with more posteriorly directed blows against the medial clavicle (posterior dislocations) or posteriorly directed blows to the distal shoulder girdle (levering the proximal clavi-cle into an anterior dislocation).90,177 Presumably there are subtle nuances in the direction and magnitude of applied forces and local anatomy that dictate whether the failure occurs in the AC joint, or in the clavicle, and the magnitude of displacement that occurs. Most (85%) clavicle fractures occur in the midshaft of the bone where, as can be seen in a cross section, the bone is narrowest and enveloping soft tissue structures (which may help dissipate injury force) are most scarce.29–32,153,155 It is typical to see a large abrasion or contusion on the posterior aspect of the shoulder in patients with displaced midshaft clavicular frac-tures, especially those who fall from bicycles, motorcycles, or other vehicles. This force vector may also contribute to the loca-tion of the injury: Midshaft fracture, distal fracture, or AC joint injury. The direction of the initial deforming force, and both gravitational and muscular forces on the clavicle are significant and result in the typical deformity seen after fracture, with the distal fragment being translated inferiorly, anteriorly, and medi-

ally (shortened), and rotated anteriorly (Fig. 38-5). With recent advances in imaging techniques, there is an increasing level of information available regarding the complex three-dimensional deformity that can result from a displaced midshaft fracture of the clavicle (Fig. 38-6).152

Simple falls from a standing height are unlikely to pro-duce a displaced fracture in a healthy young person, but can result in injury in elderly, osteoporotic individuals: These fractures are typically seen in the distal third of the clavi-cle. If the mechanism of injury is trivial and does not seem commensurate with the fracture depicted, then a careful investigation for a pathologic fracture should be performed (Fig. 38-7).32,176

Associated Injuries with Clavicle FracturesAssociated injuries are increasingly common in patients with fractures of the clavicle, compared to the incidence reported in older traditional studies.39,43,44,101,181,207 There may be several reasons for this, including more liberal use of improved

Weightof arm

Trapezius

Sternocleidomastoid

Sternoclavicularligaments

Pectoralisand latissimus

Figure 38-5 Muscular and gravitational forces acting on the frac-tured clavicle with resultant deformity. the distal fragment is trans-lated anteriorly, medially, and inferiorly, and rotated anteriorly. this results in the scapula being protracted.

Figure 38-4 the strut function of the clavicle, the only bony articu-lation between the axial skeleton and the upper limb.



diagnostic techniques (i.e., CT scanning), the greater speed and violence of many modern sports (such as motocross and snowboarding) and the improved survivorship of patients with significant chest trauma who would have succumbed prior to the institution of comprehensive treatment of the trauma patient. In fact, several studies from Level 1 trauma centers have examined the characteristics of polytrauma patients with clavicle fractures, and have noted a high mortality rate (20% to 34%) from associated chest and head traumas.101,181 Presumably these series of critically injured patients contain survivors who live to require treatment for the complications of their clavicle fractures who may not have survived without modern trauma care.

Figure 38-6 a: Preoperative three-dimensional ct scan of a patient with a displaced clavicle fracture and ipsilateral flail chest. this injury pattern represents a severe injury with significant instability of the entire forequarter. b: Following plate fixation of both the clavicle and multiple ipsilateral ribs, the flail segment became stable.

A B

Patients who have sustained high-energy vehicular trauma are more likely to have associated injures to the thoracic cage, including ipsilateral rib fractures, scapular and/or glenoid frac-tures, proximal humeral fractures, and hemo/pneumothoraces (Fig. 38-8).29,101,181 In addition to simply being good medicine, identification of these injuries is important for multiple reasons. Patients may require urgent treatment directed specifically at the associated injury (i.e., tube thoracostomy for pneumotho-rax), their presence may influence the treatment of the clavicle fracture (i.e., an associated displaced glenoid neck fracture, the so-called “floating shoulder,” see below), or (as objective infor-mation on this entity increases) they may give an indication of the likelihood of a negative outcome for the clavicle fracture

Figure 38-7 A 45-year-old previously well woman presented to the fracture clinic with shoulder pain following an episode of minor trauma. Radiographs revealed a fracture through a lytic lesion of the clavicle. this was the presentation of what subsequent investigation revealed to be a widely dissemi-nated metastatic adenocarcinoma of unknown source.



(malunion, nonunion) that may have implications regarding pri-mary fixation (Fig. 38-9). There is also some evidence that multi-ple ipsilateral rib fractures are significant for a number of reasons: The degree of disruptive energy imparted to, and the resultant deformity and instability of, the chest and shoulder girdle may be associated with higher rates of poor outcome in the associated clavicle fracture. In addition, there is increasing interest in the primary fixation of mechanically unstable chest wall segments (or “flail chest”) as a means of improving the respiratory outcome and ventilatory care of such patients (Fig. 38-6).62,183

The clavicle can also be injured from penetrating trauma including projectiles, blasts, and sword or machete blows (Fig. 38-10). In this situation, diagnosing and treating underly-ing chest and/or vascular injuries is critically important, and the clavicle can be treated on its own merits.30,32,36,69,78,111,148,187 How-ever, if a vascular repair has been performed, clavicular fixation (if possible) provides an optimally stable environment for healing.

Signs and Symptoms of Clavicle FracturesHistoryThe history should delineate a number of aspects to optimize the patient’s care. In addition to the standard demographic data, the details of the mechanism of injury are important. A clavicle fracture caused by a simple low-energy fall is unlikely to be associated with other fractures or intrathoracic injuries, while a fracture that occurs as a result of severe vehicular trauma or a fall from a height should prompt a search for other injuries. In my experience, clavicle fractures that result from falls while bicycling often have multiple ipsilateral upper rib fractures. At a Level 1 trauma center, we studied 105 polytrauma patients

(multiple system injury and injury severity score greater than 16) with fractures of the clavicular shaft and found a mortality rate of 32%, mainly due to associated head and chest injuries.101 This high incidence of associated head/chest injuries mandates careful clinical and radiographic investigation. The physical mechanism of injury is important: While the majority of fractures will result from a blow to the shoulder, failure of the bone can also occur from a traction-type injury. This usually occurs in an industrial or dockyard injury in which the involved arm is forcefully pulled away from the body as it is caught in machinery. It can also occur in vehicular trauma when the arm is pinned against or strikes a fixed object as the torso continues past it. This can lead to scapulothoracic dissociation, as the shoulder girdle fails in ten-sion at the SC joint, the clavicle or the AC joint. This is evident on the radiographs when a completely displaced, distracted frac-ture site is seen (as opposed to the typical overlapping fracture fragments) (Fig. 38-11). The high incidence of neurologic and vascular traction injuries seen in this setting mandates further investigation (i.e., angiography), because they can be limb threat-ening.30,39,58,111,136,207

If the clavicular fracture has occurred with minimal trauma, one must be alert to the possibility of a pathologic fracture (Fig. 38-7). Metabolic processes that weaken bone (i.e., renal disease, hyperparathyroidism), benign or malignant tumors (i.e., myeloma, metastases), or pre-existing lesions (i.e., congenital pseudarthrosis of the clavicle) can result in pathologic fracture. In this setting, nonoperative treatment of the clavicle fracture is recommended initially, while intervention is directed toward diagnosis and treatment of the underlying condition. Once the primary diagnosis has been made and treatment initiated, the clavicle fracture is treated based on its individual aspects. Also,

Figure 38-8 Anteroposterior radiograph of the clavicle in a 42-year-old man involved in a motor vehicle collision. Associated injuries include multiple ipsilateral upper rib fractures, an ipsilateral pneu-mothorax (arrows outlining collapsed lung), and multiple lower extremity fractures. this patient has four relative indications for operative fixation; (1) the severe displacement of the clavicle fracture, (2) the multiple upper rib fractures, which tend to destabilize the shoulder girdle, (3) the associated lower extremity fractures and the resultant need for immediate upper extremity use, and (4) the pneu-mothorax, which is indicative of the degree of trauma applied to the shoulder.



Figure 38-9 A “floating shoulder” injury. this patient was injured in a motor vehicle accident. a: An anteroposterior radiograph demonstrates a displaced, shortened left clavicle fracture. b: A ct scan of the shoulder reveals a comminuted glenoid neck fracture. C: there is significant clinical deformity. D: intraoperatively, the fracture is reduced with the aid of reduction clamps, and an anterior fixation plate is applied (e, F). Symmetry of the shoulder was restored by clavicle fixation alone, and it was not necessary to repair the glenoid fracture. g: there was an excellent clinical result with full restoration of motion and a constant score of 95.

A

C G

B F

E

D



repetitive or unusual loads may induce a stress fracture of the clavicle, typically in bodybuilders or weightlifters.134,159,169

In the past, when treatment of all clavicular shaft fractures was consistently nonoperative, a detailed history of lifestyle, occupa-tion, and medical conditions was usually perfunctory at best, since these factors did little to influence decision making. How-ever, there is now increasing evidence that operative intervention is superior in carefully selected cases of displaced clavicular shaft fracture, such that additional information gleaned from the his-tory contributes to the risk/benefit analysis regarding possible

surgery. Compliant patients in the 16 to 60 age group, who have active recreational lifestyles and/or physically demanding occupa-tions (especially those that require throwing, repetitive overhead work, or recurrent lifting) are candidates for primary operative repair if they are medically fit and have completely displaced fractures with good bone quality.15,108,140,190,209 Factors associated with noncompliance and a high rate of fixation failure, such as drug and alcohol abuse, untreated psychiatric conditions, home-lessness, or uncontrolled seizure disorders are contraindications for primary operative repair of clavicle fractures.10

Physical ExaminationWhen nonoperative treatment was chosen for the vast majority of clavicle fractures, there was little emphasis placed on a care-ful physical examination of the shoulder girdle. However, there are a number of findings that are important in surgical deci-sion making. There is usually swelling, bruising, and ecchy-mosis at the fracture site, as well as deformity with displaced fractures. Visible deformity of the shoulder girdle, best seen when the patient is standing, is an important feature to rec-ognize. The usual position seen with a completely displaced midshaft fracture of the clavicle has been described as shoulder “ptosis,” with a droopy, medially driven, and shortened shoul-der (Fig. 38-12).64,74,136,150 In addition, the shoulder translates and rotates forward: This is a deformity that can best be seen by viewing the patient from above. Due to this malposition of the shoulder girdle, inspection of the patient from behind may reveal a subtle prominence of the inferior aspect of the scapula from scapular protraction as it moves with the distal fragment.

Figure 38-10 a: A comminuted clavicle fracture resulting from a low-velocity gunshot wound with an associated hemopneumothorax and a retained intrathoracic bullet, treated with tube thoracos-tomy. the degree of clavicular deformity and the associated injuries represent a relative indication for operative repair. b: Severe injuries in a 25-year-old soldier struck by a high-velocity bullet fired by an insurgent in Afghanistan. the AK-47 bullet fractured the humerus, struck the clavicle, shattering the midportion, lacerated the subclavian vein and artery (causing life-threatening hemorrhage) and came to rest in the soft tissues of the neck. in an austere operating environment, the clavicle fragments were resected and a vascular repair was performed.

A B

Figure 38-11 emergency angiogram of a patient with a scapulo-thoracic dissociation and wide distraction of a very distal clavicle frac-ture. there is an associated axillary artery avulsion, a complete brachial plexus injury, and multiple ipsilateral upper extremity fractures.



Shortening of the clavicle should be measured clinically with a tape measure. A mark is made in the midline of the supraster-nal notch and another is made at the palpable ridge of the AC joint: Measuring this length gives the difference between the involved and normal shoulder girdle.172 The degree of shorten-ing at the fracture site is very important in the decision making of operative versus nonoperative care, as it has been reported in multiple studies to be of prognostic significance (greater shortening, especially more than 1.5 to 2 cm, is associated with a worse prognosis). Radiographs, especially of long oblique fractures, tend to overestimate the degree of shortening which emphasizes the importance of a proper clinical examination.

A careful neurologic and vascular examination of the involved limb is mandatory, especially if surgical intervention is contemplated. If a deficit is not noted preoperatively, then it may be incorrectly attributed to the surgery which has prognos-tic, medical–legal, and treatment implications.29–32

Open FracturesSurprisingly, given its subcutaneous nature and exposed posi-tion, open fractures of the clavicle are relatively rare. Most open fractures are associated with high-energy vehicular trauma, and recognition is important for a number of reasons: The frac-ture itself will require irrigation, debridement, and fixation, and there is a high incidence of associated injuries. Two large, recent series focused on open fractures of the clavicle. Taitsman et al.181 described 20 patients with this injury; 15 had pulmo-nary injuries, 13 had head injuries, 8 had scapular fractures, 11 had facial trauma, and there was a variety of other injuries. In the largest published series to date, Gottschalk et al.61 identified 53 open clavicle fractures from an active Level 1 trauma center over a 16-year period (roughly three cases per year, illustrat-ing the rarity of this condition). They also reported many asso-ciated serious injuries, with the 26 patients with penetrating injuries having a high incidence of great vessel injury, while

Figure 38-12 a: the “scout” portion of a ct scan in a polytrauma patient with a displaced clavicle fracture demonstrates the typical deformity which occurs with these injuries. b: the corresponding clinical photograph demonstrates blanching of the skin over the medial fragment (arrow).

A B

the 21 patients with blunt trauma had a 52% rate of serious head injury. They stated that an open clavicle fracture should immediately raise suspicion for a serious concomitant injury, and that a prompt and thorough evaluation should be initiated. As far as treatment of the clavicle fracture itself is concerned, no specific recommendations are available in the literature, but general principles should be followed. Prophylactic antibiotics should be administered, and in general the instability associ-ated with such a fracture will warrant operative stabilization as promptly as the patient’s general condition permits.

Imaging and Other Diagnostic Studies for Clavicle FracturesSimple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis of a clavicle fracture. The diagnosis may also be made from a single AP chest radiograph, which may be the only available film in an urgent trauma setting. The chest radiograph can also be used to evaluate the deformity of the involved clavicle relative to the normal side, and to look for associated skeletal injuries such as rib, glenoid, and scapular fractures. A measurement of length can be made on the chest radiograph comparing the injured to the uninjured side: Short-ening of 2 cm or more represents a relative indication for pri-mary fixation. To best delineate a clavicular fracture, as when one is determining whether operative intervention is warranted, a radiograph should be taken in the upright position (where gravity will demonstrate maximal deformity). Ideally, the radio-graphic beam for the AP radiograph of the clavicle should be angled 20 degrees superiorly to eliminate the overlap of the tho-racic cage and show the clavicle in profile.29–32,149,194 In addition, if the torso is internally rotated a similar 20 degrees (rotating internally when standing or by bumping up the opposite side while supine), the scapula and shoulder girdle are placed parallel to the cassette for a true AP film. CT scanning of midshaft clavic-ular fractures is rarely performed in the clinical setting, although



Figure 38-13 Fractures of the medial end of the clavicle are difficult to visualize with conventional radiography. this 32-year-old female equestrian sustained a medial clavicle fracture following a riding accident when her horse fell on her. the anteroposterior radiograph (a) reveals some asymmetry of the clavicles but it is difficult to define the exact nature of the injury due to the overlap of bony axial structures and the spinal column. b: A ct scan clearly demonstrates the medial fracture with a small residual medial fragment (small arrow) and posterior displacement of the shaft (big arrow), (C) imping-ing on the mediastinal structures. D: Plate fixation was performed, with extension of the plate onto the sternum due to the small size of the medial fragment. once bony union has occurred (between 3 and 6 months), such a plate should be removed. (case courtesy of Dr. Jeremy A. hall.)

CB

D

A



this imaging modality can demonstrate the complex three-dimensional deformity that affects the shoulder girdle with these injuries, including significant scapular angulation and protrac-tion.64 It is also useful for evaluating fractures of the medial third of the clavicle and the remainder of the shoulder girdle, such as the glenoid neck in cases of a “floating shoulder.”45,145,158

Lateral clavicle fractures can be well visualized with AP radiographs. Centering the radiograph on the AC joint and angling the beam in a cephalic tilt of approximately 15 degrees (the Zanca view) helps delineate the fracture well, by removing the overlap of the upper portion of the tho-racic cage.30,32 To accurately delineate the degree of fracture displacement, these radiographs should be taken with the patient standing and the arm unsupported by slings, braces, or the uninjured arm. On occasion, it may be useful to obtain a stress view to determine the integrity of the coracoclavicu-lar ligaments (as this can influence the choice of fixation): A 2.26- to 4.53 kg (5- to 10-lb) weight is suspended from the wrist of the affected arm and then radiographs are taken. CT scanning of lateral clavicle fractures is rarely required clini-cally; but can be useful in selected cases to determine intra-articular extension or displacement.

Fractures of the medial clavicle, especially those involving the SC joint, are notoriously difficult to accurately assess with plain radiographs. CT scanning is the radiographic procedure of choice when the anatomy of the fracture is unclear. This investigation can help distinguish between a medial epiphyseal fracture (common in individuals up to 25 years of age) and true SC dislocations (Fig. 38-13).30,167,185,206

Classification of Clavicle FracturesA number of classification schemes have been proposed for fractures of the clavicle. These have traditionally been based on the position of the fracture, with the groups originally divided by Allman into proximal (Group I), middle (Group II), and distal (Group III) third fractures. This general grouping has the advantage of corresponding to the clinical approach to these fractures of most orthopedic surgeons.30 Recognizing that this basic scheme does not take into effect factors that influence treatment and outcome, such as fracture pattern, displacement, comminution, and shortening, various authorities have refined the classification to include other variables. Due to their high rate of delayed union and nonunion, Neer divided distal clavicle fractures into three subgroups, based on their ligamentous attachments and degree of displacement (Type II was subse-quently modified by Rockwood).30,113

Type I: Distal clavicle fracture with the coracoclavicular liga-ments intact

Type II: Coracoclavicular ligaments detached from the medial fragment, with the trapezoidal ligament attached to the dis-tal fragment

IIA (Rockwood): Both conoid and trapezoid attached to the distal fragment

IIB (Rockwood): Conoid detached from the medial fragment

Type III: Distal clavicle fracture with extension into the AC joint.

Ideally, a classification scheme should be reproducible with a low rate of inter- and intra-observer variability, should help direct treatment, can be used to predict outcome, should be useful in both the clinical and research realms, and should be simple enough to be practically useful yet robust enough to include all fracture patterns. While at the present time there is no classification scheme that has been rigorously tested to meet all these objectives, modern schemes based on prospec-tive, comprehensive population-based studies are available. Nordqvist et al.123 examined over 2,035 fractures of the clav-icle over a 10-year period and essentially expanded on All-man’s original scheme by adding subtypes based on fracture displacement, including a comminuted category for midshaft fractures. In a similar population-based study in Edinburgh, Robinson155 evaluated over 1,000 consecutive fractures of the clavicle, and developed a classification scheme based on prog-nostic variables from the analysis of their data (Fig. 38-14). It continues the traditional scheme of dividing the clavicle into thirds, and adds variables that are of proven diagnostic value (intra-articular extension, displacement, and comminution). However, a feature of this scheme is that it reverses the tradi-tional numbering scheme, describing medial fractures as Type I, middle third fractures as Type II, and distal third fractures as Type III. Since distal third fractures are firmly entrenched in the orthopedic lexicon as “Type II” fractures, this can lead to significant confusion. Despite this drawback, the Robinson clas-sification is based on an extensive database that includes pro-spectively gathered, objective clinical data. For this reason, it is the classification I prefer to use clinically as it can help predict outcome and hence guide treatment, including the decision to operate and the fixation methods chosen. The AO/OTA Frac-ture and Dislocation Classification Compendium was updated in 2007 to include recent developments including a unified numbering scheme and measures to improve observer reliabil-ity (Fig. 38-15). The clavicle is designated as segment 15, and is divided into the standard medial metaphyseal, diaphyseal, and lateral metaphyseal fractures.95 An important difference is that the metaphyseal fractures in this scheme are not one-third of the length of the bone but are shorter segments, according to the AO “rule of squares.” For the all-important diaphysis, there are simple (15-B1), wedge (15-B2), and complex (15-B3) subtypes.

Outcome Measures for Clavicle FracturesIt has become apparent that outcome measures previously used for fractures in general, and clavicle fractures in particular, have not reliably demonstrated significant residual deficits following injury.115,160 Gauging success or failure based on the isolated finding of the presence or absence of union on a post-injury radiograph was shown to be inadequate by Gossard.59 They used patient-based questionnaires that revealed a 32% rate of patient dissatisfaction following the nonoperative treatment of dis-placed midshaft clavicle fractures, a significantly higher rate than expected from traditional (i.e., radiographic or surgeon-based) outcome measures. In addition, they showed that a significant proportion of patients (15%) were dissatisfied despite radio-graphic union, confirming the existence of symptomatic clavicu-lar malunion for the first time in a large series. McKee et al.99 used



Figure 38-14 Robinson classification scheme of clavicle fractures.

Robinson Cortical AlignmentFracture (Type 2A)

Undisplaced (Type 2A1)

Angulated (Type 2A2)

Robinson Undisplaced Fractures (Type 1A)

Extra-articular (Type 1A1)Craig Type I

Extra-articular (Type 1B1)Craig Type II

Extra-articular (Type 1B2)Craig Type V

Intra-articular (Type 1A2)Craig Type III

Robinson Displaced Fractures (Type 1B)


Simple or single butterfly (Type 2B1)

Segmental or comminuted (Type 2B2)Robinson Cortical Alignment

Fracture (Type 3A)

Extra-articular (Type 3A1)Neer Type ICraig Type I

Intra-articular (Type 3A2)Neer Type IIICraig Type III


Extra-articular (Type 3B1)Neer Type II

Craig Type II, IV

Intra-articular(Type 3B2)

Allman Group ICraig Group I

Allman Group IICraig Group II

Allman Group IIICraig Group III

Craig Type V



Figure 38-15 Ao/otA classification scheme of clavicle fractures.

2. Intra-articular (15-C2)

Clavicle, lateral end (15-C)1. Extra-articular (15-C1)

Location: Lateral end (15-C)

Type:C. Clavicle, lateral end (15-C)

3. Complex (15-B3)

2. Wedge (15-B2)

Clavicle, diaphysis (15-B)1. Simple (15-B1)

Location: Diaphysis (15-B)

Type:B. Clavicle, diaphysis (15-B)

Location: Medial end (15-A)

Type:A. Clavicle, medial end (15-A)

Group:Clavicle, medial end (15-A)1. Extra-articular (15-A1)

2. Intra-articular (15-A2)

3. Comminuted (15-A3)

machine-based objective strength measurements on patients with clavicular malunion to demonstrate strength deficits of up to 30% that were not apparent on the traditional manual strength testing against the physicians resisting arm.

Similar findings in other areas have prompted extensive research into the evaluation of outcome. A number of modern, validated, responsive, consistent outcome measures are now available for the evaluation following shoulder girdle injuries.

Most clinical research studies examining patient outcome in this anatomic area use a comprehensive set of outcome measures including a patient-oriented general health status measurement such as the SF-36 or MFA, a patient-oriented limb-specific out-come measure such as the Disabilities of the Arm, Shoulder, and Hand (DASH), a surgeon-based outcome score such as the Con-stant shoulder score or UCLA shoulder score, and a radiographic measure. With regard to the radiographic measurements, there is



increasing focus on standardizing technique so as to obtain con-sistent results. There are now data available from multiple studies on the effect of a clavicle fracture on these outcome measures that help the attending surgeon with treatment and prognostica-tion (see below).15,85,103,143,155

Another previously unanswered yet important question regarding outcome following clavicle fracture was the length of follow-up required to determine the time of maximal recov-ery, or when a patient “plateaued” following injury. While most scientific journals require a minimum follow-up of 2 years for outcome studies, this can be extremely difficult to obtain in the

“trauma population,” which tends to be predominantly young, male, and transient. A recent study by Schemitsch et al.164 dem-onstrated that outcome measures such as the DASH or Con-stant score do not change appreciably after 1 year in patients with midshaft clavicle fractures (Fig. 38-16). This finding has important implications. Clinically, following either operative or nonoperative treatment, patients can be told that their func-tional outcome is unlikely to change significantly from their status at 1 year post injury. Researchers can plan for a single year of follow-up post-intervention, with the knowledge that the expense and effort of longer monitoring is unnecessary as changes in outcome measures past this point are minimal. In addition, economists can use the 1-year data from such studies for definitive calculations of the long-term cost-effectiveness of various treatment methods.137

PAthoAnAtomy And APPlIed AnAtomy relAtIng to clAvIcle frActures

Bony Anatomy of the ClavicleThe clavicle is a relatively thin bone, widest at its medial and lateral expansions where it articulates with the sternum and acromion, respectively (Fig. 38-17). It has two distinct curves: The larger, obvious curve is in the coronal plane giving the bone its characteristic S shape (medial end convex anterior and lat-eral end concave anterior).107 There is also a more subtle supe-rior curve delineated in a cadaver study by Huang et al.70 This milder superior bow had its apex laterally a mean of 37 mm from the acromial articulation, with a mean magnitude of 5 mm. The medial superior surface of the clavicle was found to be flat. This article also described the fit of a precontoured clavicular plate to 100 pairs of cadaver clavicles. The authors found that there were significant sex and racial differences in the fit of the plate from best (black male clavicles) to worst (white female clavicles). This article helps explain why intraoperatively it often

100

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6 12 24Time (week)

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Figure 38-16 constant shoulder scores of patients following opera-tive versus nonoperative treatment of a displaced midshaft fracture of the clavicle at 2 years are similar to 1-year scores, indicating that function plateaus after 1-year post injury. (Adapted from: Schemitsch LA, Schemitsch eh, Veillette c, et al. Function plateaus by one year in patients with surgically treated displaced midshaft clavicle fractures. Clin Orthop Relat Res. 2011;469(12:3351–3355, with permission.)

Figure 38-17 the cross-sectional and topographic anat-omy of the clavicle. the clavicle is narrowest in its midpor-tion, explaining the high incidence of fractures in this area.



is necessary to adjust or contour even “anatomic” plates for the clavicle to achieve an optimal fit.70 The bone in the relatively thin diaphysis is typically hard cortical bone best suited for cortical screws, whereas the medial and lateral expansions are softer cancellous bone where larger pitch cancellous screws can be inserted without tapping.

Ligamentous Anatomy of the ClavicleMedialThere is relatively little motion at the SC joint, and the supporting soft tissue structures are correspondingly thick. Medially the clav-icle is secured to the sternum by the SC capsule, and although there are not easily demonstrable “ligaments,” the thickening of the posterior capsule has been determined to be the single most important soft tissue constraint to anterior or posterior translation of the medial clavicle. There is also an interclavicular ligament which runs from the medial end of one clavicle, gains purchase from the superior aspect of the sternum at the sternal notch, and attaches to the medial end of the contralateral clavicle. Acting as a tension wire at the base of the clavicle, this ligament helps prevent inferior angulation or translation of the clavicle. In addition, there are extremely stout ligaments that originate on the first rib and insert on the undersurface or the inferior aspect of the clavicle.19 A small fossa inferomedially, the rhomboid fossa, has been described as an attachment point for these ligaments, which primarily resist translation of the medial clavicle.

LateralThe coracoclavicular ligaments are the trapezoid (more lateral) and conoid (more medial) which are stout ligaments that arise from the base of the coracoid and insert onto the small osse-ous ridge of the inferior clavicle (trapezoid) and the clavicular conoid tubercle (conoid). These ligaments are very strong and provide the primary resistance to superior displacement of the lateral clavicle. Their integrity, or lack thereof, plays an impor-tant role in the decision making and fixation selection in the treatment of displaced lateral third clavicle fractures. Clavicle fractures in this location will often have an avulsed inferior fragment to which these ligaments are attached, especially in younger individuals. Inclusion of these fragments in surgical fixation selection enhances the stability of the operative repair. The capsule of the AC joint is thickened superiorly and is pri-marily responsible for resisting AP displacement of the joint. It is important to repair this structure, which is usually reflected surgically as part of the deep myofascial layer, when operating on the lateral end of the clavicle. If one is inserting a hook plate for fixation of a very distal fracture, a small defect can be made in the posterolateral aspect of the capsule for insertion of the hook portion into the posterior subacromial space.23,42,83,98,193

Muscular Anatomy of the ClavicleThe clavicle is not as important as the scapula in terms of mus-cle origin, but still serves as the attachment site of several large muscles. Medially, the pectoralis major muscle originates from the clavicular shaft anteroinferiorly, and the sternocleidomas-toid originates superiorly. The pectoralis origin merges with the origin of the anterior deltoid laterally, while the trapezius

insertion blends superiorly with the deltoid origin at the lat-eral margin (Fig. 38-18). Muscle attachment plays a significant role in the deformity which results after fracture: The medial clavicular fragment is elevated by the unopposed pull of the sternocleidomastoid muscle, while the distal fragment is held inferiorly by the deltoid and medially by the pectoralis major. The undersurface of the clavicle is the insertion site of the sub-clavius muscle, which is of little significance functionally but serves as a soft tissue buffer in the subclavicular space superior to the brachial plexus and subclavian vessels. The platysma or “shaving muscle” is variable in terms of thickness and extent, but usually envelopes the anterior and superior aspects of the clavicle and runs in the subcutaneous tissues, extending superi-orly to the mandible and the deeper facial muscles. It is divided during the surgical approach, and is typically included in the closure of the superficial, or skin/subcutaneous layer.

Neurovascular Anatomy of the ClavicleThe supraclavicular nerves originate from cervical roots C3 and C4 and exit from a common trunk behind the posterior border of the sternocleidomastoid muscle. There are typically three major branches (anterior, middle, and posterior) that cross the clavicle superficially from medial to lateral, and are at risk during surgical approaches. If they are divided, an area of numbness is typically felt inferior to the surgical incision, although this tends to improve with time. A more difficult prob-lem can be the development of a painful neuroma in the scar

Sternocleidomastoid

Trapezius

Scalenus anterior

Subclavius

Brachial plexus

Subclavian artery

First rib

Subclavian vein

Pectoralis major

Pectoralis minor

Figure 38-18 Applied anatomy of the clavicle. Anterosuperiorly, the pectoralis major muscle and fascia envelope the medial 60% of the clavicle while the lateral 40% is covered by the deltoid mus-cle and its fascia. Posterosuperiorly, the trapezius muscle attaches to the clavicle.



which, although rare, can negatively affect an otherwise good surgical outcome. For this reason, some authorities recommend identification and protection of these nerves during operative repair.75,76,174 More vital neurovascular structures lie inferior to the clavicle. The subclavian vein runs directly below the sub-clavius muscle and above the first rib, where it is readily acces-sible (for central venous access) and vulnerable (to inadvertent injury). More posteriorly lie the subclavian artery and the bra-chial plexus, separated from the vein and clavicle by the addi-tional layer of the scalenus anterior muscle medially. The plexus is closest to the clavicle in its midportion, where the greatest care needs to be taken in not violating the subclavicular space with drills, screws, or instruments. A recent study by Sinha et al.171 used reconstructed three-dimensional CT arteriograms of the head, neck, and shoulder to better define the relationship between these vascular structures and the clavicle. Their goal was to define “safe zones,” in terms of distance and direction, for potential drill penetration during plate and screw fixation of the clavicle. They divided the clavicle into medial, middle, and dis-tal thirds, and found that the subclavian vessels were closest at the medial end, with the vein directly apposed to the posterior cortex of the medial clavicle in some cases. In the middle third, the artery and vein were a mean of 17 and 13 mm from the clav-icle, respectively, at an approximate angle of 60 degrees to the horizontal (i.e., the vessels were posterior-inferior to the clavicle, Figs. 38-19 and 38-20). Laterally, the distances were greater, with the artery and vein a mean of 63 and 76 mm, respectively form the clavicle. Using these findings, the authors made a num-ber of recommendations regarding surgical technique: Extreme caution must be used when manipulating medial clavicular frac-ture fragments, and superior plating may be safer than ante-rior plating in this area. Also, they felt that anterior plating had less potential for vessel injury from drill or screw penetration, as compared to superior plating, in the more common middle third fractures. They felt the risk of iatrogenic vessel injury was

much less in the fixation of distal third fractures. Despite the proximity of these vital structures, iatrogenic injury is surpris-ingly rare in clavicle fracture fixation (see below).

clAvIcle frActure treAtment oPtIons

A recent review article focusing on evidence-based medicine outlined treatment approaches to displaced midshaft fractures of the clavicle.104 This resource summarizes the available objec-tive evidence about recommendations for the optimal treatment of these injuries (Table 38-2). The grades of recommendation are as follows.

Grade A: Good evidence (high-quality prospective, randomized clinical trials (RCTs) with consistent findings) recommend-ing for or against intervention

Grade B: Fair evidence (lesser quality RCTs, prospective com-parative studies, case-control series) recommending for or against intervention

Grade C: Poor-quality evidence (case series or expert opinions) recommending for or against intervention

Grade I: There is insufficient or conflicting evidence not allow-ing a recommendation for or against intervention

While there is an abundance of manuscripts detailing the treatment of clavicle fractures, most tend to be retrospective reviews, although there are an increasing number of prospective and/or randomized trials being published.15,59,74,154 My personal recommendations for treatment must be considered in light of the evidence available in Tables 38-1 and 38-2.

Anterior

Clavicle

Posterior

12.7 mm (3D)

6.0 mm (3D)

Lungs

SV ScapulaScapulaSA

Figure 38-19 the relationship of the subclavian artery (SA) and vein (SV) to the midshaft of the clavicle. (Adapted from: Sinha A, edwin J, Sreeharsha B, Bhalaik V, Brownson P. A radiological study to define safe zones for drilling during plating of clavical fractures. J Bone Joint Surg Br. 2001;93-B:1247–1252, with permission.)

Average angle of artery and veinmiddle one third (point ‘B’)

Anterior Posterior

HorizontalClavicle

70°

50°

SV SA

Figure 38-20 Schematic illustration indicating the location of the subclavian artery and vein in relation to the middle third of the clavi-cle, and the angle from the horizontal of potential drill/screw penetra-tion to be avoided. (Adapted from: Sinha A, edwin J, Sreeharsha B, Bhalaik V, Brownson P. A radiological study to define safe zones for drilling during plating of clavical fractures. J Bone Joint Surg Br. 2001;93-B:1247–1252, with permission.)



Nonoperative Treatment of Clavicle FracturesThe earliest reported attempt at closed reduction of a displaced midshaft fracture of the clavicle was recorded in the “Edwin Smith” papyrus dating from the 30th century BC. Hippocrates described the typical deformity resulting from this injury, and emphasized the importance of trying to correct it.1 It is usually possible to obtain an improvement in position of the fracture fragments by placing the patient supine, with a roll or sand-bag behind the shoulder blades to let the anterior displacement and rotation of the distal fragment correct with gravity, followed by superior translation and support of the affected arm. Unfor-tunately, it is difficult or impossible to maintain the reduction achieved. For this reason, over the millennia that followed the first description of treatment of this fracture, there have been hundreds of descriptions of different devices designed to main-tain the reduction, including splints, body jackets, casts, braces, slings, swathes, and wraps.1,3,16,31,59,97 At the present time, there is no convincing evidence that any of these devices reliably maintains the fracture reduction or improves clinical, radio-graphic, or functional outcomes. For many years the standard of care in North America was the “figure-of-eight” bandage: Andersen et al.3 examined its utility in a prospective, random-ized, controlled clinical trial comparing it to a simple sling in 60

patients. They could demonstrate no functional or radiographic difference between the two groups, and in general the patients preferred the sling (2/27 dissatisfied with the sling compared to 9/34 dissatisfied with the figure-of-eight bandage, p = 0.09). In a retrospective review of 140 patients treated nonoperatively, Stanley and Norris did not find any difference between a stan-dard sling and a figure-of-eight bandage, a finding confirmed by other authors.138,139,178 Also, a figure-of-eight bandage that is over-tightened can result in a temporary lower trunk brachial plexus palsy and for this reason my practice, if nonoperative care is selected, is to apply a simple, conventional sling with a padded neckpiece, and no attempt at reduction is made.

Outcomes—Nonoperative TreatmentTraditionally, clavicle fractures have been treated nonoperatively but recent studies have shown that the union rate for displaced midshaft fractures of the clavicle may not be as favorable as previously described. In a prospective series of 868 patients with clavicle fractures treated nonoperatively, Robinson et al.154 reported a significantly higher nonunion rate (21%) in displaced comminuted midshaft fractures. An analysis of this paper by Brinker et al.14 suggested a nonunion rate varying between 20% and 33% for displaced comminuted fractures in males. Hill et al.68 studied 66 consecutive displaced midshaft clavicle frac-tures and found a 15% nonunion rate and a 31% rate of patient dissatisfaction with nonoperative care. Based on their data, they concluded that displacement of the fracture fragments of greater than 2 cm was associated with an unsatisfactory result. A meta-analysis of studies of clavicle fractures from 1975 to 2005 revealed that displaced midshaft clavicle fractures treated non-operatively had a nonunion rate of 15.1%. This meta-analysis also showed that primary plate fixation was, contrary to prevail-ing opinion, a safe and reliable procedure.209 Nowak et al.125,126 examined the late sequelae in 208 adult patients with clavicle fractures at 10 years post injury. Interestingly, 96 (46%) still had symptoms despite the fact that only 15 (7%) had an established nonunion. McKee et al.99 reported on a series of patients who has nonoperative treatment of a displaced midshaft clavicle fracture a mean of over 4 years earlier. Objective muscle strength test-ing revealed significant strength deficits, especially of shoulder abduction and flexion which help explain some of the patient dissatisfaction seen despite bony union.

While it is unclear why such a dramatic difference exists in outcome between previous reports on clavicle fractures and contemporary studies, one possibility may be the inclusion of children in the older reports, which, due their inherent healing abilities and remodeling potential, may artificially improve the overall results. Also, patient-oriented outcome measures, as used by Hill et al. and McKee et al. have been shown to reveal func-tional deficits in the upper extremity that have not been detected traditionally.15,68,99 A focus on radiographic outcomes would not reveal such problems. Patient expectations and injury patterns are changing. Several studies that examined clavicular shaft frac-tures in polytrauma patients found that the presence of a clavicle fracture was associated with a 20% to 30% mortality rate (mainly from concomitant chest and head injuries), and that survivors displayed a significant level of residual disability in the involved

Table 38-2 recommendations for the Optimal Treatment of Displaced Midshaft Fractures of the Clavicle

Statement gradea references

Young active patients with com-pletely displaced midshaft frac-tures of the clavicle will have superior results with primary fracture fixation.

B 15,174,209

Anteroinferior plating may reduce the risk of symptomatic hard-ware compared to superior plating.

c 27,91

there is no difference in out-come between a regular sling and a figure-of-eight bandage when nonoperative treatment is selected.

B 3,178

there is no difference in outcome between plating and intramed-ullary nailing of displaced mid-shaft clavicle fractures.

i 7,26,63,73, 140,209

Factors associated with poor out-come following nonoperative treatment of displaced mid-shaft clavicle fractures include shortening, and increasing fracture comminution.

A 14,59,102,125, 154,174,209

aGrade of recommendation.



remodeling potential), large numbers of patients lost to follow-up, and radiographic and/or surgeon-based outcomes that are insensitive to residual deficits. Recent evidence from prospec-tive and randomized clinical trials has suggested that there is a subset of individuals who benefit from primary operative care (Fig. 38-21).15,59,74,105,140,154,169,173,192,201 Operative repair in this setting should be reserved for medically well, physically active patients who stand to benefit the most from a rapid restora-tion of normal anatomy and stable fixation. There are multiple potential indications for primary operative fixation, outlined in Table 38-4. The majority of modern prospective studies examining the potential benefits of primary clavicle fracture fixation have been in adult patients, with 16 years of age the typical (arbitrary) lowest age of inclusion. Thus, it is unclear if adolescent patients, in general, would benefit from operative repair to a similar degree as adult patients. However, adolescent patients can develop symptomatic malunion following nonop-erative treatment of displaced midshaft fractures of the clavicle, although nonunion remains rare as one would expect. Vander Have et al.189 performed a retrospective study on 43 adoles-cent patients (mean age: 15.4 years) with displaced midshaft clavicle fractures, 17 of whom underwent primary plate fixa-tion, and 25 of whom were treated nonoperatively. They found that complications in the plate group were minor, and a more rapid return to function with a shorter time to union resulted. Five patients in the nonoperative group, with a mean of 26 mm of shortening, developed a symptomatic malunion, with four patients choosing corrective osteotomy. It is clear that some adolescent patients with significantly displaced midshaft clavicle fractures have suboptimal results following closed

shoulder.101,184 Thus, there is a surviving patient population (with clavicle fractures) that has an intrinsically worse prognosis where long-term sequelae may be more common.

Although it is not typically an orthopedic priority, cosme-sis is important to patients, and an unsightly scar has been a traditional deterrent to operative treatment of clavicular frac-tures.29,30,32,115,118,128,142 However, to a body image conscious patient (predominantly young, male population), a droopy shoulder is also of significant cosmetic concern. In a recent RCT comparing operative and nonoperative treatments, despite the incidence of hardware prominence and incisional compli-cations (numbness, sensitivity) in the operative group, more patients in this group answered “yes” to the question “Are you satisfied with the appearance of your shoulder?” than in the nonoperative group (52/62 vs. 26/49, p = 0.001, Table 38-3). This study also showed superior surgeon-based (Constant score) and patient-based (DASH) upper extremity outcomes.15

In contradistinction to older case series, recent studies on the primary plate fixation of acute midshaft clavicle fractures have reported high success rates with union rates ranging from 94% to 100% and low rates of infection and surgical compli-cations. A recent meta-analysis of plate fixation for 460 dis-placed fractures revealed a nonunion rate of only 2.2%. With improved implants, prophylactic antibiotics, and better soft tis-sue handling one can conclude that plate fixation is reliable and reproducible.15,82,140,141,209

Operative Treatment of Clavicle FracturesIndications/ContraindicationsThere are numerous large series that describe relatively good results following nonoperative treatment of clavicle fractures, and it is my opinion that the majority of clavicle fractures can, and should, be treated in this fashion.3,43,49,78,115,160 However, there are serious deficiencies in these papers including the inclusion of children (who have an intrinsically good result and

Table 38-3 Cosmesis Following Operative Versus Nonoperative Care of Clavicular Fractures

ComplaintOperative

(n = 62)Nonoperative

(n = 49) p Value

“Droopy” shoulder 0 10 0.001

Bump/Asymmetry 0 22 0.001

Scar 3 0 0.253

Sensitive/painful fracture site

9 10 0.891

hardware irritation/prominence

11 0 0.001

incisional numb-ness

18 0 0.001

Satisfied with appearance of shoulder

52 26 0.001

Table 38-4 relative indications for Primary Fixation of Midshaft Clavicle Fractures

Fracture-Specific1. Displacement >2 cm2. Shortening >2 cm3. increasing comminution (>3 fragments)4. Segmental fractures5. open fractures6. impending open fractures with soft tissue compromise7. obvious clinical deformity (usually associated with 1 and

2 above)8. Scapular malposition and winging on initial examination

Associated Injuries1. Vascular injury requiring repair2. Progressive neurologic deficit3. ipsilateral upper extremity injuries/fractures4. Multiple ipsilateral upper rib fractures5. “Floating shoulder”6. Bilateral clavicle fractures

Patient Factors1. Polytrauma with requirement for early upper extremity

weight-bearing/arm use2. Patient motivation for rapid return of function (e.g., elite

sports or the self-employed professional)



treatment, and that plate fixation is a safe and reliable fixation method with a low complication rate in this group. Prospective, randomized studies of operative versus nonoperative treatment in this specific group are required to determine the exact role, if any, for primary operative repair of these fractures. At present, the consensus is that operative intervention should be reserved for older, larger adolescents with severely displaced fractures.17

External FixationThere are reports in the literature of various techniques of external fixation for clavicle fractures.35,165,186 This method takes advantage of the intrinsic healing ability of the clavicle and allows restoration of length and translation without the scar-ring or morbidity of a surgical approach. In addition, there is no retained hardware at the conclusion of treatment. Schuind165 reported on a series of 20 patients treated with external fixa-tion for clavicular injuries, many of whom had local soft tissue compromise; union occurred in all. Tomic et al.186 described the treatment of 12 patients with nonunion of the clavicular shaft by application of a modified Ilizarov device. Union was achieved in 11 of 12 patients with an increase in the mean Constant score from 30 preoperatively to 69 postoperatively. It is clear that this technique is technically possible to per-form, and may be useful in certain specific situations. Unfortu-nately, the practical difficulties associated with the position and prominence of the fixation pins, coupled with a lack of patient acceptance in the North American population, has resulted in minimal use of this technique (Table 38-5).

Intramedullary PinningPreoperative Planning. Intramedullary (IM) pinning

of fractures of the shaft of the clavicle has several advantages. These are similar to the benefits seen with IM fixation of long bone fractures in other areas, although this technique had not

been as consistently successful in the clavicle as series in the femur or tibia have reported.8,30,48,51,63,73,106 Advantages include a smaller, more cosmetic skin incision, less soft tissue stripping at the fracture site, decreased hardware prominence following fixa-tion, technically straightforward hardware removal, and a pos-sibly lower incidence of refracture or fracture at the end of the implant. Recently, modifications to the technique have included a radiographically guided completely “closed” technique.26 Since, at the present time, there is no consistently reliable way to “lock” an IM clavicle pin, complications include those common to all unlocked IM devices, namely failure to control axial length and rotation, especially with increasing fracture comminution and decreasing intrinsic fracture stability. In addition, a biomechani-cal study of clavicular osteotomies by Golish et al.57 comparing 3.5-mm compression plates to 3.8- or 4.5-mm IM pins showed that the plated constructs were superior in resisting displacement in a number of different testing modes (maximal load, cyclical

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Figure 38-21 Probability of nonunion at various time points following a mid-shaft clavicle fracture. the Pi (Prognos-tic index) becomes more negative with each of the following factors: increasing age, increasing comminution, increasing displacement, and female sex. (Adapted from Robinson cM, court-Brown cM, McQueen MM, et al. estimating the risk of nonunion following nonoperative treat-ment of a clavicle fracture. J Bone Joint Surg Am. 2004;86-A(7):1359–1365.)

Table 38-5 external Fixation of Clavicle Fractures: Preoperative Planning Checklist

oR table Radiolucent table

Position Semisitting with small pad between scapulae

Fluoroscopy location c-arm is placed ipsilateral and enters from the side

equipment external or ring fixator of surgeon’s choice

Special considerations this is a complex technique requiring a subspecialty skill level and is not well tolerated by some patients



stress) compared to both IM pin constructs. Therefore, based on clinical and biomechanical evidence, at the present time this technique is, in general, reserved for simple fracture patterns (transverse and short oblique fractures) (Table 38-6).

Patient Positioning. The technique includes positioning the patient in a semisitting position on a radiolucent table, with an image intensifier on the ipsilateral side. By rotating the image 45 degrees caudal and 45 degrees cephalad orthogonal views of the clavicle can be obtained. A small pad is placed between the scapulae to allow the shoulder to “fall back,” aiding in reduc-tion, as the typical clavicle fracture deformity results in pro-traction of the shoulder girdle. The arm may be free-draped if a difficult reduction is anticipated (i.e., as with significant shortening), but in general this is not necessary. The head is turned to the opposite side and taped in place.

Surgical Approach/Technique. A small incision is then made over the posterior-lateral corner of the clavicle 2 to 3 cm medial to the AC joint (Fig. 38-22). The posterior clavicle at this point is identified and the canal breached with a drill consistent with the planned fixation device. A reduction of the fracture is then performed, either through a small open incision or, as expe-rience increases, in a completely closed fashion using a percuta-neous reduction clamp on the medial fragment and a “joystick” in the distal fragment. Alternatively, the fixation device can be inserted using a “retrograde” technique where it is passed out from the fracture site through the lateral fragment. The fracture is then reduced and the IM device is inserted into the medial fragment under direct vision. It is important to accurately reduce length and rotation, although the latter can be quite difficult if done closed and no visual clues from the fracture configuration are available. A small incision may be necessary to reduce verti-cally oriented comminuted fragments and “tease” then back into alignment. Following this, the canal is drilled to the appropriate size to accept the planned IM device. Options include headed pins, partially threaded pins or screws, cannulated screws, and smooth wires. Although some series report favorable results with smooth wires, the North American experience with small diam-eter smooth pin fixation includes breakage and migration and is, in general, dismal.87,93,109,120 Smooth wires are contraindicated for fracture fixation about the shoulder in general and the clavicle in particular. It is important not to distract the fracture site with the fixation device, which can occur as the pin is inserted into the unyielding opposite cortex as the S-shaped clavicle comes into contact with the end of the straight pin. If this occurs, the pin must be withdrawn slightly or a shorter pin is used. The head of the pin or screw can be left prominent to facilitate early removal through a small posterior incision, or can be left flush with the bone to decrease soft tissue irritation (Fig. 38-23).

Table 38-6 intramedullary Fixation of Clavicle Fractures: Preoperative Planning Checklist

oR table Radiolucent table

Position Semisitting with small pad between scapulae

Fluoroscopy location

c-arm is placed ipsilateral, and enters from the side

equipment intramedullary pins, reamers, inserters, and any attachment guides or jigs

Special consider-ations

At present, this technique is reserved for simple fractures such as transverse or short oblique patterns without signifi-cant comminution

A B

C

Figure 38-22 intramedullary fixation with a headed, distally threaded pin (modified hagie pin). (a) Retrograde drilling of the distal fragment, (b) reduction and fixation of the fracture, (C) addi-tion of bone graft or bone graft substitute.



A

E

B

F

G

C

D

Figure 38-23 a: A comminuted, displaced, midshaft fracture of the clavicle. b: Photograph showing the operative set-up with the image intensifier in place. C: A small incision is made and the fracture reduced in an open fashion followed by retrograde insertion of the pin. D: Postoperative radiograph revealing reduction of the fracture. e: Skin irritation over prominent pin. F: Radiograph demonstrating bony union. g: Follow-up radiograph following uneventful union and pin removal. (case courtesy of, and copyright by, Dr. David Ring).



A B

Figure 38-24 a: A completely displaced transverse fracture of the midshaft of the clavicle treated with a lockable, large diameter intramedullary nail. b: while this device represents an advance in the treatment of these injuries, more outcome data is required prior to implementation in unstable fracture patterns. (case courtesy of Dr. Aaron nauth).

Postoperative Protocol. Some authors advocate leaving the pin in a prominent position subcutaneously for easy access in the clinic at the time of early (7 to 8 weeks postoperative) hardware removal. This step depends on the type of fixation device used and the philosophy of the treating surgeon. The incisions are closed in a fashion similar to that used for plate fixation, although they are typically smaller. If the surgeon is confident with the stability of the repair, early motion is insti-tuted similar to that performed following plate fixation.

Potential Pitfalls and Preventative MeasuresOutcome. While there are many theoretical advantages to

IM fixation, it would appear that the results of this method with currently available implants are more unpredictable than the results reported for plate fixation. Biomechanically, IM devices appear to be inferior in resisting displacement when compared to plate fixation.60 Two clinical studies comparing IM fixation to nonoperative treatment failed to show any advantage in the IM fixation group. Grassi et al. described a high complication rate with IM fixation including eight infections, three “refrac-tures,” two delayed unions and two nonunions with hardware failure in 40 patients.63 Judd et al.,74 in a randomized trial, failed to show an advantage of IM fixation over nonoperative care in 57 patients, with nearly half the operative group losing some degree of reduction. A recent study by Strauss et al.180 described a complication rate of 50%, (including three cases of skin necrosis) in 16 patients treated with Hagie pin fixation. They recommended against the continued use of this device. A meta-analysis by Zlowodzki et al.209 did not reveal any signifi-cant differences between plate and IM fixation, although this analysis was hampered by the lack of any direct comparative studies. Conversely, Chuang et al.26 described 100% union with no significant complications in a group of 34 patients with an acute midshaft fractures of the clavicle treated with an IM can-nulated screw. Also, these studies examine the clinical outcomes

of implants that, in general, are essentially unlocked, have poor rotational or axial control, and are not suitable for unstable or comminuted fractures. Newer devices are now available that have the potential to improve on traditional IM implants with locking capability (Fig. 38-24): Further studies will elucidate if their theoretical advantages are borne out in clinical practice. See also “Controversies: Method of Fixation,” below.

Open Reduction and Plate FixationPreoperative Planning. While this section will describe

the author’s technique of operative repair of a midshaft clavicle fracture, it is important to remember that the majority of mid-shaft fractures can be treated nonoperatively. A careful physical examination (see above) is mandatory to rule out other inju-ries, which may influence the anesthetic choice (i.e., an ipsi-lateral pneumothorax), or the surgery itself (compromised skin or deficient soft tissue, neurovascular injury). The skin in this area is typically bruised, with extensive swelling, following a displaced midshaft fracture. Since the difficulty of reduction and fixation does not increase until approximately 2 weeks fol-lowing injury, it may be prudent to delay operative interven-tion (as one would in other areas) until the soft tissue in the vicinity of the planned surgical approach is more robust. Radio-graphs of the injured clavicle are usually sufficient. The surgeon should observe the severity of the displacement, the number of fracture fragments, and the location of the main fracture line (Fig. 38-25). There is often a vertically oriented antero-superior fragment, which may benefit from lag screw fixation and minifragment screws should be available as this fragment may be quite narrow. Also, the number of screws that poten-tially can be placed into the distal fragment can be determined preoperatively, so that the appropriate size of plate can be available. Older series describing fixation of clavicle fractures have described poor results when inadequate fixation such as



cerclage wires alone or plates of inadequate size or length are used (Figs. 38-26 and 38-27).114,115,142,160 A fixation set that includes plates which are precontoured, or “anatomic,” to fit the S shape of the clavicle is ideal. Although these plates may require some intraoperative adjustments, they typically save sig-nificant time associated with the extensive contouring required to make a straight plate fit the bone. They help to decrease the soft tissue irritation that occurs when the end of a straight plate protrudes past the end of the bone as the clavicle curves away.

Currently, there are two common surgical approaches appli-cable to the fixation of clavicle fractures, each with its own advantages and disadvantages. They are as follows.

Anteroinferior. Several groups have published large series on the advantages of anteroinferior plating of acute clavicle fractures.27,82,170 Advantages of this technique include an easier screw trajectory with less likelihood of serious neurovascular injury with inadvertent overpenetration of the drill (although

A

B C

D

Figure 38-25 a: Anteroposterior radiograph of a displaced midshaft clavicle fracture. note the differ-ence in diameter of the proximal and distal fragments at the fracture site, suggesting that a significant degree of rotation has occurred. b: intraoperative photograph of a displaced fracture, (C) reduced anatomically with small fragment reduction forceps. D: Postoperative radiograph after open reduction and internal fixation with an anterior to posterior lag screw followed by fixation with an anatomic plate.



the incidence of iatrogenic nerve injury is very low), and the ability to insert longer screws in the wider AP dimension of the clavicle, and decreased hardware prominence. It is also tech-nically easier to contour a small-fragment compression plate along the anterior border as opposed to the superior surface. However, the advent of precontoured plates has largely negated this particular advantage. Collinge et al.27 reported on the use of this technique in 58 patients and described 1 fixation failure, 1 nonunion, 3 infections, and only 2 hardware removals. Poten-tial disadvantages of this technique include the lack of gen-eral familiarity with the approach, and that the plate tends to

obscure the fracture site radiographically. Also, although there remains some controversy on the matter, biomechanical studies have in general shown that the most advantageous position for plate placement is the superior surface.

Anterosuperior. Anterosuperior plating can reasonably be considered the most popular operative method for fixation of the clavicle.11,12,15,26,33 Its advantages include a general famil-iarity with this approach in most surgeons’ hands, the abil-ity to extend it simply to both the medial and lateral ends of the clavicle, and the benefit of clear radiographic views of the clavicle postoperatively. Its disadvantages include the trajectory of screw placement (from superior to inferior) that can be dif-ficult, and inadvertent “plunging” with the drill can place the underlying lung and neurovascular structures at risk. Also, the clavicle is fairly narrow in its superoinferior dimension, and typically the length of screws inserted range from 14 to 16 mm in females to 16 to 18 mm in males (Table 38-7).

Patient Positioning. The patient is positioned in the “beach-chair” semisitting position on a regular operating room (OR) table with an attached foot piece to support the legs. It has not been routinely necessary to use special tables or positioners. The head is placed on a round support and, if general anesthe-sia is to be used, the endotracheal tube is taped to the opposite side. The arm does not need to be free-draped for isolated inju-ries and is usually padded and strapped to the patients’ side. It is helpful to place a small pad behind the involved shoulder to elevate it and then check to ensure that the anticipated superior drill trajectory is free from obstruction. This is less of a concern if an anterior-inferior plate application is chosen.

Surgical Approach (Anterosuperior). A superior approach and plating is my preferred technique because of its simplicity, the well-proven clinical record of superior plate appli-cation, and several biomechanical studies that have suggested that the optimal location for plate placement is superior.60,72

Figure 38-27 Anteroposterior radiograph of a 35-year-old man who weighed over 200 pounds (200 lb), whose clavicle nonunion was fixed with a 3.5-mm pelvic reconstruction plate. early mechanical failure occurred through deformation of the plate. this type of plate may be suitable for smaller, low-demand individuals but has a higher fail-ure rate when used in larger, more physically active patients, espe-cially given the current availability of stronger, precontoured plates.

Figure 38-26 cerclage wiring in isolation is inadequate to control the deforming forces at the site of a displaced clavicle fracture. it results in all of the risks of surgical intervention with few of the benefits, and is to be avoided.

Table 38-7 Open reduction and Plate Fixation of Clavicle Fractures: Preoperative Planning Checklist

oR table A regular or radiolucent table may be used at the surgeon’s discretion

Position Semisitting with small pad between scapulae—this aids in reduction of the fracture

Fluoroscopy location

Fluoroscopy is not mandatory, and is used at the discretion of the surgeon if a diffi-cult reduction is anticipated. if used, the c-arm is place ipsilaterally, and enters from the side

equipment Precontoured plates, small fragment fixation set, drill

Special considerations

Most fractures are amenable to plate fixa-tion, and this procedure is within the skill set of most orthopedic surgeons



It is possible that anterior–inferior plating leads to less plate irri-tation than placement of the plate on the superior surface of the clavicle. In the one direct comparison (nonrandomized) between the two techniques, Lim et al.91 reported a significantly better pain visual analog scale for patients in the anterior/inferior fixa-tion group (p = 0.05). This finding awaits confirmation from fur-ther studies.

An oblique skin incision is made centered superiorly over the fracture site. The subcutaneous tissue and platysma mus-cle are kept together as one layer and extensively mobilized, especially proximally and distally. As experience with the tech-nique increases, a smaller incision using “minimally invasive” principles can be employed. Care is taken to identify, isolate, and protect any visible, larger branches of the supraclavicu-lar nerves; smaller ones may need to be divided. It is usually wise to warn patients that they may experience some numbness inferior to the incision which will typically improve with time. The myofascial layer over the clavicle is incised and elevated in one continuous layer. Therefore, at the conclusion of the procedure, fracture site and plate coverage are enhanced by having two soft tissue layers (skin/subcutaneous tissue, myo-fascial layer) to close. Care is taken to preserve the soft tissue attachments to any major fragments, especially the vertically oriented fragment of the anterosuperior clavicle that is often seen. It is not necessary to completely denude these fragments in order to reduce them.

Technique. The main fracture line and major fragments are clearly identified and cleaned of debris and hematoma, and a fixation strategy is formulated. If there is a free fragment of sufficient size to be structurally important (one-third of the clavicle circumference or greater), it can be reduced to the proximal or distal clavicle that it arose from and fixed with a lag screw, simplifying the fracture to a simple pattern (Fig. 38-28). The proximal and distal fragments are then reduced with the aid of reduction forceps; they can be held temporarily with a K-wire or, ideally, with a lag screw. A precontoured plate of sufficient length is then applied to the superior surface. If a lag screw has been placed, it is usually sufficient to secure the fracture with three bicortical screws (six cortices) both proxi-

mally and distally. If it is not possible to place a lag screw, then four screws should be inserted both proximally and distally. If the main fracture line is of a stable configuration, compression holes can be used to apply compression. If the fracture is com-minuted or of an unstable pattern, then the plate should be applied in a “neutral” mode. Care must be taken not to violate the subclavicular space and the vital structures therein. If there is any concern intraoperatively about violation of the pleural space, a Valsalva maneuver should be performed to identify any leakage of air.

In general, surgical intervention is selected for only young active patients with high-quality bone, and for this reason screw purchase is usually excellent, especially in the corti-cal area. Although there has been increasing interest in the use of locking plate technology in this area, there have been few reports on this technique in the clavicle. Celestre et al.20 reported that a superiorly placed locking plate was biome-chanically superior to a conventional compression plate, although there is little clinical information regarding locking plate use at the present time. One small retrospective series78 described their use in recalcitrant clavicular nonunions: All 11 fractures eventually healed. I have not found that locking plates are routinely necessary for the fixation of clavicle frac-tures, and I have no experience with them. Following fixation, it is important to close both soft tissue layers with interrupted, nonabsorbable sutures. Postoperative radiographs are taken in the recovery room.

Postoperative Care. The surgery can typically be done on an outpatient basis. Postoperatively, the arm is placed in a standard sling for comfort and gentle pendulum exercises are allowed, and the patient is seen in the fracture clinic at 10 to 14 days postoperatively. The wound is checked and radio-graphs are taken. The sling is discontinued, and unrestricted range-of-motion exercises are allowed, but no strengthening, resisted exercises, or sporting activities are allowed. At 6 weeks postoperatively, radiographs are taken to ensure bony union. If they are acceptable, the patient is allowed to begin resisted and strengthening activities. If delayed union is evident, then more aggressive activities are avoided. It is generally advised

B

A

Figure 38-28 a: A displaced midshaft fracture of the clavicle in a 16-year-old boy, with abrasion and tenting of the skin, approximately 2.5-cm shortening, and an obvious clinical deformity. b: the intervening fragments were fixed with a lag screw followed by plate fixation. Prompt anatomic healing occurred, as might be expected in an adolescent.



that contact (football, hockey) and/or unpredictable (mountain biking, snowboarding) sports be avoided for 12 weeks postop-eratively. However, compliance in this predominately young, male population is variable and many individuals return to such activities earlier than recommended.

The clavicle has relatively poor soft tissue coverage, and hardware prominence following plate fixation is a clinical concern. Previously, prior to the advent of plates specifically designed for the clavicle, it was often necessary to contour a straight compression plate to fit the bone by twisting it on its long axis so that it faced the bone as the underlying clavicle curved away from it.100,108 In addition to making screw place-ment difficult, this led to undue prominence of the ends of the plate and a high incidence of subsequent plate removal. With the current availability of stronger, curved, low-profile plates symptomatic prominence of the plates is much lower and rou-tine plate removal is not typically required.

Outcome—Plate Fixation. Older reports described a high rate of complications and hardware failure with primary plate fixation of the clavicle. However, with the development of improved implants, prophylactic antibiotics, and better soft tissue handling and techniques plate fixation has become a reliable and reproducible technique which can reasonably be considered the gold standard at the present time (see also “Con-troversies: Method of Fixation,” below). Recent studies on the primary plate fixation of acute midshaft clavicle fractures have reported high success rates with union from 94% to 100%. Infection and surgical complication rates are low, under 10%, and functional outcome is superior to nonoperative treatment. A meta-analysis of plate fixation for 460 displaced fractures revealed a nonunion rate of only 2.2%.14–16 In the most recently published randomized trial comparing operative versus non-operative treatment, Virtanen et al.192 reported union of all 28 fractures in the plate fixation group, with a low complication rate. In the largest similar trial reported to date, the union rate in the plate fixation group was reported to be over 95%, with the commonest complication being hardware irritation and the requirement for plate removal. While plating remains the most popular method of clavicle fixation, the position of plate place-ment is controversial, with some authorities recommending plate placement on the superior surface of the clavicle, while others recommend the anterior/inferior surface.10,15,27,31,82,208 At the present time, there is no published direct comparison between the two techniques. What is apparent is that plate fixation, for a selected subgroup of individuals with completely displaced fractures of the midshaft clavicle, is a safe, reproduc-ible, and reliable technique with a union rate of 95% and a low complication rate.

Potential Pitfalls and Preventative Measures—Operative Treatment• Patient selection is critical: Operative intervention is

reserved for young, healthy, physically active patients with good bone quality and completely displaced fractures (typi-cally with visible deformity) who stand to benefit most from operative fixation with an intrinsically low complication rate (Fig. 38-29).

• Noncompliance and substance abuse (be it alcohol, illicit drugs, or prescription narcotics) are contraindications to surgical intervention. No clavicular fixation is strong enough to withstand an unprotected fall down stairs or a physical altercation in the immediate postoperative period.49,140,141 The rates of hardware failure, nonunion, and reoperation are significantly higher in such individuals.

• It is critical to develop, protect, and securely close the two soft tissue layers. The superficial layer is the skin and subcutaneous tissue and the deep layer is the deltotrape-zial myofascial layer. This helps protect against deep infec-tion and ensures plate coverage if there is a superficial infection.

• Comminuted fragments, especially the often seen verti-cally displaced anterior-superior fragment, should be gen-tly “teased” back into position, maintaining its soft tissue attachments. They can be secured with mini- or small- fragment screws. Reduction is important but not at the cost of denuding all of the soft tissue attachment (Fig. 38-30).

• While typically it is not necessary to dissect in the subclavic-ular space to place protective retractors, it is very important not to “plunge” into this area with drills or taps. If a lung injury is suspected intraoperatively, the wound is filled with saline and the anesthetist performs a Valsalva maneuver. The presence of air escape indicates pleural injury and should prompt a chest radiograph and consultation for pleural drainage (catheter or chest tube).

• A plate of size and strength commensurate with the patients’ size and compliance should be used. In general, 3.5-mm compression plates or precontoured plates are ideal, espe-cially for larger individuals (>150 lb) or those who will reha-bilitate aggressively.

• IM fixation is reserved for simple fracture patterns (trans-verse and short oblique fractures).

Figure 38-29 the typical clinical deformity following a displaced left midshaft clavicular fracture with a short, droopy, “ptotic” shoul-der with anterior translation and rotation of the distal fragment and limb.



• Reduce the risk of refracture by avoiding routine plate removal: If required, wait a minimum of 2 years following fracture union before performing hardware removal (Table 38-8).

Plate or Hook Plate Fixation of Displaced Fractures of the Lateral Clavicle

Preoperative Planning. A careful examination of the skin over the lateral clavicle and planned operative site is important. As with midshaft fractures, temporizing until the soft tissue sta-tus improves may be prudent. The major technical challenges

in these injuries are purchase in the distal fragment and resist-ing the primary displacing forces, which draw the proximal fragment superiorly and the distal fragment (secured by the AC and coracoclavicular ligaments to the coracoid and scapula) inferiorly.4,23,42,77,83,130 In addition, the cancellous bone of the distal fragment may be inferior in quality to that of the shaft, and there may be unrecognized comminution. The treating sur-geon should template the fracture preoperatively to determine the number of screws that will have purchase in the distal frag-ment. There are a number of precontoured “anatomic” plates available for this purpose. If it is anticipated that there will be insufficient distal purchase then alternative fixation strategies

A B

Figure 38-30 a: Anteroposterior radiograph with 20-degree cephalad tilt demonstrating a com-pletely displaced midshaft clavicle fracture with shortening. there are often vertically oriented fracture fragments that arise from the anterosuperior surface of the clavicle at the site of displaced midshaft fractures, giving many fractures a “Z” pattern. if possible, they should be gently teased back into place and fixed with small or minifragment screws, followed by plate fixation. it is important not to denude the fragment when attempting to fix it. Reduction is performed by reducing the vertical intercalated fragment to the distal fragment and securing it with a 2.7-mm lag screw. the distal assembly is then reduced to the proximal fragment with the aid of two towel clip reduction forceps, followed by plate fixation with a precontoured plate. b: Postoperative radiograph revealing restoration of length and anatomic reduction.

Table 38-8 Potential Pitfalls and Prevention—Operative Treatment

Pitfall Prevention

Poor patient selection Young, active patients with displaced fractures benefit from primary fixation: Poor bone quality, medical comorbidities, and noncompliance negatively affect outcome. Substance abusers have a dramatically higher complication and reoperation rate. nonoperative care is preferred in these individuals

Deep wound infection with exposed hardware

A two layer closure, consisting of a deep myofascial layer and a superficial skin/subcutaneous tissue layer, will help decrease or eliminate this potential complication

Plate breakage Use a strong plate consistent with the size, demands, and compliance of the patient. Most precontoured plates approach the biomechanical strength of a compression plate. Avoid 3.5-mm reconstruction type plates, especially in larger individuals

hardware irritation Use a precontoured plate, especially in an individual of smaller stature

Loss of reduction and shortening

Avoid unlocked or small diameter intramedullary devices in complex or comminuted fracture patterns. obtain lag screw fixation if possible, and a minimum of six cortices on either side of the fracture site, when using plate and screw fixation

nonunion after operative fixation

Avoid excessive soft tissue stripping at the fracture site. Small comminuted fragments should be teased into the best position possible and secured with screws or suture. Soft tissue attachments are preserved



need to be considered. These can include augmenting fixation into the coracoid process or achieving purchase to or under the acromion. In this instance the use of a hook plate (a pre-contoured plate with a projection or “hook” that is inserted posteriorly in the subacromial space) can be extremely useful, especially with very distal fractures.51,56,98

Patient Positioning. Patients are positioned in the “beach-chair” or semisitting position, similar to the position used for midshaft fractures. A small pad or bump is placed behind the involved shoulder to elevate it into the surgical field. The head is placed on a round support and rotated out of the way of the operative field. Recently, frames and supports designed to give greater exposure of the shoulder (i.e., for shoulder arthroscopy) have become popular. This type of operative set-up can also be used, and may facilitate intraoperative radiography. It is not usually necessary to free-drape the involved arm, although this can be done if there is any difficulty anticipated with the reduc-tion (i.e., if the fracture is severely displaced or greater than 2 to 3 weeks old).

Surgical Approach. The surgical approach is similar to that used for superior plating of the clavicle. A skin incision placed directly superiorly over the distal clavicle, extending approximately 1 cm past the AC joint is made. The skin and subcutaneous layer is developed, and the deltotrapezial myofas-cial layer is incised directly over the distal clavicle and reflected anteriorly and posteriorly. The AC joint is identified. This can be done by inserting an 18-gauge needle into the joint from the superior aspect, and an arthrotomy can be avoided. It is pos-sible to use an anterior/inferior approach for plate fixation of distal clavicle fractures although in my experience this involves a significant amount of detachment of the deltoid and it is not possible to convert easily to coracoclavicular screw augmenta-tion or hook plate fixation.204

Technique. The fracture site is identified and cleaned of debris and hematoma. The fracture is reduced and it may be held with either a K-wire or a lag screw. Elevating the distal fragment to meet the proximal fragment may aid in reduc-tion. If the main fracture line is in the coronal plane, it may be possible to lag the fracture from anterior to posterior through a small anterior stab incision separate from the primary inci-sion. Once the fracture is reduced and provisionally stabi-lized, the optimal type of plate is chosen. Anatomic plates that fit the distal clavicle are now available, and placing four bicor-tical, fully threaded, cancellous screws in the distal fragment should be the goal (Fig. 38-31). Following fixation, the surgeon must judge whether the number and quality of distal fragment screws are sufficient to provide stability until union occurs. If fixation is judged to be inadequate, there are several options at this point. Since the primary deforming force at the fracture site is superior displacement of the proximal fragment, it is pos-sible to augment fixation by securing the proximal fragment to the coracoid with a longer screw inserted through one of the plate holes (Fig. 38-32). This screw, typically 30 to 40 mm long, helps secure the proximal fragment to the coroacoid and pre-vents this superior displacement. Since there is some intrinsic motion between the clavicle and the coracoid and scapula, with time this screw either loosens or it may break, but it will give 6 to 8 weeks of stability to secure fracture healing before doing so. Alternatively, it may be necessary to augment fixation by using a hook plate with fixation under the acromion to prevent superior migration of the proximal fragment. This technique is selected when there is insufficient bony purchase in the distal fragment with conventional screws.53,56,98 This may be readily apparent during preoperative planning (Fig. 38-33), or may only be realized intraoperatively. The advantage of subacromial fixation is that conventional plating can be rapidly converted to this technique intraoperatively. The AC joint is identified,

B

A C

Figure 38-31 Anteroposterior radiograph of a displaced distal clavicle fracture in a 38-year-old physi-cian following a fall off a mountain bike at high speed (a). Although the fracture was closed, there was significant bruising and swelling over the shoulder. the degree of displacement of this fracture sug-gests a high likelihood that of delayed union or nonunion would result with nonoperative treatment. After the soft tissue swelling had subsided 10 days post injury, operative fixation was performed with a plate specifically designed for the distal clavicle, allowing for the placement of four screws in the small distal fragment (b). the fracture healed uneventfully and the patient was able to return to work within a week of the surgery. A final follow-up radiograph (C) following hardware removal for local soft tissue irritation, a common problem in this area, shows solid union.



and the posterior edge of the distal clavicle is dissected free. An entrance into the subacromial space is then made with a pair of heavy curved scissors that will create the path of the “hook” extension of the plate. It is important that this space is made posteriorly, so that there will be no impingement of the rotator cuff in the critically tight anterior subacromial space. Once this path has been created, the hook is placed in it and the plate reduced to the shaft of the clavicle. Several different hook depths and lengths are currently available for this plate, and trial reductions can be performed to determine the opti-mal plate type. Alternatively, the plate can be “walked down”

onto the clavicular shaft by sequential placement of the screws from distal to proximal. This can be a very effective technique of fracture reduction as this maneuver “levers” the distal frag-ment to the proximal fragment. On occasion, it may be neces-sary to contour the shaft of the plate to prevent over-reduction of the fracture; however, if excessive contouring appears to be required, a more likely explanation is that the fracture is not reduced and that there is residual superior angulation. It is possible to securely repair even very distal fractures (that are essentially AC joint fracture-dislocations) with this technique. Minimal, if any, purchase is required in the distal fragment.

A B

Figure 38-32 a: it is possible to augment fixation in distal clavicle fractures with poor-quality bone or a very small distal fragment by placing a screw through the plate into the coracoid process, which helps resist the forces that displace the fracture (superior displacement of the proximal fragment, infe-rior displacement of the distal fragment). Since there is 10 to 15 degrees of rotational motion between the clavicle and the coracoid, this fixation will eventually loosen (as it has in this case) or break (b). however, typically it provides augmented fixation for 6 to 8 weeks postoperatively, which is usually enough for the fracture to heal.

B

A

Figure 38-33 a: Anteroposterior radiograph of a very distal clavicle fracture in a 22-year-old female pedestrian struck by a street car. the fracture was open with significant soft tissue damage, near transec-tion of the superior deltoid and trapezius, and severe instability of the shoulder girdle. it can be anticipated that conventional plating may be inadequate given the small size of the distal fragment and the associ-ated shoulder girdle instability. b: the radiograph following irrigation and debridement, hook plate fixation, and deltoid/trapezial muscle repair. early motion was initiated and an excellent result ensued.



Unlike static fixation across the AC joint which is doomed to loosening or fatigue failure, hook plate fixation allows some motion between the bones. A cadaver study revealed that this technique most closely reflected the biomechanics of the native AC joint, namely secure enough to provide reliable fixation yet physiologically flexible.98 Following fixation, the wound is thoroughly irrigated and a two-layer closure similar to that for midshaft fractures is performed.

Postoperative Care. The arm is placed in a sling and the patient is allowed early active motion in the form of pen-dulum exercises. At 10 to 14 days postoperatively the wound is checked and the stitches are removed. The sling is then discarded and full range-of-motion exercises are instituted; sling protection can be extended if the quality of fixation is questionable. At 6 to 8 weeks, if radiographs are favorable, resisted and strengthening exercises are instituted. Return to full contact or unpredictable sports (i.e., mountain biking) is usually discouraged until 12 weeks postoperatively. While hardware removal is typically optional for those with conven-tional plates, it can be anticipated that a high percentage of individuals with hook plate fixation will require plate removal to regain terminal shoulder flexion and abduction (see Hard-ware Removal). This is usually performed at a minimum of 6 months postoperatively.

Potential Pitfalls and Preventative Measures• The rate of delayed union and nonunion for completely

displaced distal clavicle fractures treated nonoperatively is approximately 40%.

• Even minimally displaced fractures may take an excessive period of time to heal, or may develop a fibrous union. However, without displacement, they are often not symp-tomatic enough to warrant surgical intervention.

• The technical challenge faced during operative treatment of distal clavicle fractures is the fixation of the distal fragment; the surgeon should be prepared to deal with unexpected comminution or poor screw purchase in the distal fragment using anatomic plates, coracoclavicular fixation, or hook plates.

• Hook plate fixation is an effective alternative to conventional plate fixation when faced with inadequate distal purchase. To avoid subacromial impingement, the hook should be placed posteriorly.

• A high percentage of patients treated with hook plate fixa-tion will require plate removal to regain full range of shoul-der motion.

• Rigid transacromial fixation has a high rate of loosening and fatigue failure due to the intrinsic motion at the AC joint and is therefore not routinely recommended.

Outcomes. There are a number of studies that define the outcome of nonoperatively treated fractures of the distal clav-icle.23,121,132,153,157 The largest and most comprehensive is by Robinson et al.153 who examined a cohort of 127 nonoperatively treated patients with follow-up of 101 these individuals. The mean Constant score was 93 points, although this excluded

14 patients (14%) with symptoms severe enough to warrant delayed surgical intervention. Interestingly, although 21 patients (21%) had a radiographic nonunion, they were minimally symptomatic and their outcome scores (Constant, SF-36) were no different than those in patients with uneventful union. They concluded that nonoperative treatment achieved good results in middle-aged and elderly patients, with only a small percentage (14%) requiring delayed surgery. These results were mirrored by Rokito et al.157 who compared 14 patients treated operatively for displaced distal third fractures with 16 nonoperatively treated patients and found no difference in ASES, Constant, or UCLA shoulder scores despite the fact that 7 (of 16) patients in the non-operative group developed a radiographic nonunion. In a system-atic review of 425 patients (21 studies), Oh et al.132 described a nonunion rate of 33% in the 60 patients treated nonoperatively, but noted that little functional deficit occurred. It is clear from these studies that although the nonunion rate is relatively high following the nonoperative treatment of displaced distal third clavicle fractures, functional deficit (especially in middle-aged and elderly patients) is minimal and conservative care should, at present, be considered acceptable in most cases. The same study by Oh et al. described the outcome following various sur-gical interventions in 365 patients, and recommended that cora-coclavicular fixation was preferred due to its low complication rate (4.8%) compared to hook plate fixation (40.7%) or K-wire tension banding (20.0%). IM fixation was also associated with a low complication rate (2.4%) but the number of cases ame-nable to this type of fixation is limited. In direct comparisons of surgical techniques, Tan et al.182 reported equivalent union rates between hook plate fixation and small fragment T plate fixation (100%), but that more patients in the hook plate group had residual shoulder pain that required hardware removal (15/23, 74%) for relief. Klein et al.80 compared early versus late distal clavicle fracture repair with hook plate fixation (22 patients) and superior locked plate application (16 patients). They found a high rate of success (union in 36/38 patients), but that fractures repaired early (<4 weeks) had better outcomes than the delayed group (ASES score 78 vs. 65), with a lower complication rate (7% early vs. 36% delayed). Unfortunately, there are few pro-spective or randomized trials examining distal clavicle fractures. In the absence of high-quality evidence, we must rely on avail-able information that would suggest that the majority of these injuries should be treated nonoperatively initially, especially in middle-aged or elderly individuals.23,80,121,132,153,169 Operative intervention is reserved for severely displaced fractures, high-demand patients, or for failures of nonoperative care: In these cases a variety of methods (hook plate repair, coracoclavicular fixation, tension-band wiring, etc.) can have a high degree of success.34,42,53,80,132,182,193,204

Medial Clavicle FracturesThere are very few reports on medial fractures of the clavicle, a rare entity. Low et al.92 reported the successful treatment of five cases of completely displaced medial clavicle fractures using internal fixation (plates and/or screws). They stressed the importance of preoperative imaging as this area is difficult to visualize with plain radiographs. In a similar series, this



was emphasized by Oe et al.,129 who reported on 10 cases of medial clavicular fracture. The medial clavicular epiphysis is the last long bone epiphysis to fuse in the body, and may per-sist in patients until 25 to 30 years of age. Therefore, medial clavicular fractures are often epiphyseal fracture-subluxations or fracture-dislocations. This can be defined by the preop-erative CT scan. There is little in the way of evidence-based medicine to dictate treatment, with the majority of informa-tion on this entity contained in small retrospective case series. Fractures that are significantly displaced may warrant opera-tive repair, especially if there is posterior displacement. The primary technical difficulty with these injuries is the fixation in the medial fragment. The surgical approach is similar to that made to the shaft. It is important to remember that the subclavian vessels are in close proximity to the bone medi-ally. Following identification, debridement, and reduction of the fracture, it can be temporarily held reduced with K-wires. Definitive plate fixation can then be performed in a variety of ways. If the medial fragment is large enough, then stan-dard plate and screw fixation can be performed; a plate with an expanded end section (as in a distal clavicle plate from the contralateral side) may augment multiple screw pur-chase. There is a significant expansion of the medial clavicle (Fig. 38-17) and this allows for placement of longer (22 to 24 mm) cancellous screws. If there is insufficient purchase, than the plate can be extended across the joint onto the ster-num. This construct will eventually loosen due to motion at the SC joint, but will typically stabilize the fracture long enough (3 months) for union to occur, at which the point the plate should be removed. Rarely, fixation with a hook plate intrasternally or retrosternally may be required. This is a highly specialized technique and cardiovascular support should be available in the event of inadvertent injury to the vascular structures found retrosternally. Fixation of the frac-ture using smooth wires or pins alone is contraindicated, due to the potential for migration and visceral injury.

Management of the “Floating Shoulder”The combination of ipsilateral fractures of the clavicle and scapular neck has traditionally been called the “floating shoul-der,” which has been considered to be an unstable injury that may require operative fixation.45,145,158,188,191,198,200 In fact, this injury pattern can be considered to be a subgroup of the “dou-ble disruption of the superior shoulder suspensory complex (SSSC),” a concept introduced by Goss.58,136 This describes the bone and soft tissue circle, or ring, of the glenoid, coracoid process, coracoclavicular ligaments, clavicle (especially its distal part), AC joint, and acromion. This complex is extremely important biomechanically, as it maintains the anatomic rela-tionship between the upper extremity and the axial skeleton. The clavicle is the only bony connection between the two, and the scapula is suspended from it by the coracoclavicular and AC ligaments. Thus, any injury that disrupts this ring at two or more locations is considered inherently unstable and one whose cumulative effect may be greater than the sum of its individual constituents.203 Long-term functional problems have been reported following significantly displaced injuries

of this nature, including shoulder weakness and stiffness, impingement syndrome, neurovascular compression, and pain.30,43,45,65–67,88,145,158,188,191,198,200 Such injuries have been considered relative indications for operative intervention (Fig. 38-9). Combined scapular (or glenoid neck) and clavicle fractures are the commonest type of double disruptions of the SSSC, and there remains considerable controversy over optimal treatment.

A study by Leung and Lam88 described good or excellent results in 14 of 15 patients with this injury pattern following fixation of both the clavicle and glenoid fractures. However, Herscovici et al.66 described excellent results in seven of nine patients who had their floating shoulder treated with reduc-tion and fixation of the clavicular fracture only. These findings were confirmed in a study by Rikli et al.150 who performed clavicle fixation is isolation in 11 patients with combined clavicle and glenoid fractures. They described an average final Constant score in the operated shoulders of 95% of the unaf-fected side. These studies support the concept, in selected cases, of clavicular fracture reduction and fixation alone. It is postulated that reduction of the clavicle helps to reduce and stabilize the glenoid fracture, eliminating the requirement for operative fixation of the glenoid. This is an important point, since open reduction and internal fixation of the glenoid can be a difficult and complex procedure with a high complica-tion rate, especially if the surgeon lacks experience in this anatomic area.

There are also reports that support nonoperative man-agement of this injury. Ramos et al.145 described the results of nonoperative treatment in 16 patients with ipsilateral fractures of the clavicle and glenoid. Eleven patients had a complete recovery to near-normal status, although one had a significant malunion of the glenoid neck and three had sig-nificant shoulder asymmetry. Edwards et al.43 reported good results (“pleased” or “satisfied”) in 16 of 20 patients with float-ing shoulder injuries treated nonoperatively. There were four patients who were “dissatisfied” or “unhappy” with their out-come. While the outcome assessment of these patients was suboptimal it would appear that nonoperative treatment may be considered, especially for minimally displaced fractures. Interestingly, two of the four patients with poor results had severely displaced clavicular fractures. In a clinical study, Williams et al.198 evaluated 9 of 11 patients with a floating shoulder treated nonoperatively and found five excellent, one good, and three fair results. They found that the worse clinical results were strongly associated with 3 cm or more of medial displacement of the glenoid, and recommended nonoperative care for lesser amounts of glenoid displacement. Similarly, van Nort et al.188 performed a questionnaire review including 31 of 35 floating shoulder patients treated nonoperatively and found that only 3 required late operative reconstruction for clavicular malunion or nonunion. They found that results in the nonoperative group (a mean Constant score 76) deterio-rated with increasing degrees of glenoid displacement. Inter-estingly, they also found that three of the four patients who had their clavicle fracture fixed primarily had a poor result due to scapular malunion. They believed that this failure



of indirect glenoid reduction following clavicular reduction and fixation was due to associated ligamentous injuries that caused a dissociation of the two structures.

There is some limited biomechanical evidence to support the intuitive clinical finding that increasing degrees of fracture dis-placement in floating shoulder injuries corresponds to poorer results if left unreduced. Williams et al.200 performed a cadaver biomechanical study by establishing a scapular neck fracture and investigating the effect of an ipsilateral clavicle fracture, a coracoacromial ligament injury, and an AC ligament injury. They found that substantial instability (lack of resistance to a medially directed force) only occurred after associated ligamen-tous disruption. Although there are limitations to this study (such as the uniaxial direction of the applied deforming force), it remains one of the only biomechanical studies on this topic.

Unfortunately, given the variable and sporadic nature of this injury, there is a paucity of prospective, randomized, or comparative trials upon which to base treatment recommenda-tions. What is clear is that earlier recommendations for routine operative fixation for all floating shoulder injuries were too liberal, and that poor results occur regularly with badly dis-placed fractures that are treated nonoperatively. In addition, the aggressiveness of treatment must be commensurate with the risk of intervention and the expected functional demands of the patient. Thus, an operative approach may be indicated in a young healthy individual who works overhead for a living whereas the same fracture pattern may be treated nonopera-tively in an elderly, low-demand patient with multiple medical comorbidities. Further research in this area may help iden-

tify currently unknown factors that may predict outcome and hence guide treatment.79 Currently, standard operative indica-tions include the following.

1. A clavicle fracture that warrants, in isolation, fixation

2. Glenoid displacement of greater than 2.5 to 3 cm

3. Displaced intra-articular glenoid fracture extension

4. Patient-associated indications (i.e., polytrauma with a requirement for early upper extremity weight bearing)

5. Severe glenoid angulation, retroversion, or anteversion >40 degrees (Goss Type II)

6. Documented ipsilateral coracoacromial and/or AC ligament disruption or its equivalent (coracoid fracture, i.e., AC joint disruption)

If operative intervention is chosen, then anatomic reduction and internal fixation of the clavicle is typically performed first, and the shoulder then reimaged. If there is indirect reduction of the glenoid such that its alignment is within acceptable param-eters, then no further intervention is required apart from close follow-up. If the glenoid remains in an “unacceptable” position, then fixation of the glenoid neck, typically performed through a posterior approach, is indicated (see “Fractures of the Scapula, Chapter 39”). Also, Oh et al. reported the failure of isolated clavicle fixation in two cases of floating shoulder. If this method is chosen in this setting, the clavicle may experience greater loads than with isolated fractures, and the size and length of the fixation device selected should be commensurate with these anticipated loads (Table 38-9).131

Table 38-9 Management of expected adverse Outcomes and unexpected Complications

Clavicle Fractures Common Complications Prevention Treatment

infection careful technique, short operative times, prophylactic antibiotics

irrigation, debridement, local and intravenous antibiotics, maintain fixation if stable, remove if loose

nonunion Primary fixation reduces nonunion rate in selected cases

Plate or iM pin fixation, add iliac crest bone graft or osteoinductive bone substitute if atrophic

Malunion Primary fixation reduces symptomatic mal-union rate in selected cases

corrective osteotomy and plate fixation

neurovascular injury careful technique to avoid iatrogenic injury (see text)

treatment of established injury difficult, and usually expectant. Prevention is the key (see text)

hardware failure Use a plate strong enough for size, activity level, and compliance of patient. Precon-toured plates ideal, 3.5-mm reconstruction plates should be avoided

if fracture site stable and not displaced, it may heal with observation. Most cases will require revision oRiF with stronger plate, ± iliac crest bone graft to promote healing

hardware prominence Use a precontoured plate, especially in smaller individuals

hardware removal, minimum 2 years post implantation

Refracture Avoid plate removal, if necessary, for 2 years after fixation

if minimally displaced, may heal with nonoperative Rx. if displaced or unstable, repeat oRiF indicated

Scapular winging Due to residual clavicular malposition (mal-union, nonunion). Primary fixation lessens incidence

corrective clavicular surgery with plate or iM pin may be indicated if symptoms severe



mAnAgement of exPected Adverse outcomes And unexPected comPlIcAtIons In clAvIcle frActures

Infection in Clavicle FracturesInfection had traditionally been one of the most feared com-plications following fixation of displaced clavicular fractures, and earlier series described an unacceptably high rate of deep infection.2,31,54,115 However, significant improvements have been made in a number of areas that are well recognized to decrease infection, including perioperative antibiotics, selective operative timing with regard to soft tissue conditions, better soft tissue handling, two-layer soft tissue closure, and fixa-tion which is superior biomechanically.15,82,91,117,140,141,162,166 In a recent meta-analysis that examined operative series from 1975 to 2005, Zlowodzki et al.209 reported a superficial infection rate of 4.4%, and a deep infection rate of only 2.2%; these figures are significantly improved compared to earlier studies. When infection does occur, if it is superficial, then it is usually possi-ble to temporize with local wound care and systemic antibiotics until fracture union has occurred. At that point, plate removal, debridement, and thorough irrigation have a high success rate in infection eradication.

Deep infection with unstable implanted hardware is a more complex problem. If it appears that there is progressive bone for-mation, then temporizing until union occurs followed by hard-ware removal and debridement may be successful. If there is no obvious progress toward union, then operative intervention is indicated. Hardware removal followed by radical debridement of infected bone and dead or devitalized tissue and subsequent irri-gation is performed. At this point there are several options. If the patient is healthy without comorbidities (as is usually the case) and the infecting organism is a sensitive one, then immediate reconstruction with plating, bone grafting, and local antibiotics may be warranted. Alternatively, especially with polymicro-bial infections or resistant organisms (i.e., methicillin-resistant Staphylococcus aureus), local antibiotic impregnated polymethyl-methacrylate cement beads, or an antibiotic impregnated bone substitute are implanted into any residual dead space following debridement, and systemic antibiotics are administered until clinical and hematologic markers indicate the infection has been eradicated. Delayed reconstruction can then be performed. If there is a significant soft tissue deficiency, then the assistance of a plastic surgeon who can perform soft tissue coverage, typically with a rotational pectoralis major flap, is ideal.184,199

Nonunion in Clavicle FracturesTraditionally, the rate of nonunion of the clavicle has been described as being less than 1% of all fractures. This was based on two sentinel studies, one by Neer in 1960 that described 3 nonunions in 2235 patients, and one by Rowe in 1968 in which only 4 of 566 patients developed nonunion after a fracture of the clavicle.115,160 More recently, however, the nonunion rate follow-ing closed treatment of completely displaced midshaft fractures of the clavicle has been describe as being exponentially higher, in the 15% to 20% range.15,68,154,209 The reason for this difference is unclear but probably includes more complete follow-up in

recent studies, the exclusion of children (with their inherently good natural history), changing mechanisms of injury (moun-tain biking, all-terrain vehicles, parachuting), and the modern patients’ intolerance of prolonged immobilization. In addition, several prospective population-based studies have been helpful in elucidating factors associated with the development of non-union (Fig. 38-21). Robinson et al.154 identified increasing age, female sex, fracture displacement, and comminution as risk fac-tors for nonunion in midshaft fractures. Lateral third fractures had higher nonunion rates as patient age and fracture displace-ment increased.153 Nowak et al.125 prospectively followed 208 patients with radiographically verified clavicle fractures and, 9 to 10 years post injury, found that 96 (46%) still had sequelae. They identified no bony contact between the fracture fragments as the strongest predictor for sequelae. Nonunion occurred in 15 patients (7%). Zlowodzki et al.209 performed a meta-analysis of all series of displaced midshaft fractures from 1975 to 2005 and identified 22 published manuscripts. They found that, for the specific entity of completely displaced midshaft fractures of the clavicle the nonunion rate with nonoperative treatment was 15.1%, while the nonunion rate following operative treat-ment was 2.2%. This represents a relative risk reduction (for nonunion) of 86% (95 CI 71% to 93%). This meta-analysis, in addition to recent prospective studies examining primary operative fixation of clavicle fractures, definitively terminated the postulation that primary fixation was associated with a higher, not lower, nonunion rate (Table 38-1). This observation was based on early operative studies with poor patient selec-tion, inadequate fixation (Figs. 38-26 and 38-27) and inferior soft tissue management. Undoubtedly there are other factors that contribute to the incidence of nonunion (i.e., associated fractures, soft tissue interposition, rotation at the fracture site) that have yet to be clarified.144,178,195,197 Therefore, at the present time, factors associated with the development of nonunion include complete fracture displacement (no contact between the main proximal and distal fragments), shortening of greater than 2 cm, advanced age, more severe trauma (both in terms of mechanism of injury and associated fractures), and refracture. Primary operative fixation however is not associated with a higher nonunion rate.

Nonunion is defined as the lack of radiographic heal-ing at 6 months post injury (Fig. 38-34). While a significant percentage of distal nonunions may be asymptomatic, espe-cially in the elderly,122 the majority of midshaft nonunions in young active individuals will be symptomatic enough to require treatment.5,13,40,50,89,94,110,127,133,163

Figure 38-34 An atrophic nonunion of the clavicle. the degree of bone loss demonstrated in this case suggests that an intercalary graft may be required to restore length and obtain union.



A variety of methods have been described for the treatment of an established clavicular nonunion that is symptomatic enough to warrant operative intervention.11,12,30,32,33,40,50,75,76,94,197,203 Suc-cessful nonunion repair usually decreases pain and improves function. Described methods range from noninvasive tech-niques such as electrical stimulation and low-intensity ultra-sound to minimally invasive techniques (isolated bone grafting, screw fixation) to formal open reduction and internal fixation with iliac crest bone grafting. Apart from isolated case reports, or cases described in larger series of standard treatments, there is very little objective evidence to support the use of electrical stimulation or ultrasound in this area.13,30,32 In rare cases where there is minimal deformity or shortening, a stable hypertrophic nonunion with good soft tissue coverage and no infection, and a biologically favorable host (i.e., no smoking or diabetes), such techniques may occasionally be successful in promoting union. However, the majority will require mechanical stabilization and biologic stimulation.

There are two main techniques used to achieve union, plate fixation, and IM screw or pin fixation. The gold standard treat-ment against which other methods must be compared is open reduction and internal fixation with a compression plate and iliac crest bone graft. Reported success rates with this tech-nique are high if appropriate size and length plates are used. Manske and Szabo (10/10 healed), Eskola et al. (20/22 healed), Jupiter and Leffert (16/19 healed), Boyer and Axelrod (7/7 healed), Olsen et al. (16/17 healed), and Bradbury et al. (31/32 healed) all describe excellent results with a low complication rate.11,12,50,75,94,133 It is important to note that the forces gener-ated by deformity correction and the longer healing time will mean that the operative construct for a nonunion will require greater stability for a longer period of time than that for an acute fracture. Multiple authors stress that short four-hole plates, weak 1/3 tubular plates, or even 3.5-mm pelvic reconstruction plates in larger (>200 lb) patients are inadequate for this type of fixation, and have higher failure rates (Fig. 38-27). A small fragment compression plate, a precontoured “anatomic” plate or their equivalent with a minimum of three bicortical screws in each fragment is recommended (see Authors Preferred Tech-nique, below).11,12,30,32,33,40,50,75,76,94

There are many theoretical advantages to IM pinning with open bone grafting for the treatment of clavicular nonunions. A smaller incision with better cosmesis, less soft tissue stripping, decreased hardware irritation, and easier hardware removal (often under a local anesthetic) are proposed benefits compared to plate fixation. There are several reports describing good results including Boehme et al. (20/21 healed) and Enneking et al. (13/14 healed).8,48 In the only comparative study of fixa-tion techniques for clavicle nonunion, Wu203 described union in 9 of 11 patients treated with plate fixation and 16 of 18 of those treated with IM fixation. However, Johnston and Wilkins reported pin failure in two of four patients treated in this fashion, and the two failed IM fixations in the series by Wu both healed with subsequent plate fixation.197,203 In addition to IM fixation being weaker biomechanically and not controlling length and rotation as well as a plate, others have reported difficulty with pin migration and breakage using this

technique.79,93,109,120 A randomized, prospective study compar-ing plate and IM fixation is required to define their respective roles in this setting.

Severe bone loss and/or poor bone quality, typically associ-ated with multiple failed operative procedures and infection, can complicate the reconstruction of recalcitrant clavicular nonunions. The final treatment option in such circumstances is clavicular excision, or claviculectomy (either partial or total).30,32,202 Considering the important strut effect of the clavi-cle for upper extremity function, and the availability of modern treatment options, this must be considered a salvage proce-dure. While reasonable results with retention of a full range of motion and relief of pain have been described in selected cases with severe preoperative pathology, a significant decrease in strength (especially overhead) and a loss of shoulder girdle stability typically result.

My preferred surgical treatment for a midshaft nonunion of the clavicle is open reduction and internal fixation with a precontoured anatomic clavicular plate with the addition of an iliac crest bone graft or an osteoinductive bone graft substitute. Patient positioning and draping is similar to that used for the fixation of acute midshaft fractures, with the exception of hav-ing an iliac crest bone graft site prepared (typically the con-tralateral side) if bone grafting is anticipated (see below). The surgical approach is similar to that used for a fracture, taking care to reflect and preserve the myofascial layer for later clo-sure, and the superior surface of the clavicle at the nonunion site is identified. The ends of the nonunion are identified, and judicious soft tissue dissection is performed around them to allow correction of deformity. This usually involves bringing the distal fragment out to length and translating it superiorly and posteriorly. The distal fragment is often rotated anteriorly, and derotating it brings the flat superior surface directly supe-riorly, facilitating plate placement on the superior surface. The sclerotic ends of the proximal and distal fragments are identi-fied and a rongeur is used to clear them back to bleeding bone. It is rarely necessary to resect excessive bone to do this. The medullary canals are then re-established with a drill to allow the free egress of osteoprogenitor cells to the nonunion site. Reduction forceps are then placed on the proximal and dis-tal fragments and a reduction is performed. Remembering that there is a slight apex superior bow to the native clavicle, excess superior callus is rongeured away to allow the plate to fit on the superior surface of the clavicle. Any excess callus removed in the approach, debridement or deformity correction is saved, morcellized and inserted into the fracture site at the conclu-sion of the procedure. If possible, the nonunion is then fixed with an anterior to posterior small- or minifragment lag screw (Fig. 38-35). The chance of success of this helpful step can be increased by recognizing the orientation of the nonunion line during the approach and debridement. Lag screw fixation helps hold the reduction while the plate is applied and also increases the construct stability. If this is not possible than a 2-mm K-wire can be inserted to hold the reduction while a precontoured clavicle plate is applied to the superior surface. I typically use an eight-hole plate. This allows for one or even two empty holes at the nonunion site (often necessary due to



bony configuration or lag screw interference) while providing for three bicortical screws both proximal and distal, which I consider to be the absolute minimum for fixation. If the non-union is transverse in nature the first screws on each side are inserted in a compression mode, and tightened after the provi-sional K-wire has been removed. Although they are available, I have not found it routinely necessary to use locking screws or plates in the clavicle.

If the nonunion is hypertrophic (the minority) then the morcellized autograft from the local bone is applied to the nonunion site and a standard closure, as for a fracture case, is performed. Thorough irrigation and hemostasis is achieved before closure, and drains are not used.

If the nonunion is atrophic, then either morcellized auto-graft from the iliac crest or an osteoinductive bone substitute, such as a bone morphogenic protein, is packed in and around the nonunion site. Bone substitutes with little osteoinductive capability, such as calcium phosphates or sulfates, allograft, or demineralized bone, are to be avoided. A structural or inter-calary graft may be required in certain cases where there has been excessive loss of length or failed previous surgery. Short-ening can often be determined preoperatively by comparing the

length of the clavicle radiographically to the measured clinical length. If there appears to be significant bone loss then an inter-calary graft, as per the technique of Jupiter and Ring,76 can be employed. Postoperative care is similar to that following mal-union reconstruction or acute fracture fixation.

Malunion in Clavicle FracturesTraditionally, it was believed that malunion of the clavicle (which was ubiquitous with displaced fractures) was of radio-graphic interest only, and success in the clinical setting was defined as fracture union. However, more recently, a number of investigators have described a fairly consistent pattern of patient symptomatology (with orthopedic, neurologic, “func-tional,” and cosmetic features) following malunion of displaced midshaft fractures of the clavicle.7,21,64,74,84,103,136,150 While all of the factors that contribute to the development of this condition are unclear; it is typically diagnosed in young, active patients with significant degrees of shortening at the malunion site (Fig. 38-36). As could be reasonably anticipated, shortening of the shoulder girdle (with the typical inferior displacement and anterior rotation of the distal fragment) results in a vari-ety of biomechanical and anatomic abnormalities that translate

A B

Figure 38-35 a: An atrophic nonunion 14 months following nonoperative care of a completely displaced fracture of the clavicle. b: Successful repair with correction of deformity, plate fixation, and addition of bone morphogenetic protein to the nonunion site. the oblique nature of the nonunion in the coronal plane facilitated initial fixation with two anterior to posterior lag screws.

A B

Mean shortening 2.9 cm

Figure 38-36 typical clinical features of clavicle malunion (a) with corresponding radiograph (b). note the shoulder asymmetry, and the difference in the position of the Ac joints (arrows).



directly into patient complaints. Orthopedically, shortening of the muscle-tendon units that traverse the malunion site results in a sense of weakness and rapid fatigability, with a loss of endurance strength. It has been previously shown that there are significant, objective, deficits in maximal strength and endur-ance (especially of abduction) following the healing of dis-placed midshaft fractures of the clavicle treated nonoperatively (Fig. 38-37).99,172 Narrowing and displacement of the thoracic outlet (the inferior border of which is the clavicle) result in numbness and paraesthesias, usually in the C8 to T1 nerve root distribution, exacerbated by provocative overhead activities. Due to their deformity, patients complain of the appearance of their shoulder and difficulty with backpacks, hiking packs, military gear, and shoulder straps: This has been termed a defi-cit in “functional cosmesis.” Patients with this condition also complain of upper back pain and periscapular aching, espe-cially with repetitive activity. There is objective evidence that the displacement of the distal fragment (to which the scapula is attached) results in malalignment of the scapulothoracic joint and a form of scapular winging; this produces periscapular muscle spasm and fatigue pain.64,146

It would appear that the predominant risk factor for the development of this condition is shortening at the malunion site. Gossard59 found that shortening of 2 cm or more was asso-ciated with poor functional outcome and a high rate of patient dissatisfaction. McKee et al.103 described a series of 15 patients with a symptomatic clavicular malunion who had a mean amount of shortening of 2.9 cm and Bosch et al.9 described an “extension osteotomy” in 4 patients with shortening of 0.9 to 2.2 cm. In a retrospective study, Eskola et al.49 reported on 83 patients with displaced fractures and found that shorten-ing of 1.2 cm or more was associated with increased pain at final follow-up. However, this point remains controversial. In retrospective reviews, Nordqvist et al.124 (225 midshaft clavicle

fractures) and Oroko et al.135 (41 midshaft clavicle fractures) could not demonstrate a relationship between shortening and a poor outcome. It is probable that length is just one component of a complex three-dimensional deformity that, combined with the intrinsic variability of human response to skeletal injury, explains why some individuals with a malunion function well and others determinedly seek operative correction. For patients with a symptomatic malunion who have failed a course of phys-iotherapy for muscle strengthening, the options are to accept the disability or have a corrective osteotomy.

Operative intervention is reserved for patients with signs and symptoms of malunion that are specific to the condition and suf-ficiently severe to warrant surgery. A vague and generalized ache about the shoulder (especially in a patient with medical–legal or compensation issues) and a radiographic malunion is not neces-sarily an indication for surgery. Patients selected for surgery are typically young, active, and healthy with good bone stock. The primary goal of surgery is to correct the deformity, and preop-erative planning is important (Fig. 38-38). Careful measurement both clinically and radiographically defines the degree of length to be restored. A posteroanterior thorax or chest radiograph that includes both clavicles has been shown to be a reliable way of comparing length to the opposite (normal) clavicle.172 Inferior displacement and anterior rotation of the distal fragment is cor-rected by having the plate applied to the superior surface flush both medially and laterally; some contouring of the plate may be required in the anterosuperior plane as there is a slight caudal bow to the clavicle.

Patient positioning and the surgical approach are similar to those used for acute fracture fixation or nonunion repair.102 The exception is that in certain cases it is prudent to have an iliac crest bone graft site prepared (see below). In general, it has not been routinely necessary to insert an intercalary graft to restore length. It is usually possible to identify the position of the

Shoulder strength

p < 0.05 for all

% o

f con

tral

ater

al a

rm

100

80

60

40

20

0Flexion Abduction ER IR

MaximalEndurance

Figure 38-37 objectively measured shoulder strength following nonoperative treatment of a displaced mid-shaft fracture of the clavicle (maximal, endurance) com-pared to the normal contralateral side.99 Patients were a minimum of 14 months post injury, with a mean of 54 months. eR = ecternal rotation; iR = internal rotation. (Adapted from: McKee MD, Pedersen eM, Jones c, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg AM. 2006; 88(1):35–40, with permission.)



BA

DC

E F

Figure 38-38 a: Anteroposterior radiograph of a symptomatic clavicle malunion with 2.5 cm of shortening. b: the corresponding clinical photograph showing the measurement of clavicular length from the sternal notch to the acromioclavicular joint. C: An intraoperative photograph of the malunion site demonstrating the typical displacement of the distal fragment with medial, inferior, and anterior translation. this also demonstrates the abundant local bone which is usually present at the malunion site. while it is difficult to appreciate, there is anterior rotation of the distal fragment as well. D: An intraoperative photograph following osteotomy of the malunion, recreating the original fracture line and rongeuring of excess callus (which will be used to graft the osteotomy site), and distracting the fragments to their correct length and position. it is typically not necessary to perform an intercalary bone graft, as there is rarely absolute bone loss, and the original proximal and distal fragments can be re-established using a combination of a microsagittal saw and osteotomes. e: An intraoperative photograph following reduction and plate fixation using an anatomic precontoured plate. F: An antero-posterior radiograph following union. the patient’s preoperative symptoms resolved fully.



proximal and distal fragments in most patients. The malunion site is cleared, and a mark is made in the bone proximally and distally and the length is measured. This enables the surgeon to calculate how much length has been gained by remeasuring the distance between the two marks at the conclusion of the osteotomy. Next, the osteotomy to recreate the original fracture and proximal and distal fragments is made with a combination of a microsagittal saw and osteotomes. Care is taken not to violate the subclavicular space. Following the osteotomy, the proximal and distal fragments are grasped with a reduction forceps and gently distracted to the desired position. It is not routinely necessary to free-drape the arm for traction. For difficult cases, a minidistractor can be used to correct length and maintain position while fixation is applied. Care must be taken not to overdistract the fragments as neurologic injury may result.151 Depending on the configuration of the bone ends, after the osteotomy is performed it is often possible to fashion an interdigitating or step cut contour to improve intrinsic stability and increase the bony surface area for heal-ing. The medullary canals are re-established with a drill, and the osteotomy is temporarily secured with a K-wire. It is then measured for correction of deformity and length. On occa-sion, an absolute bone deficit may be encountered, such that reduction of the fragments does not restore length. Options at this point include accepting some shortening or using an intercalary graft. This situation can be anticipated preopera-tively when the measured clinical shortening (i.e., 3 cm) is significantly greater than the degree of shortening seen on the radiograph of the involved clavicle. Once deformity correc-tion is confirmed, definitive fixation is performed. There are several precontoured “anatomic” plates designed for clavicular fixation that are ideal for this purpose.70 If a lag screw can be placed across the osteotomy then three additional screws both proximally and distally are usually sufficient. If not, four screws proximally and distally are recommended. Additional local bone can be morcellized and added to the osteotomy site. Wound closure and postoperative care are the same as that for acute fracture fixation or nonunion repair.

Neurovascular Injury in Clavicle FracturesDespite the proximity of the brachial plexus and subclavian vessels, neurovascular injury is surprisingly rare, given the number of severely displaced clavicular shaft fractures seen in practice.6,10,18,22,34,38,55,69,147,151,161,187 In general, neurovascular injuries associated with clavicle fractures can be divided into three groups: Acute injuries, delayed injuries, and iatrogenic injuries.

Acute InjuriesA careful vascular and neurologic examination is critical with any clavicular injury, especially those associated with high-energy trauma. If the signs of vascular injury are present, an angiogram is indicated. In addition to being diagnostic, with the refinement of interventional techniques such as embo-lization and stenting, the procedure can also be therapeutic (Fig. 38-39). While direct impalement of bony fragments can

occur, most neurovascular injuries occur from excessive trac-tion, which in its most severe form is termed scapulothoracic dissociation. The unique feature of these injuries is that the associated clavicular fracture is typically distracted, rather than shortened. This can be a limb or life-threatening injury. A study by Ebraheim et al. reported 3 deaths in 15 patients, and Zelle et al. described 3 deaths and 6 amputations in 22 patients in their series from a major European trauma center.39,207 If limb salvage is to be performed, shoulder girdle stabilization (typically plate fixation of the clavicle fracture) is indicated to create an optimal healing environment for the soft tissue structures.

There have also been case reports of direct neurologic injury from clavicular fracture fragments: In this situation operative decompression of the brachial plexus by reduction and fixation of the clavicle fracture is indicated.6,10,34,55,69,147,161

Delayed InjuriesDelayed injuries tend to occur due to encroachment upon the thoracic outlet, either from displacement of the borders (i.e., from clavicular displacement due to malunion or nonunion), or encroachment from inferior clavicular callus formation. This phenomenon can be especially severe in patients with a concomitant head injury (Fig. 38-40). In the case reports describing this entity, debridement of local callus with realign-ment and fixation of the clavicle injury is indicated.26,47,147 The timing of this intervention is controversial, but in general it should be performed as promptly as the patient’s general con-dition allows. The commonest reason for brachial plexus irrita-tion following clavicular fracture is the chronic thoracic outlet syndrome (TOS) that results from clavicular malunion (see above). In this setting, operative treatment should be directed toward re-establishing the preinjury dimensions of the tho-racic outlet through a corrective clavicular osteotomy.7,9,21,103 Simply removing the “bump” around the fracture site, or con-ventional treatments for TOS such as first rib resection have a high failure rate. This is due to the fact that the fundamental anatomical problem is the change in position, orientation, and contour of the thoracic outlet from the displacement of the distal clavicular segment, rather than from local impingement of callus or normal structures (i.e., the first rib). Connolly and Ganjianpour28 reported the case of a patient with TOS follow-ing a clavicular malunion that was treated with first rib resec-tion to no avail, while corrective clavicular osteotomy resulted in prompt resolution of symptoms. McKee et al.103 reported resolution of TOS symptoms in 16 patients who underwent corrective clavicular osteotomy to treat a malunion. Chronic encroachment upon the thoracic outlet leading to TOS is prob-ably the commonest form of neurovascular “injury” following displaced clavicular fractures.

Iatrogenic InjuryDespite the proximity of the brachial plexus, catastrophic injury from intraoperative penetration by drills or taps is very rare. Shackford and Connolly168 reported a case of subclavian pseudoaneurysm formation with distal embolization from



A B

C D

Figure 38-39 a: Anteroposterior radiograph of a morbidly obese 57-year-old nurse who sustained a severely displaced midshaft fracture of the clavicle in a fall from a standing height. She also had a partial brachial plexus injury and a partial laceration of the subclavian artery with pseudoaneurysm formation (arrow), demonstrated on the preoperative angiogram (b). the patient was treated with immediate stenting of the resultant pseudoaneurysm, followed by plate fixation of the fracture with a 3.5-mm limited contact dynamic compression plate (C). the indications for fixation included reducing the severe displacement and creating an optimal environment for neurologic and vascular healing. Uneventful bony and soft tissue healing ensued (D).

screw penetration after plate fixation of a clavicular nonunion, and Casselman18 described a similar case. Iatrogenic injury can occur, but is thought to occur in specific situations where dis-traction can occur. Ring and Holovacs151 described three cases of brachial plexus palsy after IM fixation of clavicle fractures. They postulated that the distraction of the fracture site (a pre-requisite for reduction and pin insertion) and the delayed pre-sentation (patients were diagnosed several weeks after their injury) led to a traction injury of the brachial plexus. Fortu-nately, all three palsies recovered completely with nonoperative care. It would appear that distraction of a shortened clavicular fracture, especially one that presents or is treated some weeks or months following initial injury, creates a risk for a traction-type injury to the adjacent brachial plexus. Overdistraction at the fracture site or any violation of the subclavicular space is to

be avoided during operative repair of clavicular injuries. Fortu-nately, with the information presently available, these injuries are usually transient in nature and a full recovery with time can usually be expected.

Hardware Failure in Clavicle FracturesThis complication occurs when the stress placed upon the implant exceeds its biomechanical strength, typically due to early overuse from noncompliance, implant/patient size mismatch, or delayed union or nonunion. This complication can be prevented by proper surgical technique (i.e., avoiding extensive soft tissue stripping, stable fixation) and the use of implants commensurate with the patient’s size and compliance (i.e., avoiding the use of 3.5-mm pelvic reconstruction plates). These technical details are described in “Plate Fixation” (above). The incidence of hardware



failure should decrease as improved implants (in terms of strength, materials and contour) become available.

Hardware Prominence in Clavicle FracturesLocal irritation from prominent hardware remains a clinical concern following the operative treatment of clavicle fractures, given its relatively scanty soft tissue coverage. The incidence of hardware removal ranges from less than 5% to essentially 100% in some series (i.e., where pin removal is a planned sec-ond stage of the procedure). The use of bulky, straight plates in thin or small individuals is associated with greater degrees of local irritation. It is probable that the incidence of plate removal can be minimized by using a precontoured plate. In addition, proponents of anterior-inferior plating suggest that this tech-nique results in less prominence and irritation, although this remains to be proven. With regard to plate fixation in general, it is clear that routine plate removal is not recommended or

desirable in the majority of cases following ORIF. Asymptom-atic plates can and should be left in situ with a low rate of long-term complications, similar to retained plates in other areas in the upper extremity such as the forearm or humerus. Plates that provoke local irritation sufficient to warrant operative interven-tion should be removed only after 2 years have elapsed since fracture union to minimize the risk of refracture (as in the fore-arm). Collision athletes should have their plates removed at the end of a season to further decrease refracture risk. Anecdotally, many patients who have symptomatology at 1 year and desire plate removal find that by 2 years post injury the symptoms have ameliorated to the point where intervention is not desired. In general, small diameter or unlocked IM devices are removed because of the high degree of backing out and prominence as the fracture consolidates. This can be performed earlier than plate removal due to the intrinsic differences in healing patterns between these implants. It is unclear if more modern lockable

A

C

B

D

E

Figure 38-40 the initial anteroposterior radiograph of a 46-year-old polytrauma patient with a head injury demon-strates a displaced clavicle fracture (a). the anteroposte-rior radiograph at 6 weeks post injury reveals abundant callus formation around the fracture (b). the patient had increasing neuralgic pain in the associated upper extrem-ity with progressive objective muscle weakness in the hand. the involved hand (C, arrow) had signs of venous obstruction with swelling, loss of skin wrinkle defini-tion, and violaceous discoloration. A ct scan confirmed obstruction of the thoracic outlet due to a combination of severe shortening and displacement of the fracture site and exuberant callus formation (D). this patient was treated with operative corrective of the deformity, com-plete resection of the supraclavicular callus, and judicious resection of infraclavicular callus followed by plate fixation. A prompt resolution of symptoms, complete neurologic recovery, and uncomplicated fracture union ensued (e).



IM devices will have a lower removal rate, although that is cer-tainly one of their theoretical advantages.

Refracture in Clavicle FracturesTrue refracture after healing of a fracture of a clavicle is surpris-ingly rare. It has been my experience that many individuals who have claimed to have sustained multiple fractures of the clavicle have in fact a nonunion of their initial fracture that has never healed completely. Recurrent episodes of trauma prompt medical attention, and new radiographs are misinterpreted as showing a “refracture.” The few cases that are reported describe a higher nonunion rate following “refracture”. Regardless of the exact etiology, patients with this condition should be counseled about the high rate of unsatisfactory outcome and that they may benefit from fixation.15,30,32

Given the increasing popularity of operative fixation of dis-placed clavicle fractures, and the patient population involved, it is not surprising that fractures at the end of a plate used for fixation of a prior clavicle fracture are being encountered. This typically happens from recurrent high-energy trauma. Large prospective series are not available and recommendations are based on only a few cases. In general, a fracture in the upper extremity that occurs at the end of a stable implanted diaph-yseal plate has a poor natural history and a high chance of delayed union or nonunion. It is my experience that these frac-tures, if displaced, generally require repeat fixation. Attempts should be made to fix the fracture and span the area of bone previously repaired (Fig. 38-41). If the fracture is minimally displaced, a trial of nonoperative care with the arm at rest in a sling is reasonable.

Scapular Winging in Clavicle FracturesScapular winging has a variety of etiologies, and there are a number of case reports describing this condition following the nonoperative treatment of displaced midshaft fractures of the clavicle. Rasyid et al.146 reported two cases of winging of the scapula, one from a “neglected” fracture of the clavicle with 2-cm of shortening. A recent paper by Ristevski et al.152 examined

18 patients with symptomatic clavicular malunion and evi-dence of scapular winging clinically (Fig. 38-42) The authors performed CT scanning of all patients and were the first to be able to describe and quantify a consistent pattern of scapular malalignment. The patients had a mean clavicular shortening of 2.1 cm, and the acromion was found to translate with the dis-tal clavicular fragment medially, inferiorly, and anteriorly. The average acromial translation was 2.4 cm. The posterior aspects of the scapula were found to translate less (superior angle, 1 cm; inferior angle, 0.6 cm). This gives the typical clinical appearance of a shortened, protracted shoulder seen in clavicle malunion or nonunion (Fig. 38-43). The main function of the clavicle is as a strut to position the scapula in its correct loca-tion. Since the scapula is the base upon which the arm and hand function, a malunion or nonunion of the clavicle alters the position of the scapula such that the mechanical advantage of the associated muscles is affected. The negative mechani-cal effects of this shoulder position are well documented, with a mean decrease in rotational strength ranging from 13% to 24% in one study.175 While it is difficult to prove a direct link between scapular malalignment and poor outcome following nonoperative treatment of displaced fractures of the clavicle, it is hypothesized that the early fatigability, weakness, spasm, and pain from the shoulder girdle musculature may be related to scapular malposition.

While the relationship between scapular malalignment and outcome may be unclear at present it may help explain some of the variability in outcome seen with clavicle fractures. While we use the measurement of clavicular shortening as a surrogate for overall displacement, it is clear that significant degrees of scapular malposition (and inherent symptomatol-ogy) can result from translation and rotation of the distal clavicular fragment and scapula with minimal “shortening” seen on standard radiographs. Prospective studies to analyze the degree of scapular malalignment in the acute setting of a clavicle fracture would help determine whether a correlation exists between this malalignment and outcome, and could aid in surgical decision making.

A B

Figure 38-41 A 40-year-old professional motorcycle racer had plate fixation of a midshaft clavicle nonunion that developed following a displaced midshaft fracture. the nonunion healed uneventfully, but 2 years later, following another high-velocity crash, he sustained a fracture at the lateral end of the plate (a). this fracture also developed into a nonunion, and required repeat fixation with a longer plate (b). this is a potential risk for individuals with plate fixation of the clavicle who continue to participate in high-risk activities.


A B

C

D

Figure 38-42 Artists rendition of typical deformity and resulting scapular malposition following clavicular malunion or nonunion. it is this malposition that results in clinical evidence of scapular winging and resultant symptomatology. a: Anterior view of inferior scapular translation. b: Side view demonstrating scapular protraction. C: Supe-rior view showing anterior translation. D: Posterior view demonstrat-ing inferior scapular translation. (Adapted from: Ristevski B, hall JA, Pearce D, et al. the radiographic quantification of scapular malalign-ment after malunion of displaced clavicular shaft fractures. J Shoul-der Elbow Surg. 2013;22(2):240–246, with permission.)

Figure 38-43 A clinical photograph of scapular winging of the left shoulder associated with a midshaft clavicle malunion with 3-cm short-ening. there is a characteristic protrusion of the inferior angle of the scapula, produced as the scapula rotates and translates anteriorly with the distal clavicular fragment.

1468



at present. For example, while most studies use the magnitude of shortening when defining fracture displacement, this alone is a relatively simplistic linear measurement of what is typically a complex three-dimensional deformity. Since most of the major muscle groups of the shoulder have a scapular origin it may be that the final position of the scapula relative to the trunk and upper arm (which is difficult to measure, see Scapular Wing-ing) may be the dominant factor in determining prognosis.64 While the prognostic index published by Robinson et al.154 is a dramatic advance in providing objective information and facili-tating our ability to predict outcome, there are still significant improvements that can be made so that intervention can be selected specifically for those patients for whom the risk/benefit ratio of surgery is favorable. It is also clear that patient noncom-pliance, especially when associated with substance abuse, is a clear contraindication for surgery. Bostman et al.,10 in a study of 103 consecutive adults with acute, displaced midshaft frac-tures of the clavicle, stated that “Patient noncompliance with the postoperative regimen could be suspected to have a major cause of the failures.”

Method of Fixation for Clavicle FracturesThere has been increasing interest in direct comparative stud-ies examining the outcome of various IM nails versus plates for displaced fractures of the midshaft clavicle. This includes

Displaced* Undisplaced, orminimal

displacement

Sling, ROM whencomfortable

Transverse or shortoblique fracture

Comminuted,segmental, or

complex fracture

Precontoured plate

*Displaced: 1.5-cm shortening, obvious clinical deformity, associated rotational deformity, and scapular winging.

IM Pin

Low demand>60 yrs of age<16 yrs of age

Medical co-morbiditiessubstance abuse

Midshaft claviclefracture

Sling, ROM whencomfortable

High demand<60 yrs of age>16 yrs of age

Active,healthy patient

Precontoured plate

Figure 38-44 clavicle: Author’s Preferred treatment.

The above figure describes the author’s preferred method of treatment of clavicle fractures (Fig. 38-44).

Author’s Preferred method of treAtment for clAvIcle frActures

controversIes And future dIrectIons In clAvIcle frActures

Patient Selection for Operative Intervention for Clavicle FracturesRecent studies have made it clear that there is a subset of patients, especially those with shortened, displaced fractures who would benefit from primary operative repair of clavicu-lar injuries.15,68,154 However, these early interventions are not without risk and consume significant health care resources. In addition, there are patients who would seem to have prognos-tic factors for a poor outcome following a clavicular fracture (i.e., displacement of greater than 2 cm) and yet heal promptly (albeit in a “displaced” position) with minimal symptomatol-ogy and full function of the involved shoulder. While some of the explanation for this is undoubtedly due to the inherent variability of patient response to musculoskeletal injury, there may be other factors that are not clearly define or understood



two prospective randomized trials, two retrospective compara-tive studies, and one meta-analysis.25,37,52,81,86 In a prospective study, Ferran et al.52 randomized 32 patients to Rockwood pin fixation (17 patients) or small fragment compression plate fixa-tion (15 patients) and found 100% union in both groups with no difference in Constant scores at final follow-up (pin group mean score 92, plate group mean score 89, p = 0.365). They concluded that both techniques were effective, although there was a high rate of hardware removal (100% of pins and 53% of plates), and their study could be criticized for its small num-bers. Lee et al. performed a similar study (Knowles pins vs. plate fixation) in 62 patients over the age of 50 years, and although there was no difference in functional outcome (Constant score 85 in the pin group vs. 84 in the plate group), there were fewer complications, decreased OR time and hospital stays, and less symptomatic hardware in the pin group. Kleweno et al.81 per-formed a retrospective review of 40 patients treated operatively for completely displaced, simple pattern (transverse or wedge type) midshaft fractures of the clavicle and were able to fol-low up 18 treated with Rockwood pins and 14 treated with plates. They reported five complications in the pin group and five adverse events in the plate group with no documented dif-ferences in functional outcome, and concluded that pinning was a suitable option for simple pattern fractures. Chen et al.25 reported on a 141 patients treated with flexible titanium elastic nails (TENs, 57 patients) or small fragment pelvic reconstruc-tion plates (plate, 84 patients). They reported no significant dif-ference between the two groups with regard to complications, although the TEN group had shorter operative times and less blood loss than the plate group, with better DASH scores (mean 8 point difference) early at 6 months. There was no difference at 2 years, with excellent DASH and Constant scores (mean 96 in both groups) in both groups. They concluded that TEN fixa-tion was an excellent option but it should be stressed that they restricted its use to simple fracture patterns in a group of patients typically much smaller than the North American population. At the present time, TEN nailing has not been widely reported in the North American literature, and caution must be used in its application. Duan et al.37 conducted a meta-analysis of these studies and concluded that the evidence failed to show a differ-ence in treatment effects between plating and IM pin fixation, although there were more hardware complications with plating. They also stress that more high-quality, multicenter comparative studies are required for firm conclusions to be made.

Timing of Surgical Intervention for Clavicle FracturesConventional thinking has been that nonoperative treatment is appropriate for most if not all fractures of the clavicle, even severely displaced injuries, with the assumption that the recon-structive repair of those that developed nonunion or symptom-atic malunion would produce results similar to that of primary operative repair of the original fracture. Since these injuries are nonarticular, and the reported “success” rate of reconstruction is high, this approach seems to have inherent merit. However, there is recent evidence that while operative reconstruction of malunion or nonunion is a reliable procedure, with increas-

ing refinement of outcome measures and objective muscle strength testing it is apparent that there are residual deficits compared to what primary operative repair can provide. Potter et al.143 examined a cohort of 15 patients who had undergone late reconstruction with plate fixation for clavicular nonunion or malunion (“delayed group”) at a mean of 63 months post injury and compared them to a similar cohort of 15 patients who had primary plate fixation of a clavicle fracture a mean of 0.5 months after injury (“acute group”). The groups were simi-lar in age, sex, original fracture characteristics, and mechanism of injury. They found that there were subtle but significant differences between the two groups with regard to shoulder scores (Constant score 89 in the delayed group, and 95 in the acute group, p = 0.02), and the delayed group demon-strated inferior endurance strength in the involved shoulder. They concluded that while late reconstruction is a reliable and reproducible procedure, there were subtle decreases in out-come compared to acute fixation, and they recommended that this information be used in decision making when counsel-ing patients with displaced midshaft fractures of the clavicle. Rosenberg et al.158 reported similar results in a group of 13 patients who had late reconstruction for clavicular malunion and nonunion. While osseous healing occurred in all cases there was a mean 20-point deficit in Constant score (61 vs. 81, p = 0.01) in the affected shoulders. The authors felt that “lasting functional impairment” was possible even with objec-tive success. With time, substantial adaptive changes (muscle atrophy, soft tissue contracture, bone loss) occur in the shoul-der girdle of individuals with clavicular malunion or nonunion that will compromise the outcome of late reconstructive sur-gery to some degree when compared to the results of primary fixation. This is useful, objective information to use when evaluating the risk/benefit ratio of early operative intervention.

clAvIcle frActure summAry

There are now available a number of high-quality, prospective, and randomized studies that define the role of primary operative intervention for fractures of the clavicle. While the majority of clavicle fractures will heal with nonoperative care (a simple sling is probably best) and a prompt return of near normal shoulder function can be expected, there is a subset of fractures that ben-efit from operative intervention. Poor prognostic signs that have been defined include increasing fracture displacement (especially shortening), fracture comminution, and an increasing number of fracture fragments, especially in older patients. A meta-analysis of randomized clinical trials comparing operative versus nonop-erative treatment for displaced midshaft fractures of the clavicle has revealed some consistent findings: Plate fixation is a reliable technique with a low nonunion rate, nonoperative treatment results in a nonunion rate of 20% to 25%, malunion remains a problem in nonoperatively treated patients, and primary fixation results in modest (10 points on a 100-point scale) improvement, in general, in the operative group. Anterior-inferior plate place-ment may have some advantages over superior plate positioning with respect to soft tissue irritation. IM fixation has many theo-retical advantages and a high rate of success in skilled hands,



although results in the literature remain inconsistent. Although the difference is small, primary plate fixation provides signifi-cantly improved results in terms of strength and shoulder scores compared to delayed reconstruction. Malunion of the clavicle is a definite clinical entity that benefits from corrective osteotomy, which can usually be performed without a bone graft. Scapu-lar winging from scapular malposition is a consistent, definable, and common finding following the failure of primary nonopera-tive care and the development of a nonunion or a symptomatic malunion, and it can lead to significant patient symptomatology. Future studies that are randomized, prospective, and compara-tive are needed to refine the indications for primary operative repair, investigate the role that scapular malposition plays, and determine the ideal method of fixation.

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